VAP | Four years ago, the Neuro Intensive Care Unit at University of Colorado Hospital began a drive to reduce the number of patients that contracted ventilator-associated pneumonia, or VAP, a preventable condition that many health care providers at the time nonetheless considered a risk that couldn’t be avoided.
The work began in 2009 as a unit-based project for Neuro ICU nurse Meredith Snyder, RN, who was pursuing certification as a level III clinical nurse through UEXCEL, the hospital’s professional development program for nurses.
Snyder learned that the unit’s VAP rate was 8.5 per 1,000 ventilator days, well above the NDNQI (National Database for Nursing Quality Indicators) benchmark of 3.1. She set out to pull together evidence-based practices that help prevent VAPs and roll the guidelines out to nurses in an organized program.
Programs can sometimes take time to yield results, and Snyder’s effort was no exception. But through late January 2013, the Neuro ICU had gone 18 months without a VAP case – as have the Cardiac and Burn/Trauma intensive care units. The Surgical ICU has gone 15 months without a VAP; the Medical ICU has gone 12.
The primary beneficiaries, of course, are patients who have been spared life-threatening infections that require extensive antibiotic treatment and extend their hospital stays. For hospitals, a single VAP typically costs $40,000 to $60,000 to treat – and the Centers for Medicare and Medicaid Services doesn’t pay for the care required to treat the infection.
VAP slap. The VAP-reduction effort was hardly a one-nurse show, Snyder quickly points out. When she began her project, for example, she drew on the work of her nurse manager, Kathi Waite, RN, CCRN, and research nurse scientist Mary Beth Makic, RN, PhD, who had emphasized the importance of oral care with teeth brushing and elevating the head of the patient bed to at least 30 degrees as keys to preventing VAPs.
Snyder extended training beyond nursing staff. She held in-services for certified nursing assistants, using mannequins to demonstrate how to administer care. The idea was to encourage VAP-prevention efforts among all team members.
As she continued her work, Snyder also collaborated with respiratory therapists, infection control specialists, informatics specialists, and of course other nurses to embed preventive practices in the units.
“The focus we had was to educate,” said Snyder, who joined the Neuro ICU in 2005. “The approach wasn’t punitive; it was to provide constant reminders to nurses.” The teaching tools included posters, bedside education and rounding the unit to observe care provided to ventilated patients.
Among the VAP prevention measures Snyder and her colleagues stressed:
Administering oral care, including inspecting the oral cavity, brushing, rinsing and suctioning
Elevating the head of the bed 30 to 45 degrees to prevent bacteria-breeding secretions from pooling
Keeping the tracheal cuff pressure high enough to prevent micro-aspiration of secretions without damaging the trachea
Documenting the care consistently in the medical record.
The idea was to remind nurses to treat each step as part of a “bundle,” or a group of practices that together have more preventive power than any one has individually.
“We gave friendly reminders,” Snyder said, “and we constantly re-educated so that it was always in the front of the brain.”
Spread the news. In 2010, the Neuro VAP initiative spread to the rest of the hospital’s ICUs. Snyder worked closely with Makic, Respiratory Services leaders Allen Wentworth, Mark Merritt and Jerome Piccoli; Infection Control practitioner Linda “B” Burton; and representatives from each of the ICUs.
In this second phase, nurses in each unit continued bedside rounding and education, but respiratory therapists also put audits in place to check head-of-bed elevation. Vivienne Smith, RN, then of Nursing Informatics, developed a database to store documentation to measure compliance with the bundle.
In addition, Snyder investigated oral-care systems that might make it easier for busy nurses to take care of that step. She found a 24- hour oral care system that includes a Yankauer tube for suctioning; toothbrushes and swabs; and chlorhexidine oral rinse. She shepherded it through a hospital product committee, making the case that the more expensive unit was justified because it would help to prevent VAPs.
The system, which hangs on the wall of the patient’s room, supplies 24 hours of oral care via six individual packs – enough to cover each four-hour cleaning period. A new set is placed in the room every 24 hours, allowing staff to monitor for compliance, Waite said.
Even as she saw VAP rates plummet in her unit, however, Waite was nervous. In May 2012, the Neuro began to hire many more nurses in preparation for the unit’s move to a much larger space in the new tower. In a matter of months, the number of nurses jumped from 32 to 66. The total includes eight new traveler nurses.
“I had a huge concern in doubling the number of nurses,” Waite said. “I worried the practices we had worked hard to perfect would suffer while new staff went through orientation and learned the standards. I also feared compliance would suffer and we would see our VAP infection rate rise.”
That hasn’t happened, a sign that the practices Snyder helped to instill have taken a deep hold, Waite noted. Snyder put together a refresher packet of prevention practices and met with each staff member to sign off on their education. Lorrie Kromka, RN, a Neuro ICU charge nurse, helped to re-educate night staff.
“Nurses and other team members have stepped up and done the things they need to do,” Waite said.
Sitting with a binder stuffed with data from the original UEXCEL project, Snyder reflected on the long road it followed.
“The work we did shows we deliver a high standard of care at the hospital,” she said. “I take a lot of pride in that.”
From 2006 and 2012, the number and rate of VAPs in the hospital’s ICUs fell to nearly zero.