The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

AN 80% REDUCTION:VANQUISHING VAP VIA CUFF PRESSURE VIGILANCE

Joe Dwan, Brian Wartell; Respiratory Care, Kaiser Sunnyside Med Center, Clackamas, OR

Benchmarking our VAP rate in 2006 showed our 13 bed Med-Surg ICU had a much higher rate at 9.7 VAPs/1000 vent days than acceptable. With the IHI Ventilator Bundle measures, our multidisciplinary teams developed the Zap Vap Program using evidence based medicine. Literature was reviewed, policies changed, extensive inservicing was completed and outcome reports were built. Four subgroups completed this work, including groups for Oral Care, Existing Practices, Kinetic Bed Protocols, and Best Practices for ETT tubes, cuffs and suctioning. Aspiration was a recurrent theme in VAP literature. A RC reference to ‘vigilant cuff pressure monitoring’ was developed into a Q4 hour cuff pressure measurement policy. Other policy changes included: RN & RT suction policies now match; limiting installation of saline; limiting breaking the vent circuit; not changing vent circuits or in-line suction devices; ending Qshift ETT retapping, minimizing transports/any ETT movement; promoting NIV; shortening VLOS, and HMEs over heated wire circuits. Additional IHI measures included Readiness to Wean protocols,& HOB>30 by RTs. Subglottal suction ETTs evidence of the RCTs of Kollef (43.2-34.5), Valles (39.6-19.9) and Smulders (22.5- 9.2) was unimpressive. METHODS: Audits of RT cuff pressure monitoring frequency were completed periodically based on ventilator pts in MS ICU over 4-8 weeks. Data was collected by date, room, shift, individual RT and meeting the Q4 hr cuff measurement frequency. VAP rates were also monitored quarterly while VLOS was measured monthly. RESULTS: VAP rates fell from 9.7 in 2006, to 4.9 in 2007, to 1.98/1000 vent days in 2008. VLOS decreased from 3.13 to 2.15 days despite a 19% increase in volume. BIPAP usage increased 630% 2006-2008. Cuff pressure audits were estimated at 50% documentation in 2006 of Q shift cuff monitoring. By 2008, compliance with Q4 cuff press monitoring increased in Jan to 93%, and to 99% byMay 2009. CONCLUSIONS: Multiple changes in practice resulted in decreased VAP rates, with vigilant cuff pressure monitoring just one factor in the improvement. Auditing compliance, posting results, and providing positive and negative feedback to individual RTs resulted in improved compliance in monitoring. Outlying RTs self-corrected when their coworkers results were better. Frequent discussion of VAP Vigilance, VLOS, and reporting audit results plus training new hires in VAP all contributed to our success. Sponsored Research - None

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