OUR LADY OF LOURDES OUR LADY OF LOURDES MEMORIAL HOSPITALMEMORIAL HOSPITALBinghamton, New YorkBinghamton, New York

Reducing Complications Reducing Complications From Ventilators in ICU: From Ventilators in ICU:

Ventilator Associated Ventilator Associated Pneumonia (VAP)Pneumonia (VAP)

Our Lady of Lourdes ICU TeamOur Lady of Lourdes ICU Team

Our Lady of Lourdes Hospital is a 267 bed Our Lady of Lourdes Hospital is a 267 bed acute care, community, not-for-profit acute care, community, not-for-profit healthcare facility which provides a full healthcare facility which provides a full spectrum of inpatient, ambulatory and spectrum of inpatient, ambulatory and emergency services. Our pilot unit is a ten emergency services. Our pilot unit is a ten bed medical surgical intensive care unit.bed medical surgical intensive care unit.

Our Team and GoalOur Team and Goal

We have a multidisciplinary team that We have a multidisciplinary team that meets weekly. We began meeting in 11/03.meets weekly. We began meeting in 11/03.

Representation includes: Administration, Representation includes: Administration, Quality, Nursing, Pharmacy, Care Quality, Nursing, Pharmacy, Care Management, Respiratory Therapy, Management, Respiratory Therapy, Nutrition, Rehabilitation Services, Infection Nutrition, Rehabilitation Services, Infection Control, Medical Staff, ICU Staff.Control, Medical Staff, ICU Staff.

Goal: to increase the number of days Goal: to increase the number of days between VAP to greater than 180 days.between VAP to greater than 180 days.

Ventilator Associated PneumoniaVentilator Associated PneumoniaVAPVAP

VAP is a pneumonia that develops VAP is a pneumonia that develops >> 48 48 hours following intubation.hours following intubation.

VAP increases hospital cost per episode VAP increases hospital cost per episode as much as $20,000, and hospital length as much as $20,000, and hospital length of stay as much as 14 days. (Archives of of stay as much as 14 days. (Archives of Internal Medicine 1991;151:1109-1114)Internal Medicine 1991;151:1109-1114)

VAP increases mortality.VAP increases mortality.

Bundle ConceptBundle Concept

A "bundle" is a group of interventions A "bundle" is a group of interventions related to a disease process that, related to a disease process that, when executed together, result in when executed together, result in better outcomes than when better outcomes than when implemented individually.implemented individually.

Ventilator Bundle Ventilator Bundle

All or None ConceptAll or None Concept

All components of the ventilator bundle All components of the ventilator bundle

must be performed on each ventilator must be performed on each ventilator patient to be compliant. If a component is patient to be compliant. If a component is contraindicated, and all other components contraindicated, and all other components are performed, the bundle can still be are performed, the bundle can still be considered compliant.considered compliant.

Ventilator BundleVentilator Bundle

Head of Bed Head of Bed >> 30 Degrees 30 Degrees Deep Vein Thrombosis (DVT) ProphylaxisDeep Vein Thrombosis (DVT) Prophylaxis Peptic Ulcer Disease (PUD) ProphylaxisPeptic Ulcer Disease (PUD) Prophylaxis Sedation VacationSedation Vacation Daily Assessment of Extubation Daily Assessment of Extubation

ReadinessReadiness

Ventilator Bundle RationaleVentilator Bundle Rationale Head of Bed Head of Bed >> 30 degrees: 30 degrees:

To reduce the frequency and the risk of To reduce the frequency and the risk of aspirationaspiration

DVT Prophylaxis:DVT Prophylaxis: Mechanically ventilated patients are at Mechanically ventilated patients are at

significant risk for DVT due to limited mobilitysignificant risk for DVT due to limited mobility

Peptic Ulcer Disease Prophylaxis:Peptic Ulcer Disease Prophylaxis: Critically ill patients requiring mechanical Critically ill patients requiring mechanical

ventilation are at a higher risk of developing life-ventilation are at a higher risk of developing life-threatening upper gastrointestinal mucosal threatening upper gastrointestinal mucosal erosions and hemorrhage.erosions and hemorrhage.

