Talking VAP staff identifying risk reduction strategies Daniel J. Barrieau, RRT, CPFT Director of Respiratory Care Services Cooley Dickinson Hospital

What we do beyond the bundle Dual-limb heated wire molecular humidity Event related/no change ventilator circuit strategy Event related/no change closed suction No in-line nebulizers ~ MDI only

What we do beyond the bundle Continuous subglottic suction No break circuit strategy Single use manual resuscitators (use & toss) Pre-flight checklist for transport Strip, clean, replace ~ no reuse

How we got there After bundle implementation, didn’t stop Knew our CCU was changing 2005 ~ <150 ventilator days 2006 ~ planned start of intensivist program

Engaged the Respiratory Therapists Challenged them to find ways to reduce risk Philosophy of always asking ‘what else can I do’? While doing their work ‘keep eyes open’, always look for opportunities Not reactive, proactive

Do the easy things Technology is nice, but so is washing your hands ~ zero tolerance Tie VAP to our actions Talk about VAP

Talk VAP Discuss VAP. . .daily Own it. Do not believe VAP is inevitable If it is ok to have some VAP’s how do staff know which ones were ok and which ones weren’t

Can lead to great ideas Staff looked at intra-hospital transport Read articles Thought of as big opportunity RT noticed, we call ‘time’ on our interventions when we travel

A great and easy idea Check sheet Developed by staff RT from talking VAP All the steps Finds approximations for our strategies Home court advantage on the road

Our Opportunities invasive ventilation FY06 = 147 FY07 = 649   FY06 = 147 FY07 = 649 non-invasive FY05 = 161 FY06 = 209 FY07 = 574

Well. . . 15 months without VAP When we had a VAP, we talked about it Kept looking for risk reduction strategies ~ yep, high risk patients Vented >19 days each Transported Difficult intubations or reintubations

What are we talking about now? Opportunities Transport ‘emergencies’ (is it really?) Difficult airways (aren’t they all?)