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Ventilator-Associated Pneumonia:

Jamie Carson, Ashley Raley, and Patty Whaley Maryville University Ventilator-Associated Pneumonia

Introduction to Ventilator-Acquired Pneumonia (VAP):

VAP is defined as “pneumonia occurring more than 48 hours after the patient has been intubated and received mechanical support” (Koenig & Truwit, 637) The Institute for Healthcare Improvement defines VAP, there is no minimum timeframe of the pneumonia occurrence VAP is noted to be the number one acquired nosocomial infection in the ICU setting Introduction to Ventilator-Acquired Pneumonia (VAP)

Definition of the Problem: VAP:

Statistics the likeliness to get VAP 10-30% risk of death 25-50% even higher mortality rate associated with resistance pathogens as of 2008, Medicaid and Medicare along with most other insurance companies do not cover nosocomial infections cost to a facility ranges $6,000-$ 50,000 Definition of the Problem: VAP


Great significance to patient care Increased hospital stays Muscle wasting, non-optimal nutrition status for healing, potential for kidney dysfunction related to antibiotic therapy Highly likeliness of developing a resistant pathogen Significance

Prevalence and Ideal Benchmark:

Research and major interest sparked in the late 1990s Major Quality Initiative Goal is ZERO prevalence Not a realistic goal, therefore should not be used as a benchmark CDC recommends a benchmark of 1.6 per 1,000 ventilator days One of the biggest problems related to using VAP as a benchmark is related to diagnosis and the disease process itself Prevalence and Ideal Benchmark

Issues with benchmarking:

Lack of consistency in diagnosis Variable Case mix Patient’s age Severity of illness Comorbidities Trauma or surgical status Hospital environment or equipment Immunologic status and condition of oral health Issues with benchmarking

Disease process that mimic VAP:

There are multiple disease processes that mimic VAP Pulmonary Edema Sepsis Acute Respiratory Distress Syndrome Pulmonary Embolism Atelectasis Disease process that mimic VAP

Goals & Objectives:

Goals: Goals should be clear and measurable Short term goals and long term goals for patients Goals communicated with team members Objectives: Head of bed elevated 30-45 degrees Sedation vacations Peptic ulcer disease prophylaxis Goals & Objectives

Buy-in Strategy – VAP Bundle:

Infection Control and Prevention Equipment & Environment Infection Control Patient Positioning Sedation Interruption/Vacation Routine Assessment of Readiness to Wean Routine Oral Care Peptic Ulcer Disease (PUD) Prophylaxis Buy-in Strategy – VAP Bundle

Data Collection: Data Needed:

Specific data that identifies areas within the VAP that lack compliance Steps in data collection process: Identify Population – Ventilator Patients Identify target infection – VAP Specify Time Frame to collect data – 3 mo., 6mo., 1 year Specify number of ventilated days – days patients are exposed to the ventilator Identify specific setting - ICU Data Collection: Data Needed

Data Collection: Data Needed:

Collect data to establish baseline Identify rates of compliance Compare rates to state, regions, or national rates Data collected: Determining compliance rates for interventions Observed performance versus observed opportunities Numerator: # of observed performances (67) Denominator: # of observed opportunities (100) Result: 67% compliance Data Collection: Data Needed


VAP can be drastically reduced Mercy Hospital in Minnesota-ventilator bundle eliminated VAP Ochsner Medical Center in New Orleans- reported a zero VAP rate for 2011 East Jefferson General Hospital in Louisiana-reported a decrease from 2.3 to 1.9 VAPS per 1,000 ventilator days Barnes-Jewish Hospital-St. Louis Missouri has been able to decrease VAP rates from 12.6 to 5.7 per 1000 ventilator days. Analysis

Improvement: Proposed Solutions:

Develop Proposed Solution that is both: Effective in prevention of VAP Cost effective Proposed Solutions: Staff Education Quality Improvement Projects New Protocols or Standardization of Care Joining outside network: 100,000 Lives Campaign Improvement: Proposed Solutions

Selecting a Solution:

Best solution: Quality Improvement Plan Initiation of VAP Bundle Ties together each solution previously described VAP Bundle: Standard of care for most institutions Must haves: P roper guidance from leadership Necessary Data Developed plan to bring about change Supporting Change Model: Lewin’s Change Model Selecting a Solution

