2012 SCONL Meeting Best Practice Prevention of VAP And Reduction in Total Ventilator Hours Donna McCauley RN,MSN,CCRN Critical Care CNS Jarrod Goforth RN, BSN Director of Critical Care Services Joseph Whitten, RRT,RCP Director of Respiratory Care

St. Francis Downtown

Introduction IHI recommendation bundles for the prevention of VAP has consistently been part of the practice in caring for ventilated patients at St. Francis. Over the course of the past 2 years, the Critical Care Division, including nursing staff, the Critical Care Intensivists, clinical pharmacists and the respiratory therapists have worked together to implement many changes in the care provided to those who are mechanically ventilated.

Major Implementations and Additions to Care Management of the Respiratory Failure Patient in 2010 and 2011 included: 1. VAP protocol education reinforced with emphasis on sedation vacation and fine tuning of individual patients’ sedation needs with reassessment of patient response 3. Addition of new oral care kit which facilitates ease of q 2 hour oral care for the ventilated patient as well as chlorhexidine oral wash q 12 hrs for the prevention of VAP 2. Addition of high-flow nasal O2 into our arsenal of options for the respiratory failure patient with impact back on the reduction of patients needing to be intubated as well as patients getting extubated sooner with this therapy utilized as a bridging therapy 4. Greater attention to lung protective strategies by utilizing ARDS net 5. Lung recruitment strategies including bi-level ventilation and lung expansion protocols. 6. Therapist driven ventilator weaning protocols.

Results and Significance of Implementation Incidence of VAP via IHI reporting is as follows: 2008 – less than 1% 2009 – 0% 2011 -- 0.42% and 2012 VAP rate of 0.00%.

Results and Significance of Implementation cont… Also, along with reduction of VAP, the total ventilator days has been reduced by 20% since 2008.. Reported ventilator days for 2008 = 7.6 days, 2009 = 6.7 days 2010 = 5.4 days 2011 = 5.4 days 2012 = 4.2 days Vent days reduced from 2357 in 2011 to 2017 days for 2012

Ventilator Utilization Results cont… Ventilator Utilization 2009-2010 54% 2010-2011 51% BiPAP Utilization 2009-2010 28% 2011-2012 15%

450 patient days x $2,000 per day = $900,000 Financial Impact 5000 / 12 = 450 patients – 1 day x 450 = 450 450 patient days x $2,000 per day = $900,000

Financial Impact cont… Overall hospital LOS for patients receiving BiPAP Reduced by 4.5 days Potential savings > $4,000,000

With a multidisciplinary approach to treatment of the mechanically ventilated patient, both VAP and ventilator days have been reduced and modifications /additions to the IHI bundle delivery has assisted our team in not only reducing vent days but also keep VAP rates at an absolute minimum/absent.

Summary of Outcomes Lessons learned? Minimal to no VAP Continued reduction in ventilator days Continued reduction in BiPAP utilization Lessons learned? A continued team approach to delivery of care to the complex, critically ill patient dramatically improved patient care outcomes!