Reducing VAP for Long-Term Mechanical Ventilation Patients using the Ventilator Bundle

Coler-Goldwater Specialty Hospital and Nursing Facility
Roosevelt Island, New York, USA

Team
Dr. Edouard Hazel, Facility Epidemiologist
Patrick Driscoll, RPH, Associate Executive Director, Clinical Services
Dr. Vasudeva Raju, Chief of Service, Department of Medicine, Hospital
Dr. Michael Schuster, Chief, Infectious Diseases
Leah Matias, RN, Chief Nurse Executive
Jocelyn Juele-Cesareo, RN, Director Infection Prevention and Control
Stanlee Richards, RN, Deputy Director of Nursing
Cecile Lim, RN, Associate Director of Nursing
Jacqueline Schuster, RN, Nurse Practitioner
John Nieves, Respiratory Care Therapist
Dr. Mohammed Billah, Pulmonary Consultant


Aim
To decrease the incidence of ventilator-associated pneumonia (VAP) among patients who are on long-term mechanical ventilation.

Measures
Rate of VAP per 1,000 ventilator days

Changes

With approximately 110 patients on long-term mechanical ventilators on any given day, preventing VAP is a major goal for Coler-Goldwater.

 
When IHI released the Ventilator Bundle, we wanted to add this to our arsenal of strategies to drive our rates even lower. Since all elements of the Ventilator Bundle do not apply to our targeted patients, a multidisciplinary team developed our "Long-Term Ventilator Ventilator Bundle," which included some of the elements of the IHI Ventilator Bundle and other elements applicable to our patients on long-term mechanical ventilation. Furthermore, we developed a method to enhance compliance with our head of the bed elevation with the use of an inexpensive green tape.
  • Implemented a VAP protocol that was applied to new admissions on ventilators and new patients placed on ventilators. Protocol included an initial Dental Consult and referral to Pulmonary Consultant for secretion management.
  • Used a green tape to mark the 30 to 45 degree head of bed elevation. Tape provided staff with a quick visual to assess bed level, an effective self-monitoring tool for all clinical staff, since bed seen outside of the green zone was determined to be either too low or too high.
  • Developed and implemented a comprehensive oral care program that included use of suction toothbrush.
  • Customized oral care kit to the specifications of the staff which enhanced compliance with oral care.
  • Assessed patients for eligibility for nocturnal feeding schedule.

Results

 

Graph_Coler_VAPper1000VentDays.jpg

Summary of Results / Lessons Learned / Next Steps

At the start of the project, our VAP rate was 2.4 per 1,000 ventilator days. While the progressive implementation of the various bundle elements brought a steady decline of our rates, the substantial reduction in rates was noted in the second quarter of 2007 after we implemented the green tape visual which enhanced staff compliance with the head of the bed elevation. By the fourth quarter of 2007, our rates dropped to 1 VAP per 1,000 ventilator days and continued to remain low up to the first quarter of 2008.

 

Lessons Learned:

  • Involve senior leadership. Staff buy-in is easier to obtain once the right people are involved.
  • Encourage staff creativity to provide solutions to perceived barriers. In our project, the unit staff provided an inexpensive but effective tool in the form of a green tape to improve compliance among clinical staff with the head of the bed elevation.
  • Empower staff. Staff designed the customized the oral kit which improved the efficiency of the process by having all the essential items they need to provide oral care in all shifts packed into one bag.

 

Contact Information
Jocelyn Cesareo
Director, Infection Prevention and Control
Coler-Goldwater Specialty Hospital and Nursing Facility

Jocelyn.Cesareo@nychhc.org

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