Chip Veal, MD, Medical Director, Intensive Care Unit
Derel Finch, MD, Intensivist
George Pappas, MD, Intensivist
June Altaras, RN, BSN, Clinical Manager, Adult Intensive Care Units
Steve Hoppe, RN, Manager eICU
Joya Pickett, RN, MSN, CCRN, Critical Care Clinical Nurse Specialist
Marie Arnone, RN, MA, CCRN, Clinical Development Specialist
Patti Feley, RN, BSN, Manager, Providence Intensive Care Unit
Will Shelton, M(ASCP) CIC, Director of Epidemiology
Jim Kumpula, RRT, LRCP, Manager of Respiratory Care/Pulmonary Function
Nancy Siegle, RN, Manager, Ballard Intensive Care Unit
Jennifer Harville, MHA, Director, Clinical Effectiveness
Theresa Bervell, MHA, Administrative Resident, Clinical Effectiveness
Tom Moore, RRT, LRCP, Respiratory Care Practitioner
Marjorie Svrjcek, RN, BSN, Manager, Respiratory Care
Debra Gruber, RRT, LRCP, Manager, Respiratory Care
Caroline Truong, RN, BSN, Clinical Care Supervisor, Adult ICU
Lilia Mullins, RN, CRNI, Clinical Supervisor, IV Therapy
Laura Manke, RN, BSN, Manager, IV Therapy 

• Reduce the number of ventilator-associated pneumonias (VAPs) to below the National Nosocomial Infections Surveillance System's (NNIS) tenth percentile
  
• Achieve 150 days or greater between occurrences of VAP by March 15, 2005
  
• Achieve 95 percent compliance will all components of the Ventilator Bundle

• Ventilator Bundle compliance
  
  Head of bed up 30 degrees
  Daily "sedation vacations"
  Daily assessment of readiness to extubate
  Peptic ulcer disease prophylaxis
  Deep vein thrombosis prophylaxis
  
  
• Ventilator-associated pneumonia infection rates

• Attended the Institute for Healthcare Improvement (IHI) International Summit in March 2004, decided to join IHI Intensive Care Unit (ICU) Ventilators and Central Lines Collaborative, and formed the IHI Critical Care Collaborative at Swedish.
• Identified sponsoring committee (Critical Care Committee) as the umbrella committee where protocols and initiatives are approved before implementation.
• Developed a team charter and set objectives to improve outcomes for ICU patients.
• Defined the goals to create a "no harm" culture.
• Established shared understanding of bundle concept for VAPs and VAP-associated infections.
• Established that progress will be monitored through rapid plan, do, study and act change cycles.
• The tested change is supposed to be for one patient, one physician, and one time.
• Identified the pilot unit and implemented bundles.
• Held weekly IHI Critical Care Collaborative meeting where we decide on one or more tests of change.
• Each test of change is supposed to be for one patient, one physician, one time. Then it’s evaluated in a “huddle” between the providers caring for the patient, and a decision is made to extend the test to more patients based on the result of the first test of change.
• Developed a protocol and algorithm for sedation interruption and introduced the Modified Ramsay Sedation Scale MRSS. Daily sedation interruption was one of our first tests of change. We piloted the protocol with one patient, one nurse, one respiratory therapist, and one doctor. Each time we tested this change we would get feedback and adjust the process based on the input and add more patients and more nurses.
• Received feedback that the set time for sedation interruption was not the best for the night shift staff. Now the night shift nurse and respiratory therapist have a conversation to coordinate the time of interruption.
• Added additional layer of patient monitoring by eICU® (remote electronic ICU monitoring).  The eICU is staffed by a physician, nurse, and secretary during the night shift.
• The eICU doctor helped with the test of change by gently nudging the nurses to interrupt the patients' sedation. This process resulted in the nurses shifting their culture around sedation and no longer needing reminders.
• Implemented standing orders that are now placed on new ventilated patients. The orders are kept with the ventilator and are initiated by the respiratory therapist (with the nurse) when a patient is placed on a ventilator.
• Implemented VAP prevention orders:
  • Reverse Trendelenberg 30 degrees unless contraindicated by hypotension
  • Sedation interruption daily (unless specifically contraindicated)
  • Famotidine 20 mg IV Q 12H (unless history of allergy)
  • Heparin 5,000 units SQ Q 12H (unless post-op heart, other anticoagulant ordered)
• Completed several rapid tests of change in our pilot unit, and spread the protocol to the other ICU floors across other campuses where the nurse manager or charge nurse audits the bundle elements and follows up immediately with one-to-one education. Representatives from the other units and campuses were part of the collaborative team from the beginning.
• The bundle is also addressed during daily multidisciplinary rounds.
• Built in redundancy to continue to hold the gains. We continue to monitor, communicate, and educate our staff.
  

For the years 2002 through 2004, Swedish was consistently in the top 10 percent for VAP infections according to NNIS data, but we wanted to decrease further. By following IHI concepts (bundles, reliability, standardization, redundancy) we have been able to decrease our rates from a range of 3 percent to 5 percent, to 1.1 percent. We averaged 23 VAPs per year (system-wide) for the two years prior to working with IHI. In 2005, we have had 5 VAPs (system-wide); this is a 74 percent reduction in VAPs.

Lessons Learned

• Get started — do not wait to design the perfect process. Get physician buy-in, get your orders written (do it in draft form; do not wait on forms committees), and start bundling your first patient.
• Once you start, get daily feedback from the RNs, RTs, and physicians about what did and did not work. Change your process accordingly, over and over, until you develop the process that achieves maximum compliance.
• Show your staff the data on compliance and the VAP status weekly. Post the graphs everywhere — staff lounges, bathrooms, and report rooms. The positive/frequent feedback was very validating and motivated staff to continue their good work.
• Get board and senior leadership buy-in, develop physician champions, identify administrative champions, obtain management support, and cultivate RN leadership.
• Empower the staff and encourage ownership of the effort and investment in participation.
• Educate board and senior leaders throughout the duration of the project.
• Celebrate team success.
• Communicate, communicate, communicate — there is never too much communication. Encourage crucial conversations and drive out fear.
• Education:
  • One patient, one physician, one time
  • Group education followed by one-to-one education with manager
  • Staff involvement, hold in-service, provide tools
• Change the culture through repetition and built-in redundancies.
• Implement multidisciplinary rounds in the ICU.

Next Steps

• Continue to refine our ICU rounds recording tool to efficiently record the patient’s daily goals and greatest safety risk.
• To continue the spread of our improvement efforts, we have also implemented the Central Line Bundle to prevent central line-associated blood stream infections (CL-BSI); deployed Rapid Response Teams; and joined the 100,000 Lives Campaign.

June Altaras, RN, BSN, Clinical Manager, Adult ICUs
Swedish Medical Center
Email: June.Altaras@swedish.org