Reduction Of Ventilator Associated Pneumonia - Steps To Success

Background:  Boston Medical Center (BMC) is a 626 bed not-for-profit teaching hospital with approximately 30,000 total discharges per year. From 2006 - 2007 the rate of ventilator-associated pneumonia (VAP) ranged from 5-9/1000 ventilator days in the ICUs. The unit specific VAP rate often exceeded the unit specific NHSN 50^th percentile benchmark.  Development of VAP increases patient morbidity, mortality, length of stay, and cost of hospitalization. In 2008, a quality improvement project was initiated in all ICUs at BMC to reduce the incidence of VAP and improve patient care.

Objective: The objective of this intervention was to reduce the incidence of VAP to a rate below the NHSN 25th percentile.

Methods: Quality Improvement Project

Ten Steps to Success:

1) Formation of multidisciplinary ICU specific teams

2) Implementation of the following VAP bundle:

a) Elevation of the head of the bed (30 degrees)

b) Daily "sedation vacations" and assessment of readiness to extubate

c) Peptic ulcer disease (PUD) prophylaxis

d) Deep venous thrombosis (DVT) prophylaxis 

e) Mouthcare with Chlorhexidene mouthwash

3) Initiation of twice daily rounds by the Respiratory Therapy department in the ICUs to assess bundle compliance and document findings in an electronic database

4) Daily assessment by an Infection Preventionist (IP) to identify any new VAP

5) Confirmation of VAP by Infectious Disease and Pulmonary attendings 

6) Real time alert of clinicians caring for patients identified with VAP

7) Multidisciplinary meeting to discuss VAP and possible preventative measures

8) Weekly Email of ICU days since last VAP by VP of Nursing to all nurses

9) Monthly review of ICU bundle compliance at Critical Care and VAP Committees 

10) Participation in a multi-center study entitled ASPIRRE (Attaining Safety for Patients through Interdisciplinary Risk Reduction Efforts ) to reduce healthcare-associated infections through implementation of evidence-based training tools designed in collaboration with the Joint Commission and the Agency for Healthcare Research and Quality (AHRQ)

Results:

Since 2006, the rate of VAP has decreased from 8.46/1000 ventilator days to 1.18/1000 ventilator days (Z score for comparison of proportions 6.29; p< 0.00001; and was 0/1000 ventilator days in several ICUs.  This represents a greater than 7 fold reduction in VAP hospital-wide. The attached graph depicts the overall trend in the reduction of VAP before, during, and after the intervention period. 

Conclusions:

Implementation of this quality improvement project has contributed to a statistically significant reduction in ventilator-associated pneumonias in the ICUs. The decreased incidence of VAP has resulted in improved patient care, and decreased morbidity, mortality, length of stay and cost of patient specific hospitalization.