Ventilator Bundle RationaleVentilator Bundle Rationale Sedation Vacation:Sedation Vacation:

Daily interruption of sedative drug infusions decreases the Daily interruption of sedative drug infusions decreases the duration of mechanical ventilation and length of stay in ICU. duration of mechanical ventilation and length of stay in ICU. Sedation vacation is defined as:Sedation vacation is defined as: Sedation held for equal to or greater than 12 hoursSedation held for equal to or greater than 12 hours

oror Until patient follows commands at least once during the day Until patient follows commands at least once during the day

oror Patient follows commands without sedation being held.Patient follows commands without sedation being held. If sedation is restarted, attempt dose that is half of previous If sedation is restarted, attempt dose that is half of previous

dosedose Daily Assessment of Extubation Readiness:Daily Assessment of Extubation Readiness:

Daily screening for liberation from the ventilator, followed by trials Daily screening for liberation from the ventilator, followed by trials of spontaneous breathing can reduce the duration of mechanical of spontaneous breathing can reduce the duration of mechanical ventilation, decrease complications and costs of ICU care.ventilation, decrease complications and costs of ICU care.

Testing the Ventilator BundleTesting the Ventilator Bundle

Start Small!Start Small! Begin with one ICU RN, one patient, one Begin with one ICU RN, one patient, one

Respiratory Therapist and one physician.Respiratory Therapist and one physician. Make changes as appropriate based on Make changes as appropriate based on

the initial test.the initial test. Add one more RN, patient, and RT.Add one more RN, patient, and RT. Continue to make changes as appropriate Continue to make changes as appropriate

and continue to add RNs, patients, RTs and continue to add RNs, patients, RTs and physicians until the entire population and physicians until the entire population is included.is included.

Monitoring the Test of Change for Monitoring the Test of Change for ImprovementImprovement

When we began, we measured the entire When we began, we measured the entire ventilator bundle, as well as each ventilator bundle, as well as each component of the bundle. component of the bundle.

This enabled us to identify which This enabled us to identify which components were not being performed components were not being performed and we could focus our efforts to improve and we could focus our efforts to improve compliance.compliance.

Ventilator Bundle Compliance with Head of Bed 30 Degrees

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Ventilator Bundle Compliance with DVT Prophylaxis

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1/19/

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1/22/

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1/27/

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1/30/

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Ventilator Bundle Compliance with Peptic Ulcer Disease (PUD) Prophylaxis

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1/13

/04

1/19

/04

1/22

/04

1/27

/04

1/30

/04

2/2/

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2/5/

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2/8/

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/04

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/04

2/18

/04

2/21

/04

2/24

/04

2/27

/04R

ate

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Ventilator Bundle Compliance with Sedation Vacation

020406080

100

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pli

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Ventilator Bundle Compliance with Daily Assessment of Extubation Readiness

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20

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60

80

100

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Ventilator Bundle Compliance (All 5 Components Must be Completed)

0

20

40

60

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100

1/13

/04

1/16

/04

1/20

/04

1/23

/04

1/28

/04

1/31

/04

2/4/

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2/9/

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2/12

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BarriersBarriers Staff felt this was more paperwork.Staff felt this was more paperwork. Medical Staff did not really understand what a “bundle” was.Medical Staff did not really understand what a “bundle” was. Monitoring and documentation of the monitors was Monitoring and documentation of the monitors was

inconsistent.inconsistent. Empowering staff to emphasize importance of compliance Empowering staff to emphasize importance of compliance

with ventilator bundle with medical staff.with ventilator bundle with medical staff. Daily assessment of extubation readiness.Daily assessment of extubation readiness. Respiratory Therapists uncomfortable with initiating Respiratory Therapists uncomfortable with initiating

weaning protocolweaning protocol

Strategies to Improve Compliance Strategies to Improve Compliance with Ventilator Bundlewith Ventilator Bundle

Every staff member was held accountable for monitoring and documentation.

Nurses were empowered to understand accountability for lack of practicing evidenced based care.

