Michael Westley, MD, Medical Director Critical Care and Respiratory Therapy
Joe Streiff, Director Respiratory Therapy
Brenda Hardin-Wike, RN, Manager Critical Care
Penny Gilliatt, RN, Educator Critical Care
Rebecca Walsh, RN, Critical Care
Shirley Sherman, RN, Critical Care
Sue Dunn, RN, Critical Care
Rosemary Tempel, RN, Clinical Practice Improvement

Reduce ventilator-associated pneumonia to zero.

• Head of Bed (HOB) elevation greater than or equal to 30 degrees
• Ventilator Bundle (Head of Bed greater than or equal to 30 degrees, spontaneous breathing trial, daily sedation vacation)
• Ventilator-associated pneumonia (National Nosocomial Infections Surveillance System definition)
• Appropriate hand hygiene in CCU

• Monitored and reported Head of Bed (HOB) position found during daily walk rounds
• Added HOB position to an every two-hour nurse assessment flow sheet and an every three-hour ventilator check/documentation form for RT
• Displayed graphs depicting HOB and monthly VAP in prominent locations
• Developed communication plan between Medical Director, RT Director, and Manager of Critical Care for staff RNs and RTs (group meetings and individual feedback sessions)
• Formed Quality Collaborative Teams to champion initiatives and gain traction on goals
• Implemented standard Spontaneous Breathing Trial protocol
• Implemented standard ventilator sedation/analgesia order set
• Implemented Daily Sedation Vacation protocol
• Changed standard care/work practices:
  • Endotracheal tubes maintained in sterile wrapper/conditions before intubation (Anesthesia)
  • Decreased use of saline lavage in suctioning (RN and RT)
  • Developed oral care routines (RN and RT)
  • Emphasized appropriate use of noninvasive ventilation where appropriate
  • Implemented unit-wide hand hygiene initiative involving all staff, residents and families
  • Educated collaborative team on oral care and began every two-hour mouth care using standardized products
  • Initiated every two hourly mouth care using standardized products
  • Evolved to monitor and report compliance with Ventilator Bundle by RT
• Celebrated early and subsequent success at meetings and organization newsletter
• Provided positive reinforcement at all opportunities of improvement
• Maintained a focused storyboard to communicate ongoing gains and challenges

• Monitoring and publicly displaying results from random monitoring Head of Bed position demonstrated that we were not reliably keeping patient’s in preferred position to prevent VAP despite our “feeling” that we were doing the best for patients.
• Adding HOB position to both nursing and respiratory therapy flow sheets provided redundancy and a forcing function to better assure HOB in proper position.
• Physician staff agreed upon standard Spontaneous Breathing Trials, sedation/analgesia and daily holidays from sedation reducing unintended delays in weaning.  Over this interval our average time on mechanical ventilation fell from 4 days to about 3 days.
• Respiratory Therapy monitors “vent bundle” data daily to help champion changes and “hold the gains”.
• Celebrating the gains in quality and maintaining / refocusing on quality moves the process forward.

Michael Westley MD, FCCP Medical Director Critical Care
Virginia Mason Medical Center
michael.westley@vmmc.org

[Storyboard presentation at IHI's National Forum, December 2004]