Contraction of ventilator-associated pneumonia (VAP) in the ICU used to seem inevitable, but each year healthcare workers become more cognizant of the fact that VAPs are largely preventable and are almost always unacceptable. Fortunately, as the philosophy changes, so do habits.
Several VAP prevention guidelines exist and have led to positive changes at facilities across the nation. This evolution is happening not a moment too soon as ventilator-associated pneumonia is the most common hospitalacquired infection (HAI), tacks an average of 4.3 days onto a patients stay, and costs between 5,800 and $20,000 per incidence. Worst of all, mortality rates are from 20 percent to 70 percent.² In the paper, Best-practice protocols: VAP prevention, researchers from the Centers for Disease Control and Prevention (CDC) state that in order for a condition to be diagnosed as a VAP, the patient must have been mechanically ventilated for more than 48 hours and exhibit at least three out of the five following symptoms: fever, leukocytosis, change in sputum (color and/or amount), radiographic evidence of new or progressive infiltrates, and worsening oxygen requirements.
TRANSFORMATION OF THE ICU (TICU)
Healthcare facilities have several options when it comes to choosing VAP prevention guidelines and while each plan has pros and cons, the common benefit is that these guidelines systemize a myriad of steps that could otherwise be easily overlooked.
Organization is key and is an integral part of the Transformation of the ICU (TICU) program, says Denise Moeschen, RN, CCRN, at Bryan LGH Medical Center in Lincoln, Neb. TICU offers research, resources and guidelines to interested facility leaders and is a program of VHA Inc. VHA (which is not an acronym) is based in Irving, Texas, and is a healthcare provider alliance of more than 2,400 not-for-profit healthcare organizations. In 2001 VHA launched its TICU program and since then 47 hospitals that represent more than 76 ICUs have participated.
Without it being systematically checked, there are so many variables that can come into play on any given day for any number of days, Moeschen says. The staff at Bryan LGH has participated in the TICU program since 2003 and recently celebrated two years VAP-free in its med-surgical ICU.
If your patient maybe became very critical or the patient in the next room becomes very critical and youre pulled away, without the standardization and checks and balances where everyone involved is all looking at the same stuff (mistakes can be made), Moeschen says.
Accountability is extremely important, and can be supported by frequent surveillance. Once a week on a random day between roughly 8 a.m. and 10 a.m., Moeschen walks around the unit and checks each ventilated patient.
Is the head of bed elevated, did they have their sedation vacation, is their glucose controlled? she asks. TICU authors assert that this information should be collected weekly.
The data quickly showed that the Bryan LGH team wasnt performing as well as some staff members presumed. Instead of keeping the heads of beds raised at 30 degrees as TICU requires, the team was generally angling the beds around 20 or 25 degrees. The drive to improve, however, was present. The team initially was around 50 percent compliant when it came to elevating the head of the bed properly, Moeschen says, but is now above 90 percent compliant.
This move and many others are important, yet simple, says Kevin Barcelos, RN, who has worked at Community Regional Medical Center in Fresno, Calif., for eight years. His facility saw a 30 percent reduction in VAP rates during the first year of TICU implementation.
So much of it is extremely basic nothing that is rocket science, Barcelos says. Its stuff were doing everyday, but what the TICU program does is they bring in a lot of tools and resources for you. They help you get the program up and running and theyre there to support you and help you along the way.
There are lots of peers that we have now been able to network with across the country and to commiserate with about what has worked and hasnt worked, he adds. We can learn from other peoples successes and failures and we dont have to reinvent the wheel or start from scratch.
One of the most helpful aspects of the program, he adds, is TICUs share and learn secure online database that offers policies, forms, presentations and forums.
The main VAP prevention tips that VHA recommends are as follows:
1. Evaluate current infection rates
2. Identify evidence-based practices via literature and case studies of other healthcare organizations
3. Investigate how often and effectively staff members are washing hands and using hand sanitizer
4. Create checklists to ensure that processes are being done every time with every patient
6. Implement ventilator bundle guidelines
7. Educate staff and stakeholders about infection prevention
8. Prove to stakeholders that infection prevention reduces cost
9. Collect data that shows progress as well as areas that need improvement
10. Strive for accountability by returning data to stakeholders4
Individual components of TICU and other VAP-prevention systems are vital, but using them in conjunction with each other is even more important and will lead to significantly better outcomes, according to the Institute for Healthcare Improvement (IHI), a non-profit organization that strives for healthcare improvement throughout the world.
