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Rapid Response Teams	Pressure Ulcers
Acute Myocardial Infarction	High-Alert Medications
Medication Reconciliation (ADE)	Congestive Heart Failure
Central Line Infections	MRSA
Surgical Site Infections	Surgical Complications
Ventilator-Associated Pneumonia	Boards on Board

Use this table to quickly find a mentor for the prevention of Ventilator-Associated Pneumonia with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Aiken Regional Medical Centers – Aiken, SC
Availability Status: Available to answer requests
Licensed Beds: 225
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Marilyn Swanson, RN
Mentor Contact Email: marilyn.swanson@uhsinc.com
Mentor Contact Phone: 803-641-5773

Additional Information:

• The success of Ventilator Bundle initiative is due to enthusiastic involvement of front line care providers from involved disciplines, identification of physician champions, and facilitation by Quality Management Dept.
• Appropriate time spent at the onset of the team to ensure that everyone had a strong grasp of the 100K Campaign initiative.  This contributed to the team members taking personal ownership of this project with quality patient outcomes as its sustaining motivation.
• After showing the short motivational 100K Lives Campaign video to the team, it became a requested topic at future staff meetings, which resulted in contagious enthusiasm.
• After our first 4 months without any cases of VAP, we held a formal celebration for those involved departments, which included our senior adminitrative staff providing a short message of encouragement and congratulations, and a gift of the IHI 100K Lives pin for each associate.
• We continue to post the data on a monthly basis in the ICU, Respiratory Therapy Department, and the Physician Lounge in order to keep our progress visible and fresh.
• No cases of VAP for 8 months
• Estimated number of lives saved – 5
• Estimated savings $440,000 ($40,000 x 11 cases)
• 232 fewer ventilator days since ventilator bundle initiated as compared to same time period for previous year
• Decrease in average per patient stay on vent from 5.3 days to 4.3 days
[6/2/06]

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Albany Memorial Hospital – Albany, NY
Availability Status: Available to answer requests
Staffed Beds: 85
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: June 2005
Mentor Contact Name: Susan Vitolins
Mentor Contact Email: Vitolins@nehealth.com
Mentor Contact Phone: 518-271-3246

Additional Information:

Compliance with the bundle has been achieved through education, cooperation between respiratory therapy and nursing and buy-in of the physicians.   Peptic ulcer and DVT prevention were standards of care  prior to the bundle implementation.  

Elevating the head of the bed and sedation vacation were added during 2005.  At Memorial Hospital, a blue piece of painter's tape is put on the wall behind the bed at the 40 degree level.  The tape serves two purposes:  It reminds staff to elevate the head of the bed and is a visual cue to indicate where to set the head of the bed.  In addition, the respiratory therapists also added a check for head of the bed elevation to the vent check sheet they use every 4 hours.  The respiratory therapists are strong members of the team and their involvement is an important part of Memorial Hospital's success.

Sedation vacation is done daily, unless contraindicated by the patient's condition.  At first, there was variation in what staff considered a contraindication for sedation vacation. This required clarification for all staff and the private physicians.  In addition, the primary pulmonary physician, who is also the critical care medical director, expected the patients to have had the sedation vacation and be in the weaning process by early morning.  This process was in place prior to instituting the vent bundle sedation vacation.

The vent bundle has become the standard of care due to the diligence of the staff during training of new staff members.  Leadership attention, both at the physician and management level, has been important in "hard wiring" implementation of the vent bundle in the critical care unit at Albany Memorial Hospital.

Compliance with the vent bundle in 2005 ranged from 58% to 90%.  During 2006, implementation of the bundle became more reliable with compliance rates between 85 to 100%.  Beginning in January 2006, Albany Memorial has had 100% bundle compliance every month with no ventilator associated pneumonia since September of 2006.
[4/10/08]

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Allegheny General Hospital – Pittsburgh, PA
Availability Status: Available to answer requests
Licensed Beds: 819
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2003
Mentor Contact Name: Pamela Zajdel, Manager Clinical Effectiveness
Mentor Contact Email: pzajdel@wpahs.org
Mentor Contact Phone: 412-359-6064

Additional Information:

Allegheny General Hospital has implemented workflow redesign around two areas:
a) weaning
b) the maintenance of endotracheal tubes in patients requiring mechanical ventilation

The workflow redesign is based upon the IHI Ventilator Bundle with some "local" modifications that were made based upon observations of the care of the endotracheal tubes, within our nursing units.
These modifications include:
a)  specification of the placement of the ambu bag at the bedside
b)  designation and documentation that the Yankauer catheters are changed every day
c)  plans to change the ventilator tubing, on a weekly basis, to avoid water contamination

Weaning protocols were developed based upon the identification of clinical features designed to stratify patients as either:
a)  rapid weans (less than 12 hours)
b)  progressive weans (less than 48 hours)
c)  long term weans
Identification of such patients, allows for the application of resources in the establishment of clear goals in an attempt to remove patients from the ventilator.

