Laura Espinosa, RN, MSN, CS, Clinical Director, Nursing
Kristin Price MD, Chair Ad Interim, Clinical Associate Professor
C. Lee Parmley, MD, JD, Clinical Director, Critical Care
Cynthia G. Segal, RN, MSN, Senior Clinical Quality Improvement Analyst
Joni Herman, RN, BBA Productivity Coordinator
Todd Kelly, MD, Assistant Professor, Critical Care
Joseph Nates, MD, Associate Professor, Critical Care
Clarence Finch, BS, RRT, Director, Respiratory Care
Brenda Hackett, CIC, MPH, BS, Senior Infection Control Practitioner
Linda Bixler, RN, BSN, Assistant Nurse Manager, Critical Care
Tami Johnson, PharmD, Pharmacy Clinical Specialist
Anne Tucker, PharmD, Pharmacy Clinical Specialist
Sharon Martin, MEd, BS, Vice President, Quality Management
Patrick King, Data Analyst, Critical Care
Brenda Hagen RN, MSN, Advanced Practice Nurse
Anna Banford RN, MSN, Clinical Nurse Specialist
Leekesha Williams, Inpatient Services Coordinator
Staci Eguia, RN, Clinical Nurse
Jenise Mouser, RN, Clinical Nurse
Dolores Mejia, RRT, RCP
Mary Ann Kosinski, RRT, RCP

• Reduce ventilator-associated pneumonia(VAP) by 26 percent within 6 months
• Reduce average mechanical ventilation days by 50 percent

• Ventilator-associated pneumonias per 1,000 patient days
• Ventilator days per 1,000 patient days

• Implemented Ventilator Bundle including head of bed (HOB) up at least 30 degrees, peptic ulcer prophylaxis (PUD), deep vein thrombosis prophylaxis (DVT), sedation protocol, glucose control with an insulin protocol, oral care every 2 hours
• Educated staff regarding VAP risk factors and preventative measures
• Pre- and post-test inservices
  • Poster “What’s Wrong With This Picture?”
  • Developed video tape with CEUs, “Nosocomial Pneumonia: A Team Approach”
  • Newsletter
• Monitored compliance with ventilator bundle, ventilator days, and VAP rate
• Reported VAP rate and bundle compliance to staff on a regular basis
• Utilized daily goal sheet
• Developed and implemented insulin protocol
• Developed and implemented sedation protocol
• Enhanced daily multidisciplinary rounds
• Added evening intensivists to staff
• Split patients by service into teams to reduce the physician-to-patient ratio
• Changed oral care policy to every two hours

Our goal was achieved within three months of the beginning of the initiative, and some months we have reduced VAP by 50 percent.  We met our reduction of ventilator days in 12 months and they continue to decline.  A truly multidisciplinary approach was necessary because any one group doesn’t own the entire spectrum of what needs to be done to prevent VAP.

• Need strong champions in each discipline to get everyone in their group involved.
• Visual aides very effective in showing proper care (i.e., HOB up 30 degrees).
• Constant feedback to the bedside staff is critical so that they can see the results of their work.
• Make data collection role specific and not person specific, or you will have single point failures.
• Engage bedside staff in Plan-Do-Check-Act cycles.
• Encourage staff to do research, produce educational material, analyze data, etc.  They will gain a much more in-depth knowledge of issues and will have stronger buy-in to the process.
• Build on existing processes for data collection and change.
• NO RECREATIONAL DATA COLLECTION!  Only collect that you need to analyze process and no more.

Joni Herman, Productivity Coordinator
The University of Texas MD Anderson Cancer Center
jherman@mdanderson.org

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