The medical ICU (MICU) at Penn Presbyterian Medical Center (PPMC) has attained a major nursing care achievement, having gone more than 1,000 days without any patients acquiring ventilator-associated pneumonia (VAP).
PPMC is a 305-bed hospital located in West Philadelphia, and in 2009 the MICU only had 0.8 VAP's per 1,000 device days. Since then there have been none.
According to MICU nurse manager Wendy Rines, MSN, RN, this accomplishment took the combined efforts of the nursing, respiratory and medical staff and the implementation of the VAP prevention guideline, an evidence-based bundle of interventions designed to reduce the likelihood of infection. Reaching 1,000 days without a VAP is essentially approaching elimination of the hospital-acquired infection, Rines said.
The VAP prevention guideline was approved by the Evidence-Based Practice Committee at PPMC for adoption as nursing policy and was endorsed by the head of PPMC's Respiratory Care Division. Implementing the new guideline began by educating the nursing staff through rounding and inservicing with a critical care educator and a representative from the manufacturer of the oral care kits used in the MICU.
In conjunction with these rounding sessions, the nurse manager and educator led an intense campaign of one-on-one education with critical care nursing staff. They were surprised to find variations in oral care, even among those with years of experience. The nurse manager and educator asked each nurse to demonstrate proper mouth care, and those that needed it were educated on the spot. Having the nurse manger present made a huge impact.
In addition to hands-on training, a self-learning packet was developed and approved by the Infection Control Department. This packet, now available online through the Penn website, is assigned annually as part of evaluations for all nursing staff in critical care areas.
Unit-based educators also audit on a weekly basis - using a tool developed through the University of Pennsylvania Health System's Critical Care Collaborative - to assess whether practices for VAP prevention are consistent throughout the health system. The audit findings are discussed at the unit's weekly unit-based council leadership meetings, which include the medical director, nurse manager, infection control practitioner, nurse educator and quality improvement specialist. The audits provide data that help the team look for areas of improvement.
In addition to education about nursing care to prevent VAP, there has been extensive education about the Institute for Healthcare Improvement's VAP bundle, a set of evidence-based elements that should be included in the care of all mechanically ventilated patients to decrease VAP rates. Including these elements was based upon collaboration with the Infection Control Department.
The elements of the bundle are:
• positioning - head of bed at 30-45 degrees, even during transportation;
• mouth care every 4 hours - brush teeth and gums once per shift;
• deep oral suctioning with tube repositioning or cuff deflation;
• daily sedation vacation;
• deep vein thrombosis (DVT) and peptic ulcer disease (PUD) prophylaxis;
• no routine instillation of saline for suctioning, rinsing saline catheters after use; and
• tube feeds off an hour before transporting, procedures and extubations to reduce the risk of aspiration.
PPMC's MICU implemented sedation vacation in the fall of 2009 along with the new mouth care kits. To help with this implementation, the MICU nursing staff developed the sedation vacation and pressure support weaning tool. The goal was to have sedation off by 5 a.m. and place the patient on pressure support (PSV) before the next shift arrived at 7 a.m. This holds nursing and respiratory therapy staff accountable for ensuring the sedation vacation and pressure support trials are performed correctly.
Turning sedation off at 5 a.m. in ventilated patients who qualified was a smooth transition with the MICU nurses. The unit-based educator also adjusted her schedule to be present at 6 a.m. to make sure the staff was following the plan and ensure the patient was ready to be placed on PSV and extubated by the time rounds started. Those who failed sedation vacation were restarted at half the dose and not weaned to PSV trial.
An instrument developed by the nurses and nurse manager in the MICU unit that has proved to be an effective tool for patient safety is the daily rounding sheet. This form is completed twice a day, once on each 12-hour shift. The rounding sheet gathers data about the patient and helps assess the patient's progression of care, including assessing whether the patient:
• is mechanically ventilated;
• is able to have a spontaneous breathing trial or sedation vacation;
• has appropriate DVT and PUD prophylaxis;
• needs central line placement;
• has any skin or wound issues;
• is meeting the goals of care for the day;
• has a scheduled hospice consult; and
• has any other health issues that may cause her to be readmitted quickly.
The rounding sheet is an excellent way to objectively gather information about the patient, remind the staff of any issues that may need to be addressed and make sure the patient's care is appropriately progressing.
Trish O'Brien is a nurse educator in the MICU at Penn Presbyterian Medical Center, Philadelphia.