Ventilator Associated Pneumonia
Reduction in a Medical ICU
Bela Patel, MD
Tammy Campos, RN, MSN
Ruth Siska, RN
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“Nosocomial” Infections
• Nosocomial Infections
– Not present or incubating upon admission to the
hospital (48hr rule)
• Preferred: Hospital Acquired Infections (HAIs)
• 5-10% of patients admitted to hospital or 2
million patients
• 88,000 deaths per year
• Costs exceed 4.5 billion/year
• 1 outbreak per 10,000 discharges
From a public health issue to…
A very public issue
On the horizon for us
• Texas reporting
– Law passed requiring mandatory reporting of HAI to
TDSHS starting 2008
– Rates will be publicly available
• Federal reporting
– Bill introduced requiring mandatory reporting to CDC
through NHSN
– New national guidelines on infection control 2008
• Medicare
– SCIP as core measure
– Lower rate reimbursement for patients with HAI
starting 2008
VAP
• Leading cause of death amongst hospitalacquired infections
• Mortality 46% compared to 32%
percent for ventilated patients who do not
develop VAP
• Increased ventilator days
• Increased ICU LOS
VAP defined
• Patients mechanically ventilated for
greater than 48 hours
• Exhibit at least 3 or 5 following symptoms:
– Fever
– Leukocytosis
– Change in sputum (color and/or amount),
– Radiographic evidence of new infiltrates
– Worsening oxygen requirements
CDC 2003
Cost of VAP at MHH
Cocanour, et al. Surgical Infections 2005.
Prognosis
VAP prevention
“Vent Bundle”
• Suctioning
• Head of bed > 30o
• Oral care
• “Sedation holiday”
Memorial Hermann -MICU
• 16 bed unit admitting 1100 patients per year
• 60% ventilated >3 days putting them at
greater risk for VAP
• Chief diagnoses include septicemia,
respiratory failure, HIV/AIDS, renal failure,
and multisystem organ failure secondary to
multiple co-morbid conditions
• Previous improvement work had made
respectable reductions in VAPs from 2-3 per
month to <10 per year, however it was felt
more was achievable
Aim and Measures
Aim
To reduce VAPs in the MICU to Zero within
six months.
Measures
• Reduction in number of VAPs per 1000
ventilator days
• Increased compliance with all aspects of
the ventilator bundle.
Where to start?
MICU - VAP Fishbone
People
Policies
Believed “Zero”
was not possible
Lack of
communication
between unit Nursing,
RT and MDs
Inconsistent in
practice
recommendations
Lack of
communication about
policy and processes
PRN staff and off
service physicians
did not capture
importance
“This is an
expected
complication”
Didn’t know
rates
Policy not readily
available
“Our patients
are too sick”
Thought we were
good enough
No understanding
of national benchmarks
Isolation equipment
not readily available
Oral hygiene supplies
not readily available
Supplies
No way to
track oral care
Off service patients
not following protocol
Processes
Ventilator
Associated
Pneumonia
Occurs
Inconsistent
bundle
implementation
Staff misunderstand
bundle elements
Lack of accountability
for bundle implementation
Interventions: Education
• MICU “Huddles” on VAP and mortality
• Posted rates in the unit for staff and MDs
to see
• Posted rates in public areas for patients
and family members to see
• Reviewed bundle compliance regularly in
multidisciplinary team meetings
• Reviewed compliance and VAP rates at
local and system critical care committees
Interventions: Implementation
• Developed physician Rounding Tool to address VAP bundles
• Appointed unit champions to assure patients were out of bed on
daily basis
• Formalize oral care process using chlorahexadine
• Trained Patient Care Assistants (PCAs) in oral care
• Mandated that oral care be a shared responsibility by RNs,
Respiratory Therapists and PCAs increasing oral care from 4 times
per day to 10 times per day
• Computerized reminder alert for the care team
• Located all oral care supplies near ventilators
• Located isolation supplies –gowns, gloves, masks at entrance to
every patient room
Interventions: Implementation
• Increased isolation practices for all infected
patients to include booties, head coverings
• Implemented glycemic protocol to keep
glucose between 80 and 150
• Implemented automatic insulin drip for all
patients who had 2 consecutive finger sticks
above 150
• Implemented standardized sedation protocol
• Improved Sedation holiday practices by team
approach to assessment
• Improved transportation practices
Interventions: Audits
• Implemented daily manager rounds to assure
bundle compliance
• Assured compliance with unit protocols by PRN
staff and consulting MDs
• Implemented a mini-RCA process for all VAPs to
detect specific patient characteristics and system
risk factors
• Infectious Disease Dept conducts random weekly
audits for bundle compliance
• Infectious Disease Dept reviews all cases to
diagnose VAPs based on CDC criteria
Results: Bundle Compliance
VAP Bundle Compliance - Jan06-Jul09
100
Percent compliance
95
90
85
80
75
70
Variable
HOB
Sxn
Oral Care
Peptic Ulcer Disease Px
Sedation Holiday
DVT PX
65
Q1-06 Q2-06 Q3-06 Q4-06 Q1-07 Q2-07 Q3-07 Q4-07 Q1-08 Q2-08 Q3-08 Q4-08 Q2-09 Q2-09
Does “vent bundle” work?
More to do: FMEA
• Aspiration during transport
• Cuff leaks
• Unplanned extubations requiring reintubation
Results: VAP Rate
Results: Overall
• VAP rate went from 8-12 per year to zero
within three months.
• No VAPs have occurred in the MHH-TMC
MICU for 26 consecutive months
• Compliance with all aspects of the VAP
bundle is between 98 - 100%.
Results: Cost Savings
• A financial analysis completed by our
infectious disease and financial
departments concluded that a VAP in any
of our ICUs adds $57,000 in additional
costs for additional antibiotics, ventilator
time and ICU stay.
• Cost avoidance for this project based on
avoiding 8 VAPs per year is $456,000.
Sustainability
• Takes a Village to raise a “Zero”
– Culture Changed
•
•
•
•
Goal became Expectation
Work flow changes became routine
Reporting of “near misses”
Created a highly functioning
multidiciplinary team
Conclusions and Next Steps
• With concerted and focused effort “zero” is
possible as an outcome.
• As with any major improvement, the
challenge is to maintain this level of
performance.
• Build on this methodology to achieve similar
improvements for other hospital acquired
infections in the Intensive Care Units.
Acknowlegements
• UT Divisions of Critical Care, Pulmonary
and Sleep Medicine
• MHH ICU Nursing Staff
• MHH Respiratory Therapy
• MHH Nutrition Support
• UT-MHH Academy of Patient Safety &
Effectiveness