​Swedish Medical Center
Seattle, Washington, USA

Team

Swedish Medical Center's Adult ICU team has spread ventilator-associated pneumonia rate improvements made in their Medical ICU to include a total of six ICUs.

Aim

Reduce the number of ventilator-associated pneumonia (VAP) cases to below the National Nosocomial Infection Surveillance 10th percentile and 150 days or greater between occurrences by 3/15/05 and achieve 95 percent compliance with all components of the Ventilator Bundle by 1/15/05.

Measures

• Ventilator-associated pneumonia (VAP) rate per 1,000 ventilator days
• Ventilator bundle compliance

This team participated in the September 2004-May 2005 IHI Breakthrough Series Collaborative on Reducing Complications from Ventilators and Central Lines in the ICU. They used the Collaborative change package and specifically report the following changes:

• Implemented a weekly IHI Critical Care Collaborative meeting where the team decided on one or more “tests of change.” 
• Conducted each test of change with one patient, one physician, one time; then evaluated the change in a “huddle” among the providers caring for the patient, and decided whether to extend the test to more patients based on the result of the first test of change.
• Developed a protocol and algorithm for sedation interruption and introduced the Modified Ramsay Sedation Scale (MRSS). Daily sedation interruption was one of the first tests of change. The team piloted the protocol with one patient, one nurse, one Respiratory Therapist, and one doctor. Each time they tested this change, they got feedback and adjusted the process based on the input, adding more patients and more nurses.
• Responded to feedback that the set time for sedation interruption was not the best for the night shift staff. Now the night shift nurse and Respiratory Therapist have a conversation to coordinate the time of interruption.
• Added additional layer of patient monitoring via e-ICU® involvement and support from a remote location. The eICU is staffed by a physician, nurse, and secretary during the night shift.
• The eICU doctor helped with tests of change by gently nudging the nurses to interrupt the patients’ sedation. The nurses'  culture around sedation subsequently shifted, and reminders are no longer needed. 
• Implemented standing orders that are now placed on new ventilated patients. The orders are kept with the ventilator, and are initiated by the Respiratory Therapist (with the nurse) when a patient is placed on a ventilator.
• Implemented VAP prevention orders:
  • Reverse Trendelenberg 30 degrees unless contraindicated by hypotension
  • Sedation interruption daily (unless specifically contraindicated)
  • Famotidine 20 mg IV Q 12H (unless history of allergy)
  • Heparin 5000 units SQ Q 12H (unless post-op heart, other anticoagulant ordered)
• Completed several rapid tests of change in the pilot unit, and spread the protocol to the other ICU floors across other campuses where the nurse manager or charge nurse audits the bundle elements and follows up immediately with one-to-one education. Representatives from the other units and campuses were part of the Collaborative team from the beginning
• Addressed bundle during daily multidisciplinary rounds
• Built in redundancy to continue to hold the gains 
• The team continues to monitor progress, communicate results, and educate staff

Results

Summary of Results / Lessons Learned / Next Steps

During their participation in the Collaborative, Swedish Medical Center reduced the number of ventilator-associated pneumonia (VAP) cases below the National Nosocomial Infection Surveillance 10th percentile and went 168 days without a VAP in six intensive care units spread across three campuses.