2004 OPEN FORUM Abstracts
“VENT BUNDLES”METHOD TO ELIMINATE VAP
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.
Method: 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.
Results:
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.
Conclusions: 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