83% reduction in ventilator associated pneumonias (from 46 VAPs to 8) in one year.
Quantified the investment ($17 per patient) and the savings (approximately $16,000 per case) associated with VAP reduction.
Monitored the compliance with the established goals, on a monthly basis, to ensure that all staff members are up-to-date on their understanding of the importance of the initiative.
[1/31/06]

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Baptist Memorial Hospital - Golden Triangle – Columbus, MS
Availability Status: Available to answer requests
Staffed Beds: 216
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: September 2004
Mentor Contact Name: Sherry Elmore or Ron Norris
Mentor Contact Email: sherry.elmore@bmhcc.org; ron.norris@bmhcc.org
Mentor Contact Phone: Sherry @ (662) 244-1115; Ron @ (662)244-2176

Additional Information:

• The Critical Care Unit at Baptist Memorial Hospital - Golden Triangle adopted and implemented the ventilator bundle.
• The ventilator bundle components were integrated into the admission orders for Critical Care with the details of the bundles printed on the reverse side of the orders.
• Respiratory Therapy and the Critical Care Nurses work in collaboration on the components of the bundle including the assessment for readiness to extubate.

• 100% utilization of the ventilator bundle components.
• 41 months without a ventilator-acquired pneumonia in Critical Care as of January 2008.
[3/6/08]

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Bay Regional Medical Center – Bay City, MI
Availability Status: Available to answer requests
Licensed Beds: 415
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: March 2004
Mentor Contact Name: Sue Lathrom
Mentor Contact Email: sue.lathrom@bhsnet.org
Mentor Contact Phone: 989-894-3008

Additional Information:

Goal:  Eliminate or reduce ventilator associated pneumonia, duration of mechanical ventilation and ICU length of stay.
 
Implementation:
1) Developed a dedicated team including Senior administration
2) Provided evidence based education to all critical care, respiratory and medical staff.
3) Developed ventilator standing orders and intergrated clinical pathway.
4) Developed daily rounding form to collect data and utlized as a compliance tool,
5) Rounded every AM on ventilator patients that were ventilated > 24 hours.
6) Monthly review of data including action plans to improve outcomes
7) Reported monthly results to various committees throughout organization and posted results for staff to evaluate.

We ask staff to implement the following standing vent orders:
1) Elevate the head of bed
2) Provide peptic ulcer and venous thrombosis prophylaxis
3) Appropriately sedate ventilated patients/shift evaluation of mental status
4) Test daily if patients can be extubated. 
5) Use continuous subglottic suctioning/oral care
6) Implement standing orders for blood glucose levels > 150 (Portland protocol)

Bay Regional recently completed 14th consecutive month with no ventilator associated pneumonias
[6/2/06]

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Bloomington Hospital – Bloomington, IN
Availability Status: Available to answer requests
Licensed Beds: 355
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2005
Mentor Contact Name: Vince Holly
Mentor Contact Email: vholly@bloomingtonhospital.org
Mentor Contact Phone: 812-353-5593

Additional Information:

• The development of the Critical Care Improvement Team, a multidisciplinary team, was key to the success we achieved with the implementation of the evidence-based bundle.
• Implemented registered nurse/respiratory therapist (RN/RT) rounds, reviewing ventilator settings and patient goals (7/05).
• Revised nursing documentation of VAP worksheet to include head of bed (HOB), mouth care, chest radiograph results (8/05).
• Instituted monthly posting of VAP performance improvement data by infection prevention and control department. To make data more meaningful to staff, the infection prevention and control department reported the number days each unit had gone without a VAP, utilizing the logo “ZAP the VAP” (9/05).
• Standardized case review for each VAP using Root Cause Analysis to identify areas of improvement.
• Revised ventilator protocols to include initiating weaning upon intubation, for all patients in ICU (10/05).
• Revised ICU orders for ventilated patients to include evidence-based improvements: HOB elevation greater than 30 degrees, oral care, RT to begin weaning the patient immediately based on RT-driven protocol, daily evaluation of readiness to extubate, glycemic control, deep vein thrombosis prophylaxis, and peptic ulcer disease prophylaxis (10/05).
• Instituted glycemic control best practices in Cardiovascular Critical Care.  Lowered blood sugar goal from 130 to 110 for all patients, tracked diabetics and non-diabetics, created a more aggressive insulin drip management protocol, and involved Certified Diabetic Educators (CDE) in daily patient rounding (12/05).
• RT implemented heated wire circuits to minimize condensate in the ventilator tubing.
• Implemented a standardized mouth care kit for 24-hour care, including covered yankauer and above the cuff suctioning. Oral care performed every 2 - 4 hours and prn, teeth brushed every 12 hours, above the cuff suction performed once a shift and every time the ETT is repositioned or cuff deflated (2/06).
• Revised nursing documentation flow sheet to include space for documentation of ventilator bundle (5/06).
• Revised RT ventilator flow sheet to include ventilator bundle for use hospital-wide (6/06).
• Revised Critical Care Unit ventilator orders to include initiating insulin drip if patient’s blood glucose is >160 mg/dL (6/06)  (The goal was changed to 150 mg/dL in February 2007).
• Revised Cardiovascular orders to maintain blood glucose at 80-110 mg/dL with an insulin drip started for blood glucose >110 mg/dL post CABG.

• The median ventilator days decreased from 3.0 days to 1.5 days in the Medical/Surgical Critical Care and 1.5 days to 0.4 days in the Cardiovascular Unit. (The CV Unit includes cardiothoracic and medical/surgical patients.)
• The Medical/Surgical Critical Care Unit has gone 487 days without a VAP.
• The Cardiovascular Unit had 1 VAP in 487 days.

