975 Expansion of Bundle Elements to Eliminate Ventilator-Associated Pneumonia

Sunday, March 21, 2010
Grand Hall (Hyatt Regency Atlanta)
Eileen O'Rourke, MT(ASCP), MPH , The Lankenau Hospital, Wynnewood, PA
Mary Lance-Smith, RN, MSN, CCRN , The Lankenau Hospital, Wynnewood, PA
Mary Beth Sedwick, BSN, MS, CCRN , The Lankenau Hospital, Wynnewood, PA
Susan Gregory, MD , The Lankenau Hospital, Wynnewood, PA
Mark Ingerman, MD , The Lankenau Hospital, Wynnewood, PA
Background: In 2004 the Institute for Health Care Improvement (IHI) launched its 100,000 Lives Campaign which evolved into the 5 Million Lives Campaign. Recommendations to prevent ventilator-associated pneumonia (VAP) are head of bed (HOB) elevation, daily assessment for readiness to wean, daily sedation vacation, deep vein thrombosis (DVT) and peptic ulcer disease (PUD) prophylaxis. Interventions such as oral care, subglottic suctioning, and daily assessment of bundle compliance with feedback to staff are not included.
An inter-disciplinary team previously examined VAP reduction methods, however, VAPs increased to a rate of 10.7 in 1st quarter FY09 and 10.3 in the 2nd. In July 2008 we were charged to reduce VAP rates with the goal of VAP elimination.
Objective: To expand the IHI VAP bundle to include elements that augment efforts to eliminate VAPs.
Methods: Interventions to address the VAP problem initiated in 2004 included using a closed suction system, subglottic suctioning, oral care every 4 hours, sedation vacation and HOB elevation communicated to staff, PUD and DVT prophylaxis added to order sheets, and daily rounds with physicians. A method to document that staff adhered to these recommendations was not implemented. A Performance Improvement Team was formed in July 2008 to examine best practice. The following items were instituted from July 2008 thru April 2009: cards placed beside as a reminder to discuss bundle elements in rounds; Wash/Glove/Wash policy implemented; HOB alarms installed in ICU beds and tape placed at top of the bed to determine proper bed height; dedicated stethoscope for every bed; enhanced patient room cleaning with feedback to housekeepers using a system which measures bioburden; technician hired to clean respiratory equipment; mouth care increased to every 2 hours with twice daily use of chlorhexidine gluconate; monthly review of every patient who acquires a VAP to determine if required prevention measures were missed or other risk factors observed; computerized data collection tool developed for daily data collection; daily audits compiled with information tagged to specific practitioners; an automated email is then immediately sent to appropriate individuals: patient care managers, attending physicians for PUD and DVT prophylaxis, and primary nurse for other indicators.
Results: The sustained implementation of these initiatives show remarkable results:
FY07 19 VAPs: rate = 4.4
FY08: 43 VAPs: rate = 8.3
FY09: 25 VAPs: rate = 5.5
7/08 thru 12/08: 23 VAPs, rate = 10.5
1/09 thru 6/09: 2 VAPs, rate = 0.9

21 less patients acquired a VAP in 6 months, for a savings of $525,000 but more importantly, we provided a safer environment for our patients.
Conclusions: Daily, independent audits of ventilator-bundle compliance with feedback to staff and management are a key component in reducing VAP. Additional elements incorporated into the VAP bundle are important in working toward elimination of VAPs.