How We Zapped VAP

• During the past six years, our Multidisciplinary Pneumonia Team has worked to reduce Ventilator Associated Pneumonia (VAP).

• Through these efforts, our facility has reported zero VAPs within the last 58 months (May 08-Present).

• Our multidisciplinary pneumonia team explored evidence-based research through the Georgia Hospital Association (GHA), Partnership for Health and Accountability (PHA), National Health and Safety Network (NHSN), and the Institute of Healthcare Improvement (IHI) 5million Lives Campaign to determine best practice approaches.

• Armed with this information, our organization implemented a ventilator bundle incorporating the following criteria listed in the next section.

Objectives

To achieve compliance with the VAP bundle:• elevate the head of bed to 30 degrees• conduct daily awakening and assess readiness

to extubate• ensure peptic ulcer disease prophylaxis• ensure deep vein thrombosis prophylaxis • oral care with CHG (chlorohexidine) twice a

day (Purple Packs)

Process

Process:Bundle implemented in 2006. With numerous revisions due to changes in evidence based practice guidelines and our internal findings.• Latest update included the addition of the daily

readiness to extubate assessment in ’09 and adding sacral dressing to minimize the shirring effect on the skin due to the elevated HOB.

• Also in ‘09 we added the Critical Care Sedation Physician Order set for the ventilated patient.

PDCA• Plan

– Multidisciplinary team approach to create the Vent bundle. The team included an intensivist/ pulmonologist, pharmacy, respiratory therapy, IT, physical therapy, dietician, wound therapy, and critical care RN.

– 2006 we launched our efforts to eradicate VAP in our healthcare system. Focusing on ICU and NCCU

– With the 5 key elements listed in our bundle/order-set it quickly passed through all approval process (Critical Care Committee, Quality Committee, Medical Executive Committee, and Senior Leadership.

PDCA

• Do– It took a team to develop the Vent bundle which

was implemented in early ‘07. – Many changes were made to keep up with best

practice guidelines as well as fixing what was not working with in out process.

– Ultimately the end result encompassed all objectives that were checked for compliance.

PDCA

• Check/Study– Each bundle element was studied to look for

challenges in compliancePUD data July 2008 – March 2014

0

20

40

60

80

100

Compliance

1stQtr

4thQtr

7thQtr

10thQtr

13thQtr

16thQtr

19thQtr

22ndQtr

Quarters

PUD

PDCA

• Check/Study– Each bundle element was studied to look for

challenges in compliance

– After compliance with HOB was 100% for so long we considered this a culture change and no longer kept the data.

HOB Elevated to 30 degrees data July 2008 - June 2012

98.498.698.8

9999.299.499.699.8100

Compliance

1stQtr

3rdQtr

5thQtr

7thQtr

9thQtr

11thQtr

13thQtr

15Qtr

QuartersHOB 30

PDCA• Check/Study

– Each bundle element was studied to look for challenges in compliance

– VTE data will most likely drop off after this quarter as we have met 100% for 14 qtrs.

VTE Compliance July 2008 – March 2014

0

20

40

60

80

100

Compliance

1stQtr

3rdQtr

5thQtr

7thQtr

9thQtr

11thQtr

13Qtr

15thQtr

17thQtr

19thQtr

21stQtr

23rdQtr

Quarters

VTE

PDCA• Check/Study-Multidisciplinary Rounding

In the winter of 2010 our facility hired an intensivist group to lead critical care multidisciplinary rounding. Rounding in the intensive care units reinforces the use of our Ventilation Order Set. The pharmacy member of the multidisciplinary team checks for PUD and VTE on each patient prior to rounding and makes recommendations to the attending when necessary. Within a year the culture changed and now very few recommendations are made for PUD and VTE. Each morning prior to the scheduled rounding time all members of the team fill out the Interdisciplinary Care Plan on each patient in the ICU. The patient’s primary nurse presents the patient to the team and receives recommendations from the intensivist and team.

PDCA• Check/Study-Readiness to Wean

– Obstacle: was the readiness to wean process. These orders were not part of the original bundle and we did not have a standardized sedation order set

– During the implementation of the sedation protocol, we discovered that the readiness to wean assessment on the respiratory documentation tool was lacking key information. In working with the clinical informatics department, a new and improved assessment tool was implemented. The Critical Care Sedation Order Set now guides the practitioners through the daily weaning process.

Daily Awakening

• Hold/stop sedation at 0800• Assess patient’s sedation level• Perform weaning mechanics or chart

contraindications• If awakening is tolerated and continued sedation is

needed RESTART infusion at 50% previous rate (if sedation regimen has been longer than 5 days reduce rate by 20% and monitor for withdrawal)

• If daily awakening NOT performed MUST document rational on daily rounds sheet.

PDCA• Check/Study-Readiness to Wean

Readiness to Wean Data from November 2009-March 2014 (Status post Sedation Order set go live)

0102030405060708090

100

Compliance

1stQtr

4thQtr

7thQtr

10thQtr

13thQtr

16thQtr

19thQtr

22nd

Quarters

Readiness to wean

PDCA• Act-Lessons learned for future improvement

– Ensure oral care and documentation completed every two hour

– Ensure placement of the Critical Care Sedation Protocols on each patient’s chart that is on a ventilator

– Educate in the readiness to wean guidelines and encourage proper respiratory therapy documentation

– Reinforce sedation agitation education and documentation every hour

– Monitor daily awakening and evaluate patients at risk for self extubation

Results

Total 02 Total 03 Total 04 Total 05 Total 06 Total 07 Total 08 Total 09 Total 10 Total 11 Total 12 Total 130

5

10

0.00

5.00

10.00

3 4 3 3 2 6 2 0 0 0 0 0

7.48

4.96

6.48

4.173.89

8.46

2.34

0.00 0.00 0.00 0.00 0.00

HospitalVentilator Associated Pneumonia (VAP)

ICU and NCCU Combined

# Of Infections Rate Infections/1000 Device Days

# o

f In

fec

tio

ns

Ra

te o

f In

fec

tio

ns

/10

00

ve

nt

da

ys

Multi- Disiplinary rounds started Nov. 2010

Initiation of VAP Bundle 2007

ZEROSince May

2008Going on 6 years

Added CHG to oral care .Feb2011

Bundle Compliance DataCriteria 2009 2010 2011 2012 2013 Bundle

Compliance

Head of bed elevated (30°)

98% 100% 100% 100% 100% 85.36%

Peptic ulcer disease 78% 96% 95% 98% 97%

VTE Prophylaxis 62% 93% 94% 96% 99%Readiness to wean 42% 76% 94% 92% 85%

Oral Care No data

47% 78% 85% 81%