Michael Apostolakos, MD, Director Adult Critical Care
Mary Wicks, RN, MPA, Associate Critical Care Director of Nursing
Barry Evans, MSN, CNS, Adult Critical Care Data Coordinator/Project Manager
Tim Kehl, MSN, Nurse Manager
Janice Bell, RN, Nurse Leader
Lucille Nelson, RN, MICU Care Coordinator
Jennifer Carlson, RRT, Supervisor Critical Care Respiratory Therapy
David Kaufman, MD, Medical Director, Surgical Intensive Care Unit
John McIntyre, RN, Nurse Manager
Mary Comerford, MSN, NP, CNS
Deborah Hurley, RN, Nurse Leader
Daniel Nowak, MSN, Nurse Manager, CVICU
Anna Lambert, RN, Nurse Leader
Julius Cheng, MD
Michael Stapleton, RN, Nurse Manager
Nancy Freeland, MSN, CNS
Margaret Odhner, RN, Nurse Leader

Our aim was to maintain a gain of zero ventilator-associated pneumonia (VAP) in the Medical Intensive Care Unit (MICU) and implement a spread initiative of the Ventilator Bundle to reduce VAP occurrences to >150 days in the Surgical, Cardiovascular, and Burn/Trauma Intensive Care Units.

• Monthly Compliance Rate with Bundle Components
• Frequency of Ventilator-Associated Pneumonia
• Days between Ventilator-Associated Pneumonia

We were able to prevent ventilator-associated pneumonia in the adult intensive care units by implementing clinical practice guidelines that have been proven to improve patient outcomes (the Ventilator Bundle).  Two additional interventions employed that enhanced effectiveness of the Ventilator Bundle were a structured oral care protocol and a patient mobility component.

• Daily Goal Sheets were tested and implemented in SICU/CVICU
• Ventilator Bundle was tested and implemented on SICU/CVICU.  Reeducation and reinforcement were carried out for all staff on the MICU to improve bundle compliance.
• Respiratory Therapy Driven Weaning Protocol was tested on the MICU and spread to SICU, CVICU and BTICU
• Daily Sedation Interruption was tested, implemented and spread to the SICU

• An Adult Critical Care Goal Sheet/Nursing Care Plan was developed that included the sum of all the bundles implemented in the ICUs to promote continuity of patient care across the entire ICU service.  This sheet was tested in all four ICUs for a week.  Feedback was solicited from the nursing staff and four modifications were made and tested before the final version was rolled out and implemented in June 2005.

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 Units.

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 Therapy Driven Wean 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 tracking of VAP 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 Wean 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.

Barry Evans, MSN, CNS
Adult Critical Care Data Coordinator/Project Manager
University of Rochester/Strong Health
Barry_Evans@urmc.rochester.edu