How a hospital brought VAP rates to zero

It used easily adaptable tools and steps

No one would argue that ventilators are lifesaving tools for many critically ill patients. But like so much in healthcare, too much of a good thing can be bad. Getting patients off of them is vital in the effort to reduce rates of ventilator-associated pneumonia (VAP), one of the hospital-acquired infections that are the increasing focus of national regulators and payers.

That makes what Mercy Hospital in Buffalo, NY, did all the more impressive: Using easily adaptable tools and steps that led to the reduction in the use of sedation and the amount used with patients, the hospital was able to bring down VAP rates in the intensive care unit to nothing, and keep them there for an extended period of time.

Hospital infections have been on the hospital's radar for a long time, says Linda Horton, vice president for clinical innovations and outcomes at the facility. "The focus came out of the Institute for Healthcare Improvement's (IHI) Million Lives campaign, and we were really energized by looking at the concept of using bundles." Partnering with the Hospital Association of New York State (HANYS), the hospital began studying the tools available and the processes in place.

Increasingly, they were seeing literature that talked about getting to zero, having no events, Horton says. "We wanted to think about that and go in that direction, even though we know that in our industry, there will always be patients who try that idea."

They started by implementing the IHI's VAP prevention bundle, which calls for five steps:

  • elevate the head of the bed — they raise it to 30 degrees;
  • give the patient daily sedation vacations and determine if extubation is possible — these are scheduled daily;
  • peptic ulcer disease prophylaxis;
  • deep vein thrombosis prophylaxis;
  • daily oral care with chlorhexidine — this is done every four hours.

Each of these elements alone is associated with decreased risk of VAP. More in-depth information on the bundle is available at

Respiratory therapists, nurses, and physicians all participated, "taking a dynamic look" at what was in place and what was added, Horton says. The goal was to do every element every time. There was also team rounding, with infection control, respiratory therapists, and nurses who were encouraged to interact with each other and not merely make a report at the bedside.

"We got some positive traction out of that," she says. "Nurses got better bedside tools and things like oral care resources. They tested different products and we got their input on whether something worked better." Being the cheapest product wasn't a guarantee they would use it; being the best was.

They worked on issues such as how to transport patients for MRIs or other tests and how to splint chests so that patients can better clear their lungs and oral secretions so that they can remain extubated. The latter topic drew on the expertise of people outside the ICU: nurses from cardiology.

All of the team members worked together to identify patients who met the criteria for the project. "I think a lot of the improvement stems from the team approach we took," says Patricia Jones, RN, MS, CIC, director, infection prevention and control for the Catholic Healthcare System, of which Mercy Hospital is part. "You can't just go to one discipline and win. You have to have physicians on board, and nurses and therapists. You have to look at each element of the bundle, and it has to be a focused team approach."

Checklists and tools

The team created and continues to use a checklist, as well as a ventilator order sheet. Team members use specific tools related to the use of propofol, and educate appropriate team members on how to interpret Motor Activity Assessment Scale (MAAS) scores.

If something doesn't go right, Horton says they are quick to look at every element of the program: the process, the people, and the tools and resources alike.

If something isn't getting done, why not? If it's related to oral hygiene, is there a lack of oral care kits? Was a patient off the floor and missed a scheduled sedation vacation? One incident involved a therapist who was on vacation. The replacement person didn't document the work on the checklist appropriately. "The work was done, but not documented," she notes. That means they need to do a better job of training of people who don't work regularly with these patients.

Every vent patient's chart is reviewed weekly, she says, and every checklist from every day is evaluated and recorded. There is a dashboard on the unit that shows the unit's performance on implementing the bundle, patient outcome, vent days, and various process steps. If there was a VAP case, infection control would be called in to look at what might have gone wrong and what could be done differently.

If something shows up as a miss on the dashboard, nurse managers investigate, although those cases are fewer over time, Horton notes. Now the team is looking at more complex cases, such as end-of-life patients who have some additional risks, to see if there are things that can be changed or tweaked to ensure the same infection rate successes.

"We are looking to see if there is some other way we can manage those cases," says Horton. "Maybe the pulmonologist can be brought in in a more timely way."

There is always something to learn, she continues. "We had a patient once who had cardiac surgery. He did very well and was extubated in a timely way. But he ended up with more pulmonary and oral secretions and had a really tough time coughing and rebreathing. We had to reintubate him. The challenge was to determine if we did it too early and whether we could learn something. It wasn't too early, because he was stable. But he couldn't manage the secretions because of his sternal wound, even with pain management."

What they needed was a way to better support the wound and a way to train the patient before surgery on how to do what needs to be done. Using a pillow as a brace wasn't working. But a flat-backed stuffed bear, stiff but soft, does. Now, all patients who are having chest surgery have one of those at the bedside, ideally preoperatively if possible, so they can learn to use the bears before they need them.

Looking just at propofol use that extended for more than three days, Mercy recorded a reduction of 77.2% in days on the drug, and 82.2% reduction in the doses dispensed. VAP rates? They've been at zero for more than 18 months now.

Keep teaching

The project was a wild success, but Horton says there are things she would do differently if she started over, including looking at the propofol use in particular earlier than they did. She thinks you should work very hard to get the tubes out of patients as early as possible, and by weaning them off propofol — perhaps using a smaller dose — you can achieve that goal. "I wish we had created a protocol for a sedation vacation earlier," she notes.

If you want to get to zero, you can, she says. Start by tracking your vent days, your sedation use, and your VAP rates. Put up a dashboard so that everyone can see your progress and celebrate the successes. "You have to be patient and persevere. It isn't something you can take your eye off ever. You will have fewer and fewer infections as you get better, but you have to be vigilant. You may not be as hardwired into the daily practice as you think, and you will always have new staff you need to keep teaching."

For more information on this topic, contact Patricia Jones, RN, MS, CIC Director Infection Prevention and Control, and Linda L. Horton RN, MSN, CPHQ, VP Clinical Innovation, Mercy Hospital of Buffalo (NY). Telephone: (716) 828-2066.