The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

IMPROVEMENT EFFORT PRODUCES POSITIVE OUTCOMES IN REDUCING BOTH VENTILATOR ASSOCIATED PNEUMONIA (VAP) RATES AND MORTALITY IN PATIENTS WITH VAP

Carol Agard BS, RRT, Diane Brenessel BS, RRT, Scott Gallacher MD, Carolyn Sanders MS, MT,CIC. The Queen’s Medical Center, Honolulu, Hi

BACKGROUND: The primary risk of a patient developing a VAP is ventilator utilization and most of our ICUs range from 35-65% of patient days as ventilator days. Our VAP rates (# of infections per 1000 vent days) for fiscal year 2002 (July 2001 – June 2002) were higher than the National Nosocomial Infection Surveillance System (NNIS) mean rates and our internal trends were increasing over previous years. VAP reduction was chosen as a Performance Improvement (PI) organizational goal for fiscal year 2003 (July 2002-June 2003)

METHODS: We formed a task force from members of our multidisciplinary Respiratory Care Committee comprised of a Critical Care Intensivist, Infection Control Coordinator, Nursing Director of ICUs, Respiratory Care Practitioners (RCPs), ICU Nurses, Pharmacists and CRNAs. Our two goals were to decrease VAP rates to meet NNIS benchmark by ICU type and to consistently apply in practice the Guidelines based on CDC recommendations for VAP prevention. Utilizing the Plan, Do, Check, Act (PDCA) methodology we reviewed the CDC Guidelines for VAP Prevention, identified gaps in our practice and developed consensus of key stakeholders. We determined that improving weaning assessment, minimization of risk for aspiration, and preventing cross contamination were areas that needed improvement. Our physician champion communicated the plan to key physicians and other members of the team supported this effort on a broader scale. The Respiratory Care Department took the lead in developing and providing the education for nurses and RCPs on the recommended practice changes. Respiratory, Nursing, CRNAs and Pharmacists assumed accountability for the development, implementation and monitoring of discipline specific practice changes. Respiratory posted VAP Prevention tips in each ICU and on RCPs clip boards, implemented the transport on a ventilator of all ICU vented patients to avoid breaking the circuit and introduced the Continuous Aspiration Subglottic Secretions (CASS) ET tube for patients who met the criteria with support of the CRNAs. Nursing improved and implemented procedures for oral care and monitoring the Head of Bed elevation 30-45 degrees. Pharmacy developed VAP Guidelines for Empiric Therapy. Nursing and Respiratory performed bedside monitoring for compliance to guidelines and communicated the results to staff. The Infection Control Coordinator provided quarterly updates on VAP outcomes by ICU type at the Respiratory Care Committee Meeting and other ICU Committee Meetings. These updates provided the stimulus to maintain our focus, correct as necessary, and celebrate our overall success as a health care team.

RESULTS: There was a 34% reduction in the number of VAPs from FY ‘03 to FY ‘04 and a 46% decrease in mortality. Two of the four ICUs were below NNIS benchmark. There were 30 VAPs prevented with estimated cost avoidance of $240,000 @$8,000 per incident.

CONCLUSIONS:
A multidisciplinary PI effort, utilizing the PDCA methodology can substantially lower VAP rates, decrease mortality rates and result in cost avoidance in four different adult specialty ICUs.

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