The key components that should be monitored in the ventilator bundle are:
- Head of the bed elevation level
- Daily sedation vacations and assessment of readiness to extubate
- Peptic ulcer disease prophylaxis
- Deep venous thrombosis prophylaxis4
The bundle is a prime combination of tools, says Terri Gingerich, RN, BSN, CCRN, the director of VHAs TICU program. Every patient every day is assessed for weaning, because we know that if we get them off the vent sooner they have less chance of getting a VAP, she says. Every patient every day has their sedation decreased (once) to the point that they can follow commands because if their sedation is controlled and theyre not under sedated or over sedated, we can more easily get them off the ventilator.
The head of the bed intervention is fairly straight forward, Gingerich says, but even that can be difficult to implement when staff members are busy and/or stubborn. Gingerich was the critical care unit educator and TICU project manager at Porter Memorial Health System in Valparaiso, Ind., and saw firsthand the ups and downs of implementing the program.
We did meet resistance initially, Gingerich says. Most of it just related to the fact that the nurses werent so sure that doing these relatively simple interventions and bundling them was going to make a difference.
We decided that we would start with head of the bed elevation because it would be so easy, and we soon found out that it wasnt easy as we thought, she says. Theres a misconception that the head of the bed is at 30 degrees when actually it was elevated maybe only 20 degrees. The nurses feared there would be some scooting down and would be uncomfortable, and that the family members wouldnt like it.
Some pioneers, however, provided hope.
There were people who were early adapters, Gingerich says. It took six months of repeated discussions about it and bringing it forward at each of the unit meetings and showing them the data.
As for the team at Community Regional Medical Center in Fresno, bundle progress has been steady. When the team started the TICU program they were about 30 percent compliant with the ventilator bundle and are now above 90 percent.
Ultimately the goal is 100 percent, Barcelos says, but 100 percent is hard to get all the time.
The one good side to high VAP rates is that theres plenty of room to improve, as several facilities have found. Community Hospital East in Indianapolis, Ind., for instance, has gone 25 months without a VAP in the critical care unit¹ and other ICUs in the system are close to going two years without a VAP, according to Theresa Murray, RN, MSN, CCRN, a critical care clinical nurse specialist.
We feel like were the gold standard when it comes to preventing VAP, she says.¹
At Kaiser Permanente Bellflower Medical Center in Bellflower, Calif., the team there has only seen one case of VAP in more than two-and-a-half years.³ This success is largely due to adherence of bundle guidelines, says Margaret Thompson, RN, MSN, CPHQ, in a 2007 IHI progress report.
Another important factor is the units intensivists, she says.
Its not just the ICUs leaders who are preventing VAP, Thompson says. There is a commitment on everyones part, the doctors, nurses, respiratory therapists, every member of the team. Everyone takes a great deal of pride in doing the best they can, in delivering care that is effective and safe.³
Data measurement and evaluation is the cornerstone of any good VAP prevention system and should be enacted early, according to Gingerich. This data can drastically alter how staff members view their work.
For years we had the misconception that once you were placed on a ventilator, the risk of pneumonia just kind of went along with it and that we were powerless in that prevention, but I think we have learned through programs such as TICU that we are able to prevent VAP, Gingerich says. With the TICU program we really look at measures that have the strongest evidence that are feasible for our teams to implement and through that we can make a direct correlation that these measures do indeed decrease (VAPs), she adds.
There are a lot of organizations that prior to joining the TICU team say, Oh we do all that but our VAP rates arent where we need them to be, but once you start measuring, you realize there is a big difference between what your perception of your performance is, and what your performance actually is, she adds.
Scoreboards arent just for sporting events. They are an integral part of staff training and accountability.
Weve given this responsibility to the frontline staff to keep their patients safe and to provide all these high tech, complicated interventions that were doing but weve never really given them a scorecard and the feedback to say, This is what youre doing and this is how its affecting your patients, Gingerich says. Healthcare workers want nothing more than to keep their patients safe, but their perceptions arent (always) valid and they need the ability to get feedback on their performance.
Since intervention can often seem like one more item on a never-ending to do list, it is important to provide motivation in any way possible, even in the form of healthy competition.
What we did was said, This is how were doing, and this is how the nation is doing, Gingerich says. This was the first time theyd ever seen their VAP rates and this isnt unusual in ICUs the data gets collected but never gets back to the people who can affect it At Porter, the day we showed them their data it was the most exciting day.
The teams scores were average much to the dismay of its members, all of whom wanted to strive for higher standards.
All the sudden they were like, Were not an average ICU and we dont want to be an average ICU we want to be an A-plus ICU, Gingerich says.
Sure, change sounds nice, unlike two little words that Barcelos uses to describe the early days of the TICU program at his facility: near mutiny.
He is only half kidding.
