Development of an Evidence-Based Policy for the Prevention of Ventilator Associated Pneumonia by Building on Existing Systems

ISSUE: Evidence-based guidelines were well established for the prevention of ventilator associated pneumonia (VAP). All major interventions were in place for patients requiring mechanical ventilation; however there was no set protocol or policy for grouping interventions for the care of the patient requiring mechanical ventilation. PROJECT: Critical Care Unit (CCU) Nursing Staff, CCU Physician Director, and Pulmonary Care Staff collaborated to develop a policy specific to the care of the ventilated patient including prevention measures for VAP. Performance improvement measures were also included in the policy to increase awareness of staff to expectations. Literature review was conducted; incorporating Institute for Healthcare Improvement “ventilator bundle.” Data collection continued by Pulmonary Care to assist in identification of VAP. A data collection tool was attached to each ventilator to make readily available when the ventilator was put into use. Once the ventilator was taken out of service, the form was sent to infection control. Additional cases were identified via traditional surveillance, Staff and Physicians reports. Mouth care protocols were outlined and a standard product selected, making all supplies readily available. We replaced non-covered oral suction devices with one with a resheathing cover. Staff education was conducted on proper mouth care. Laminated signs were implemented to place over the head of the bed to keep head elevated at least 30 degrees at all times. Staff was provided with immediate feedback when surveillance rounds were conducted for compliance with the IHI Bundle components by the use of a bulletin board with results posted as the rounds are conducted. RESULTS: There is one policy that includes all interventions for the prevention of VAP, allowing easier reference and review with staff. VAP rate decreased from 1.9/1000 ventilator days in 2004 to 0 in 2005. LESSONS LEARNED: Consolidation of expected interventions, process and outcomes measures into one document increases staff awareness and compliance resulting in improved patient outcomes.