| Learning Objective #1: Understand the best available evidence supporting the significance of ventilator-associated pneumonia in mechanically ventilated patients and interventions to improve patient outcomes | |||
| Learning Objective #2: Understand the development, implementation and evaluation of an evidence-based "ventilator bundle" program, including program outcomes and lessons learned |
Type of Evidence Used and Synthesized to Implement and Evaluate the Program: The best available published evidence related to the incidence and prevention of adverse events in the adult mechanically ventilated patient population was used to develop guidelines/protocols to decrease the risk of adverse events, and the number of ventilator days. Adverse events targeted by this program are DVT, PUD, VAP, and prolonged ventilator weaning from inappropriate sedation. The specific types of evidence used to develop the program interventions include published experimental and non-experimental studies, systematic reviews, national guidelines, national benchmark data, and local secondary hospital data. Both process and outcome program evaluation involved the use of self-report survey, chart audit, observation, and hospital secondary data for quality control.
Planned Strategy for Improvement: The Focus, Development, Development, and Evaluation (FADE) process was used to implement the program. A systematic program analysis and needs assessment was conducted prior to program implementation relative to the practice problem. Barriers to implementation were identified and considered when developing the implementation plan. Relevant principles from Titler (2001) model were employed in the development, implementation, and evaluation of the ventilator bundle program.
Program Implementation: Systematic review of the current best evidence Program analysis including determination of total cost and savings opportunities Development of a Multi-disciplinary Evidence-Based Practice group to facilitate implementation and provide expertise to guide practice and policy change Consensus building among stakeholders for policy change Development of policy and guidelines Funding acquisition to cover purchase of oral care products Development of documentation methods/forms Development of process and outcome evaluation plan Phased implementation including education interventions Process monitoring via audits, direct observation and survey Outcome evaluation for VAP, ventilator days, intensive care unit (ICU) length of stay utilizing hospital secondary data
Method of Evaluation: 1) Process Process monitor survey of staff Compliance audits via chart reviews for documentation Observation via rounds by an advanced practice nurse to audit HOB elevation, oral care product use, sedation interruption 2) Outcome Indicators measured include average ICU length of stay, average ventilator days, incidence of VAP utilizing hospital secondary data source Cost of program/ average cost savings
Outcomes and Results: Approval of a new infection control position to measure device related infections including VAP Implementation of a new policy stating that the frequency of in-line suction catheter changes be done only for visible soiling or malfunction; and that the frequency of ventilator circuitry changes be done on admission only resulting in cost savings Inability to reliably measure incidence of VAP due to lack of Infection Control Department resources and delays in implementing a new measurement process 1) Process evaluation consisted of measuring compliance to the ventilator bundle interventions through documentation via chart audits for the first quarter after program implementation. Compliance results were: Oral care 86% PUD prophylaxis 99% DVT prophylaxis 97% HOB elevation 79% Sedation interruption 40% 2) Outcomes at six months: Mortality decreased from 22% to 19% Antibiotic use decreased by 54% Average ventilator days decreased from 6.76 to 4.86 resulting in an average cost savings of $5,868 per patient Average ICU length of stay decreased from 6.72 to 6.23
Lessons Learned: Have a fully functioning individual and process in place to measure and benchmark VAP rates prior to program implementation Pilot in one unit only Implement each component separately instead of all at once Use separate order form for sedation awakening, and include a protocol for daily neuromuscular blockade interruption Incorporate the sedation interruption criteria and assessment with the established Pain Assessment Form Determine the acceptable variance for oral care compliance, and determine potential reasons for non-compliance to oral care policy, and track them
Actions Based on Program Evaluation: Re-educate physician and nursing staff on the sedation interruption intervention and the use of the Riker Scale to measure level of sedation Pilot of the re-education intervention and implementation of the sedation interruption assessment and protocol in the Medicine Intensive Care Unit