Implementing a Ventilator-Associated Pneumonia Bundle in an Academic Emergency Department L.A. DeLuca, L.R. Stoneking, K. Grall, A. Tran, J. Rosell, A. Vira, J. Gonzaga, W. Larson, A. Westergard, B. Munzer, L. Cox, Don Davidson MD, Erik Gerlach, K.R. Denninghoff REFERENCES 1.Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M (1995) The prevalence of nosocomial infection in intensive care units in europe. Results of the European prevalence of infection in intensive care (EPIC) study. Epic international advisory committee. JAMA 274:639– Eckert MJ, Davis KA, Reed RL, Santaniello JM, Poulakidas S, Esposito TJ, et al. Ventilator-associated pneumonia, like real estate: location really matters. J Trauma. 2006;60:104– Nguile-Makao M, Zahar JR, Francais A, et al. Attributable mortality off ventilatorassociatedpneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models. Intensive Care Med 2010;36:781–9. 4.Eckert MJ, Davis KA, Reed RL, Santaniello JM, Poulakidas S, Esposito TJ, et al. Ventilator-associated pneumonia, like real estate: location really matters. J Trauma. 2006;60:104–110 5.Decelle L, Thys F, Zech F, Verschuren F. Ventilation-associated pneumonia after intubation in the prehospital or emergency unit. European Journal of Emergency Medicine. 2013; 20: Green RS, MacIntyre JK. Critical care in the emergency department: an assessment of the length of stay and invasive procedures performed on critically ill ED patients. Scand J Trauma Resusc Emerg Med Sep 24;17:47.(doi): / VAP causes significant increase in hospital LOS, ventilator days, and financial costs Eckert demonstrated 26.5% of trauma patients intubated in ED develop VAP Decelle (2013) showed 20% VAP rate for patients intubated in a European ED Critically ill patients are frequently boarded in the ED for multiple hours, and receive the majority of their critical care from ED providers during that time (Green and McIntyre) VAP prevention efforts initiated in the ED may reduce burden of this disease. INTRODUCTION Pre-intervention: Existing QI database used to identify patients: Two 6 month periods in 2007 and 2009 identified 404 patients (17 excluded) Diagnosed with VAP if: At risk for VAP (intubated 48+ hours with no pneumonia prior) new infiltrate + leukocytosis/penia and fever Treated by primary team with abx for PNA Positive respiratory cultures Diagnosed with VAC if: Stable period of FiO2/PEEP for 48 hours followed by worsening for 48 hours. Infectious VAC (IVAC): SIRS + abx Post-intervention: Prospectively identified patients intubated in the ED: Total of 72 patients evaluated in Phase I (June – Oct 2012) 90 patients in Phase II (January – June 2013). Nursing education and feedback: Prior to Phase 1: competency trainings, group huddles, power point presentation, multiple-choice quiz. Phase 2: clinical nurse specialist real- time feedback at the bedside and department-wide s emphasizing compliance. Core measures: head of bed elevation, periodic oral care, subglottic suctioning, sedation minimization/vacations, daily spontaneous breathing trials (SBT), stress ulcer prophylaxis. Compliance data obtained from nursing documentation METHODS CONCLUSIONS An ED VAP prevention bundle is feasible, and compliance with core measures can be improved with a coordinated educational effort utilizing a dedicated clinical nurse specialist Our ED intubated patients who developed VAP and VAC had significant morbidity and mortality. These results validate a need for VAP prevention strategies at our hospital and larger scale study. Compliance estimate may be affected by accuracy of nursing documentation Single hospital trial LIMITATIONS RESULTS Pre intervention Mortality Total cohort: 28% (109/387) VAP at-risk cohort: (+)VAP: 18.18% (6/33) (-)VAP: 8.89% (4/45) VAC at-risk cohort: (+)VAC: 40% (2/5) (-)VAC: 11% (5/45) Incidence VAP total cohort: 8.5% (33/390) VAP at-Risk cohort: 42.3% (33/78) Post-Intervention Mortality Further analysis pending Incidence Phase 1: 1/68 VAP At-risk group 10% (1/10) Phase 2: 5/89 VAP At-risk group 20% (5/20 ) In this study we sought to Determine the incidence of Ventilator- Associated Pneumonia (VAP) and Ventilator-Associated Conditions (VAC) in the Emergency Department Determine the effect of a coordinated Ventilator-Associated Pneumonia (VAP) prevention effort on VAP bundle compliance in the ED Assess mortality rates for pre and post-intervention cohorts OBJECTIVES Phase IPhase IIp-value N=72N=90 VAP Bundle Measure n (%) Head of bed elevated35 (49)63 (70)0.006 Oral care39 (54)71 (79)0.001 Subglottic suctioning28 (39)52 (58)0.02 Titrated sedation18 (31)80 (89)<0.001 Daily sedation vacation0 (0)5 (6)0.07 Spontaneous breathing trial0 (0)5 (6)0.07 Stress ulcer prophylaxis1 (1)20 (22)<0.001 DVT prophylaxis6 (8)19 (21)0.03 Compliance with VAP Bundle Measures