[6/5/07]

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The Brooklyn Hospital Center – Brooklyn, NY
Availability Status: Available to answer requests
Licensed Beds: 476
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: November 2005
Mentor Contact Name: Anthony Lisske
Mentor Contact Email: arl9004@nyp.org
Mentor Contact Phone: 718-250-8174

Additional Information:

• The senior management along with the clinical stakeholders at The Brooklyn Hospital Center expressed their commitment in participating in the IHI 100K Lives Campaign.
• The institution developed an IHI team representing members from the following hospital services: Medical & Surgical ICU MDs & RNs, Respiratory Therapy, Radiology, Infection Control, Emergency Department, Pharmacy, Quality Management and Clerical Support Associates.
• The IHI team started meeting in August 2005.  They developed a time line to roll out the VAP project.  The team formulated policies, procedures, education materials, data collection tools and aggregation methodologies.
• Feedback and updates on the initiative are reported monthly to Clinical Services Committees and other ancillary departments involved.
• Reduction in the VAP rate from 7.0 per 1000 vent days in the 3rd Qtr 05 to 4.3 per 1000 vent days in the 1st Qtr 06 in our MICU.
• Reduction in the VAP rate from 5.3 per 1000 vent days in the 3rd Qtr 05 to 0 per 1000 vent days in the 1st Qtr 06 in our SICU (the VAP rate has been 0 for the past 6 months in our SICU).
• The institution rolled out our version of the “VAP Bundle Tool” on 11/01/05 and for the past 17 weeks the bundle compliance has been 100% on both our SICU and MICU units.  We attribute this success to the provider specific educational in-services performed prior to and continually throughout our VAP initiative.
[5/12/06]

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BryanLGH Medical Center – Lincoln, NE
Availability Status: Available to answer requests
Licensed Beds: 641
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: January 2004
Mentor Contact Name: Joyce Nass, CNS Critical Care Services
Mentor Contact Email: jnass@bryanlgh.org
Mentor Contact Phone: 402-481-3810

Additional Information:

BryanLGH Medical Center has three ICUs at 2 locations.  The CVICU and Medical Surgical ICU began working on eliminating VAP in January 2004.  The Neuro Trauma ICU joined this project in January 2005. 

Project successes are related to:

• Participation in the VHA collaborative provided support, guidance, benchmarking and networking.
• Strong emphasis on teamwork to plan, design, implement and enforce changes.  Perseverance in early stages was key to ensure practice changes and avoid variance.  The continued involvement of a core leadership team has helped to sustain the gain.
• Multidisciplinary rounds with the involvement of an intensivist and use of a daily goal sheet.  This is an essential component to success.  Standard order sets were developed to standardize care of ventilated patients.
• Immediate feedback to staff related to improved compliance with vent bundle standards.  Posting compliance data, as well as the date of last VAP and number of days VAP free.  Celebrations at major milestones.
• Collaborative efforts on the part of all disciplines involved in care.

The CVICU went from a VAP rate of 5.3 per 1000 vent days to 1.95 per 1000 vent days and had a VAP-free stretch of 395 days. The Medical Surgical ICU had a VAP rate of 1.5 per 1000 vent days when we began and is now over 22 months without a VAP. We will celebrate 2 years VAP-free in March 2007. The Neuro Trauma ICU has had several extended periods VAP-free, the longest was 125 days.  However, we continue to encounter VAPs there at about the same rate and have a multidisciplinary team working on factors related to differences in Neuro Trauma patient populations. All three units are above 90% compliance (green) for all areas of the ventilator bundle. In addition to the vent bundle, other measures we have focused on include oral care, subglottic suctioning, mobility and intrahospital transport guidelines.

The success of care provided to ICU ventilated patients is being used to develop protocols for care of ventilated patients in the Progressive Care Unit setting. In other efforts to spread and sustain our accomplishments, we are developing a project to incorporate frontline staff members in surveillance to insure continued focus. We have also included VAP prevention in the nursing curriculum and orientation for nurses and respiratory therapists, created a process for continued monitoring of compliance, and are producing a video to introduce all new employees to the Medical Center’s dedication to delivery of quality care, highlighting our participation in all six components of the 100K Lives Campaign.

[2/28/06; updated 2/07]

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Butler Memorial Hospital – Butler, PA
Availability Status: Available to answer requests
Licensed Beds: 234
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: August 2005
Mentor Contact Name: Diane Wilson
Mentor Contact Email: dlw.nur@butlerhealthsystem.org
Mentor Contact Phone: 724-284-4862

Additional Information:

• The reduction of Ventilator Associated Pnuemonia was identified as a key initiative in 2003.
• Using rapid small tests of change, Butler Memorial Hospital was able to reduce VAP. Initially, the team focused on one unit, but expanded the initiative to other applicable departments within 4 months. 
• Key program enhancements included hand hygiene education, standardized care for the ventilator patient, enhanced oral care, head of bed elevation, Hi Lo subglottic suctioning ET tubes and the sedation vacation.
• Key to the success of this initiative was providing immediate 1:1 feedback to the staff and the posting of results.
• As improvements in care led to a decrease in VAP, the staff took great pride in the accomplishment.
• The involved departments were recognized with a luncheon.
• Reduction of VAP from 12.5 VAP/1000 ventilator days in 2004 to 1.08 VAP/1000 ventilator days in 2006
• Reduction Ventilator Associated deaths from 12.5 VAP/1000 vent days X 2250 vent days x 0.25 deaths per VAP = 7 deaths/year to 1.08 VAP/vent days x 1956 vent days  X.25 deaths per VAP = 0.52 deaths per year or 1 death every 1 year 11 months
[6/2/06]

