The University of Rochester/Strong Health team participated in IHI's Breakthrough Series Collaborative on Reducing Complications from Ventilators and Central Lines in the ICU.

• To maintain a previous gain of zero cases of ventilator-associated pneumonia (VAP) in the Medical ICU
• To implement a spread initiative for the Ventilator Bundle to reduce VAP occurrences to >150 days between cases in the Surgical, Cardiovascular, and Burn Trauma ICUs

• Days between cases for ventilator-associated pneumonia
• Ventilator-associated pneumonia rate per 1,000 ventilator days (for both Medical ICU and the other three ICUs)
• Ventilator Bundle compliance

The team, which had improved VAP rates in the Medical ICU through previous participation in IHI programs, used the change package outlined in the Collaborative to support their spread efforts. These were their key changes:

• Tested and implemented Daily Goal Sheets in the Surgical ICU and Cardiovascular ICU
• Tested and implemented the Ventilator Bundle in the Surgical and Cardiovascular ICUs 
• Carried out re-education and reinforcement for all Medical ICU staff to improve bundle compliance
• Tested a Respiratory Therapist-Driven Ventilator Weaning Protocol in the Medical ICU, and spread it to the Surgical ICU, Cardiovascular ICU, and Burn Trauma ICU
• Tested and implemented daily sedation interruption; spread it to the Surgical ICU
• Developed an Adult Critical Care Goal Sheet/Nursing Care Plan that included the sum of all the bundles implemented in the ICUs, in order to promote continuity of patient care across the entire ICU service 
  • Tested this sheet in all four ICUs for a week, and solicited feedback from the nursing staff
  • Four modifications were made and tested before the final version was rolled out and implemented

The results accomplished by implementing the Ventilator Bundle are significant for this institution. The Medical Intensive Care Unit led this initiative as the pilot unit and have only reported three cases of VAP in two years. The effectiveness of the Ventilator Bundle has been proven and reinforced in our institution when similar significant reduction in VAP rates and days between occurrences were reproduced in the Surgical and Cardiovascular Intensive Care.

Lessons Learned

• Developing Nurse and Physician Champions is vital. The support of Medical Director, Associate Director of Clinical Nursing, Administration Leadership and staff involvement are key factors in our success.
• Start small; institute small tests of change and use Plan, Do, Study, Act (PDSA) cycles to refine the implementation process on a few patients before widening the scope to all patients. Utilization of Daily Goal Sheets helps keep team efforts patient-centered during bundle implementation.
• Education of nurses, residents, and attending physicians needs to be ongoing. Frequent reinforcement and reeducation are valuable in maintaining the momentum for change.
• Involvement of staff has been key to maintaining the ongoing work in the initiative. Nursing staff formed a committee and developed a Nursing Implemented Sedation/Delirium Protocol.  This was helpful in improving our compliance with sedation vacation.
• Track, trend, and report results so staff could visualize results of their work.
• Adding a Respiratory Therapist-Driven Ventilator Weaning Protocol increased our efforts in weaning patients from the ventilator.
• Create a team concept with a focus on accountability. This approach is vitally important to promote implementation strategy, problem solving and optimal outcomes.
• Exposure of team members to the IHI Learning Sessions has been valuable in teaching the culture of change.

Barriers

• Lack of complete physician buy-in as the spread initiative was implemented. We were unable to completely implement the Ventilator Bundle and track VAPs in the Burn/Trauma ICU until June 2005.
• Large tests of change initially produced poor results and low compliance with Ventilator Bundle implementation.
• Resistance to practice change. Staff initially perceived this change as an increased workload and another quality improvement project that would go away.
• Insufficient time for staff education when Respiratory Therapist-Driven Ventilator Weaning Protocol was initially trialed was problematic for staff and resulted in less than optimal outcomes. Even though the test of change was small, it was not well received by the nursing staff. This was a significant issue of boundaries of practice for nursing staff and required extensive in-services, one-on-one education and reinforcement before we reached successful implementation.

Next Steps

• Continue our work in spreading the Ventilator Bundle to the Burn/Trauma Intensive Care Unit 
• Hold the gain achieved in reducing VAP by creating redundancies to promote culture change
• Continue exposing our teams to a learning environment by joining another IHI Collaborative to improve care in our adult intensive care units

03/06/2006