What is Ventilator-Associated Pneumonia? Ventilator-Associated Pneumonia, or VAP, is a lung infection in critically ill patients who require mechanical ventilation to help them breathe. A ventilator is a piece of medical equipment that supports the patient’s breathing by delivering oxygen through a tube that is placed in the patient’s lungs.
Baystate Health (BH) is committed to preventing VAP by ensuring that every patient on a ventilator, both adult and pediatric, receives all evidence-based recommendations that have been shown to reduce the risk of developing a VAP: elevating the head of the bed (HOB) to at least 30 degrees for all adult patients and older pediatric patients; NICU babies HOB should be 15-20 degrees. Additional prevention measures include: sedation vacation/daily assessment of readiness to wean, peptic ulcer disease (PUD) prophylaxis, oral care, and venous thromboembolic (VTE) disease prevention. These recommendations, collectively known as the “ventilator care bundle,” were implemented across BH facilities under the direction of the BH VAP Prevention Collaborative started in 2005. After system-wide review and adoption, the ventilator care bundle was added to our Clinical Information System (CIS) as a nested care set for patients on ventilators. That serves as an electronic reminder for clinicians so that they reliably prescribe best practice interventions. Ordered via the VAP Care Set, healthcare workers can implement bundle measures easily via the electronic medical record. The Care Set was revised in October 2008 to include the addition of chlorhexidine oral rinse twice a day for all patients, without contraindications, over 2 months of age.
Highlights
Baystate Health Ambulance
- Focus has been on improved hand hygiene and use of barrier precautions before and during patient transport.
- BHA has adopted:
- preemptive suctioning prior to position change
- using a closed suction system as appropriate
- elevating the head-of-bed as tolerated by the patient’s condition to prevent aspiration during transport (100% compliance with 30 degree requirement)
- BHA has added transport ventilators (LTV 1000) to ambulance equipment and has trained paramedics in its use to prevent transported patients from aspirating when mechanically ventilated.
- Since the addition of the LTV 1000, < 1% of transported ventilator-dependent patients require a respiratory therapist to accompany them, down from 30% prior to its use.
- To date, there have been no know VAP cases resulting from our transport of ventilated patients.
Baystate Medical Center
- BMC utilized VAP prevention recommendations across all areas where patients receive mechanical ventilation, and compliance with the bundle remains high. Focus has been on improved oral hygiene, head-of-bed elevation, and prevention of aspiration. The Springfield 1 Unit celebrated 1,201 days without a VAP, engaging staff, patients, and family in VAP prevention.
- Collaboration between our bedside care and healthcare quality staffs has helped to decrease VAP. VAP Prevention Rounds were included as part of bringing best practice discussions to the bedside with the Directors of Infection Control, Performance Improvement, and the manager of Respiratory Therapy rounds on ventilated patients, speaking with care providers about evidence-based practice and barriers perceived in implementing them. Bedside care staff feedback has been very favorable, glad to have the experts discuss care with providers at the bedside, out of the conference room setting.
- “TAP VAP” was implemented to prevent transported patients from aspirating when mechanically ventilated. This is a collaborative effort between respiratory therapy and the bedside nurse.
- The Surgical ICU has adopted early ambulation for ventilated patients, getting eligible patients up to the bedside chair as part of care innovation to prevent complications in the ventilated patient.
- The Mini Bronchial aspiration specimen collection (known as a MiniBAL) is in place, assisting in identifying the organisms that cause pneumonia to aid in diagnosis and treatment, as well as to prevent antibiotic overuse.
- Daily assessment of need, along with overall reduction in ventilator days have contributed to decreasing VAP rates for NICU, PICU and Springfield 1. All these units have had prolonged periods of more than a year without a case of VAP.
- Bedside rounds in 2011 identified opportunities with irrigation and suction clearance, reinforcing best practices with sterile water and impacting a change for patient safety.
- Currently, engineered endotracheal tubes with intermittent subglottic suctioning is being considered for the cardiac surgery population.
Baystate Mary Lane Hospital
- BMLH continues to have a 0% VAP rate since 2007.
- All critical care staff are provided with continuing education in VAP prevention during annual Competency Days.
- The ventilator care bundle documentation is online in the ICU nursing documentation flow sheet.
Baystate Franklin Medical Center
- Focus has been on improved documentation of the VAP bundle.
- Ongoing review of compliance with the evidence-based best ventilator care bundle occurs at critical care service line team with a focus on improved oral hygiene, head of bed elevation, and prevention of aspiration.
- BFMC has had two cases of VAP in the past 4 1/2 years.
- Cases of VAP are discussed with the Critical Care Service line team and a potentially preventable review is done to identify gaps in best practices and to determine opportunities for improvement. Additionally, a root cause analysis is performed if an increase in rate is noted.
Baystate Home Infusion & Respiratory Services
- A multidisciplinary group developed best practice care sets for the prevention of VAP and adapted the CDC’s guidelines for VAP reduction for homecare use.
- Focus was placed on improved hand hygiene before patient care.
- Education was provided to caregivers on:
- providing oral care at set time intervals
- elevating the head-of-bed to prevent aspiration
- suctioning prior to position change
- using a closed suction system
- appropriately using metered dose inhalers vs. wet nebulized medication within the ventilator circuit
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