Doctor, don't be a hero: Getting VAP to zero takes teamwork

Giving up a little of his traditional role in ventilator-associated pneumonia prevention has paid off in a lighter workload and better patient outcomes for one hospitalist at Bloomington Hospital in Bloomington, Ind.


Giving up a little of his traditional role in ventilator-associated pneumonia (VAP) prevention has paid off in a lighter workload and better patient outcomes for one hospitalist at Bloomington Hospital in Bloomington, Ind.

The key was recognizing the importance of using admission order sets that included VAP, said Peter Wallskog, MD, lead hospitalist for a four-person unit that's part of a 60-physician multispecialty practice at the hospital. “It sounds simple, but as a physician trained in the ‘cowboy’ model, which involves independence and self-reliance, this represents a major change,” he said.

Using the order sets has saved time formerly used to rewrite long lists of orders and make telephone calls to clarify orders or omissions, he said, plus it reassures patients the hospital is doing all it can to prevent VAP, which occurs in up to 15% of patients who receive mechanical ventilation and is associated with an increase in ICU and hospital days.

When Dr. Wallskog relinquished some of his oversight, he gave it to Vince W. Holly, RN, the hospital's critical care clinical nurse specialist. Mr. Holly, who spearheaded the hospital's VAP initiative in 2005, knew the 355-bed hospital could do better than two VAPs per quarter despite a general lack of physician concern.

So when the Institute for Healthcare Improvement (IHI) included VAP prevention as part of its 100,000 Lives Campaign (), Mr. Holly took action. He created a multidisciplinary team and then went to work on the IHI's somewhat controversial bundle of initiatives. As a result, the hospital has done what some thought nearly impossible—become VAP-free and stayed there for nearly two years.

The ventilator-associated pneumonia team at Bloomington Hospital includes from left Raja Hanania pharmacist Vickie Vandeventer infection control practitioner Derek Fields pharmacist Jody Hill
The ventilator-associated pneumonia team at Bloomington Hospital includes, from left, Raja Hanania, pharmacist; Vickie Vandeventer, infection control practitioner; Derek Fields, pharmacist; Jody Hill, clinical director of the cardiovascular unit; Vicki Phelps, clinical director of critical care; Vince Holly, critical care clinical nurse specialist; Sharon Parsons, critical care educator; LeAnne Horn, director of quality; and Ted Jackson, director of respiratory. Photo courtesy of Bloomington Hospital.

Like other hospitals that have focused on VAP prevention, Bloomington Hospital needed to get creative in how it rolled out changes, consider what other protocols needed to be added and look at the costs associated with putting them into place. But, Mr. Holly emphasized, the most important aspect of getting to zero was collaboration with physicians, respiratory therapists and nurses.

Getting started

At Bryan LGH Medical Center in Lincoln, Neb., a 606-bed two-campus facility, the VAP team includes intensivists, nurses, a respiratory therapist, a pharmacy representative, a physical therapist and a dietitian. When rounding, the team also includes, as appropriate, social workers, case managers and chaplains. “It cannot be one person's job [or] somebody's pet project,” advised Denise Moeschen, critical care data coordinator.

While it's easier to start with people who are already enthusiastic about the project, the IHI and others recommended sharing baseline data on VAP rates and, later, results of improvement efforts—Bryan LGH has seen declining VAPs in its three ICUs, one going 27 months without one—to get buy-in from everyone.

The IHI includes four recommendations in its ventilator bundle:

  1. 1. Elevate the head of the bed between 30 and 45 degrees.
  2. 2. Provide a daily sedation vacation with extubation readiness assessment unless contraindicated.
  3. 3. Provide peptic ulcer disease prophylaxis.
  4. 4. Provide deep venous thrombosis (DVT) prophylaxis.

Each of these measures presents its own set of challenges—and, for the latter two, some debate. Elevating the head of the bed consistently can be difficult because patients are always being turned and staff may get called out for another emergency. “[Correct bed elevation] is harder to do than you think at first,” Ms. Moeschen said. Some hospitals instigate regular checks, say every two hours; others show families how the head of the bed should look so they can notify staff if it's not correct.

Visual clues can help, such as a line or piece of colored tape on the wall that can only be seen if the bed is below a 30-degree angle, a reminder poster at the head of the patient's bed, or even a protractor to show staff what 45 degrees of elevation looks like. At Bloomington Hospital, when Mr. Holly found that two types of beds had inaccurate digital readouts, he brought in a goniometer to help the nurses check on the beds' angles.

When implementing the second recommendation, providing a sedation vacation, St. Joseph's Mercy Health Center in Hot Springs, Ark., made a mistake by not initially including a pharmacist, said John Campbell, executive director. When the staff found that patients were being too heavily sedated, they brought pharmacists on board to evaluate each ventilator patient and came up with a lighter sedation protocol. Bryan LGH coordinates the sedation vacation with respiratory therapists' extubation readiness assessments in the morning so that the data are available when the intensivist rounds at 7 a.m.

Once Bloomington Hospital put weaning protocols into place, it saw it needed to add them to its one-page ventilator order to eliminate separate orders and speed things up. “It takes a lot of weaning work off [hospitalists'] shoulders by having a protocol,” Mr. Holly said.

A controversial bundle?

Although many see the benefits of the IHI's first two recommendations, some say the next two, providing peptic ulcer disease prophylaxis and deep venous thrombosis (DVT) prophylaxis, are not central to VAP and that other, perhaps more important elements, such as oral care, should have been included.

Peter Dodek, MD, said the prophylaxis recommendations, while good ideas, have not been shown to reduce VAP, and noted that IHI did not include other measures specified in guidelines commissioned by the Practice Guidelines Committee of the Canadian Critical Care Society and Canadian Critical Care Trials Group. This set of guidelines, which appeared in Annals of Internal Medicine in 2004 and for which Dr. Dodek was the lead author, included subglottic secretion drainage. An updated version, which will also include use of chlorhexidine mouthwash, will be published this fall, Dr. Dodek said.

