Background: Guidelines (compiled into a “ventilator bundle”) exist to minimize complications in ventilated patients, including ventilator associated pneumonia (VAP). The effectiveness of ventilator bundles on reducing VAP has been questioned.
Objective: To improve bundle adherence and reduce VAP by implementing a sustainable comprehensive program that includes a real-time bundle compliance dashboard.
Methods: In 2007 a comprehensive program was developed that included assessment of barriers to care, education, and consensus institutional ventilator bundle development (head of bed elevation; peptic ulcer and deep venous thrombosis prophylaxis; oral care/hypopharyngeal suctioning at defined intervals; targeted daily sedation score; and spontaneous breathing trials). To assess bundle compliance and to stimulate instant course correction of non-compliant parameters, a real-time computerized dashboard was developed. The dashboard, integrated with nurse/respiratory therapy charting and physician orders, displays on the bedside computer screen the up-to-the-minute bundle element compliance status for every ventilated patient. Color-coded designations note practices that are in compliance, are near expiration, and are out of compliance. Program impact from implementation (August 2007) through July 2009 in 6 adult intensive care units was assessed. Bundle compliance was noted as an overall cumulative bundle adherence assessment (Z100- score), reflecting the percent of time all elements were concurrently in compliance. VAPs were determined using Centers for Disease Control and Prevention definitions by trained infection preventionists blinded to patient-specific bundle adherence data.
Results: Prior to program implementation, the rate of VAP in all ICUs combined from January 2006 through July 2007 was 18.3 VAPs/1000 ventilator days. Following program implementation in August 2007, this rate declined to 11.4/1000 ventilator days in 2009 (p< 0.001, Figure). Bundle compliance significantly increased following implementation (Z100-score of 23% in August 2007 to 87% in July 2009 [P<0.001]). Using the pre-implementation VAP rates as baseline, we estimate that 153 VAPs may have been prevented following program implementation. Based on literature estimates, this equates to a savings of $3,499,875 and 1,469 hospital days due to VAP prevented.
Conclusions: A prevention program using a real-time bundle adherence dashboard displayed at the bedside was associated with significant decreases in VAP rates and significant increases in bundle compliance among adult ICU patients. These changes were sustained for two years after implementation. Measuring compliance over an entire day vs. by spot performance audits provides a more accurate assessment of practice and may explain the reported lack of association of improved bundle adherence with VAP reduction.