reducing complications from ventilators: ventilator associated pneumonia university of rochester...
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Reducing Complications from Ventilators: Ventilator Associated
Pneumonia
University of Rochester Strong Health
700 bed tertiary care medical center. Strong health is a Trauma Center, Transplant Center (bone marrow, kidney, liver & heart). 4 adult ICU’s: MICU (17 beds), SICU (14 beds), Burn/Trauma (17 beds), and Cardiovascular ICU (14 beds)
MICU Critical Care Team Members
Team Leader: Michael Apostolakos, MD, Director Adult Critical Care
Day to day leadership: Michael Apostolakos, MD. Isabelle Michaud, MD, Critical Care Attending Mary Wicks, RN, MPA, Associate Director, Adult Critical
Care Barry Evans, MSN, Adult Critical Care QI Data Coordinator Tim Kehl, RN, Nurse Leader Janice Bell, RN, Nurse Leader
Additional key members: Lucille Nelson, RN, MICU Care Coordinator, Jennifer Carlson, RRT, Supervisor Critical Care
Respiratory Therapy
Why is reduction of VAP a priority?
Mortality 50-70%
Increased LOS ICU 17.7 vs 6.1
Complications ARDS Atelectasis Pneumothorax Sinusitis
Cost of treating 1 case of VAP $5,000 – $27,000
VENTILATOR BUNDLE Elevate HOB 30 degrees unless
contraindicated Sedation Holiday
Reduce or turn off sedation daily DVT Prophylaxis PUD Prophylaxis Test for readiness to wean or
ability to extubate daily
HMOPREVENT VENTILATOR
ASSOCIATED PNEUMONIA
HOB HOB is elevated at 30 degrees unless medically
contraindicated Reduces aspiration of oropharyngeal/gastric
secretions Mobility
Turn Q 2 hrs/ OOB when appropriate Mobilizes secretions
Oral Care Perform Oral Care Q 2 hrs following structured oral
care protocol Removes pathogens from oropharynx
VAP CRITERIA > 48 hours on ventilator
At least 3 out of 5: Fever Leuckocytosis Change in sputum Radiographic evidence of new or
progressive infiltrates Worsening O2 requirements*Final determination of VAP diagnosis is
made by the attending physician
Vent Bundle Compliance
0
20
40
60
80
100
120
Dates
Per
cent MICU
SICUCVICU
Frequency of Ventilator Associated Pneumonia
02468
101214161820
Dates
Rat
e (%
)
MICU Rate SICU RateCVICU Rate
1
2
1 Vent Bundle implemented2 Reeducation
1
1
2
Days between incidences of VAP: MICU
0
100
200
300
400
500
600
Dates of VAP
Da
ys
bet
wee
n V
AP Days without
VAP
1 Vent bundle reeducation2 Oral Care Protocol
12
212 Days
492 Days
Ventilator Bundle: Cycles of Improvement
Numerous, rapid PDSA cycles of vent bundle as part of goal sheet on a few patients led to refinement of goal sheet.
Support of Medical Director and nurse leaders key to implementation
Training of attendings, residents and bedside nurses vitally important (education)
Posting results, positive reinforcement leads to more excitement Focusing all initiatives on patient centered care and not in
isolation Importance of initiatives echoed by senior leadership during walk
rounds PDSA cycles continue as utilization continues to vary (ie
percentage utilization decreases under certain attendings) Constant feedback from nurses Forms remain as permanent record
Keys to Success, Barriers and Lessons Learned
Involve key front line staff Ongoing education….why are we doing
this? Participation by senior leaders Medical Director and Nurse Manager
must be fully supportive Administrative assistance Resistance to change Perceived increased workload Another QI project which will go away