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MIU, 2 years VAP free By Chandra L. Speight MIU, 2 years VAP free On June 8th, 2012, the Medical Intermediate Unit at Vidant Medical Center celebrated two years VAP free. MIU, a 48 bed unit, averages 13-15 ventilated patients per day and has the second highest length of ventilator stay in the organization. This document details how MIU staff conquered VAP in their quest to provide exceptional care to the patients we touch, serve, and support every day. Ventilator-Associated Pneumonia, or VAP, is an airway infection that occurs more than 48 hours after a patient is mechanically ventilated. The leading cause of death among hospital acquired infections (HAI), VAP is the second most common HAI. Mortality of patients with VAP is 46% compared to 32% in ventilated patients who do not develop VAP. VAP adds significantly to hospital and intensive care lengths of stay. Moreover, VAP adds approximately $40,000 per incidence to hospitalization costs. The high physical and economic costs of VAP as well as increasing evidence that VAP is a preventable HAI led Vidant Medical Center to act to combat VAP. In October 2008, Vidant Medical Center adopted the Institute for Healthcare Improvement (IHI) VAP bundle. This bundle includes the following: Mouth care every 2 hours Teeth brushing with chorhexidine every 12 hours Subglotting suctioning every 8 hours Head of bed elevation > 30 degrees Gastric ulcer prophylaxis with H2 blocker or proton pump inhibitor Pharmacological deep vein thrombosis prophylaxis Sequential compression devices or Ted hose Hand washing Facility adoption of VAP bundles constituted the first step in VAP prevention. However, work at the unit level engaged staff in VAP prevention and ultimately created a unit culture committed to zero VAP. Denise Harper, MSN,RN, ACNS-BC, CRNI; Patricia Rice, MS, PA-C; and Effie Jefferson, BSN, RN, PCCN were among the first MIU VAP champions. A clinical nurse specialist, physician assistant, and Staff Development Assistant, respectively, these champions went pod to pod, educating staff about adoption of the new bundles. Rice stated, “We knew that success depended on education. Staff awareness of the high physical, emotional, and economic costs of VAP would fuel meaningful compliance. Staff needed to understand VAP bundles not as another set of tasks but as a key component of competent and compassionate nursing care.” Weekly rounds provided us a time to educate staff on VAP, review bundles, and answer questions. These rounds discovered and resolved barriers to VAP bundle compliance. One barrier involved making mouth care kits convenient. VAP mouth care kits include 12 kits that are attached to one another via perforation; clorhexadine mouth wash and a toothbrush are included in the first and 7 th package, or the 8am and 8pm mouth care kit. Thus, kits “begin” at 8am. Rounding revealed that day shift nurses found it difficult to make time to pull a new kit from the Pyxis in the busy first hour of their shift. Informal collaboration between day and night shift nurses brought a solution. Night RNs pull and label mouth care kits for the day nurses. Each Page 2 of 3 morning, the day nurse arrives to find a VAP kit at bedside, with each 2-hour kit labeled. This labeling helps keep staff on point. In a busy day, it is more difficult to forget a 2 hour mouth care with the bags hung and labeled. Jessica Kesler, RN, states. “With your VAP mouth care kits labeled and ready to go when you arrive for your shift, it’s very easy to stay complaint with the mouth care portion of the bundle.” Additionally, VAP components were incorporated into the MIU Kardex. In order to ensure compliance with gastric ulcer prophylaxis, sequential compression devises or Ted hose, and pharmacologic deep vein thrombosis prevention, the Kardex requires nurses to document these bundle components. Nurses use these Kardexes for shift report. Ashley Taylor, RN, notes that Kardex coverage of the bundles also for shiftly assessment of bundle compliance. Taylor explains that during shift report, oncoming and offgoing RNs review these components. Taylor notes that nurses often find that gastric ulcer or pharmacologic DVT prevention has “fallen off” or is about to fall off the MAR, particularly in extended stay patients. Nurses then remind physicians to re-order these components of the VAP bundle. When KaSheta Jackson, BSN, RN joined MIU as Manager in 2010, she recognized a growing need to place VAP prevention at the forefront. In 2009, MIU had expanded to include the Respiratory Intermediate Unit, a unit that adopted a multi-disciplinary approach to ventilator weaning of difficult to wean patients. Consequently, MIU would serve an increased number of patients on ventilators. In 2011, Jackson created a new unit level Quality Nurse role to augment organizational efforts. Seasoned MIU nurses Anne Chadwick and Shanon Brown were chosen for this role. Chadwick and Brown audit quality bundles and provide one-on-one and unit education to correct any deficiencies they note. Central to their success is the engagement of staff in the bundles. For example, when MIU hand hygiene fell below desired levels, a team of Care Partners was approached to start a hand hygiene campaign. The “Wipe Your Paws” campaign was spearheaded by Carol Sanders, NAII. A bulletin board was posted and “Hand Hygiene Cops” were appointed. Unit staff seen failing to use proper hand hygiene were issued verbal warning and given playful “paws” in their mailboxes. These paws reminded staff to wash their hands at every opportunity. Sanders remarked that she takes pride in supporting unit quality initiatives, infection control, and VAP prevention in this important way. Ashley Taylor, RN, saw the hire of many new nurses in the winter of 2012 as an opportunity to offer unit education on Quality Bundles. Ashley and colleagues developed a class covering quality bundles; the class was mandatory for new hires but all staff were encouraged to attend. VAP bundles were reviewing, reminding nurses of required bihourly, hourly, and shift requirements. Further, Bundle Requirement handouts were placed in every pod book on the unit, providing nurses convenient information. Taylor stated, “Our nurses want to provide the best care. In the face of increasingly complicated patients, it is important to provide reminders and ongoing education. Further, providing education in the pod books gives us a way to direct nurses to required activities and documentation. If a nurse floats to us from another unit, we can point him or her to Bundle reminders in the Pod notebooks.” Supporting all these activities is the VAP Committee, chaired by Chloe Linton, RN. Linton partners with Quality Staff at the unit level to provide any needed education. Further, monthly emails update staff on Hospital Wide VAP initiatives. Chart checks for bundle compliance are also completed each shift by charge and float RNs. All charts are audited every day for bundle compliance. Staff who do not meet bundle requirements are immediately notified and required to address deficiencies before the end of their shift. Page 3 of 3 Finally, the unit and the organization have worked together to reward staff for their efforts to reach ZERO. On the first anniversary of VAP, each member of the team received a t-shirt; these shirts could be work to work instead of a scrub top. In addition, a “NO VAP” cake parties were thrown on both day and night shifts to reward staff. At the two year celebration, Appreciation “portal bucks” were given to all MIU staff. MIU staff were recognized in various organization publications. These rewards foster staff pride and satisfaction, further entrenching MIU’s commitment to ZAP VAP.