At a community hospital in Indianapolis, strict adherence to protocols resulted in zero incidents of ventilator-associated pneumonia (VAP)—without the benefit of the latest technology.
By Rich Smith
At Community Hospital East, Indianapolis, records reveal zero ventilator-acquired pneumonia (VAP) cases in more than a year. Even more impressive, in one of its ICUs, 2 years have now passed since a patient last contracted VAP.
Perhaps most stunning, the 257-bed comprehensive care facility accomplished this without benefit of the latest in ventilator technology.
“The equipment we’re using is just basic gear; it offers none of the extraordinary modes of ventilation now available with newer models,” says Dan Kidwell, RRT, RCP, clinical practice specialist for respiratory care.
What accounts for Community Hospital East’s remarkable success against VAP? Strict adherence to an inventive—and comprehensive—set of internally devised ventilator protocols used by everyone who has bedside contact with patients. Along with respiratory therapists, that includes nurses, physicians, infection-control teams, radiology technologists, and phlebotomy staff.
“Our protocols allow us to reliably protect even the most difficult patient from infection,” says Laurie Fish, RN, certified infection-control practitioner, who helped design them.
Kidwell emphasizes that each patient placed on a ventilator is treated in accordance with the protocols, a requirement he says stems at least in part from the organization’s desire to invest in the abilities and expertise of staff.
“We’ve created a tool that allows the people on the front line of care who are here 24/7 to do their job, and in about the most proactive ways possible,” Kidwell explains. “Because of this approach, we’ve been able to keep some very compromised patients safe from a potentially deadly outcome.”
Covers It All
Community Hospital East is part of Community Health Network (CHN), a health-delivery system that operates at more than 60 sites across central Indiana. Those sites include Community Hospital North, Community Hospital South (both in Indianapolis), Community Hospital Anderson, and Indiana Heart Hospital. The ventilator protocols are in place at each of those locations.
Community Hospital East—like CHN itself—embraces a corporate culture of never accepting the status quo when it comes to quality.
“For us, ‘good enough’ is never good enough,” says critical care clinical nurse specialist Theresa Murray, RN, MSN, CCRN, CCNS, one of the architects of the ventilator protocols. “We’re constantly trying to improve on things here.”
To facilitate best practices, many areas of the enterprise have adopted multidisciplinary models of care delivery—respiratory being among them. Indeed, a multidisciplinary model is at the very heart of the protocols responsible for eliminating VAP at Community Hospital East. Those protocols, by the way, are set forth in a tool known internally as the Ventilator Pathway Order Sheet (VPOS) and owned equally by respiratory therapists, nurses, infection control specialists, and others. Kidwell clarifies that the VPOS is not intended solely to address VAP, however—although its effectiveness in eliminating VAP alone makes the tool worth its weight in gold (Kidwell estimates hospitals lose approximately $30,000 for every VAP case they must treat).
“Our VPOS covers every level of care for the patient, starting with routine vent settings and then going all the way through to weaning and prophylaxis,” he says. “It addresses mobility: the expectation of getting the patient out of the bed and into a chair. It includes an order for head-of-bed 30 degrees, unless contraindicated. If a patient requires glucose control, that’s in there too.”
There is even a scale-driven protocol for sedation (more properly referred to within CHN as anxiety management).
“There’s a big push around the country for the daily withholding of comfort drugs until the patient is agitated or uncomfortable, but we do not engage in that here. It’s not allowed,” says Murray. “Instead, we provide just enough medication so that the patient can tolerate what we need to do for them.”
No single element of the protocol is most responsible for dropping VAP to zero, the hospital’s clinicians insist. Rather, they say, it is the synergistic result of all the pieces combined.
One of those VPOS elements features as its built-in objective the rapid weaning of ventilator patients.
“The protocols direct us to assess the patient daily for readiness to wean and, once the criteria for weaning readiness are met, to immediately begin weaning,” says Kidwell. “From there, we move very quickly to the CPAP trial. We’re having so much success with this that our ICU length-of-stay numbers have declined by an average of nearly 2 days per vent patient.”
Noteworthy is the fact that it is respiratory therapists and nurses who decide whether a patient meets the ready-to-wean criteria—and, thus far, no one they have green-lighted for weaning has turned out to be an inappropriate candidate or fared poorly once the process commenced.
“That record of safety and success has been a tremendous moral victory for the staff,” says Murray.
Kidwell adds that attending physicians do not become much involved with weaning until just prior to extubation.
