Health system implements VAP prevention bundle

Focus is on six key interventions

Ventilator associated pneumonia (VAP) rates have dropped significantly in a level II adult neuro/trauma unit at Essentia Health System in Duluth, MN, largely as a result of the unit following this six-step intervention:

1. Identify VAP reduction team champions on all shifts to reinforce VAP prevention strategies with front-end staff.

The champions are employees who cover all shifts and were selected based on their commitment to patient safety and, most importantly, their ability to tactfully intervene and educate coworkers, says Rennae Houle-Burns, RN, CIC, an infection preventionist at Essentia. There were 10-12 champions who worked alongside of staff and helped identify times when someone might have forgotten to follow the VAP prevention best practices.

"We wanted to create an environment to assure that everyone recognized best practices, were going to be held accountable and be partners in the patient safety initiative," she. "We needed the right people for this role, and we didn't want to cause any hard feelings."

So they selected employees who had both leadership qualities and tactfulness interpersonally. "The bottom line is it's about patient safety and providing the best care to our patients," she says.

2. Review and reinforce bundle elements during daily care rounds.

The ventilator bundle includes these five elements:

  • Make sure beds are elevated above 30 degrees. Elevation prevents micro-aspirations into the respiratory tract. If the elevation is below 30 degrees, the nurse must either adjust the HOB level or ensure there is documentation within the medical record of the reason why it is contraindicated.
  • Provide patients with peptic ulcer disease prophylaxis.
  • Provide patients with deep vein thrombosis prophylaxis to prevent blood clots.
  • Assess for daily sedation vacation and assess readiness to liberate from the ventilator.

"Often, people are under sedation when on the ventilator, and they are more relaxed, so we lighten up their sedation and assess if they can breathe on their own," Houle-Burns says. "We have set policies for sedation vacations and weaning that has a multidisciplinary approach," says. "We follow specific guidelines to see if a patient is a candidate to be weaned, and it is assessed every day."

  • Provide oral care. "We have a two-hour oral care product that involves teeth brushing, suctioning, and mouth swabbing," she says. "The kit tells staff what needs to be done and when; it's user friendly."

The hospital also has a competency on oral care as part of staff education. "We want to make sure we provide standardized care, and everyone is doing the same thing in the same time frame," she says.

"The bundles are built into the daily care rounds, and I audit them, as well," Houle-Burns says. "A pharmacist is part of the care round team, and the pharmacist verifies that the patient is on a DVT and SUP prophylaxis."

Nurses discuss with respiratory therapists and physicians whether patients are medically stable and meet weaning criteria, which is necessary before they can be taken off the ventilator.

3. Assign chart audits to unit staff to assure documentation of head of bed elevation.

"Initially, we had the units do some performance audits because I think it's important for people to pay attention to other people's practices as they're auditing," Houle-Burns says. "I believe that helps them be more aware of their own practices as well."

The assignment of chart audits coincided with the hospital's transformation from paper documentation to an electronic medical record. "We needed to make sure everyone was documenting in the same way and that things were done correctly," she explains. "I gave them the same audit tool I use, a one-page form with room for multiple patients and to check for bed elevation and bundle compliance."

The auditors looked for instances when staff might have forgotten to follow the oral care guidelines or failed to document or perform bundle items. Houle-Burns conducted at least 15 of these audits per month, and she expected the front-line staff member doing the audit to do the same number during the transition period to best practices in VAP prevention. The audits are conducted on all shifts.

"These audits are labor intensive and time consuming, so once we had the best practices nailed down and they had incorporated them into their daily practice, their audits stopped," she explains. "But I continue to do my daily audits."

Each month, Houle-Burns randomly selects 15 charts to audit. If she finds problems she notifies managers with the specific details. When the auditing process began, the medical center's five intensive care units averaged 68% compliance at documenting VAP prevention practices. In one quarter in 2009, the compliance rate had dipped to 50%. "It wasn't that they were not doing best practices, but the documentation was missing," she Burns says.

Since units were trained and monitored for VAP prevention best practices, the compliance rate has risen dramatically. The neuro/trauma unit has had compliance rates above 90% since July 2010, and the unit has had 100% compliance for the past four quarters, she says.

4. Re-educate and audit staff on the use of oral care products and protocols.

Prior to the implementation of best practices, there were inconsistent practices in oral care for patients. Nurses would document that oral care was performed, but there was no way of knowing exactly what they had done, Houle-Burns notes. The hospital developed an oral care competency with specific care activities to be done every two hours using a two-hour oral care product. The goal was to prevent gaps where oral care was neglected.

"The comprehensive 24 hour system makes it easy to do what they are supposed to and to be able to document it," she says. "The kit has 12 different items to be used sequentially, every two hours. So you take off one item at midnight, and at 2 a.m., you take a second, etc."

Before the oral care competency was developed, nurses often did not recognize the importance of oral care, Houle-Burns says.

"I think people were doing oral care, but some were not using product correctly," she explains. "When patients' mouths are full of secretions and bacteria, there's an increase in the risk of micro-aspirations and colonization, so we just wanted to make sure we were keeping the oral cavity as clean as possible."

When the new oral care protocol was developed, staff leadership rolled out the protocol and competency during their educational Skills Day. This educational session was followed up with monitoring and then additional education, as needed, she notes.

5. Designate separate oral and endotracheal suction set-ups to reduce environmental and hand contamination.

"We had an adapter to allow staff to have a suction set up with a designated oral and an endotracheal suction set up for suction," she says. But Houle-Burns learned the front-line staff did not like using it because it didn't always work well and didn't meet their needs. Their suggestion was that two different suction set-ups be used.

"This was in one of our newer units, and we were able to put two suction set ups designated for the respiratory tract in every room," she notes.

So each ventilator patient now has one closed suction set up for suction of the endotracheal tube and another set up for suctioning the oral cavity. Having two systems reduces the potential for cross-contamination and increased staff satisfaction.

6. Implement transfer procedures for ventilated patients, including subglottic and endotracheal suctioning prior to transfer and maintaining a greater than 30 degree head of bed elevation.

"When we looked at the patient population, we saw that our neuro/trauma ICU patients had more transports off the unit than any other of our ICUs," Houle-Burns says. "Patients leave the unit for diagnostic tests or surgeries. So we asked what we could do when the patients are off the unit or being transferred to ensure we're maintaining best practices."

The solution was to develop transfer policies that included having the endotracheal cuff pressures checked and having suctioning done prior to transport to prevent micro aspiration of secretions with the movement during transporting, she says.

When a patient is on a ventilator and has to be moved to another location, a respiratory therapist and nurse must accompany the patient. "This team work helps ensure best practices and they maintain head of the bed at 30 degrees during transport unless it is contraindicated," she says.