Driving Down VAP Rates: One Hospital's Success Story

Mercy Hospital in Coon Rapids, Minn., stands out among its peers. The 271-bed hospital, part of Allina Hospitals and Clinics, has nearly wiped out cases of ventilator-associated pneumonia (VAP) among its intensive care unit (ICU) patients.

From left, Pam Madrid, critical care clinical nurse specialist; Michelle Farber, board certified infection preventionist; Kelly Erhart, ICU-RN from the Infection Prevention Clinical Action Team; and Ann Burton, ICU-RN from the Respiratory Clinical Action Team. Not pictured are Larry Bachmeier, Stacy Weldon (IP CAT-ICU RNs) and Lynn Nelson, RCAT-ICU RN. Photo by Patricia Lund, Allina marketing

By Karin Lillis

Mercy Hospital in Coon Rapids, Minn., stands out among its peers. The 271-bed hospital, part of Allina Hospitals and Clinics, has nearly wiped out cases of ventilator-associated pneumonia (VAP) among its intensive care unit (ICU) patients.

Mercy Hospital is among fewer than 150 hospitals nationwide to be designated as a Mentor Hospital by the Institute for Healthcare Improvement (IHI). The IHI granted the designation to Mercy for its success in preventing two types of healthcare-associated infections (HAIs): VAP and central line-associated bloodstream infections (CLABSIs).  IHI is an independent not-for-profit organization that works with healthcare providers and leaders throughout the world to achieve safe and effective care. As an IHI Mentor Hospital, Mercy will provide support, advice and clinical expertise to hospitals seeking help with their own efforts.

In 2003, infection preventionist Michelle Farber, RN, CIC, joined Mercy Hospital just as it was launching its VAP prevention program in its ICU. At the invitation of the hospitals medical director and a clinical nurse specialist in the ICU, Farber helped develop the hospitals prevention program. Mercy Hospital developed a respiratory clinical action team that included clinical educators, two high-performing ICU nurses, a clinical preceptor and critical care clinical nurse specialist. The team met every month and reviewed all charts of patients who were on ventilators.
The ICU teams found that the consistent use of relatively simple procedures, such as brushing patients teeth and frequent handwashing, dramatically reduced VAP, according to a release from Allina Health Care. They also put into practice a concept known as ventilator bundle, a grouping of five low-tech interventions demonstrated to reduce length of time on the ventilator:

All patients received medication to prevent stress ulcers in the stomach and intestines.
All patients received medication to prevent blood clots that can form during inactivity.
The head of each patients bed was elevated to prevent mouth secretions from flowing into the trachea.
Instead of waiting for a physician to make the call, nurses checked every day to see if patients were ready to be weaned from the ventilators.
Instead of removing patients sedation medication all at once, medication dosages were gradually reduced each day, allowing for better neurological examinations.

 We whittled away at the bundle elements, Farber says. The director and manager of the ICU, as well as the units medical director, helped to remove barriers to the projects implementation.

The VAP rates plummeted. When Mercy Hospital first initiated the VAP bundles on its ICU, the hospital reported around seven cases a year. By the next year, that rate dropped to two patients and held steady before it dropped to one. So far this year, the hospital has reported zero cases of VAP for 2011.

We have not completely eliminated cases of ventilator associated pneumonia, but we have gone periods of up to 18 months with zero cases, Farber says. Patients in the ICU are getting more complex.
Since 2004, the hospital has reported 100 percent or compliance with the ventilator bundle protocol (except for 2005 and 2009, where compliance was at 99 percent). That number was 53 percent in 2003, according to the information the hospital posted on the IHIs Mentor Hospital Registry.

The hospitals goal was to wean patients from ventilators as quickly as possible. Respiratory therapists and other clinicians established a protocol and a standard order set to begin early weaning, Farber says.
That protocol is now hard-wired into order sets on the unit, allowing a nurse and respiratory therapist to wean the patient from the ventilator early in the morning. By the time disciplinary rounds started at 10 a.m., that RT and RN could review the weaning process with the team that includes a respiratory therapist, pharmacist, charge nurse intensivist and patient nutrition coordinator.

That practice was very successful, Farber says, allowing the hospital to track ventilator times, as well as intubation and re-intubation rates. Ventilator care is hardwired in order sets creating a documentation trail and feedback compliance.

In addition to the oral care thats given every two hours, patients on Mercy Hospitals ICU have their teeth brushed twice a day with an oral clorhexidine gluconate solution.

Farber offers suggestions to other clinicians who want to follow Mercys example:

Skip the blame. When a patient has any kind of infection, staff at Mercy Hospital look for the source of the problem and how it happened. Well look at the history of the patient, the kinds of interventions that were done and what was happening at the patient at that time, Farber says. The person responsible gets feedback and the opportunity to make improvements. Peer coaching is more important than me telling someone, Hey, you gotta fix this.

Were looking for things missing in the chart or deviations from standard practice, she explains. For example, if the head of the patients bed is not elevated for no documented reason, the team drills deeper to find out what happened.

There has to be some indication in the [notes] that the head of the bed needs to be flat like in the case of a head injury or a patient who is hypotensive, Farber says.

When a patient presents with an infection, staff at Mercy Hospital conduct a mini root-cause analysis, Farber says. Well look at the history of the patient, the kinds of interventions done, what was happening with the patient at that time and look for opportunities for improvement.

That practice, Farber says, helps staff find recommended practices that might have been overlooked, as well as highlighting what interventions were successful.

The information is shared with the nursing staff, putting a face with the number. Extra training can include skills days on the un it, peer-to-peer training or at-the-elbow training, Farber says.

Keep an open culture. The unit displays successes and room for improvement on a corner of a bulletin board or similar location. Even patients and families can seeits open for everyone, every infection in the ICU.

Silos dont work. Infection prevention is a hospital-wide priority, Farber says. One department cant do it alone.
You have to establish good rapport with the infection prevention team. Its not all about that department. You cant move the dots working in a silo, Farber adds.

Find champions in your organization to help you move forward, help remove barriers, Farber says. At Mercy hospital, the medical director is a steadfast champion if its infection prevention program.
Mercy Hospital, part of Allina Hospitals & Clinics, is only one of four hospitals in the U.S. to be awarded an Outstanding Leadership Award from the U.S. Department of Health and Human Services (HHS) for achievements in eliminating two types of hospital acquired infections.
Out of 250 hospitals that applied nationwide, Mercy is the only hospital in Minnesota to earn an Outstanding Leadership Award, the highest level, for eliminating central-line associated bloodstream infections (CLABSI) and VAP.

Out of 2,400 patients who receive care at Mercys intensive care unit every year, there have been no cases of CLABSI for nearly three years and only one case of VAP per year, according to a hospital release.

Karin Lillis is a freelance writer.