After reading this article, you will be able to:
Identify preventative measures for ventilator-associated pneumonia (VAP)
Discuss tactics of UPenn Health System’s (UPHS) electronic ICU that helped reduce VAP rates
Describe strategies for implementing a bundle to prevent VAP
VAP is a constant headache for hospitals around the country. It has been on the list of the Institute for Healthcare Improvement’s (IHI) interventions since the inception of the 100,000 Lives Campaign in 2005. It is one of the most acquired conditions by ICU patients on ventilators, and its presence exacerbates existing conditions and adds costly days to ICU stays.
To help lower its VAP rates, UPHS in Philadelphia used an electronic ICU (eICU), a system already in place at the organization that used telemedicine to monitor patients, and realized a cost savings of more than $138,000 in a two-year span.
An eICU can add an extra level of monitoring for ICU patients because not only does it provide visual surveillance, but it also offers a level of data and analysis that bedside caregivers alone cannot provide.
“Telemedicine receives alerts and alarms through a software package,” says Joseph DiMartino, BSN, RN, outcomes coordinator at the Penn E-lert eICU, a part of UPHS. The eICU monitors quality initiatives at the Hospital of the University of Pennsylvania, Presbyterian Hospital, and Pennsylvania Hospital. “That allows us to see and detect alerts for patients earlier than maybe the bedside nurse might see,” DiMartino says.
He explains that bedside caregivers often set patient alarms so they only go off in an emergency and are not ringing all day and becoming a distraction. The eICU’s system is set to be alerted whenever there is a 20% or higher change in a vital sign, and the eICU staff can alert the bedside caregiver if necessary. “They’ll set their range for heart rates, for example,” says DiMartino. “They may set their range for heart rates to be between 60 and 120. If the patient’s heart rate is anywhere between those two numbers, the bedside alarm is not going off. But if their heart rate is 60 and all of the sudden it shoots up to 119, we want to know that.”
The Penn E-lert eICU was started in 2005, and the VAP initiative began in 2006. The eICU contains three surveillance stations: two for each of the nurses and one for the physician. There is a smaller setup for the data coordinator as well. A surveillance station contains six computer screens, each displaying pertinent data, pictures, or video, mounted on a desktop. A phone and alarms are attached.
Currently, the eICU is staffed by two nurses from 11 a.m. to 11 p.m. and one nurse from 11 p.m. to 11 a.m. Additionally, a physician monitors the eICU from 7 p.m. to 7 a.m. The data coordinator’s shifts vary.
Initially, the Penn E-lert eICU staff members were monitoring each patient three times per day, but decided that the middle shift was unnecessary and scaled back to two times per day.
“We’re really looking for the change from the a.m. to the p.m.,” says DiMartino. If the eICU staff recommends a change to the ICU bedside caregivers in the morning, it looks to see that the change has taken place by that night.
Integrating eICU technology with VAP prevention
DiMartino’s team originally approached the bedside team at an ICU in Presbyterian Hospital to discuss using telemedicine to lower the rate of VAP. Selling the idea coincided with the introduction of electronic documentation at that ICU. DiMartino says although the idea garnered overall acceptance, some staff members needed to warm up to the idea.
“There are always individuals who aren’t really accepting of the eICU and what we do. People might think we’re spying on them, another set of eyes,” says DiMartino. “We’re trying to show them how we can help them.” Staff members needed to be educated about telemedicine, as well as what the responsibilities of the eICU would be.
The eICU surveillance team is trained to watch for the care techniques identified in the IHI’s bundle of care for preventing VAP. This means head-of-bed elevation between 30º and 45º and prophylaxis for stress ulcers and deep vein thrombosis. The bedside caregivers are responsible for measuring the patient’s readiness to extubate and ensuring that daily sedation holidays have been implemented. Learn more about IHI’s VAP bundle.
To accurately estimate a patient’s head-of-bed elevation, the data coordinators working at the eICU underwent a two-week training period that helped them become accustomed to the measurement.
“We have the ability to go in and visualize what’s going on in the room, so we trained the data coordinators to figure out where the head of the bed is elevated based on visual cues behind the bed—if the bed is flat or at 10º, 20º, 30º, or 40º elevated,” DiMartino says.
Additionally, eICU staff members check each patient’s documentation to ensure that adequate prophylaxis has been ordered and is being delivered. Is the patient taking an anticoagulant? Does that patient have compression boots, and are they being worn properly? The same goes for stress ulcer prophylaxis: Has an acid blocker been prescribed and administered?
Each day, the data coordinator compiles this information and e-mails it to a nurse or attending physician staffing the ICU.
Read about other practices to prevent VAP from occurring healthcare settings.
Data from the original ICU show that in 2006, there were 17 cases of VAP. That number dropped to nine in 2007 due to the eICU surveillance. The program has been expanded to ICUs at all three UPHS hospitals and continues to reduce VAP numbers.
Learn how another facility used IHI’s bundle and achieved a zero VAP rate for eight consecutive months in their ICU.
1. Evans, B. (2005). Best-practice protocols: VAP prevention. Nursing Management. 36(12):10-16. Retrieved April 16, 2009, from http://www.nursingcenter.com/pdf.asp?AID=618948
2. IHI. Implement the ventilator bundle. (2009). Retrieved April 16, 2009, from http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
3. IHI. Improvement report: Reducing ventilator-associated pneumonia. (2009). Retrieved April 16, 2009, from http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVentilatorAssociatedPneumoniaOwensboro.htm