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Cape Coral Hospital – Cape Coral, FL
Availability Status: Available to answer requests
Licensed Beds: 281
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: September 2004
Mentor Contact Name: Annette Forlenza
Mentor Contact Email: annette.forlenza@leememorial.org
Mentor Contact Phone: 239-574-0159

Additional Information:

Cape Coral Hospital began its work 15 months ago with the goal to reduce VAP by 50%. 
Early on, we had issues with data collection and validity and were able to resolve these by using the change package.  Our multidisciplinary team worked diligently to identify areas for improvement using PDSA cycles.  Our multidisciplinary team meets daily during the week to identify goals that are transferred onto a chalkboard for communication.  Our staff have initiated nurse-driven rounds on nights and weekends, where goals and goal attainment are reviewed and communicated to the oncoming shift. 
Changing culture has been the most challenging and the most rewarding.  We have learned not to accept the status quo and continuously seek out the best evidence to provide the safest care. 
We have high reliability with the vent bundle and are in the process of spreading to those areas (PACU, ED) where ventilator patients may spend time.

• Ventilator bundle compliance is greater than 95%.
• We are on our 5th month without a VAP.  We reduced the rate by 50%, however we are now measuring number of days between episodes.
[2/14/06]

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Capital Region Medical Center – Jefferson City, MO
Availability Status: Available to answer requests
Licensed Beds: 100
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: June 2005
Mentor Contact Name: Melodie White, RN, MBA Director of Quality
Mentor Contact Email: mwhite@mail.crmc.org
Mentor Contact Phone: 573-632-5205

Additional Information:

Capital Region was able to decrease ventilator associated pneumonia to zero for 6 months instead of the original goal of decreasing our infections by 20% in 6 months
Capital Region was able to make this turn around in 3 months time
The new patient care processes are looked at very positively by the nursing staff and physicians

0 ventilator associated pneumonias for 3rd Quarter 2005 and 4th Quarter 2005 with 488 ventilator days. Cost savings of approximately $35,000 per case.
[1/31/06]

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Carondelet St. Joseph’s Hospital – Tucson, AZ
Availability Status: Available to answer requests
Licensed Beds: 425
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: April 2005
Mentor Contact Name: Chris Scullary
Mentor Contact Email: cscullary@carondelet.org
Mentor Contact Phone: 520-872-6684

Additional Information:

In CY-05, a VAP team was implemented and met monthly starting in April 05. Our hospital requires formal ventilator privileges for managing mechanical ventilation after 24 hours.  Our pulmonogists actively participated in the VAP team and were responsible for the development and implementation of a mechanical ventilation pre-printed order set, a sedation vacation pre-printed order set, and a weaning protocol. Respiratory therapy has provided ongoing data collection and all disciplines were active in supporting the implementation of the VAP bundle.

Prior to implementing a VAP team, the mean VAP rate was 7.3/1000 with the NNIS mean being 5.99/1000 vent days.  January 06 we had 41 patients with 190 vent days and 0 VAPs
February 06 we had 59 patients with 252 vent days and 0 VAPs.

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Carteret General Hospital – Morehead City, NC
Availability Status: Available to answer requests
Licensed Beds: 117
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: June 2005
Mentor Contact Name: Gaye Fulcher, RRT
Mentor Contact Email: gfulcher@ccgh.org
Mentor Contact Phone: 252-808-6196

Additional Information:

2 goals were set for the VAP Campaign:

1. Decrease CGH’s VAP Rate by 50% within one year
2. Gain 95% or greater compliance with Ventilator Bundle

Steps:
1. Obtained baseline VAP rate and VB compliance
2. Physician, Nursing and RT education
3. Initiated evidenced-based practices
4. Assigned responsibility for data collection (RT)
5. Tracked compliance daily in 8-bed CCU
6. Reported data back to staff / physicians, and ICC
7. Changed practices and re-educated as needed

Top reasons for success:

• Strong encouragement from Administration and their complete support.
• Formation of a Multidisciplinary Team (Nursing, Respiratory Therapy, Case Management and Infection Control) and complete commitment from staff members.  This team was carefully selected.  Members include direct caregiver staff members. We held this team accountable for implementation, reporting and results.   
• Key stakeholder buy-in.  This was achieved through education.  Direct caregivers were educated first (physicians, nursing and respiratory).  Educational objectives focused on "why" our campaign was necessary, not on "how" we were going to achieve results. Our focus was always on patient care. Once key stakeholders were educated, our multidisciplinary team educated staff members on how we would approach changes. Small, simple changes can have a major impact.
• Set clear goals.  Too often, a goal is set and before results can be obtained, the goal is changed.  This approach is confusing to stakeholders and staff members.
• Continuous monitoring of patients.  We used a daily checklist system to assess bundle compliance.  At least once per day, an assigned respiratory therapist surveys all ventilated patients. If non-compliance is found, the primary nurse is notified and the physician is contacted for appropriate orders (DVT or PUD prophylaxis are the most common).
• Make your success (and failures) public.  Report to staff FIRST.  Staff members are the individuals implementing the changes and they know what works.

