Marilyn Kole, MD, Corporate Medical Director, Intensive Care Services
Donna Giannuzzi, RN, MBA, CNAA, BC, Chief Patient Care Officer
Annette Forlenza, RN, BSN, CCRN, Director, Critical Care, Cape Coral Hospital
Becky Watt, RN, MBA, Decision Support
C.J. Quiggle, RNC, Staff Nurse, ICU
Denise Mitchell, RN, BS, CIC Infection Control
Denise Noel, ARNP, MS, CCRN, ARNP
Diane Sobel, RRT, Respiratory Care Manager
Gena Wunder-Lohmiller, RRT, CCM, Care Management
Jackie Becker, ARNP, MSN, ARNP
Jim Lewis, RN, BSHA, Clinical Education
Joann Andrews, RN, BSN, Infection Control
John Gough, RRT, Respiratory Care Supervisor
Jonathan Hollander, RN, BS, Director, ICU, Lee Memorial Health System
Joseph C. Daley, III, MD, MSC, Intensivist
Kathy Shierling, RN, BSN, MS, CNAA, BC, Executive Director, Lee Cardiac Care
Lori Lupe, RNC, MSN, Director, ICU, Health Park
Sandy West, RN, Staff Nurse, ICU
Timothy Keyes, MD, Intensivist
Wendy Piascik, RN, MS, CCRN, CNAA, BC, VP, Patient Services, Cape Coral Hospital
Colleen Higgins, MBA, Decision Support

• Ventilator Bundle compliance
• Rate of ventilator-associated pneumonia per 1,000 per ventilator days

Initiation of the Ventilator Bundle led to multiple rapid PDSA (Plan-Do-Study-Act) cycles which changed how we delivered care to our ventilator patients from both the nursing and respiratory perspective. These changes created enthusiasm, which spread among the team and led us to our biggest breakthroughs in improving outcomes.

• Raised awareness by aggressive hand washing campaign, resulting in an increase in compliance from under 40 percent to over 80 percent.
• Required waterless soap available at entrances to all patient rooms.
• Educated families and visitors on the importance of hand washing. Reminders placed in all rooms.
• Added oral care to the Ventilator Bundle based on evidence. 
• Changed HME filter brand to decrease breaks in the ventilator circuit while reducing the frequency of filter changes from 24 to 72 hours.
• Replaced all nebulizers with MDIs.
• Banned use of Yankauer suction for ventilator patients in favor of a more protected product.
• Capped or gloved resuscitation bags for storage and dated for discard after 7 days.
• Discontinued the practice of saline lavage for routine suctioning.
• Required ventilator control panel and tubing cleaned with antiseptic wipes every 12 hours.
• Obtained computer keyboard covers to facilitate cleaning.
• Required ventilator circuit to be capped or covered with a non-powdered glove whenever disconnected from the patient.
• Maintained as close to 30 degree head of bed elevation for transporting ventilator patients.
• Performed deep glottic suction every 6 hours routinely and PRN for ET repositioning and/or patient transport.
• Ensured availability of equipment in radiology to allow for deep glottic and/or routine suctioning of ventilator patients who must lie flat for diagnostic procedures.
• Required physician order with rationale for ventilator patients if 30 degree head of bed elevation is contraindicated.
• Provided each ventilator patient with dedicated role of tape for ETT repositioning.
• Collected data to insure compliance with initiatives.
• Reported outcome measures monthly to all; results are evaluated by the Home Team, which meets weekly.
• Monitored Ventilator Bundle compliance daily and reported weekly.
• Collected ventilator days manually to ensure accuracy.
• Reviewed charts (MD, Infection Control, and Nurse Educator) of all suspected VAPs to verify using CDC criteria.
• Placed bulletin board in physician lounge to communicate aim, goals and run charts with outcome measures.

At the end of our nine-month improvement initiative we reached our goal of a 50 percent reduction in VAP. Multiple small tests of change led to our greatest success by March 2005.

Our Ventilator Bundle compliance gradually increased as we examined our processes and made rapid changes.         

Lessons Learned:

• Meet with your staff from Day 1 and provide the reason for the improvement initiative, why it is important, and what part they have to play in improving care (it avoids rumors and miscommunication from the beginning).
• Meet with every department that sets foot in your ICU and explain what, why, how, and share your data. This avoids inadvertently leaving people out and having to apologize after the fact.
• Meet with staff, not just supervisors (the message doesn’t necessarily filter to the front-line worker).
• Make rapid changes and test them often. Make it simple and don’t get bogged down in details.
• Do not try to fix every policy/procedure in your hospital as you uncover problems. Correct only those that are required for your success with this project.
• Observe your staff performing specific components of the bundle. You will find that many people have their own view of how things should be done and standardization is essential.
• Clarify your data reliability prior to start of the initiative. If it is not good, accept that as a defect and move forward with the accurate collection of data.
• Include Infection Control in your processes from the beginning. Help to join efforts and help each other.
• Avoid pointing fingers or blaming each other or other departments for infections. It leads to defensive posturing and slows down your success.
• Understand that “culture” keeps staff from joining your collaborative effort. Every unit has their own “culture” and you need to concentrate efforts on people who believe in your overall ideas.
• Use every failure/defect to analyze your process and make changes. You will uncover many defects.
• Expect failures; they will happen.
• Enjoy successes; they will keep you going and help your team move forward.
• Recognize that “resistance” comes in many different faces and forms. Openly recognize them and move on.
• Use all your friends and colleagues throughout the country every day. They give you encouragement and help you see that you are not the only one struggling.
• Ask everyone for help and do not reinvent the wheel. Chances are that someone has already tried it and you do not have to start from scratch.
• Quitting is not an option no matter how difficult that day becomes because the end result is saving lives.
• Meet one-on-one with physicians and bring data in any form or shape you can think of to get your message across. 
• Engage a physician champion from your own hospital. A local physician who shares your ideas can help you tremendously spread concepts.
• Recognize that our success was and still is about building relationships, between physicians, nurses, respiratory therapists, and the rest of your team.
• Learn some essential tools early on such as Change, Resistance, Team Building, and Spread. It will help you understand your struggle and give you tools that will help.

Marilyn Kole, MD, Corporate Medical Director, Intensive Care Services
Lee Memorial Health System
Marilyn.Kole@leememorial.org

[Storyboard presentation at IHI's National Forum, December 2005]