Implemented daily multidisciplinary rounds which allowed for immediate assessment of compliance with ventilator bundle.

A round table meeting was held with nurses, team leader, respiratory therapists and pulmonologists. Evidence based information was provided and the team discussed it until it was resolved.

SuccessesSuccesses ICU Team, ICU staff, and Pulmonologists educated on ICU Team, ICU staff, and Pulmonologists educated on

ventilator bundle and rationaleventilator bundle and rationale ICU Team developed a ventilator bundle monitoring toolICU Team developed a ventilator bundle monitoring tool Incorporated ventilator bundle into pre-printed physician orders Incorporated ventilator bundle into pre-printed physician orders

for mechanical ventilationfor mechanical ventilation Incorporated ventilator bundle into ICU nursing flow sheetIncorporated ventilator bundle into ICU nursing flow sheet Began testing small, made changes as appropriate, and Began testing small, made changes as appropriate, and

continued to test until entire ventilator patient population continued to test until entire ventilator patient population includedincluded

ICU staff monitor compliance with ventilator bundle every shiftICU staff monitor compliance with ventilator bundle every shift Implemented multidisciplinary rounds for all ICU patientsImplemented multidisciplinary rounds for all ICU patients Developed a Respiratory Therapist driven Weaning Protocol, Developed a Respiratory Therapist driven Weaning Protocol,

which was approved by the Pulmonologistswhich was approved by the Pulmonologists In the event of a VAP, ICU Team performs case reviewIn the event of a VAP, ICU Team performs case review

ResultsResults

ICU Ventilator Bundle Compliance

0

50

100

Rat

e Began testing 1/13/04

ResultsResultsNumber of Days Between Ventilator Associated Pneumonia

(VAP)Goal: 180 days

0 12

290

96

30 44

0

150

300

3/15/2004 3/27/2004 1/11/2005 4/17/2005 5/17/2005 6/30/2005

# o

f D

ays

Bet

wee

n

Began testing Ventilator Bundle 1/13/04

6/30/05: end date only, not a VAP

ResultsResults

Lourdes Hospital Rate of Ventilator Associated Pneumonia

Before and After Implementation of Ventilator Bundle NNIS Rate = # VAP / # ventilator days X 1000

5.53

1.85

0

6

Before Vent Bundle After Vent Bundle

Rat

e

2003 2004

66% reduction Began testing ventilator bundle 1/13/04

Next StepsNext Steps The 3 VAPs that occurred after the stretch of 290 days The 3 VAPs that occurred after the stretch of 290 days

between VAPs, were reviewed. 2 of the 3 patients were between VAPs, were reviewed. 2 of the 3 patients were surgical patients, and elevating the head of the bed was surgical patients, and elevating the head of the bed was contraindicated. The ventilator bundle was followed except contraindicated. The ventilator bundle was followed except for this component. for this component.

Team is researching the CASS Endotracheal Tube: Team is researching the CASS Endotracheal Tube: Continuous Aspiration of Subglottic Secretions.Continuous Aspiration of Subglottic Secretions.

The CASS endotracheal tube is recommended by the The CASS endotracheal tube is recommended by the CDC as a strategy to prevent VAP. CDC as a strategy to prevent VAP.

VENTILATOR BUNDLE MONITORING TOOL

SHIFT: TOTAL # VENT PTS:

DATE RM # PT INITIALS

HOB 30° DVT Prophy.

PUD Prophy.

Sedation Vacation

Daily Assessment Extubation Readiness ***PERFORMED ON

DAY SHIFT*****

ICU Monitoring ToolDate: _________ Shift: ____ Census: _____ Vent Census: ______

Key: (+) completed; (-) not done; (n/a) not applicable; (contra) contraindicated; (EOB) edge of bed

RM#

PtInit

Rounds with Daily Goals

Vent Central Line CL

CL Daily Necessity assessed

Foley HOB 30°

DVTProphy

PUDProphy

SedVac7-3

Assess Ext.Ready DAY-SHIFT

Blood Sugar(BS)

If Hospitalist pt and BS >150 is pt on glucose protocol

Oral Careq 4 h

Mobility RNInit

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