Goal 1:

• Reported 0 VAPs during IHI campaign per campaign criteria
• Reduced CGH’s VAP rate by approximately 60% for year
• Reduced Ventilator Days by approximately 30% for year

Goal 2:

• Gained 100% compliance of Ventilator Bundle within 6 months (data collected on all shifts)

[8/31/06]

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Cayuga Medical Center at Ithaca – Ithaca, NY
Availability Status: Available to answer requests
Licensed Beds: 204
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: June 2003
Mentor Contact Name: Shawn Newvine
Mentor Contact Email: snewvine@cayugamed.org
Mentor Contact Phone: 607-274-4491

Additional Information:

We began implementation of ventilator bundles and prevention of VAP in June of 2003. 
We were able to rapidly implement measures to improve the overall care of our mechanically ventilated patients and were able to show very early success.
As part of our initiatives, we implemented a wonderful system of interdisciplinary rounds which has improved the care of all of our ICU patients, not only the mechanically ventilated patients.
The success of our program has become a great source of pride for the ICCU staff and we have been asked to present our success stories for various organizations such as VHA and HANYS as well as a joint conference for HANYS and IHI.

Since initiation of our program, we have only had 1 incident of ventilator acquired pneumonia in almost 3 years.  We have successfully demonstrated a 79% reduction in VAP and along with our program have experienced no incidence of DVT or PUD in our mechanically ventilated patients.
[4/17/06]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: July 2005
Mentor Contact Name: Kathy Bailey, RN, CIC
Mentor Contact Email: kathy.bailey@centrahealth.com
Mentor Contact Phone: 434-947-7780

Additional Information:

Centra Health implemented a VAP bundle observation process in July 2005.
Each manager was petitioned to observe all ventilated patients in their unit 5 days/week for bundle compliance.
Units and attending physicians are notified if all elements of the bundle are not in place.
Oral care was the primary omission and as been addressed with unit specifc interventions for improvement.
A pattern of peptic ulcer prophylaxis omission was linked to prophylaxis not being re-instituted immediately following TPN discontinuation. Intervention is being addressed by critical care committee. 

The VAP bundle compliance began at 89.5% and has improved to a 96.8% rate with a goal of 100% compliance.
Centra Health's VAP infection rate was at 7.7/1000 ventilator days prior to attention to the bundle elements and is now at 3.7/1000 ventilator days.

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Central DuPage Hospital – Winfield, IL
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 361
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: December 2004
Mentor Contact Name: David Cooke, M.D. (general contact); Rita Brennan, R.N. (Pediatric VAP)
Mentor Contact Email: David_Cooke@cdh.org; Rita_Brennan@cdh.org
Mentor Contact Phone: (DC) 630-933-3012; (RB) 630-933-6459

Additional Information:

Recognition of the need to reduce VAP rates in early 2003 led to process changes that were predicted to improve outcomes but, in fact, failed to do so. Additional data analysis and research resulted in further process change and a significant reduction in VAP rate. Prevention of unintended extubation was accomplished by a carefully performed method for securing the endotracheal tube.

Pediatric “Ventilator bundle” implemented in the Fall of 2004:

ETT care:
• In-line suctioning instituted, suction tubing to remain continuously attached. Used Ballard “Y” suction tubing.
• Modified umbilical cord clamp used for ETT stabilization.
• Carefully evaluate infant prior to removing an ETT when infant is in distress, manually bag infant, suction if indicated.
• Minimize number of intubations/ reintubations
• Carefully evaluate need for intubation, choose less invasive ventilatory support if possible

Oral care:
• The RN begins check of patient with assessment of ETT and oral care
• No use of bulb syringe on ventilated patients
• All oral care products single use.
• Use sterile H2O and 2x2 to wipe lips and gums, oral care every 3-4 hours
• Good hand washing prior to ETT, oral care, etc, use of gloves with care
• Suction mouth and then nose

Equipment care: 
• Ventilators circuits are changed as needed when mechanically malfunctioning or visibly soiled
• CPAP systems are allowed to remain on stand-by for 12 hours with flow and heater remaining on
• Oxygen therapy equipment are changed as needed when mechanically malfunctioning or visibly soiled, this equipment may be cleaned, rinsed, and allowed to air dry
• Resuscitation bags are never to be placed on the bed. They are to be hung outside of the isolette or above the Ohio bed.  Resuscitation bags are to be replaced once per week.

A process change to prevent unintended extubation was put into place in late 2004. The rate of accidental extubations declined from 6.6 events/1000 vent days to 0 by third quarter 2005. The 2004 VAP rate was 13 per 1000 vent days and fell to 5.4 in 2005.
[3/30/06]

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Charleston Area Medical Center – Charleston, WV
Availability Status: Available to answer requests
Licensed Beds: 913
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: Fall 2003
Mentor Contact Name: Kim Kendrick, Six Sigma Black Belt
Mentor Contact Email: kim.kendrick@camc.org
Mentor Contact Phone: 304-388-4310

Additional Information:

Worked through the ICU collaborative process with IHI to implement the Ventilator Bundle concept for all ICUs
Standardized process of care for HOB elevated 30% utilizing by adding scales and red dot to show 30 degrees
Incorporated respiratory staff to help maintain 30 HOB elevation and day to day monitoring with visual inspection by staff/management
Addressed PUD and DVT prophylaxis in ICU through use of daily goal sheet and interdisciplinary rounds-primary nurse for patient contacted the physician for patients who had not started treatment
Education and monitoring processes developed to track compliance with individual measures and ‘all or nothing’ scores for bundle concepts
Utilize ICU tracking forms to monitor individual and system progress toward goal
Educational posters developed to help improve staff understanding of bundle concepts.
 
