University of Rochester Strong Health Reducing Complications from Ventilators: Ventilator Associated Pneumonia University of Rochester Strong Health 700 bed tertiary care medical center. Strong health is a Trauma Center, Transplant Center (bone marrow, kidney, liver & heart). 4 adult ICU’s: MICU (17 beds), SICU (14 beds), Burn/Trauma (17 beds), and Cardiovascular ICU (14 beds)

MICU Critical Care Team Members Team Leader: Michael Apostolakos, MD, Director Adult Critical Care Day to day leadership: Michael Apostolakos, MD. Isabelle Michaud, MD, Critical Care Attending Mary Wicks, RN, MPA, Associate Director, Adult Critical Care Barry Evans, MSN, Adult Critical Care QI Data Coordinator Tim Kehl, RN, Nurse Leader Janice Bell, RN, Nurse Leader Additional key members: Lucille Nelson, RN, MICU Care Coordinator, Jennifer Carlson, RRT, Supervisor Critical Care Respiratory Therapy

Why is reduction of VAP a priority? Mortality 50-70% Increased LOS ICU 17.7 vs 6.1 Complications ARDS Atelectasis Pneumothorax Sinusitis Cost of treating 1 case of VAP $5,000 – $27,000

VENTILATOR BUNDLE Elevate HOB 30 degrees unless contraindicated Sedation Holiday Reduce or turn off sedation daily DVT Prophylaxis PUD Prophylaxis Test for readiness to wean or ability to extubate daily

HMO PREVENT VENTILATOR ASSOCIATED PNEUMONIA HOB HOB is elevated at 30 degrees unless medically contraindicated Reduces aspiration of oropharyngeal/gastric secretions Mobility Turn Q 2 hrs/ OOB when appropriate Mobilizes secretions Oral Care Perform Oral Care Q 2 hrs following structured oral care protocol Removes pathogens from oropharynx

VAP CRITERIA > 48 hours on ventilator At least 3 out of 5: Fever Leuckocytosis Change in sputum Radiographic evidence of new or progressive infiltrates Worsening O2 requirements *Final determination of VAP diagnosis is made by the attending physician

Vent Bundle Compliance

Frequency of Ventilator Associated Pneumonia 1 1 1 2 2 1 Vent Bundle implemented 2 Reeducation

Days between incidences of VAP: MICU 2 1 1 Vent bundle reeducation 2 Oral Care Protocol

Ventilator Bundle: Cycles of Improvement Numerous, rapid PDSA cycles of vent bundle as part of goal sheet on a few patients led to refinement of goal sheet. Support of Medical Director and nurse leaders key to implementation Training of attendings, residents and bedside nurses vitally important (education) Posting results, positive reinforcement leads to more excitement Focusing all initiatives on patient centered care and not in isolation Importance of initiatives echoed by senior leadership during walk rounds PDSA cycles continue as utilization continues to vary (ie percentage utilization decreases under certain attendings) Constant feedback from nurses Forms remain as permanent record

Keys to Success, Barriers and Lessons Learned Involve key front line staff Ongoing education….why are we doing this? Participation by senior leaders Medical Director and Nurse Manager must be fully supportive Administrative assistance Resistance to change Perceived increased workload Another QI project which will go away