OUR LADY OF LOURDES MEMORIAL HOSPITAL Binghamton, New York

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OUR LADY OF LOURDES MEMORIAL HOSPITALBinghamton,
New York

• Reducing Complications From Ventilators in ICU
  Ventilator Associated Pneumonia (VAP)

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Our Lady of Lourdes ICU Team
Our Lady of Lourdes Hospital is a 267 bed acute
care, community, not-for-profit healthcare
facility which provides a full spectrum of
inpatient, ambulatory and emergency services. Our
pilot unit is a ten bed medical surgical
intensive care unit.

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Our Team and Goal

• We have a multidisciplinary team that meets
  weekly. We began meeting in 11/03.
• Representation includes Administration, Quality,
  Nursing, Pharmacy, Care Management, Respiratory
  Therapy, Nutrition, Rehabilitation Services,
  Infection Control, Medical Staff, ICU Staff.
• Goal to increase the number of days between VAP
  to greater than 180 days.

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Ventilator Associated PneumoniaVAP

• VAP is a pneumonia that develops gt 48 hours
  following intubation.
• VAP increases hospital cost per episode as much
  as 20,000, and hospital length of stay as much
  as 14 days. (Archives of Internal Medicine
  19911511109-1114)
• VAP increases mortality.

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Bundle Concept

• A "bundle" is a group of interventions related to
  a disease process that, when executed together,
  result in better outcomes than when implemented
  individually.

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Ventilator Bundle

• All or None Concept
• All components of the ventilator bundle must be
  performed on each ventilator patient to be
  compliant. If a component is contraindicated, and
  all other components are performed, the bundle
  can still be considered compliant.

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Ventilator Bundle

• Head of Bed gt 30 Degrees
• Deep Vein Thrombosis (DVT) Prophylaxis
• Peptic Ulcer Disease (PUD) Prophylaxis
• Sedation Vacation
• Daily Assessment of Extubation Readiness

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Ventilator Bundle Rationale

• Head of Bed gt 30 degrees
• To reduce the frequency and the risk of
  aspiration
• DVT Prophylaxis
• Mechanically ventilated patients are at
  significant risk for DVT due to limited mobility
• Peptic Ulcer Disease Prophylaxis
• Critically ill patients requiring mechanical
  ventilation are at a higher risk of developing
  life-threatening upper gastrointestinal mucosal
  erosions and hemorrhage.

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Ventilator Bundle Rationale

• Sedation Vacation
• Daily interruption of sedative drug infusions
  decreases the duration of mechanical ventilation
  and length of stay in ICU. Sedation vacation is
  defined as
• Sedation held for equal to or greater than 12
  hours
• 
  or
• Until patient follows commands at least once
  during the day
• or
• Patient follows commands without sedation being
  held.
• If sedation is restarted, attempt dose that is
  half of previous dose
• Daily Assessment of Extubation Readiness
• Daily screening for liberation from the
  ventilator, followed by trials of spontaneous
  breathing can reduce the duration of mechanical
  ventilation, decrease complications and costs of
  ICU care.

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Testing the Ventilator Bundle

• Start Small!
• Begin with one ICU RN, one patient, one
  Respiratory Therapist and one physician.
• Make changes as appropriate based on the initial
  test.
• Add one more RN, patient, and RT.
• Continue to make changes as appropriate and
  continue to add RNs, patients, RTs and physicians
  until the entire population is included.

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Monitoring the Test of Change for Improvement

• When we began, we measured the entire ventilator
  bundle, as well as each component of the bundle.
• This enabled us to identify which components were
  not being performed and we could focus our
  efforts to improve compliance.

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Barriers

• Staff felt this was more paperwork.
• Medical Staff did not really understand what a
  bundle was.
• Monitoring and documentation of the monitors was
  inconsistent.
• Empowering staff to emphasize importance of
  compliance with ventilator bundle with medical
  staff.
• Daily assessment of extubation readiness.
• Respiratory Therapists uncomfortable with
  initiating weaning protocol

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Strategies to Improve Compliance with Ventilator
Bundle

• Every staff member was held accountable for
  monitoring and documentation.
• Nurses were empowered to understand
  accountability for lack of practicing evidenced
  based care.
• Implemented daily multidisciplinary rounds which
  allowed for immediate assessment of compliance
  with ventilator bundle.
• A round table meeting was held with nurses, team
  leader, respiratory therapists and
  pulmonologists. Evidence based information was
  provided and the team discussed it until it was
  resolved.

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Successes

• ICU Team, ICU staff, and Pulmonologists educated
  on ventilator bundle and rationale
• ICU Team developed a ventilator bundle monitoring
  tool
• Incorporated ventilator bundle into pre-printed
  physician orders for mechanical ventilation
• Incorporated ventilator bundle into ICU nursing
  flow sheet
• Began testing small, made changes as appropriate,
  and continued to test until entire ventilator
  patient population included
• ICU staff monitor compliance with ventilator
  bundle every shift
• Implemented multidisciplinary rounds for all ICU
  patients
• Developed a Respiratory Therapist driven Weaning
  Protocol, which was approved by the
  Pulmonologists
• In the event of a VAP, ICU Team performs case
  review

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Results
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Results
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Results
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Next Steps

• The 3 VAPs that occurred after the stretch of 290
  days between VAPs, were reviewed. 2 of the 3
  patients were surgical patients, and elevating
  the head of the bed was contraindicated. The
  ventilator bundle was followed except for this
  component.
• Team is researching the CASS Endotracheal Tube
  Continuous Aspiration of Subglottic Secretions.
• The CASS endotracheal tube is recommended by the
  CDC as a strategy to prevent VAP.

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VENTILATOR BUNDLE MONITORING TOOL SHIFT TOTAL
VENT PTS
DATE RM PT INITIALS HOB 30 DVT Prophy. PUD Prophy. Sedation Vacation Daily Assessment Extubation Readiness PERFORMED ON DAY SHIFT








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ICU Monitoring Tool Date _________ Shift ____
Census _____ Vent Census ______ Key ()
completed (-) not done (n/a) not applicable
(contra) contraindicated (EOB) edge of bed
RM Pt Init Rounds with Daily Goals Vent Central Line CL CL Daily Necessity assessed Foley HOB 30 DVT Prophy PUD Prophy Sed Vac 7-3 Assess Ext.Ready DAY-SHIFT Blood Sugar (BS) If Hospitalist pt and BS gt150 is pt on glucose protocol Oral Care q 4 h Mobility RN Init
1 - - - - - - contra - contra - contra n/a - contra - contra n/a - - ROM EOB chair ambul
2 - - - - - - contra - contra - contra n/a - contra - contra n/a - - ROM EOB chair ambul
3 - - - - - - contra - contra - contra n/a - contra - contra n/a - - ROM EOB chair ambul
4 - - - - - - contra - contra - contra n/a - contra - contra n/a - - ROM EOB chair ambul
5 - - - - - - contra - contra - contra n/a - contra - contra n/a - - ROM EOB chair ambul