Ventilator all or nothing score- increasing from 80-86%
PUD prophylaxis 94.5% mean over 1 year
DVT prophylaxis 94.4% mean over 1 year
HOB 30degrees: 96.6% mean over 1 year
Sedation Holiday: mean 90.05% over 1 year (lowest measure current focus work for the group)
[1/31/06]

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Chesapeake General Hospital – Chesapeake, VA
Availability Status: Available to answer requests
Licensed Beds: 310
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: April 2005
Mentor Contact Name: Maralyn Spittler
Mentor Contact Email: maralyn.spittler@chealth.org
Mentor Contact Phone: 757-312-6838

Additional Information:

• Implemented an ICU Bundle sheet that is completed by the Charge Nurses on morning rounds.
• The Respiratory Therapy department has implemented a rapid weaning protocol to expedite the weaning process.
• Education on the ventilator bundles was provided to medical and clinical staff

• FY05 VAP's = 5  FY06 YTD = 0
• FY05 Rapid weaning interventions were implemented on 90% of our ventilated patients; fiscal year to date, we have implemented rapid weaning measures on 100% of our ventilated patients.
[3/30/06]

*                *                  *

Cincinnati Children's Hospital Medical Center – Cincinnati, OH
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 451
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: March 2005
Mentor Contact Name: Uma Kotagal, MD, Vice President for Quality and Transformation
Mentor Contact Email: uma.kotagal@cchmc.org
Mentor Contact Phone: 513-636-0178

Additional Information:

Evaluated and adapted adult bundle for peds with focus on strategies to prevent bacterial colonization of oropharynx, stomach and sinuses:
• Meticulous hand hygiene before and after contact with vent circuit
• Change vent circuits and in-line suction catheters only when visibly soiled
• Drain condensate from circuit at least every 2 – 4 hours
• Store oral suction devices in non-sealed plastic bag at the bedside
• When soiling from respiratory secretions is anticipated, wear gown before providing care to patient
• Provide mouth care at least every 4 hours
• Prevent aspiration of contaminated secretions
• Elevate head of bed 30 – 45 degrees unless contraindicated by written order
• Drain ventilator circuit before repositioning patient
• Respiratory Therapist and RN review compliance with the bundle every four hours together. 

Care bundle implemented in all units by August 2005 and heated vent circuits introduced in September 2005.  

The combined rate for calendar year 2004 for the three ICU's (PICU, CICU and NICU) was 6.0 per 1,000 vent days.

Rate for October 2005 - March 2006 is 1.4 per 1,000 vent days.
[5/12/06]

*                *                  *

Claxton-Hepburn Medical Center – Ogdensburg, NY
Availability Status: Available to answer requests
Licensed Beds: 129
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: Spring 2004
Mentor Contact Name: Jennifer S Shaver, RN  NM/ICU, Manager/Respiratory Services
Mentor Contact Email: jshaver@chmed.org
Mentor Contact Phone: 315-393-3600, ext 5337

Additional Information:
At Claxton-Hepburn Medical Center, we affected a culture change in the care of ventilated patients. In our ICU, ventilator management was traditionally contingent upon individual   physician preference, and did not consistently employ (current) evidence-based strategies.  In 2004, we began addressing the occurrence of VAP in our 10-bed Medical Surgical ICU. The only physician champions that ‘bought in’ to the process were heavily vested in other initiatives. The team:

• Provided both formal and informal education to all involved disciplines on VAP, as well as evidence-based measures proven to reduce VAP occurrence.
• Shared feedback to providers regarding successes. 
• Supported nursing and respiratory staff in (discipline-specific) clinical decision making.
• Facilitated the redesign of our nursing and respiratory therapy documentation to easily capture the expectation of care.
• Praised the nurse, respiratory and physician leaders who ‘bought in’ early, and coached the skeptics.
• Provided current evidence-based literature for those critical conversations that involved coaching opportunities
• Implemented a physician-order set after we had developed an ICU- and respiratory therapist-driven culture that was highly motivated to reduce VAP. 
• Posted graphs inside the ICU to detail compliance with the vent bundle performance measures.
• Implemented a physician order set for all ICU ventilated patients that was ultimately embraced by our medical staff. 
• Initiated a framework for successful employment of subsequent initiatives.
• Offered assistance to peers from other institutions in regards to developing and applying similar protocols.

• 100% compliance with ventilator bundle performance measures in 2007
A collateral benefit, not foreseen at the initiation of our project, was the actual reduction in ventilator hours per patient. Traditionally tracked as “vent days,” our rural setting allows a more hands-on approach to documentation, and subsequent data collection.
    • Ventilator hours per patient: time frame from ventilator application – liberation
    • Number of patients ventilated for less than 12 hours, 12-24 hours, 25-48 hours, 49-72 hours, 72-96 hours, 97-120 hours, 121-144 hours, 145-168 hours, and greater than 168 hours.

