Exceeding PICU Goal With 0 VAP Cases

Abstract

“In Our Unit” highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an upcoming “In Our Unit,” send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, ccn@aacn.org. The staff’s commitment to the change process is more powerful than the cultural norms of the department and leads to sustained outcomes. In 2005 the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign inspired many organizations to rethink the occurrence of ventilator-associated pneumonia (VAP) and see it as a preventable disease rather than a side effect of mechanical ventilation. Sacred Heart Medical Center and Children’s Hospital in Spokane, Washington, has always been committed to patient care quality and embraced the 100,000 Lives Campaign (and subsequent 5 Million Lives Campaign) to eliminate unnecessary injuries or illnesses associated with hospitalization. Despite emphasis on the VAP bundles for care, the pediatric intensive care unit (PICU) continued to experience increasing VAP rates throughout 2006. In alignment with the organizational goals of no preventable injuries or death, we defined the Centers for Disease Control and Prevention (CDC) benchmark of 2.9 pnemonias/1000 ventilator days as the department target. A 2-year timeline was set to reach the target, with a stretch goal of 50% reduction in the first year. A team of nurses, respiratory therapists, infection control specialists, and department managers collaborated to research the problem and identify solutions, including the IHI bundle for pediatrics. Analyzing the problem was key to create a sense of urgency and to ensure that staff believed the problem was preventable. This process included the following: • Reviewing VAP case studies to get a sense of the “high-risk” elements of care • Researching information from the Internet and nursing and respiratory journals to understand best practices • Researching pediatric VAP bundles from the IHI • Brainstorming best practice • Rating potential elements of care with respect to effectiveness, cost, and staff willingness to adopt The resulting program was designed and implemented with 3 areas of focus: education, monitoring, and changes in care practices. Modifications in practices included the following: • Revise oral care standards for children with and without teeth • Eliminate saline lavage during suctioning • Reduce suctioning to only as needed • Elevate head of bed 25° to 30° • Change ventilator circuit only when dirty, rather than routinely • Separate oral suction equipment from nasal suction equipment and change canisters daily These practice modifications were included in an educational poster for staff, which was posted in all patient and staff rooms. In addition, several In Our Unit