1. University of Rochester Strong Health
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 ICU’s: MICU (17 beds), SICU (14 beds), Burn/Trauma (17 beds), and Cardiovascular ICU (14 beds)

2. 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

3. 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

4. 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

5. HMO PREVENT 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

6. VAP CRITERIA > 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

7. Vent Bundle Compliance

8. Frequency of Ventilator Associated Pneumonia1 1 1 2 2
1 Vent Bundle implemented
2 Reeducation

9. Days between incidences of VAP: MICU2 1
1 Vent bundle reeducation
2 Oral Care Protocol

10. 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

11. 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