Sentara Williamsburg (VA) Regional Medical Center (SWRMC) marked five years without a case of ventilator-associated pneumonia (VAP) in February 2009 and is hoping to report six years in February 2010.
This milestone, which at one time many facilities believed to be unattainable, has been achieved through members of the care team adhering to protocols, understanding the importance of their jobs, and evaluating the need for placing patients on a ventilator in the first place.
"We focus heavily on device utilization, because if you don't put a patient on a vent, [he or she] can't get ventilator-associated pneumonia," Kathy McCoy, ¬RN-BC, BSN, CCRN, ICU manager and director of patient care services at SWRMC, said in a presentation at the IHI's 21st National Forum on Quality Improvement in December 2009. "The less days you have them on a vent, the less their chances are of developing ventilator-associated pneumonia."
When patients arrive, staff members evaluate whether they need to be ¬intubated, or whether there is a bridge, such as BiPAP, that can be done instead, said McCoy.
SWRMC is a 145-bed nonprofit hospital (part of the larger Sentara system) with a 16-bed ICU. The ICU's average daily census is seven patients, and on average there are two or three new patients per week on a ventilator, who spend an average of 2.3 days using it. ICU patients at SWRMC cost an average of $6,000 less than patients at comparable facilities, and its rate of zero VAPs has allowed the facility to reside in the top 10% of all facilities in the United States, with respect to VAP rates.
So how has SWRMC managed to banish VAP, the second most common hospital-acquired infection (HAI) in hospitals and the most common HAI in ICUs? Although many factors are involved, the simplest way to describe the achievement is the hospital's increased focus on reducing length of stay in addition to decreasing ventilator days. Because so few patients are placed on ventilators at SWRMC, even one case of VAP will cause the facility's VAP rate to skyrocket. Additionally, SWRMC's ICU has the luxury of utilizing its own dedicated intensivist to manage patients.
Practices changed to prevent VAP
In 2003, members of the ICU staff created an ICU partnership council. It was made up of a nurse, respiratory therapist, physician, nutritionist, and pharmacist. They focused first on caring for the ventilated patient.
To start, the council implemented the IHI's ventilator bundle, which includes the following actions:
- Elevation of the head of the bed
- Daily "sedation vacation" and assessment of readiness to extubate
- Peptic ulcer disease prophylaxis
- Deep venous thrombosis prophylaxis
To adhere to this bundle, the council developed policies and procedures, said McCoy. First, the team worked on a ventilator order sheet. The order sheet contained the criteria that needed to be implemented for patients on a ventilator, most of which are listed in the IHI bundle. Next, the team developed a procedure for sedation vacation, defining what tasks should be done during a vacation and what taking one means for a patient, and an intensive insulin protocol. Last, staff members focused largely on oral care procedures.
"We really had no guidelines on what oral care meant," said McCoy. "We used to do oral care whenever the staff felt like the patient needed oral care." Staff members were also using saline down the endotracheal tube, she said. The staff changed its policy so that saline was used only rarely and put an oral care procedure in place to define what was expected of staff members.
To ensure compliance with the VAP bundle, a member of the quality improvement staff audits ICU staff members' practices. Staff members are held accountable if they are aware of their responsibilities but fail to perform them, said McCoy. Charge nurses in the ICU participate in peer coaching with other nurses on the unit to help them improve compliance. McCoy also posts the compliance rates with the bundle indicators so that staff members have an idea of how they are performing.
Additionally, the ICU implemented daily interdisciplinary patient rounds. When they first began, the rounds consisted of a nurse and respiratory therapist. Now, the three- to five-minute rounds consist of those staff members plus a physician, a nutritionist, a pharmacist, a case manager, infection control specialists, and a palliative care nurse.
"This is probably one of the best things that our team agreed to try," said McCoy. "It took showing the staff what interdisciplinary rounds could do for the patient—that [the rounds were] truly helping the patient get well, rather than just busywork for them."