We affected a culture change in the care of ventilated patients in our ICU which resulted in a 55% reduction in the hours per ventilated patient, a 27% reduction in the ventilation hours patient in patients ventilated less than 1 week and a 250% reduction in the number of patients ventilated for more than a week, all of which we feel significantly contributed to a zero occurrence of VAP for 48 months (YTD).
[2/8/08]
[Updated 10/23/08]

*                *                  *

Columbus Regional Hospital – Columbus, IN
Availability Status: Available to answer requests
Licensed Beds: 325
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: June 2002
Mentor Contact Name: Jennifer Dunscomb
Mentor Contact Email: jdunscomb@crh.org
Mentor Contact Phone: 812-376-5575

Additional Information:

Developed a culture of safety through enhanced interdisciplinary relationships using complex adaptive science
Developed mechanical ventilation orders that include all bundle interventions
Developed a hyperglycemia standing order policy where nurses initiate insulin therapy based on blood glucose without a physicians order/exam
Use of information systems to conduct concurrent review on bundle indicators

> 1800 ventilator days without a ventilator associated pneumonia
92% on compliance to bundle indicators
Mortality and LOS significantly lower than predicted hospitals measured through APACHE
[1/31/06]

*                *                  *

Community Hospital East – Indianapolis, IN
Availability Status: Available to answer requests
Licensed Beds: 400
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Cleo Ann Burgard
Mentor Contact Email: cburgard@ecommunity.com
Mentor Contact Phone: (317) 621 5329

Additional Information:

This intervention is spread throughout our five (5) Network hospitals:  Community Hospital Anderson, Community Hospital East, Community Hospital North, Community Hospital South, and the Indiana Heart Hospital

• We utilize internally designed, Network-wide redundancy tools such as physician order sets, bundles, and protocols to maintain compliance with evidence-based ventilator care
• We have system-wide multidisciplinary involvement where the culture climate is generative, and safety minded
• Awarded the 2005 VHA Leadership Award for Clinical Excellence for our VAP performance and outcome measures
• The Community Health Network has been engaged in this intervention since the original IHI program in 1996, and were rated in the ‘Best Performers’ category in the IDICU and TICU initiatives

• We maintained "Green Light" (> 90% compliance) Network performance in the Ventilator Bundle for 2005
• One (1) Network ICU has had zero VAP's for 25 months and counting, Six-Sigma performance!
• Network aggregate VAP rate between NNISS 10th and 25th percentile, with several units at zero

[2/14/06]

*                *                  *

Contra Costa Regional Medical Center – Martinez, CA
Availability Status: Available to answer requests
Licensed Beds: 166
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2004
Mentor Contact Name: Steven Tremain, MD
Mentor Contact Email: stremain@hsd.cccounty.us
Mentor Contact Phone: 925-370-5122

Additional Information:

Successful prevention of VAP's has resulted from the use of a multidiscplinary project team, bundled order sets with "opt-out," elevation of head of bed using tape on wall behind headboard to mark 30 degrees, and real-time bundle compliance by integrating the bundle into the nursing flow sheets.  VAP prevention has become an "automatic process".  The initiative champions are the Medical Director of Critical Care and the Nurse Manager of Critical Care. We encourage families to assist us by edcuating them as to the importance of head of bed elevation, and request that they remind us to elevate the head if they can "see the line on the wall." Posters to support this family involvement are placed in the Critical Care Unit and in the CCU family waiting room.

Process measures:  Bundle compliance is "automatic." It is incorporated into the physician's order sets and nursing work flow, flow sheets, and documentation systems. Compliance is 100%.  Outcome measures:  VAP rate for 2003 = 20/1000 vent days; 2004 = 8/1000; 2005 = 1.5/1000; 2006 = 1.5/1000.   This included a period of 17 months from May of 2005 to October of 2006 with no VAPs.   The VAP in October of 2006 was a witnessed aspiration.  Immediately the bundle compliance was checked and found to be 100%.  Other possibilities were considered and it was determined that the cuff pressure had decreased.  The bundle has now been modified to include increased periodicity of cuff pressure checks.
[3/13/07]

*                *                  *

Cooley Dickinson Hospital – Northampton, MA
Availability Status: Available to answer requests
Licensed Beds: 125
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: July 2004
Mentor Contact Name: Tammy Cole-Poklewski, RN, MS
Mentor Contact Email:  Tammy_Cole-Poklewski@cooley-dickinson.org
Mentor Contact Phone:  413-582-4736

Additional Information:

Cooley Dickinson Hospital implemented the bundle of practices to prevent ventilator associated pneumonias in July 2004.  In 2005, a multi-disciplinary rounding/goal setting process and form were implemented which further solidified the expectation of 100% compliance with the bundle.

CDH has moved to counting "days between" Ventilator-associated pneumonias.   We had reached 297 days since last VAP until March 2006.   We have begun our days between count again, hoping to exceed the 297 days.  Our goal and philosophy is one of "zero infections" now.

