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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
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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.
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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.