Statewide campaign slashes VAP rates

Follow-up provides strong support for facilities

The Minnesota Hospital Association (MHA) recently completed a successful pneumonia prevention program for hospital patients on ventilators, crediting it with saving an estimated 53 lives and $7 million in health care costs. All 84 Minnesota hospitals that treat ventilator patients participate in the Ventilator-Associated Pneumonia (VAP) Initiative, which MHA estimates reduced pneumonia cases by 175, or 57% over 15 months.

The effort, part of the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign, was launched in the spring of 2005. "We received an invitation to participate in a day-long presentation and discussion on how to reduce VAP in Minnesota," recalls Roberta Basol, RN, MA, CNA, BC, department Director of the ICU at St. Cloud Hospital. "They made recommendations on things to do, such as implementation of the ventilator bundle, oral care, subglottic suctioning, and so forth."

A head start

The MHA benefited in turn from the experiences of Mercy Hospital in Coon Rapids, which began its own initiative in 2003. "As soon as they heard our data, they knew we were a little bit ahead of the curve," recalls Pam Madrid, RN, CNS, CCNS, CCRN, a clinical nurse specialist at Mercy's ICU. Accordingly, she says, MHA asked Mercy to participate in presentations to other hospitals.

Three key elements contributed to success at Mercy, according to Madrid: Good hand hygiene, ventilator bundles, and good oral care.

"We started using alcohol-based foam [for hand hygiene] and put colorful 'foam in, foam out,' signs on the doors. We even encouraged family members to foam when going in and out of the room," Madrid shares.

Some of the staff, she continues, would try to call each other and offer reminders. "One weekend some nurses even started yelling 'Foaming in, foaming out,'" she says.

Foam dispensers are located "everywhere," adds Madrid. "We also started using some wipes to help wipe off stethoscopes." Compliance was measured by counting how much foam was used. "We doubled our count," she reports.

The second element, the ventilator bundle, included three elements: Head of the bed elevated 30 degrees; DVT (Deep Vein Thrombosis) prophylaxis by 24 hours; and stress ulcer prophylaxis by 24 hours. "We scheduled a weaning readiness assessment and lightening of sedation at least once a day to see if the patients were ready to be weaned off the ventilator," she adds.

The oral care initiative involved brushing patients' teeth twice day, and in between that doing swabs with a bicarbonate of soda base. New endotracheal tubes were purchased that make suction of secretions easier.

The result? "We have gone 515 days without a single case of VAP," Madrid reports.

An easy sell

Because of the experiences of Mercy and other facilities across the country, the MHA's VAP initiative was an "easy sell," says Basol. "There was a lot of supportive data, so it did not take much for you to participate. For example, IHI's data showed that if you just elevated the head of the bed to 30 degrees, you could reduce VAP by 18%." In addition, she notes, VAP has a 25% mortality rate, "So it was so convincing to say, 'We can save lives.'"

All participating facilities submitted data on what their past VAP rates had been, and reported ongoing VAP rates monthly to MHA. "The data process was really quite easy, and the measures were clear (i.e., VAP rate per 1,000 days) so we all compared the same things," says Basol.

Upon leaving the seminar, recalls Basol, the MHA challenged all the hospitals to immediately do one new thing. "We did two," she says. "We made signs to remind ourselves to keep the head of the bed elevated at 30 degrees, and we also put little reminder cards at the entrance of the room to use alcohol foam. We also had a 'Foam in, foam-out' sign."

Those "little" things made a big difference, she says, as did improved oral care and subglottic suctioning. "We also looked at how frequently we changed vent tubing and how frequently we change suction canisters; we even changed where we were storing resuscitation bags," says Basol. At the start of their initiative, the staff also conducted an extensive search of the literature to identify best practices.

The staff really took to the initiative, she adds. "We are very proud, for example, that we have had 100% compliance with the ventilator bundle for going on over a year," says Basol.

At the project's end in June 2006, St. Cloud reported a 75% reduction in VAP. "This was very significant, even though I did not think we had very high rate to begin with." says Basol. "By CDC statistics, we had been outperforming more than half the hospitals in the country, but I did not realize there was an opportunity to really reduce VAP."

Basol is now a big supporter of the IHI's collaborative model. "We shared successes with other hospitals, and we would send e-mails back and forth, offering assistance, and checking on how each other was doing," she says. "You also get good ideas from other people; we took ideas from other hospitals, and we implemented them here."

[For more information, contact:

Roberta Basol, RN, MA, CNA, BC, Director, ICU, St. Cloud Hospital, St. Cloud, MN. Phone: (320) 251-2700 x 54110. E-mail:

Pam Madrid, RN, CNS, CCNS, CCRN, Clinical Nurse Specialist, Mercy Hospital, Coon Rapids, MN. Phone: (763) 236-8331.]