The IHI contends that its four recommendations stem from an earlier critical care initiative that included teamwork and communication by focusing on a “bundle” of care elements for ventilated patients and showed declining VAP rates. When VAP was included in the 100,000 Lives Campaign, IHI decided not to mess with success and kept the ventilator bundle intact. That campaign ran from December 2004 to June 2006, and the VAP initiative is now part of the IHI's 5 Million Lives Campaign, which was announced in December 2006.

“We remind people that it's not a VAP bundle,” said Fran Griffin, project director at the IHI. “Physicians asked to implement the ventilator bundle as a way to reduce VAP often argue that the prophylaxis measures do not reduce VAP risk. And they're correct. We included these two items because peptic ulcers and blood clots are two serious complications for which ventilator patients are at risk. The link to VAP is tangential at best, and hospitals have better success with physicians when they acknowledge this.”

The VAP bundle as a whole, Ms. Griffin said, is a way to improve teamwork and communication in the ICU by focusing on high-risk complications in ventilator patients. Also, the IHI said that hospitals should view the recommendations as a group because doing so leads to better outcomes: More than 95% compliance with the initiatives reduced VAP by 61% versus 40% for those with less than 95% compliance.

However, Dr. Dodek, an intensive care physician at St. Paul's Hospital in Vancouver, British Columbia, questioned that notion. “I have not seen any compelling evidence that promoting interventions as a bundle is any better than promoting them as separate components, so I'm concerned about the way it's rolled out—that you need to do all of these things to get credit for doing any of them,” he said. “The spirit of IHI is great, but it's important to get the science right first.”

The IHI encourages hospitals to incorporate other initiatives. Bryan LGH Medical Center did just that, adding oral care every two hours, subglottic suctioning every six hours and as needed and mobilization work with a physical therapist. Bloomington Hospital keeps oral care kits on hooks at the bedside above the cuff suction catheters and also has made oral care part of routine care.

Still in control

The results of VAP prevention efforts can pay off, literally. Each VAP translates into an extra $40,000 per hospital admission, according to the IHI. Plus, success can increase staff satisfaction and, some say, even affect recruitment and retention.

“Getting information back to physicians is key,” said Lynn Cooman, MD, vice president of medical affairs at the 190-bed Mercy Medical Center Merced in Merced, Calif. Otherwise, she said, the efforts can come off as just the “initiative du jour.” When physicians found out the hospital had gone 12 months VAP-free, she said, it was a wake-up call about the initiative's positive effects.

The idea of getting to zero for VAP has changed the landscape of what's possible. When a VAP does occur, it is usually because the patient is particularly high risk and can't have the head elevated or has problems with oral bleeding or reintubation, said Karen Dike, director of critical care services at Bryan LGH. “It's been a cultural change … because now VAP is not seen as inevitable,” she said.

Just seeing the numbers go down has been gratifying at St. Joseph's Mercy Health Center. It had only two VAPs in 2007, an 85% drop, Mr. Campbell said. When Mercy Medical Center Merced had one VAP last January—in a patient who had been in the ICU for four months—staff went through the chart carefully yet found the cause hard to pin down, said Patricia L. Harrison, RN, infection control director. Still, they talked about what could have happened and opportunities for prevention.

It's part of staying on top of VAP prevention, even in the midst of success. “We keep looking at our processes, keep celebrating,” Ms. Dike said. “We went two years [at zero] and now we're looking to do three.”

Paula S. Katz is a freelance writer in Vernon Hills, Ill.

The 100,000 Lives Campaign

The Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign ran from June 2004 to December 2006. This article is the last in a retrospective series examining the campaign's initiatives:

  • Deploy rapid response teams
  • Deliver reliable, evidence-based care for acute myocardial infarction
  • Prevent adverse drug events
  • Prevent central line infections
  • Prevent surgical site infections
  • Prevent ventilator-associated pneumonia (VAP)

For information on IHI and links to tools and case studies on VAP, go to ihi.org.

Tips for success

Here are some tips for improving the way your hospital handles ventilator-associated pneumonia (VAP) prevention from those who spoke with ACP Hospitalist:

Don't let up. Put VAP prevention initiatives in place every day on every shift, some advise. Keep track of data and staff training. When Bloomington Hospital in Bloomington, Ind., initiated its “Zap the VAP” efforts, Vince W. Holly, RN, critical care clinical nurse specialist, rounded on each patient every day to assess VAP initiative compliance.

Make documentation as simple as possible. St. Joseph's Mercy Health Center in Hot Springs, Ark., uses a check sheet with a yes/no portion on one side and space for contraindications on the other.

Start small. The Institute for Healthcare Improvement recommends beginning with one nurse, one doctor and one patient. Next, pilot test the changes in one ICU, test on all shifts and all appropriate ventilated patients and measure results to check for improvement. Finally, make the protocol part of standing orders.

Consider everyone who may be affected. Changing something in a unit can have an impact outside of the ICU. For example, when Bryan LGH Medical Center in Lincoln, Neb., began oral care compliance, they ran out of kits because they forgot to tell distribution. Now Bryan LGH puts VAP prevention in its orientation for everyone from nurses to distribution.

Communicate results in a timely manner. Some facilities update bulletin boards monthly with new data and tallies of VAP-free days for units.

Celebrate success. Whatever the goal, congratulate the unit in person, send notes or food to the unit or sponsor off-site parties. Get local media coverage when you hit the important landmarks, such as one or two years. Talk about results on rounds, in the morning report and in your newsletter.