The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts


Michael Westely, MD, Medical Director, Critical Care Unit and Respiratory Care W. Joseph Streiff, RRT, Manager, Respiratory Care Department Janis Cunningham, RRT, Clinical Specialist, Respiratory Care Department
Virginia Mason Medical Center 925 Seneca Street, H10-RTH Seattle, WA 98111

Background:Ventilator Associated Pneumonia (VAP) is a serious and expensive CCU-acquired complication that kills 15-35% of patients and adds $10-20,000 to their hospital bill should they survive. Because ventilated patients are seriously ill, often with multiple infections, VAP’s have become a dreaded but accepted CCU complication. Various methods have been used to reduce VAP’s, most focusing on staff
education. These efforts overall result in reduced VAP rates of about 30%. We hypothesized that by consistently applying the best evidence-based recommendations demonstrated to reduce VAP we could dramatically reduce or eliminate VAP from our 30-bed med/surg CCU.

We had already taken the usual steps to reduce VAP by implementing in-line suction catheters, use of HME’s, prn ventilator patient circuit changes and other methods to reduce opening of ventilator patient circuits. Also included was GI prophylaxis, promotion of Q3hr oral care, subglottic suctioning of patients with Endotracheal (Hi-Lo Evac). With these measures, we were able to reduce VAP rates from 21.39 cases to 7.73 cases per 1000 device days over a 5-year period. That was still too high. Over 18 months, we collected data on approximately 600 ventilated non-Open Heart patients in our CCU. We tracked the actual VAP rate. We were looking to further improve our results. With the support of our CCU/RT Medical Director we instituted an intense campaign of handwashing, keeping the patient HOB @ 30 degrees, Intensivist championing all efforts, daily spontaneous breathing trials (SBT’s), Q3 hour oral care, and a daily sedation vacation protocol. We instituted changes on both the RT ventilator flow sheets and Nursing documentation that tracked these items as well as keeping the Head of Bed >30 degrees so that all practitioners were held accountable. A handwashing campaign was initiated that included all disciplines (physicians, RCP’s, RN’s, radiology, lab, physical therapy and others entering the patient rooms) to follow proper hand hygiene. We created a daily “Ventilator Therapy Bundle Monitoring” checklist. Our goal was to decrease VAP rate by actively promoting these measures with daily audits, posters, and multidisciplinary interaction.

After 18 months and constant campaigning with daily checklist auditing and promotion, we have not had a case of VAP in 7 months. A “0” VAP month was considered an aberration two years ago. Now with constant vigilance, a single VAP case at any time is considered an aberration.

Only by looking at this on a continuous basis can you hold any gains. Measuring these areas of care seem to reduce or eliminate VAP. Cost of one of our patients who develops VAP is approx $60,000. We have been able to avoid our previous 15 cases in one year, saving approx $900,000.00.

Bibliography: Kollef,M. Critical Care Medicine 2004 Jun

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