Quality initiative slashes occurrences of VAP

Interdisciplinary team changed practices in ICU

A team approach to quality measures has resulted in a significant drop in ventilator-associated pneumonia for patients in the intensive care unit at Columbus Regional Hospital (IN) and helped the hospital earn the 2007 American Hospital Association-McKesson Quest for Quality Prize.

"When we started looking at ventilator- associated pneumonia [VAP] in 2001, we had a high rate of occurrence. Our interdisciplinary team reviewed the literature to determine the best practices, compared that to what we were doing, and found areas where we could improve," says Shannon Page, RN, BSN, CCRN, intensive care unit-based case manager and critical care clinical data coordinator.

The hospital reaches between 98% and 100% compliance with the recommended ventilation-associated pneumonia interventions. Before the quality improvement initiative, the staff were compliant with the recommendation that patients' heads of the bed be elevated above 30 degrees to 45 degrees about 60% of the time, Page adds.

VAP is the leading cause of hospital-acquired infections and adds considerable cost to a hospital admission, adds Jennifer Dunscomb, RN, MSN, CCRN, system clinical nurse specialist.

"We looked at what we could do to ensure that everyone follows evidence-based care for every patient, every time. We identified the gaps that were occurring and generated ideas to determine how we could close those gaps," she adds.

The team that designed the initiative included Dunscomb and Page; the intensive care unit medical director; licensed and unlicensed staff from the ICU; the inflectional control practitioner; and representatives from dietary, respiratory care, pharmacy, and physical therapy.

"We take an interdisciplinary approach to any type of change. Everybody on the team feels free to speak up and advocate for the patient," Page says.

Four standard practices identified

After researching and evaluating current practices, the team identified four standard practices that should be followed with ventilator patients in order to avoid VAP:

  • elevating the bed between 30 degrees and 45 degrees and monitoring it every two hours during respiratory therapy ventilator checks;
  • peptic ulcer prophylaxis;
  • daily sedation vacations and assessment for readiness to extubate by performing daily spontaneous breathing trials;
  • deep venous thrombosis prophylaxis.

Those measures were included in the Institute for Healthcare Improvement's VAP bundle in its 100,000 Lives campaign that began in 2004.

Columbus Regional Hospital uses a differentiated nursing practice. The case managers are all nurses, certified in a specialty area with at least three years' experience in the clinical unit.

The case manager looks at every patient on the unit to make sure he or she continues on the clinical pathway. They intercede in cases where patients have complex medical, psychological, or psychosocial needs. These include patients with family issues, those who are on ventilators at home, and those who are frequent admissions.

"In the ICU, the case manager is probably following 90% of the patients. They are the knowledge experts and work with the primary care nurses to coordinate care. We sustain our improvement because the case manager helps hold nurses accountable daily on the ventilator-associated pneumonia for the bundle measures," Dunscomb says.

Team approach to QI

Columbus Regional Hospital's approach to quality improvement is to make everyone in the hospital accountable for quality and involve them in the quality initiatives, Dunscomb says.

"We involved everyone, right down to the transporters and the housekeepers, in our quality initiatives. It takes a team approach to be successful," she adds.

The team developed standard order sets that include the measures and developed educational competencies for the entire staff about evidence-based care of ventilator patients. For instance, after an awareness program for unit nurses about elevating the head of the bed, the unit manager noted when nurses failed to follow the requirement and talked with them individually, notifying them of the expectation and that they would be held accountable.

"Now, we're so hardwired toward our goals that it's not even necessary for anyone to prompt the staff to ask why Mr. Smith's head is flat. Head-of-bed elevation is consistently maintained at 100%. The measures are very ingrained in our day-to-day practices," Page says.

The team made a presentation to the nonclinical leadership, breaking down each requirement and why it was important so that the nonclinical leaders could understand why the requirements are pertinent to their staff's activities. For instance, the radiology department was educated that ventilator patients' heads need to be elevated, not left flat, when they come for X-rays. The housekeepers were educated to notice if the heads of the bed were flat and point it out to the nurse.

"I met with the director who is responsible for housekeeping and asked that the housekeepers observe what is going on in the unit. House-keepers are there all the time and are nonbiased," says Dunscomb.

For instance, the housekeepers noted when staff left the room breaking isolation precautions, how many times they touched the ventilator without wearing gloves, or if the staff are diligent about washing their hands.

"It's a matter of creating awareness. We all get busy but the one time someone doesn't put gloves on to change the ventilator tubing may be the time the patient gets ventilator-associated pneumonia," Dunscomb adds.

Tracking compliance

The team tracks compliance with the measures every day in real-time.

Page receives automated reports for all intensive care unit patients every morning. The reports provide information on quality indicators for patients on continuous sedation along with documentation that they have had a sedation vacation assessment, peptic ulcer disease and venous thromboembolism prophylaxis, glycemic control, as well as on ICU predicted vs. actual length of stay and predictive mortality information used daily for the ICU interdisciplinary rounds. The respiratory therapists provide documentation on the head-of-the-bed data and help evaluate breathing trials to assess readiness to be extubated.

"One of the first trends we noted relative to prophylaxis is that patients were coming to the ICU after surgery without anticoagulation prophylaxis ordered," Page says.

The team talked with the surgeons and created standardized order sets that include deep vein thrombosis (DVT) prophylaxis.

"Our DVT initiative has been filtered into other committees, such as the surgical care improvement committee. Instead of looking at separate protocols for surgery and the ICU, we are working to accomplish our goals from a systematic approach," Dunscomb says.

An intensivist manages a significant number of patients in the unit but other physicians, including surgeons, cardiologists, and internal medicine physicians also manage patients on the unit. The intensivist is the team's physician champion. His responsibilities include assuring the treatment of patients using evidence-based standards and holding other physicians accountable for their practice.

"If the physician doesn't order a component of the recommended care, there is a mechanism in place to hold them accountable. The nurses and case managers can make recommendations and suggestions but if the physician chooses not to do it and doesn't document why, our hands are tied. That's how our physician champion can work with the physicians to change their practices," Dunscomb says.

The ICU interdisciplinary team holds daily rounds led by the medical director. Participants include the staff nurse, respiratory therapist, pharmacy representatives, and case management.

The team sees every patient, evaluates the plan of care for effectiveness, and revises interventions as indicated to optimize outcomes in alignment with the patient's and the family's goals, Dunscomb says.

"It's a great educational opportunity for the nurses involved. We often take this opportunity to update the family on the patient's progress when the entire team is available for questions," Page says.