“At that point,” he says, “we give to the physician the patient’s new parameters and ratios, then in response he gives us a yea or nay to proceed with extubation,”
Part of the reason the fast-tracked weaning—and the entire gamut of ventilator care, for that matter—goes so well is that there is strong emphasis throughout on clinician communication.
“We’ve got the therapists and nurses talking to one another in ways they didn’t before,” says Kidwell. “For example, the way things are set up, the therapist isn’t likely to initiate any changes without first talking to the nurse, since the nurse might see or know something or have a plan for anxiety management or transportation that the therapist doesn’t know about. The reverse is true as well. The nurse isn’t going to want to change the anxiety management plan until they talk to the therapist, since to do otherwise might interfere with the therapist’s efforts to wean.”
Bottom line, relationships among the disciplines have been strengthened.
“We’re a stronger, better team than ever before, and the big winners because of that are the patients,” says Kidwell.
Undeniably, the clinicians—respiratory therapists, nurses, and others—feel empowered by the VPOS.
“They now have a real sense of ownership over their vent cases,” says Kidwell.
Empowerment and ownership, like the VPOS itself, did not happen overnight, though. “It was the result of years of effort at building an evidence-based track record and, in the course of that, convincing physicians that our well-trained nursing and respiratory staff could be entrusted to implement the protocol in a very safe and collaborative way,” says Murray.
The history of the VPOS within the CHN organization dates back to even before 1998, when officials formally decided something needed to be done about ventilator-acquired pneumonia.
“For years prior, we’d had higher-than-expected vent pneumonia rates,” says Fish. “But, no matter what
we did, we could not produce a significant drop.”
Fish was not the only one concerned about that. It had long been weighing on the mind of Murray. In 1998, the two teamed up to brainstorm ideas on attacking the infection problem. They started with a 6-month-long, comprehensive review of literature in the hope of discovering useful insights.
“We developed from our literature review a list of actions we felt we could take to reduce the incidence of VAP,” says Fish.
At that point, a task force consisting of Fish, Murray, an RCP educator (not Kidwell; he hadn’t yet joined CHN), a pharmacist, and several other types of clinicians in the chain of ventilator care was formed. The mission was to devise a multidisciplinary program for addressing VAP infections using best practices.
The protocols that emerged from that task force in 1999 have been revised about 15 times since, and now bear only fleeting resemblance to the original.
“In the earliest iterations, we had what could be thought of as a basic recipe,” says Kidwell. “It was effective, it brought us good results. But we knew there was lots of room still for improvement. In subsequent iterations, we were able to take that basic recipe and tie it back into evidence-based practice, which delivered far greater effectiveness and results.”
This “basic recipe” in first-draft form was written with nursing input only. Big mistake, the organization quickly discovered.
“The respiratory therapists,” says Murray, “were concerned that they had not been consulted, and rightly so. From that time on, every change made to the protocols involved input from respiratory, as well as from other disciplines. By consulting the others, namely those who would later be responsible to one degree or another in working with the protocols on a daily basis, we were able to obtain from them a strong sense of ownership over the protocols. And that, as we discovered, was very important to ensuring the protocols would be strictly followed.”
The VPOS rolled out enterprise-wide in 1999. Accompanying its debut was intensive training—mandatory for both the nursing and respiratory staffs. To convey the degree of seriousness attached to the endeavor, even the chief executive officer of CHN lent a hand in the training.
“We had produced a video demonstrating the level of best practices we expected to be used at bedside—the patient in this exercise being none other than our CEO,” says Fish.
The video was but a small part of the training. Additionally, each staffer was made to walk a figurative mile in the shoes of their patients.
“We did things like ask them to lie in the rotational specialty bed so they could have the experience of feeling the incline rotation to the 30-degree position and thereafter be better able to assure patients who might feel as if they’re going to fall out of the bed that they won’t,” says Murray. “This also helps the nurse educate the family about the bed, relieving some additional anxiety.”
Beyond that, there was an education station manned by a respiratory therapist who provided instruction to the nurses on ventilator modes. Another station, manned again by a therapist, focused on the weaning protocol and the expected documentation to go along with it.
“We also had a clinical pharmacist from our critical care unit talk about our sedation scale and protocol as well as the Society of Critical Care Medicine guidelines we were implementing in conjunction with it,” says Murray. “We also had a clinical nurse specialist at a station where the overall care of the patient was described along with the Ventilator Pathway Order Sheet and related documentation.”