They were very skeptical and hesitant, Barcelos says. Healthcare and a lot of industries seem to be very cyclical sometimes. You do something and then a couple years later you undo it and then a few years later youre doing it all over again.
Barceloss team started working on reducing its VAP rates (without TICU) in 1999, met mild success, and then hit a wall.
We had been able to bring it down but we had kind of settled in this range where regardless of what we did, we couldnt get it any lower, but we were actually happy with that, Barcelos says.
We thought we were doing a good job but when this program came along and we started it, people were skeptical that we werent going to be able to do it, that it was too good to be true, that is was just another thing someone was jumping on the bandwagon on, he says. But what we said was, Lets try it and see where it goes, we cant lose. Just into it for a few months we started seeing the results almost immediately and the staff bought into it. We told them too, Even if we only prevent one case of ventilator associated pneumonia, thats one patient.
And with that, the culture of the Community Regional Medical Center staff was changed. A similar evolution happened with Gingerichs team at Porter.
Once we really transformed the culture to being a data driven culture, the nurses responded to that immediately, Gingerich says.
By giving them feedback on their performance, and the data, they will tell you what needs to be done, she adds. Once they have that accountability and that empowerment, they make the changes, theyre the drivers, theyre the protectors of their patients. It doesnt matter if its a neighboring rooms patients, theyll still make sure the beds are up. Because when you get that ownership and that empowerment, its pretty powerful. It feels good to them.
Its possible that team members almost care too much, as they can be very hard on themselves if a VAP case does occur.
I talked to the project managers pretty frequently and what we used to think of as a side effect of being on a ventilator that we accepted and tolerated for years (is no longer accepted), Gingerich says. When these teams have a VAP the project managers have to go out and almost have a little pep talk with their teams, because they grieve it. Theyve seen that (TICU) works, that this cannot only save lives and money, but that staff is happier and the patients and families are happier. Its effective.
For Moeschens team, the beginning was a little rough.
Its been hard to try and get so many different people in so many different places to do the same thing and to attach the same value to it, she says. But that was at the time when we were still meeting some resistance. If I sit back and look at it now, Im amazed at how easy it was.
One of the main reasons that the process became easier is that as people left, their replacements were trained on bundle guidelines from the very beginning. Eventually, the staff reached a tipping point where the culture supported strict adherence.
Moeschens team members redecorate a bulletin board every month to reflect how many days the team has gone without a VAP, and there is a direct correlation between high numbers and big smiles.
They see that number climb on a daily basis and they get excited, she says. Since its grown and grown they kind of think, Look at what weve done, we cant stop now.
ICU nurses are very possessive of their patients and would defend them to the death and their pride in their work when we approached the one year point came to, Well were not going to get a VAP in this unit and were certainly not going to get a VAP in my patients room, Moeschen adds.
Everyone just got into delivering the best care. Theyve gotten good at identifying the higher risk patients and being very aggressive with their therapies.
The success leads to better team building, and that team building leads to greater success. The cycle, Moeschen says, is wonderful.
Lengthy strides would be impossible though, without the teamwork and dedication of the frontline staff.
There are those of us who work in offices and collect data and develop educational inservices, but were not the actual ones at the bedside making sure that all these things get done, she adds.
When Moeschens staff members move to other facilities, they frequently are appalled at how much lower the VAP prevention standards are than at Bryan LGH, she says.
Every facility should want to reduce VAPs not just for humanitarian reasons, but for financial reasons too, according to Barcelos. In its first year of TICU compliance, Community Regional avoided $850,000 in VAP-related costs. Incredulousness and competing priorities were challenging but did little to impede progress.
The intrinsic value of a job well done is hard to top, but a good party or slab of cake helps too. Its essential to celebrate success whenever possible, Moeschen says.
We are very excited (about our progress) and we do celebrate along the way, she says. We do little things like bring a cake or cookies, and we do big things.
In March of 2007, when one of Bryan LGHs ICUs was celebrating its second VAP-free year, the staff enjoyed a whole week of mini festivities that started with a celebratory breakfast.
There are a lot of things that the nurses and the respiratory therapists and everyone else whos involved with this are expected to do on a daily basis, so if we dont take the time to say, Hey youre doing this really well, then it sometimes falls into the background and they start losing sight of how important it is to do these things, Moeschen says.
Barceloss staff receives candy and other novelties as progress is made, and at one particular milestone they ordered a cake with an edible picture of their improving VAP rate chart.
Proper oral hygiene goes a long way in protecting ventilator-assisted patients and more facilities are understanding that, says Gingerich.
