2005 OPEN FORUM Abstracts
VENTILATOR ASSOCIATED PNEUMONIA (VAP) TRENDS IMPROVE DESPITE A DOUBLING OF INTRAHOSPITAL TRANSPORTS
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 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 became an organizational goal in fiscal year 2003.
METHODS: A multidisciplinary task force comprised of a physician champion, respiratory, nursing, pharmacy and infection control set goals to decrease VAP rates to meet NNIS benchmark by ICU type and to consistently apply in practice, evidence based protocols and guidelines for VAP prevention in four specialty adult ICUs. Gaps in practice were identified with focus on improving weaning assessment, minimization of risk for aspiration, and preventing cross contamination. Our physician champion communicated plan to physicians and other members of the team supported this effort. Education for nurses and RCPs on the recommended practice changes was done including discipline specific accountability for the development, implementation and monitoring of practice changes. VAP Prevention tips were posted in ICUs and on RCPs clipboards. Respiratory implemented a practice change with a new ventilator transport procedure and competency checks to ensure artificial airway stability during transport. All ICU vented patients were then transported on their own 840 Puritan Bennett ventilator to maintain settings and avoid breaking the circuit. The Continuous Aspiration Subglottic Secretions (CASS) ET tube was introduced for patients who met the criteria. VAP Guidelines for empiric therapy were implemented by pharmacy and nursing improved procedures for oral care and monitoring of head of Bed elevation 30-45 degrees. Bedside monitoring for compliance was performed and results communicated to staff. Quarterly updates by infection control on VAP outcomes by ICU type were done, and these updates provided the stimulus to maintain focus, educate staff and take corrective action.
RESULTS: From FY '03 to FY '04 there was a 103% increase in ventilator dependent patient intrahospital transports with their ventilator versus manual ventilation and oxygenation during transport, with no incident of accidental airway dislodgement and no increase incidence in VAP rates. Across the ICUs there was a 34% reduction in the number of VAPs from FY '03 to FY '04 and a 46% decrease in mortality in patients with VAP. Two of the four ICUs were below NNIS benchmark and 30 VAPs were prevented.
CONCLUSIONS: Critically ill mechanically ventilated patients who are at increased risk of morbidity and mortality during transport with manual ventilation and oxygenation, can be safely transported utilizing the 840 Puritan Bennett ventilator. Practice changes supported by a team approach can substantially lower VAP rates and decrease mortality rates.