Ventilator-Associated Pneumonia

Getting to the Bundle (and Getting Beyond the

Bundle?)
At an Academic Medical Center
MICHAEL D. HOWELL, MD MPH

JEAN GILLIS, RN

Director, Critical Care Quality

Associate Director, Medical Critical Care
Beth Israel Deaconess Medical Center
Harvard Medical School

Clinical Nurse Specialist

Patient Care Services
Beth Israel Deaconess Medical Center

BETH ISRAEL DEACONESS MEDICAL

CENTER

These slides are only meant

Note

to illustrate the discussion;

they arent a discussion of
the topic in and of
themselves.

Key Lessons Learned at BIDMC

Sell the problem, not the solution.
Common, lethal, expensive, preventable.
If you sell the problem, the clinicians will help you find
the solutions.
Definitions are inadequately explicit for real

work

Defining VAP is subjective, variable, and expensive.

Vent bundle definitions are inadequately explicit, but can
be really useful.

The head-of-bed angle is like an onion.

Having a kit matters for oral care.

Defining VAP
Pre-call Question:
How are people defining/diagnosing a VAP?
Even using the CDC definition, we find there
is room for interpretation. In the end, we
can define it for our organization and just
focus on improving our rate. However, many
folks are reporting rates of zero and payers
may refuse to pay for the care associated w/
VAP.So the definition becomes more
important.

The CDC definitions are complicated and

subjective.

(This is just part of PNU-1.)

What do you mean

by VAP symptoms?

CDC PNU1 VAP Symptoms,

as best we

can figure out

Which definition you use affects the

answer you get.
Depending on the
definition evaluated,
criteria were met for a
diagnosis of VAP from as
low as 4% of patients by
the Johanson definition to
as high as 48% of patients
by the CDC definition.

Our conclusions about defining VAP

Its hard, time-consuming, subjective, and expensive
We use somewhere between 0.25 0.5 FTE of experienced
critical care nurse time to screen four of our nine ICUs.
We review all CXRs with three critical care MDs to arbitrate the
final rate. This is about 15-20 hours of physician time per
month screened.
We therefore only do it for 3 5 months per year. The rest of
the time, we work on process.
It makes sense to follow your own, internal VAP

rate if you do it the same way, time after time.

Be very wary about comparing rates among
hospitals.

Implementing Change
THE BUNDLE

Pre-call Question:
To improve, we find measuring the process more
helpful than following the rate (though the outcome is
certainly important!). We have questions about what
and how people are measuring the process. Are folks
just reviewing compliance w/ the bundle? once a day?
Once a shift? Etc.?

Surrogate Team Function Metric?

Measure
Head of bed
Stress ulcer proph
DVT proph
Daily wake-up
RSBI / SBT

Disciplines Required
RN / RT
MD / RN / Pharmacy
MD / RN / Pharmacy
RN / RT / (MD)
RT / RN / MD

Approach: Unit Champions

Selection of local nurse and respiratory therapy

leaders
Incorporation of them into data gathering phase

Three snapshots per week

Distributed across shifts around the clock
Metric is therefore approximately proportional to ventilator
days

Two-week feedback cycles, using unit champions

to disseminate change
Supported by Clinical Nurse Specialists (0.5 - 1.0
FTE)

Four Useful Lessons (among many!)

Documentation Reality!
Corollary: The head of the bed is like an onion.
The Bundle definitions are not explicit enough for our

needs.
Oral care kits make implementation easier.

Corollary: People like gizmos.

Issue: Our experience was that not all oral care kits are the same.

We provided three things that (we think) helped accelerate

change

Data that is trusted by providers

Very frequent data feedback to each ICU (q 2 weeks while improving)

18 times a month!

Actionable analysis of the q2 week data, when needed

The head of the bedWe

ishypothesized
like an onion.
that head
of bed angles would be at or
above 30 degrees among
mechanically ventilated
patients throughout the day
due to a hospital-wide
initiative on ventilatorassociated pneumonia
prevention and standardized
electronic order entry system
to keep head of bed at an
angle of 30 degrees or greater
... . Contrary to our
hypothesis, all patients had
head of bed angles less than
30 degrees.

10

The head of the bed is like an onion

Our beds electronic Fowlers angle: wrong
(randomly, by random magnitudes)

10

We needed more explicit bundle

definitions.

11

Oral Care: Gizmos make implementation

easier,
but not all gizmos are the same.

12

Results

Process Measure

13

14
Note: We use a temporal bundle for oral care. If you miss one oral care
chance during a 24-hour period, you get a 0 for the day. (We just made
this up, though).

Outcome Measure

Outcomes

No VAP rate data)

15

16

17

Resource Utilization
Measure

No vent day data

18

Throughput Impacts
CAVEAT: LOTS OF OTHER THINGS WERE GOING
ON!

19

20

Summary

(ICU Throughput)

Better

(Three-ICU Sample)

Better

Ventilator Days

No data

(Three-ICU Sample)

Better

VAP Cases

Better

Ventilator Bundle
Compliance

Long-Stay ICU Patients

Better

Number of ICU Patients

(% of patients with ICU LOS > 10 days)

21

Conclusions

Conclusions
Defining VAP is complicated and challenging.

but may be useful to follow internal.

The Ventilator Bundle is really useful.

but documentation may not equate to reality!

Our providers responded to

Selling that a real problem exists

Data they trust (and help collect)
Frequent data feedback (q 2 weeks), with actionable analysis

Delivered by a respected Clinical Nurse Specialist

When Ventilator Bundle (and oral care)

compliance improve, VAP goes down.

Thank you.
Questions? Please email mhowell@bidmc.harvard.edu