In my opinion, in combination with the evidence that already supports the correlation between oral hygiene and VAP reduction, we have seen with our teams and heard testimony with our teams that there is a correlation, she says. (At Porter) the nursing staff felt very strongly that (oral hygiene) had a huge impact on the VAP rates. We were very easily convinced that that was an important measure. You could really see the effects of that.
Many good VAP-prevention oral hygiene products are on the market, but some facilities are still using low-tier products that are more complicated to use than necessary, Gingerich says.
Sage, on the other hand, provides simple solutions, she believes.
I think the thing that Sage has really nailed is that in order for people to be compliant I think this holds true to all the interventions that weve worked on through the TICU program you need to make it easy and convenient and as easy as you can for them to be compliant, she says. Theyre incredibly busy people and we ask them to do so much. They are the warriors out there trying to keep their patients safe and we just need to provide them with the tools to do that.
Well before TICU was implemented Gingerichs team provided oral care, but not systematically and not effectively.
The practices were all different, everyone was kind of just doing their own thing, she says. There was no process around it, so now were saying, Here are the tools to do it, and heres how often to do it, and every patient gets this type of care, every day. Once you put a process around it and they see their VAP scores drop, they make that correlation. Instead of (organized oral care) becoming one more thing to do, it becomes absolutely a very important thing to do.
Bundle guidelines are essential, but the proper tools and products to support this process are also paramount, says Suzanne M. Pear, RN, PhD, CIC, a healthcare epidemiologist for Kimberly-Clark Health Care.
Having the proper equipment is the infrastructure upon which these (bundle) practices depend, Pear says. For example, using closed suction system for tracheal suctioning helps the healthcare worker (HCW) provide cleaner, safer tracheal suctioning. Using an endotracheal tube which minimizes subglottic secretion aspiration reduces aspiration risk. Having an oral care system available which makes providing oral care easier and safer will encourage and allow the HCW to provide better oral care. The best products and the best processes of care are inextricably linked to best outcomes.
Do most facilities have the adequate tools?
I would like to think so, Pear says. Often times though, innovative, best practice products may be difficult to adopt in certain facilities because the focus of the administrative and purchasing executives is on the additional up-front costs attached to these practice and product changes.
The solution, according to Pear, is for the infection prevention specialist in a given facility to present the business case for VAP and other HAI preventions.
Since Medicare reimbursement for VAPs is so low, a facility that prevents even one case of pneumonia could more than recover whatever additional costs may be incurred by providing best care practices and best equipment, she adds.
One product developed to fight VAPs is Kimberly-Clarks Microcuff Endotracheal Tube, an airway management device that is designed to reduce leaks of potentially infectious secretions into the lungs. Secretion leakage past the cuff micro-aspiration is considered a leading cause of VAP, company literature states. The Microcuff seal is made from micro-thin polyurethane.
A VAP-prevention product meant for oral or nasal intubations during critical care or long-term applications is the Mallinckrodt® Hi-Lo evac endotracheal tube with evacuation lumen from Tyco Healthcare Nellcor. The integral suction lumen aims to allow continuous aspiration of the subglottic space above the ET tube cuff without risking trauma to the vocal cords. The tubes suction pooled secretions that otherwise could contaminate the lower respiratory tract.
Company literature claims, studies have documented that use of the Hi- Lo Evac ET Tube in place of standard ET tubes has reduced the incidence of VAP by up to 75 percent.5
Considering that products such as these are widely available and that clear research is only as far as the nearest computer, is any case of ventilator-associated pneumonia acceptable?
No, its not, Moeschen says. I think that there are enough cases of success right now to kind of blow away the old thought that its inevitable, she says.
People used to think, Youve got patients on ventilators, they are going to develop pneumonias, Moeschen adds. Youve heard the stories that Grandpa went into the hospital and surgery went real well but then he got a pneumonia? Well, we just dont want to have that here.
The average HCW cares immeasurably for their patients, but after implementation of effective VAP-prevention guidelines the work ethic of most employees gets even better, according to Gingerich.
The hallmark of success for the TICU teams is that they transform the culture so that any harm to their patient is unacceptable, any negative effect of any intervention they do is unacceptable, she says. Instead of just saying Yeah, Im punching in and out, and Im coming into work, its not about that. Its about, When I come here, I can make a difference.
A difference that matters for an innumerable amount of grandpas, and other patients.
1. Community Hospital East goes 25 months without a VAP in the critical care unit. IHIs 2006 progress report: www.ihi.org.
2. Evans B. Best-practice protocols: VAP prevention. December 2005, Vol.36.
3. Kaiser Permanente Bellflower Medical Center has only one case of VAP in two-and-a-half years. IHIs 2007 Annual Progress Report: www.ihi.org.
4. VHA Inc. website: www.vha.com.
5. Valles J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med. 1995.