Although Pneumonia is a risk faced by any patient being admitted to a hospital, when patients are placed on a ventilator, the risk increases from 3 to 10-fold. The Critical Care Unit at CSMC experienced 14.9 cases of Ventilator-Associated Pneumonia (VAP) per 1,000 ventilator days in 2001 and 19.9 cases in 2002, exceeding the Center for Disease Control's (CDC) median rates of 4.2 to 16.3. Fortunately, CSMC did not have any mortalities due to VAP, but statistically, the hospital was experiencing a process that was out of statistical control. Even more importantly, this situation was contrary to the value system of excellence in patient care, which is exemplified daily by the dedicated staff in the Critical Care Unit through its philosophy of family-centered care.

Type of evidence used:

Several tools and techniques, including brainstorming; benchmark and observational studies; and the use of a cause and effect diagram, were used to identify possible root causes. Subsequently, the Team established a data collection plan to gather baseline measurements on these areas. The data was displayed in Pareto charts, histograms, run, and control charts. Performance benchmarks served as the basis for further root cause identification. In order to eliminate potential root causes, the Team analyzed the data and the numerous research studies and journal articles. A Fish Bone Diagram was used to further drill down potential root causes. A Flow Chart was developed that highlighted the role of airway management in the pathogenesis of hospital acquired pneumonia. Our practices for providing oral care did not meet the best practices identified in evidence-based protocols. Further analysis of the observation studies demonstrated that this process was inconsistent.

Method used to obtain and review evidence:

A Force Field Analysis was conducted and assessed, and an action plan was established. The Team chose three processes to trial. The top three products included a homegrown oral care product and the products from two different vendors. Pilot testing was conducted, and observational studies were further analyzed using a Pareto diagram. The two vendor-based products were trialed for comparison and assessed against an array of factors considered critical to quality. The Team used multi-voting to find the highest priority for product use. The Team validated the acceptance level of the staff by monitoring the standardization during the final pilot period. We saw 100% standardization in the technique, times, and overall process. In the past, we observed variability in all three of these areas.

Implementation:

An evidence-based protocol was implemented in October 2002.The Sage Oral Care system was purchased. Oral care was conducted 2-3 times per day on all ventilator dependent patients. Staff and physician education was conducted. A Gantt chart was used to structure the project implementation. The Chief Nursing Officer and the Chief Financial Officer approved the expenditure of $25,000 for the oral care products. Their approval demonstrates how the final solution merged clinical and business effectiveness. The outreach of the VAPNET Team is also being accomplished through Joint Commission surveyors, who reviewed our practices in November 2003. The surveyors identified our VAPNET Team as a “best practice” and share our protocol during surveys nationwide. CSMC received a Joint Commission score of 99, which is received by only 2% of hospitals across the country.

Impact/Outcomes/Results:

The financial impact to the organization was striking, since the cost of VAP over the prior fiscal year was over $800,000! The CDC's median rates for VAP are 4.2 to 16.3 cases per 1,000 ventilator days in an adult Critical Care Unit; CSMC's data revealed 14.9 cases per 1,000 ventilator days in 2001, with an increase to 19.9 cases in 2002. VAPNET achieved 1.9 cases per 1,000 ventilator days in 2003 - an 89% reduction in VAP, and well below the median rates published by the CDC. The estimated incidence of VAP in Intensive Care Units (ICU's) is between 10-65%, according to the CDC; CSMC's rate was 33%. Our goal was to reduce the incidence rate to at most 10% - but we surpassed our goal. VAPNET achieved 0% VAP incidence rates for the last twelve (12) consecutive months. According to the CDC, VAP is fatal for 20 - 50% of patients. The current scientific literature also reflects that VAP accounted for 60% of all deaths due to hospital-associated infections. VAPNET sustained a mortality rate of 0%, well below the rates published by the CDC. In addition, the Protocol for preventing VAP has been officially implemented District-wide, effective January 2004. The estimated cost benefit for this Fiscal Year is expected to be over $4,000,000! The VAPNET Team won in May 2004 the Governor's Florida Sterling Conference's Team Showcase Award for Quality.

Lessons learned:

1. Go back and review the basics. 2. Don't be afraid to challenge long standing practices. 3. Those closest to the work know best how to improve their performance. 4. Prevention and proactive problem solving can be leveraged across the organization.