Implementation Plan:

Compliance with all healthcare staff Mandatory education classes Evaluations for areas to improve Chart audits for nursing compliance Implementation Plan

Communication Plan:

Good communication is vital Leadership should communicate the following: 1. Inform staff of plan for change and developed method 2. Educate staff and address staff questions/concerns 3. Emphasize importance of why change is being made 4. Support rationale with evidence-based findings End Result: Staff works cohesively to achieve greater patient outcomes New-norm New Standardization of Care Increased compliance Prevention of VAP Communication Plan

Sustaining Change:

Importance of VAP prevention understood by healthcare staff Outcomes prove cost savings Communication and educating are the best way to sustain change Sustaining Change


Detriment of VAP to staff and patients VAP may never be completely eliminated but greatly reduced with simple measures such as: Timed oral care, stress ulcer prophylaxis, elevating HOB, draining condensation for ventilator tubing, early intervention Implementing change Lewin’s change model Discussion


Aardema, H., Dijkema, L. M., Lazonder, M. G., Ligtenberg, J. J., Tulleken, J. E., & Zijlstra, J. G. (2010). Value and price of ventilator-associated pneumonia surveillance as a quality indicator. Critical Care , 14 (1), 403. Bird, D., Zambuto, A., O’Donnell, C., Silva, J., Korn, C., Burke, R., & Agarwal, S. (2010). Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. American Medical Association , 145 (5), 465-470. Cason, C., Tyner, T., Saunders, S., & Broome, L. (2007). Nurses’ implementation of guidelines for ventilator-associated pneumonia for the Centers for Disease Control and Prevention. AJCC , 16 , 28-37. Centers for Disease Control and Prevention. (2013, January). Ventilator-associated pneumonia (vap) event. Retrieved from East Jefferson General Hospital (2009). Nurses driving change: 2009 nursing annual report. Retrieved from Institute for Healthcare Improvement (2010). Overview of the 100,000 Lives campaign. Retrieved from 5MillionLivesCampaign/Documents/Overview%20of%20the%20100K% 20Campaign.pdf References

References con’t:

Institute for Healthcare Improvement (2011, April 26). Ventilator-associated pneumonia (vap) rate per 1,000 ventilator days. Retrieved from Institute for Healthcare Improvement (2012). Getting started kit: Prevent ventilator-acquired pneumonia. Retrieved from Karhu, J., Ala-Kokko, T. I., Ylipalosaari, P., Ohtonen, P., Laurila, J. J., & Syrjala, H. (2011). Hospital and long-term outcomes of icu-treated severe community- and hospital-acquired, and ventilator-associated pneumonia patients. Acta Anaesthesiol Scandinavica , 55 , 1254-1260. Kay, I. U., Ahmed, Q. A., Sax, H., & Pittet, D. (2008). Ventilator-associated pneumonia as a quality indicator for patient safety. Clinical Infectious Diseases , 46 (4), 557-563. Klompas, M., Kulldorff, M., & Platt, R. (2008). Risk of misleading ventilator-associated pneumonia rates with the use of standard clinical and microbiological criteria. Clinical Infectious Diseases , 46 (9), 1443-1446. Koenig, S. M., & Truwit, J. D. (2006, October). Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clinical Microbiology Review , 19 (4), 637-657. Lillis, K. (2011, December 7). Driving down vap rates: One hospital’s success story. Retrieved from Lisboa, T., & Rello, J. (2009). Ventilator-associated pneumonia prevalence: To benchmark or not to benchmark. Critical Care Medicine , 37 (9), 2657-2659. Ochsner Health System (2011). 2011 nursing annual report: Achieving excellence. Retrieved from O’Keefe-McCarthy, S. (2006). Evidence-based nursing strategies to prevent ventilator-acquired pneumonia. Dynamics , 17 (1), 8-11. Safdar, N., Dezfulian, C., Collard, H. R., & Saint, S. (2005). Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Critical Care Medicine , 33 , 2184-2193. Scott, R. D. (2009, March). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes . West Sussex, UK: Wiley-Blackwell. Van Hooser, D. T. (n.d.). Ventilator-associated pneumonia: Best practice strategies for caregivers. Retrieved from References con’t

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