Hospital Tackles VAP

Vol. 15 •Issue 2 • Page 12
Best Practices

Hospital Tackles VAP

Oral care is an important part of the puzzle.

The respiratory department staff at Overlake Hospital Medical Center, a 337-bed hospital in Bellevue, Wash., wanted to revisit the tough task of reducing rates of ventilator-associated pneumonia.

Back in the late 1990s, they had tackled VAP and were initially successful, saving lives and money, said Terry Smith, RRT, BS, director of respiratory care and EEG services. But over time, their efforts grew lax, and rates crept back up.

Then the Institute for Healthcare Improvement started its 100,000 Lives Campaign, an effort to encourage hospitals to adopt measures proven to improve care and save lives. One of the areas the campaign targeted was VAP. Figuring this was a great chance to recommit to reducing VAP rates, the facility signed on.

The process

Overlake’s VAP strategy centered around a slew of measures, including elevating the head of the bed at least 30 degrees, a daily sedation lightening or “vacation,” peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, glucose monitoring, adequate nutrition, and an aggressive weaning protocol.

An important part of the puzzle was frequent oral care, something not always emphasized in many facilities, Smith said. On a regular basis throughout the day, staff brushed teeth and rinsed mouths with chlorhexidine. Subglottic suctioning also was continuously performed.

These oral care measures had two important goals: one, to decrease the volume and frequency of aspirations, and two, to reduce bacteria if an aspiration did occur.

All these changes needed to be accepted and engrained in the staff. “You need to hardwire,” said Roger Gilbert, RRT, adult respiratory care clinical specialist, who educated staff members and listened to their comments.

Staff hung oral care kits in patient rooms to visually remind clinicians to perform that treatment, and he used checklists on rounds.

The outcomes

Overlake’s VAP initiative started in fall 2004 and saw some impressive results.

In the year prior to the intervention, the hospital had a VAP rate of 18.7 cases per 1,000 ventilator device days. In the 12-month period ending November 2005, that rate dropped to 1.45 VAP cases per 1,000 ventilator device days.

The facility estimated that they saved 29 patients from contracting VAP in that same period. In all, just three cases were reported.

A key aspect of the facility’s efforts was the aggressive weaning protocol, for the quicker patients are taken off the ventilator, the less likely they are to get VAP, Gilbert said. The protocol doesn’t require a physician’s order, so it automatically starts when a patient is ventilated.

Five years ago, patients’ length of stay on a vent averaged five days. Over the years, that rate has steadily fallen, and from January through November 2005, thanks to the aggressive protocol, that rate dropped to 1.44 days.

Add it all up, and the VAP effort saved the hospital $1.4 million during the course of a year.

Finally, the teamwork the effort required strengthened the staff. “It built relationships,” said Jim Fielder, RRT-NPS, neonatal pediatric respiratory care clinical specialist. “We feel we’re better buddies now. It has been good for the hospital.”

The lessons learned

Knowing full well that improvements can easily slip away, the facility is making sure that the new VAP practices remain hardwired. Gilbert is auditing respiratory care charting and the daily rounds performed in the critical care units. “This way I can give immediate feedback to ensure that this practice change sticks,” Gilbert said.

John Crawford is a freelance writer based in Philadelphia.