Reducing Complications from Ventilators: Ventilator Associated

Pneumonia

University of Rochester Strong Health

700 bed tertiary care medical center. Strong health is a Trauma Center, Transplant Center (bone marrow, kidney, liver & heart). 4 adult ICU’s: MICU (17 beds), SICU (14 beds), Burn/Trauma (17 beds), and Cardiovascular ICU (14 beds)

MICU Critical Care Team Members

Team Leader: Michael Apostolakos, MD, Director Adult Critical Care

Day to day leadership: Michael Apostolakos, MD. Isabelle Michaud, MD, Critical Care Attending Mary Wicks, RN, MPA, Associate Director, Adult Critical

Care Barry Evans, MSN, Adult Critical Care QI Data Coordinator Tim Kehl, RN, Nurse Leader Janice Bell, RN, Nurse Leader

Additional key members: Lucille Nelson, RN, MICU Care Coordinator, Jennifer Carlson, RRT, Supervisor Critical Care

Respiratory Therapy

Why is reduction of VAP a priority?

Mortality 50-70%

Increased LOS ICU 17.7 vs 6.1

Complications ARDS Atelectasis Pneumothorax Sinusitis

Cost of treating 1 case of VAP $5,000 – $27,000

VENTILATOR BUNDLE Elevate HOB 30 degrees unless

contraindicated Sedation Holiday

Reduce or turn off sedation daily DVT Prophylaxis PUD Prophylaxis Test for readiness to wean or

ability to extubate daily

HMOPREVENT VENTILATOR

ASSOCIATED PNEUMONIA

HOB HOB is elevated at 30 degrees unless medically

contraindicated Reduces aspiration of oropharyngeal/gastric

secretions Mobility

Turn Q 2 hrs/ OOB when appropriate Mobilizes secretions

Oral Care Perform Oral Care Q 2 hrs following structured oral

care protocol Removes pathogens from oropharynx

VAP CRITERIA > 48 hours on ventilator

At least 3 out of 5: Fever Leuckocytosis Change in sputum Radiographic evidence of new or

progressive infiltrates Worsening O2 requirements*Final determination of VAP diagnosis is

made by the attending physician

Vent Bundle Compliance

0

20

40

60

80

100

120

Dates

Per

cent MICU

SICUCVICU

Frequency of Ventilator Associated Pneumonia

02468

101214161820

Dates

Rat

e (%

)

MICU Rate SICU RateCVICU Rate

1

2

1 Vent Bundle implemented2 Reeducation

1

1

2

Days between incidences of VAP: MICU

0

100

200

300

400

500

600

Dates of VAP

Da

ys

bet

wee

n V

AP Days without

VAP

1 Vent bundle reeducation2 Oral Care Protocol

12

212 Days

492 Days

Ventilator Bundle: Cycles of Improvement

Numerous, rapid PDSA cycles of vent bundle as part of goal sheet on a few patients led to refinement of goal sheet.

Support of Medical Director and nurse leaders key to implementation

Training of attendings, residents and bedside nurses vitally important (education)

Posting results, positive reinforcement leads to more excitement Focusing all initiatives on patient centered care and not in

isolation Importance of initiatives echoed by senior leadership during walk

rounds PDSA cycles continue as utilization continues to vary (ie

percentage utilization decreases under certain attendings) Constant feedback from nurses Forms remain as permanent record

Keys to Success, Barriers and Lessons Learned

Involve key front line staff Ongoing education….why are we doing

this? Participation by senior leaders Medical Director and Nurse Manager

must be fully supportive Administrative assistance Resistance to change Perceived increased workload Another QI project which will go away