Transcript Document

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:
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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
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$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
HMO
PREVENT 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
Oct
Dec-02
Feb-02
Apr-03
Jun-03
Aug-03
Oct -03
Dec-03
Feb-03
Apr-04
Jun-04
Aug-04
Oct -04
Dec-04
Feb-04
Apr-05
Jun-05
-05
Percent
Vent Bundle Compliance
120
100
80
60
40
MICU
SICU
CVICU
20
0
Dates
De
J cFaen-002
Mab-03
r 3
MAapr--03
Juy-0033
J nAuul- 003
Se g- 03
Op 3
Noc t--003
Dev-0 3
J c- 3
Faen-003
Mab-04
r 4
MAapr--04
Juy-0044
J nAuul- 004
Se g- 04
Op 4
Noc t--004
Dev-0 4
J c- 4
Faen-004
Mab-05
r 5
MAapr--05
Juy-0055
n-0
5
Rate (%)
Frequency of Ventilator Associated
Pneumonia
20
18
16
14
12
10
8
6
4
2
0
1 Vent Bundle implemented
2 Reeducation
1
1
2
Dates
1
2
MICU Rate
SICU Rate
CVICU Rate
1 Vent bundle reeducation
2 Oral Care Protocol
11
11/22
12/27/02
/1 /0
1 8/ 2
4/ /2/02
7/25/03
8/17/03
1/26/03
3/31/03
5/31/04
6/31/04
7/21/04
8/31/04
9 3 /04
10 /31
0
11/311/04
/
12 30/044
/ /
1/31/04
2/31/04
3/28/05
4/31/05
5/30/05
6/31/05
30 05
/0
5
Days between VAP
Days between incidences of VAP:
MICU
600
200
492 Days
500
400
212 Days
300
1
2
100
0
Dates of VAP
Days without
VAP
Ventilator Bundle: Cycles
of Improvement
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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
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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