MICHAEL D. HOWELL, MD MPH Director, Critical Care Quality Associate Director, Medical Critical Care Beth Israel Deaconess Medical Center Harvard Medical SchoolVentilator-Associated Pneumonia Getting to the Bundle (and Getting Beyond the Bundle?)At an Academic Medical CenterJEAN GILLIS, RN Clinical Nurse SpecialistPatient Care ServicesBeth Israel Deaconess Medical Center BETH ISRAEL DEACONESS MEDICAL CENTER

NoteThese slides are only meant to illustrate the discussion; they arent a discussion of the topic in and of themselves.

Key Lessons Learned at BIDMCSell 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 workDefining 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.

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. Defining VAP1

The CDC definitions are complicated and subjective.(This is just part of PNU-1.)2

CDC PNU1 VAP Symptoms, as best we can figure out3

Which definition you use affects the answer you get.4

Our conclusions about defining VAPIts hard, time-consuming, subjective, and expensiveWe 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.

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THE BUNDLEImplementing ChangePre-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.?6

Surrogate Team Function Metric?MeasureDisciplines RequiredHead of bedRN / RTStress ulcer prophMD / RN / PharmacyDVT prophMD / RN / PharmacyDaily wake-upRN / RT / (MD)RSBI / SBTRT / RN / MD7

Approach: Unit ChampionsSelection of local nurse and respiratory therapy leadersIncorporation of them into data gathering phaseThree snapshots per weekDistributed across shifts around the clockMetric is therefore approximately proportional to ventilator daysTwo-week feedback cycles, using unit champions to disseminate changeSupported by Clinical Nurse Specialists (0.5 - 1.0 FTE)8

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 changeData that is trusted by providersVery frequent data feedback to each ICU (q 2 weeks while improving)18 times a month!Actionable analysis of the q2 week data, when needed

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The head of the bed is like an onion.10

The head of the bed is like an onionOur 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

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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).14

Outcome Measure

Outcomes No VAP rate data) 15

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Resource Utilization Measure

No vent day data18

Throughput ImpactsCAVEAT: LOTS OF OTHER THINGS WERE GOING ON!

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Summary

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Conclusions

ConclusionsDefining 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 toSelling that a real problem existsData they trust (and help collect)Frequent data feedback (q 2 weeks), with actionable analysisDelivered by a respected Clinical Nurse SpecialistWhen Ventilator Bundle (and oral care) compliance improve, VAP goes down.

Questions? Please email mhowell@bidmc.harvard.eduThank you.

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