Reducing Complications from Ventilators: Ventilator Associated Pneumonia

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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
ICUs MICU (17 beds), SICU (14 beds),
Burn/Trauma (17 beds), and Cardiovascular ICU (14
beds)
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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

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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

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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

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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

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VAP CRITERIA

• gt 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

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Vent Bundle Compliance
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Frequency of Ventilator Associated Pneumonia
1
1
1
2
2

1 Vent Bundle implemented 2 Reeducation
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Days between incidences of VAP MICU
492 Days
212 Days
2
1
1 Vent bundle reeducation 2 Oral Care Protocol
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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

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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