Clinical Nurse Leader and Ventilator Associated Pneumonia Prevention Program

Background:  A Clinical Nurse Leader (CNL) is a master prepared nurse that facilitates concepts of care linked to evidence based practices. A CNL is also educated to implement process improvement, measure outcome effectiveness, and analyze data for presentation.   South Texas Veterans Health Care System (STVHCS) Infection Control Program has employed a CNL to improve processes of care for patients. The first process improvement activity that the CNL tackled was the prevention of ventilator associated pneumonia (VAP), an area where infection rates had steadily increased to 6.2 per 1000 ventilator days in the first quarter FY09.

Objective: Infection prevention strategies were implemented by the CNL to show how interventions established by the CNL are associated with reduction in VAP rate.   

Methods: The CNL provided improved surveillance of bedside care in relation to VAP prevention.  Evaluations indicated specific oral care practices utilizing chlorhexidine gluconate (CHG) oral products, dedicated in-line endotracheal tube suction processes, and in-line nebulizer apparatus management were deficient.  Initial bedside evaluations showed a CHG oral care practice compliance of 40% in the surgical intensive care (SICU) and 65% compliance in the medical intensive care unit (MICU).  Also, dedicated in-line endotracheal tube suction practice compliance for SICU was at a very low 9% and 40% in MICU.  Finally bedside observations identified in-line nebulizer apparatuses when disconnected were left in the open either hanging on a ventilator machine or on a bedside rail as opposed to placing in a covered plastic bag protected from the environment. The CNL implemented education modules related to VAP pathophysiology as well as improved care practice change requirements identified.  Surveillance outcomes were also provided to the multidisciplinary VAP committee to provide transparency in care.  This also provided support for practice change.  Concurrent VAP chart review outcomes were also provided to the VAP committee.  Finally, care compliance deficiencies identified by the CNL during surveillance were “highlighted” to the bedside staff for on-the-spot corrections.

Results: After the above process improvement strategies, nebulizer care practice compliance improved to 100% in both MICU and SICU.  Dedicated endotracheal tube suction compliance improved to 86% in SICU and 75% in MICU.  Finally oral care compliance with use of CHG products improved to 100% in both MICU and SICU.  Quantitative implementation outcome results indicate that the STVHCS VAP infection rates trended down significantly from 6.2 in FY09 1^st quarter to 1.5 in FY09 4^th quarter. 

Conclusions:   Although the target rate of 3.0 was not reached by the end of FY 2009, the VAP rate did trend down significantly after initiation of care practice.  The CNL process improvement indicates strong association to VAP rate reduction.