Multi-step bundle eradicates VAPs

Build evidence before checklists

Before Crozer-Chester Medical Center (PA) engaged in a four-year study to eliminate incidents of ventilator-associated pneumonia (VAP) from its surgical unit, the medical director of Crozer Regional Trauma Center, Riad Cachecho, MD, MBA, FACS, admits he was a naysayer.

"I thought, like any other surgeon with an ego, that you're giving the best care, and no one is going to make you give better care," he says. But now he's a believer, and the numbers prove him right. After the four-year study period and the introduction of the VAP bundle, the pneumonia rate dropped to 1.5 per 1,000 ventilator days compared to 7.9. And, Cachecho reports, the hospital has had no VAPs for almost a year.

When he began the study in 2005, he says guidelines were nowhere near standardized. So the team looked for the strongest evidence "and then we went to chlorhexidine every six hours, and it worked. In the beginning, about 60% of patients were getting mouth care every six hours, or it might be that nurses were giving it, but they were not documenting it so it was difficult to figure out. Was it really lack of care or lack of documentation?"

Cachecho says when he started at Crozer, they had a checklist. He says, clinicians walked into a room, checked the boxes but "no one understood the importance of it, no one really put any thought into it." Improvement, he says, doesn't start with a checklist. "You start out with finding out what your problems are... What does it mean for me to look at something every day when I don't believe it makes a difference? First, you have to build your team, you have to build the culture, and then the checklist comes later."

Now, the hospital has two bundles — the VAP bundle and the central line-associated bloodstream infection (CLABSI) bundle — and they're intertwined. The VAP bundles includes:

  • all intubated patients should be in semi-recumbent positions unless the patient is in shock or it's specifically contraindicated;
  • mouth care by nurse every six hours with additional checks within that period;
  • gastrointestinal bleeding prophylaxis;
  • DVT prophylaxis;
  • daily assessment of weaning and daily drug holidays. (Every morning without an order, the nurse stops all sedation until the patient awakens. Once awake, the nurse restarts the medications at the lower rate if the patient was too sedated for assessment. "Obviously we won't do that if the patient is in the extreme, like hypoxic and needs high airway pressure," he says.);
  • blood glucose control.

The blood glucose measure, he says, began before any of the bundles. "When I came to Crozer, I was concerned about blood glucose levels in the shock trauma unit." Working with a committee comprising a pharmacist, an endocrinologist, nursing, medical critical care, internal medicine, and nursing leadership, Crozer developed an evidence-based protocol. Cachecho says it was one of the hospital's first culture-changing moments. It was tough, he says, "to get nurses to accept the idea of sticking a finger every hour and getting sugars, and adjusting insulin levels without physicians all day."

Though the sell was tough, it made the adoption of further bundles easier. "Now it's part of daily care. No one questions, no one complains. Everyone is literally proud of the results."

Now the daily progress note in the ICU has all the components of the bundles, which the resident is supposed to check on early morning rounds. The attending physicians sign the sheet after their rounds and double check what the resident checked.

During rounds, he says, staff — including the primary nurse, the charge nurse, the resident, the attendings, and the performance improvement coordinator — used to use laminated cards, which had the same elements as the progress note. The team discussed each item and served as reminders to each other. "By Wednesday of the week, you know all your patients. You don't have to literally go over, 'Well, do I need that line?' We know. Yesterday we discussed why that patient needed a line. But we have to have a mind-check that we discussed it. We discussed the Foleys, we discussed the air lines, we discussed the labs.

"Everything that someone misses, someone else on the team brings up. And we have a pharmD with us who would bring up the medication-related issues. And the social worker brings up family issues. This is part of the checklist, not part of the bundle, so there are things on the checklist that are beyond the bundle and we discuss every day, too. We got so good at it that we don't look at those laminated cards any more. It's just part of our subconscious to talk about that stuff."

The QI coordinator checks documentation and patients, documentation for the drug holiday, that the respiratory therapist is weaning patients in the morning, and DVT and GI prophylaxis is in the patient's medication list. Glucose and insulin values are hung on the wall, and she checks that the insulin is within the appropriate range.

A newer initiative the hospital has added is limiting the amount of blood drawn for routine labs. "Personally, I have always had issues with routine daily labs, and I always give people a hard time when they just get labs because they need to get labs," Cachecho says. He says he used guidelines from two journal reports in 2005 to back us his "personal bias," and the critical care committee is on board. "So now, part of our checklist every day is a discussion about whether the patient needed a complete blood count the day after, whether they need electrolytes. We really now have a much lower threshold for blood transfusion, a lower trigger value for a blood transfusion."

Cachecho plans to look over the next two years if the trend of blood usage and the number of labs ordered has decreased. The lab also uses pediatric tubes or smaller adult tubes when it's appropriate so less blood is drawn.

No longer a naysayer, Cachecho says the goal of the four-year study was to decrease hospital-acquired infections, "but my bigger goal is just to give better care."