VAP Rates Plummeted
Following completion of rounds at the training stations, each clinician was given an opportunity to put his newly acquired knowledge to the test.
“A room was set up for this,” says Murray. “They’d walk in and find a practice dummy lying in the bed and hooked up to a vent, but every line and setting were wrong: The head of the bed was down, and the infection team had planted Glo-Germ all over everything. The staff had to fix it all—and then remember to wash their hands, which we checked them on under a blacklight.”
There was a written examination, too, which, as with the laboratory portion, most everyone passed on the first try, Murray assures. However, cognizant of the way time tends to cloud memories, CHN required its staff to undergo an annual VAP education and prevention refresher course (of which the VPOS is a significant piece), complete with retesting.
Once the rollout and inaugural training ended, Fish and Murray monitored the staff to ensure compliance with the protocols.
“We didn’t rely only on looking at charts; we watched people at bedside as they performed tasks,” says Fish.
Within a month, Fish and Murray were able to report high levels of compliance. VAP rates almost immediately thereafter plummeted by an astounding 50%.
“Before we had the VPOS to work from, our infection rate was running at around the 75th percentile—where a lot of institutions are when you look at the national benchmarks for incidence of VAP,” says Fish. “In a matter of weeks, we were doing much, much better than average.”
And things have only improved since then, owing in some degree to the way CHN has chosen to go about informing its staff of progress against infection.
Here again is Fish: “Instead of giving general data, which isn’t particularly useful, we started reporting our infection rates by specific case, attaching the actual patient name to it. That small difference in reporting made it personal to the staff. ‘Oh, Patient X didn’t do well and he was one of mine’ was the kind of reaction staff had to the reporting by case. Suddenly, they were paying closer attention, because they owned the results and they wanted to see those improve.
“We also began posting information about things like how often people were remembering to elevate the head of the bed and how often condensate was detected in the vent circuits. This further helped the staff recognize the linkage between actions or inactions and how those affected their patients.
“Recently, we’ve been posting elapsed-days-since-last-infection, listed by staff. This is giving them the fullest picture yet of how well they’re doing.”
Kidwell believes this information strategy inspires the team to one and all try harder.
“The higher the number of days since last infection, the more excited the staff gets,” he says. “They have a competitive spirit about it, and that’s good, good for everyone involved.”
Not About to Stop
Disappointingly, not all of CHN’s hospitals where ventilator care is provided have been able to entirely eliminate the incidence of VAP, despite their use of the ventilator protocol order sheet. By the organization’s own admission, those sites have a way to go to catch up to Community Hospital East. The reason for the disparity among campuses, as Murray explains, is that no two of the hospitals are exactly the same in terms of physician and staff mix, staff skill levels, physical layout, and patient demographics—all of which have a bearing on the efficacy of the VPOS as a support tool.
Also, Community Hospital East has made the greatest gains because that was the first facility to implement the protocol package. Hence, it has the most experience with it.
“Since [Community Hospital East] has been at it the longest, it makes sense that it would be the farthest ahead in VAP rate reductions,” Murray says.
Still, reductions in infection rates at the other hospitals have been nothing if not impressive in and of themselves.
“All our units across the organization are below the 25th percentile on those VAP rates, far below that national benchmark,” says Fish. “But we’re not going to stop at that. Our goal is to bring the VAP infection rates at those other hospitals down to zero, the same as at Community Hospital East.”
That could well be doable, and then some.
“In the beginning, I was the first to say I thought it would be impossible to have zero vent-acquired pneumonia,” says Fish. “But our VPOS and comprehensive prevention program have paved the way for us to cut right to the chase on that and on additional improvement work for other conditions we encounter in the hospital.”
Adds Kidwell, “Our expectation is that, 5 years from now, we should be able across the organization to not only eliminate VAP infection, but also sharply reduce or eliminate the problems of sepsis, internal wound infection, out-of-control glucose, everything. When you step back and consider the big picture, it’s all very exciting because so much is now possible. All it takes is the right set of empowering protocols and a determination to follow them to the letter.”
(On June 28, CHN was presented with the first-ever Indianapolis Patient Safety Hero Award, which recognizes individuals and teams who are making a difference to enhance patient safety in Indianapolis hospitals. The award was presented to Kim Schaefer, RN, and Bill Mercer, a respiratory care practitioner, for their leadership in reducing the incidence of VAP in two intensive care units at Community Hospital East—Ed.)
Rich Smith is a contributing writer for RT.