1. Ventilator Associated Pneumonia Reduction in a Medical ICU
Bela Patel, MD
Tammy Campos, RN, MSN
Ruth Siska, RN
Bela Patel MD
Tammy Campos RN
Ruth Siska RN

2. “Nosocomial” Infections
Not present or incubating upon admission to the hospital (48hr rule)
Preferred: Hospital Acquired Infections (HAIs)
5-10% of patients admitted to hospital or 2 million patients
88,000 deaths per year
Costs exceed 4.5 billion/year
1 outbreak per 10,000 discharges

3. From a public health issue to… A very public issue
Five of 10 facilities are understaffed based upon recommended staffing ratios.
7 of 10 facilities used non standardized criteria
Half of the facilities completed specific infection control risk analysis required by JCAHO.
Hand hygiene not done in all facilities, variable criteria, no inter rater reliability
4 of 10 completed OSHA required annual TB risk assessment
The lack of risk analysis, hand hygiene data, TB risk assessment, annual program evaluation and plan with measurable goals as required by accrediting agencies and OSHA suggests obvious lack of knowledge and oversight.

4. On the horizon for us Texas reporting Federal reporting Medicare
Law passed requiring mandatory reporting of HAI to TDSHS starting 2008
Rates will be publicly available
Federal reporting
Bill introduced requiring mandatory reporting to CDC through NHSN
New national guidelines on infection control 2008
Medicare
SCIP as core measure
Lower rate reimbursement for patients with HAI starting 2008

5. VAP Leading cause of death amongst hospital-acquired infections
Mortality 46% compared to 32% percent for ventilated patients who do not develop VAP
Increased ventilator days
Increased ICU LOS

6. VAP defined Patients mechanically ventilated for greater than 48 hours
Exhibit at least 3 or 5 following symptoms:
Fever
Leukocytosis
Change in sputum (color and/or amount),
Radiographic evidence of new infiltrates
Worsening oxygen requirements CDC 2003

7. Cost of VAP at MHH
Cocanour, et al. Surgical Infections 2005.

8. Prognosis

9. VAP prevention “Vent Bundle” Suctioning Head of bed > 30o Oral care
“Sedation holiday”

10. Memorial Hermann -MICU
16 bed unit admitting 1100 patients per year
60% ventilated >3 days putting them at greater risk for VAP
Chief diagnoses include septicemia, respiratory failure, HIV/AIDS, renal failure, and multisystem organ failure secondary to multiple co-morbid conditions
Previous improvement work had made respectable reductions in VAPs from 2-3 per month to <10 per year, however it was felt more was achievable

12. Aim and Measures
Aim
To reduce VAPs in the MICU to Zero within six months.
Measures
Reduction in number of VAPs per 1000 ventilator days
Increased compliance with all aspects of the ventilator bundle.

13. Where to start?

14. Interventions: Education
MICU “Huddles” on VAP and mortality
Posted rates in the unit for staff and MDs to see
Posted rates in public areas for patients and family members to see
Reviewed bundle compliance regularly in multidisciplinary team meetings
Reviewed compliance and VAP rates at local and system critical care committees

16. Interventions: Implementation
Developed physician Rounding Tool to address VAP bundles
Appointed unit champions to assure patients were out of bed on daily basis
Formalize oral care process using chlorahexadine
Trained Patient Care Assistants (PCAs) in oral care
Mandated that oral care be a shared responsibility by RNs, Respiratory Therapists and PCAs increasing oral care from 4 times per day to 10 times per day
Computerized reminder alert for the care team
Located all oral care supplies near ventilators
Located isolation supplies –gowns, gloves, masks at entrance to every patient room

17. Interventions: Implementation
Increased isolation practices for all infected patients to include booties, head coverings
Implemented glycemic protocol to keep glucose between 80 and 150
Implemented automatic insulin drip for all patients who had 2 consecutive finger sticks above 150
Implemented standardized sedation protocol
Improved Sedation holiday practices by team approach to assessment
Improved transportation practices

18. Interventions: Audits
Implemented daily manager rounds to assure bundle compliance
Assured compliance with unit protocols by PRN staff and consulting MDs
Implemented a mini-RCA process for all VAPs to detect specific patient characteristics and system risk factors
Infectious Disease Dept conducts random weekly audits for bundle compliance
Infectious Disease Dept reviews all cases to diagnose VAPs based on CDC criteria

20. Results: Bundle Compliance

22. Does “vent bundle” work?

23. More to do: FMEA Aspiration during transport Cuff leaks
Unplanned extubations requiring reintubation

25. Results: VAP Rate

26. Results: Overall
VAP rate went from 8-12 per year to zero within three months.
No VAPs have occurred in the MHH-TMC MICU for 26 consecutive months
Compliance with all aspects of the VAP bundle is between %.

27. Results: Cost Savings
A financial analysis completed by our infectious disease and financial departments concluded that a VAP in any of our ICUs adds $57,000 in additional costs for additional antibiotics, ventilator time and ICU stay.
Cost avoidance for this project based on avoiding 8 VAPs per year is $456,000.

28. Sustainability Takes a Village to raise a “Zero”
Culture Changed
Goal became Expectation
Work flow changes became routine
Reporting of “near misses”
Created a highly functioning multidiciplinary team

29. Conclusions and Next Steps
With concerted and focused effort “zero” is possible as an outcome.
As with any major improvement, the challenge is to maintain this level of performance.
Build on this methodology to achieve similar improvements for other hospital acquired infections in the Intensive Care Units.

30. Acknowlegements
UT Divisions of Critical Care, Pulmonary and Sleep Medicine
MHH ICU Nursing Staff
MHH Respiratory Therapy
MHH Nutrition Support
UT-MHH Academy of Patient Safety & Effectiveness