1. OUR LADY OF LOURDES MEMORIAL HOSPITAL Binghamton, New York Reducing Complications From Ventilators in ICU: Ventilator Associated Pneumonia (VAP)

2. Our Lady of Lourdes ICU Team Our Lady of Lourdes Hospital is a 267 bed acute care, community, not-for-profit healthcare facility which provides a full spectrum of inpatient, ambulatory and emergency services. Our pilot unit is a ten bed medical surgical intensive care unit. Our Lady of Lourdes Hospital is a 267 bed acute care, community, not-for-profit healthcare facility which provides a full spectrum of inpatient, ambulatory and emergency services. Our pilot unit is a ten bed medical surgical intensive care unit.

3. Our Team and Goal  We have a multidisciplinary team that meets weekly. We began meeting in 11/03.  Representation includes: Administration, Quality, Nursing, Pharmacy, Care Management, Respiratory Therapy, Nutrition, Rehabilitation Services, Infection Control, Medical Staff, ICU Staff.  Goal: to increase the number of days between VAP to greater than 180 days.

4. Ventilator Associated Pneumonia VAP  VAP is a pneumonia that develops > 48 hours following intubation.  VAP increases hospital cost per episode as much as $20,000, and hospital length of stay as much as 14 days. (Archives of Internal Medicine 1991;151:1109-1114)  VAP increases mortality.

5. Bundle Concept  A "bundle" is a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually.

6. Ventilator Bundle  All or None Concept  All components of the ventilator bundle must be performed on each ventilator patient to be compliant. If a component is contraindicated, and all other components are performed, the bundle can still be considered compliant.

7. Ventilator Bundle  Head of Bed > 30 Degrees  Deep Vein Thrombosis (DVT) Prophylaxis  Peptic Ulcer Disease (PUD) Prophylaxis  Sedation Vacation  Daily Assessment of Extubation Readiness

8. Ventilator Bundle Rationale  Head of Bed > 30 degrees:  To reduce the frequency and the risk of aspiration  DVT Prophylaxis:  Mechanically ventilated patients are at significant risk for DVT due to limited mobility  Peptic Ulcer Disease Prophylaxis:  Critically ill patients requiring mechanical ventilation are at a higher risk of developing life- threatening upper gastrointestinal mucosal erosions and hemorrhage.

9. Ventilator Bundle Rationale  Sedation Vacation:  Daily interruption of sedative drug infusions decreases the duration of mechanical ventilation and length of stay in ICU. Sedation vacation is defined as:  Sedation held for equal to or greater than 12 hours or or  Until patient follows commands at least once during the day or or  Patient follows commands without sedation being held.  If sedation is restarted, attempt dose that is half of previous dose  Daily Assessment of Extubation Readiness:  Daily screening for liberation from the ventilator, followed by trials of spontaneous breathing can reduce the duration of mechanical ventilation, decrease complications and costs of ICU care.

10. Testing the Ventilator Bundle  Start Small!  Begin with one ICU RN, one patient, one Respiratory Therapist and one physician.  Make changes as appropriate based on the initial test.  Add one more RN, patient, and RT.  Continue to make changes as appropriate and continue to add RNs, patients, RTs and physicians until the entire population is included.

11. Monitoring the Test of Change for Improvement  When we began, we measured the entire ventilator bundle, as well as each component of the bundle.  This enabled us to identify which components were not being performed and we could focus our efforts to improve compliance.

14. Barriers  Staff felt this was more paperwork.  Medical Staff did not really understand what a “bundle” was.  Monitoring and documentation of the monitors was inconsistent.  Empowering staff to emphasize importance of compliance with ventilator bundle with medical staff.  Daily assessment of extubation readiness.  Respiratory Therapists uncomfortable with initiating weaning protocol

15. Strategies to Improve Compliance with Ventilator Bundle   Every staff member was held accountable for monitoring and documentation.   Nurses were empowered to understand accountability for lack of practicing evidenced based care.   Implemented daily multidisciplinary rounds which allowed for immediate assessment of compliance with ventilator bundle.   A round table meeting was held with nurses, team leader, respiratory therapists and pulmonologists. Evidence based information was provided and the team discussed it until it was resolved.

16. Successes  ICU Team, ICU staff, and Pulmonologists educated on ventilator bundle and rationale  ICU Team developed a ventilator bundle monitoring tool  Incorporated ventilator bundle into pre-printed physician orders for mechanical ventilation  Incorporated ventilator bundle into ICU nursing flow sheet  Began testing small, made changes as appropriate, and continued to test until entire ventilator patient population included  ICU staff monitor compliance with ventilator bundle every shift  Implemented multidisciplinary rounds for all ICU patients  Developed a Respiratory Therapist driven Weaning Protocol, which was approved by the Pulmonologists  In the event of a VAP, ICU Team performs case review

17. Results

18. Results

19. Results

20. Next Steps  The 3 VAPs that occurred after the stretch of 290 days between VAPs, were reviewed. 2 of the 3 patients were surgical patients, and elevating the head of the bed was contraindicated. The ventilator bundle was followed except for this component.  Team is researching the CASS Endotracheal Tube: Continuous Aspiration of Subglottic Secretions.  The CASS endotracheal tube is recommended by the CDC as a strategy to prevent VAP.

21. VENTILATOR BUNDLE MONITORING TOOL SHIFT:TOTAL # VENT PTS: DATERM #PT INITIALS HOB 30 ° DVT Prophy. PUD Prophy. Sedation Vacation Daily Assessment Extubation Readiness ***PERFORMED ON DAY SHIFT*****

22. ICU Monitoring Tool Date: _________ Shift: ____ Census: _____ Vent Census: ______ Key: (+) completed; (-) not done; (n/a) not applicable; (contra) contraindicated; (EOB) edge of bed RM#RM# Pt Init Rounds with Daily Goals VentCentral Line CL CL Daily Necessity assessed FoleyHOB 30° DVT Prophy PUD Prophy Sed Vac 7-3 Assess Ext.Ready DAY-SHIFT Blood Sugar (BS) If Hospitalist pt and BS >150 is pt on glucose protocol Oral Care q 4 h MobilityRN Init 1 + - +-+- +-+- +-+- +-+- + - contra + - contra + - contra n/a + - contra + - contra n/a + - +-+- ROM EOB chair ambul 2 + - +-+- +-+- +-+- +-+- + - contra + - contra + - contra n/a + - contra + - contra n/a + - +-+- ROM EOB chair ambul 3 + - +-+- +-+- +-+- +-+- + - contra + - contra + - contra n/a + - contra + - contra n/a + - +-+- ROM EOB chair ambul 4 + - +-+- +-+- +-+- +-+- + - contra + - contra + - contra n/a + - contra + - contra n/a + - +-+- ROM EOB chair ambul 5 + - +-+- +-+- +-+- +-+- + - contra + - contra + - contra n/a + - contra + - contra n/a + - +-+- ROM EOB chair ambul