[7/25/06]

*                *                  *

Exempla Saint Joseph Hospital – Denver, CO
Availability Status: Available to answer requests
Licensed Beds:  563
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: September 2002
Mentor Contact Name: Maria Kinsella
Mentor Contact Email: kinsellam@exempla.org
Mentor Contact Phone: 303-866-8514

Additional Information:

Exempla Saint Joseph Hospital was a participant in VHA's Transformation of the ICU program. Our facility started implementing the ventilator bundle in 4th quarter 2002. The combined efforts of Respiratory Therapy, Pharmacy, Intensivists and Nursing have helped to maintain a consistently low rate of ventilator-associated pneumonia. By including the bundle elements in daily rounds and providing ongoing data feedback to staff, we have been able to maintain a consistently low rate of VAP. We have received the Leadership Award from VHA for 6 consecutive months of zero VAP

By consistenly applying the ventilator bundle to our patients, we succeeded by having a total of only 6 VAPs during 2005. We had a six month zero VAP stretch during that time. Our overall VAP rate is currently at 2.3 per 1000 patient ventilator days.

*                *                  *

Faquier Hospital – Warrenton, VA
Availability Status: Available to answer requests
Licensed Beds:  86
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: January 2006
Mentor Contact Name: Catherine Walsh
Mentor Contact Email: walshc@fauquierhospital.org
Mentor Contact Phone: 540-349-0584

Additional Information:

Patient records are reviewed for signs and symptoms of pneumonia prior to, during and post-ventilation to determine progression of disease or development of new disease process during ventilation and 48 hours post-extubation.    

Ventilator device days are collected by counting ventilators in use in the ICU during nursing supervisor morning rounds, as required in the CDC reporting module. In addition to tracking ventilator associated pneumonia, processes are implemented to reduce risks for VAP. 

The numerator in this survey is the number of intensive care unit patients on mechanical ventilation at time of survey for whom all four elements of the ventilator bundle are documented and in place.  The denominator is every patient that is ventilated and remains in the ICU for one day.  

The staff were educated on the appropriate documentation and appropriate care of the patient on mechanical ventilation was reinforced.  The bundle elements are scored as meeting all elements required, or receiving no "credit."  The Infection Control Practitioner conducts a monthly review of all ventilated patients and gives feedback to staff directly and through department director for those in non-compliance of documentation.  The hospital also recognizes the team caring for patients on mechanical ventilation for their continued provision of the highest standard of care.

Policies and standing orders related to caring for ventilated patients were reviewed to include the above components.

Information related to these bundle components was collected at the bedside by the care providers.  Of the 119 patients on mechanical ventilation longer than 12 hours, data collection was completed on 116 patients through nursing documentation of compliance with bundle element.  Of the 116 patients with documentation, 89 or 76.7% of the patients were 100% compliant with bundle implementation for the entire intubation period.

To enhance accurate data collection and promote the highest standard of care for our ventilated patients, the bundle criteria was built by Information Systems into the ICU Ventilator Management screen of the Electronic Medical Record.  The electronic recording will prevent loss of papers and forms and place the criteria at every caregiver’s attention daily, thus reminding staff of the standard of care we provide our patients.

To promote oral hygiene every four hours for the ventilated patient, a new mouth care product was selected by the ICU staff and approved by the Hospital Equipment Materials Review Committee.  The product comprises all equipment for 24 hours of oral care, including a Yankeur catheter, suction catheters, toothbrushes, cleaning and moisturizing lotions, in a convenient 7 piece kit that provides at a glance assessment of the frequency of mouth care for the patient that day. The component materials of the equipment provide a gentler cleaning action to prevent damage of the oral cavity and daily disposal of a self covering Yaunker tip, promoting cleanliness and reducing contamination of the equipment. 

Monitoring Effectiveness of Action Taken:

2004 – 1 pneumonia in 434 device days = rate of 2.30

2005 – 0 pneumonia in 531 device days = rate of 0

2006 – 1 pneumonia in 742 device days = rate of  1.35

2007 – 0 pneumonia in 638 device days = rate of 0

Total number of patients reviewed for hospital-acquired nosocomial pneumonia related to intubation and mechanical ventilation from January 1, 2007 to December 31, 2007 in the ICU is 119 .  Total number of ventilation device days is 638.  The rate of infections per 1000 device days is 0.  No ventilator associated pneumonia was identified in 2006 and 2007; none to date in 2008. 
[4/18/08]

*                *                  *

Geneva General Hospital – Geneva, NY
Availability Status: Available to answer requests
Licensed Beds:  132
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: September 2004
Mentor Contact Name: Barb Weinberg
Mentor Contact Email: barb.weinberg@flhealth.org
Mentor Contact Phone: 315-787-4662

Additional Information:

Geneva General Hospital has been successful because we realized the importance of involving the entire team (physicians, ICU staff, and respiratory therapists) in our efforts to reduce VAP.  We worked collaboratively and creatively to develop tools and methods to effectively implement the VAP bundle.  There was constant open dialogue and a willingness to change methods when needed.

As we implemented all aspects of the VAP bundle, we provided consistent feedback to the staff on compliance.  This was accomplished primarily through review and analysis of the data.  This also helped us to better understand our processes and the role each discipline played.

September 2004:  100% compliance with 3 (HOB elevation, PUD prophylaxis, and DVT prophylaxis) of the 5 measures in the bundle.

September 2005:  100% compliance with HOB elevation, appropriate sedation, PUD prophylaxis, and DVT prophylaxis with 75% compliance in weaning assessment.  This resulted in no ventilator associated pneumonia cases in the past 24 months.
[6/10/06]

*                *                  *

Harford Memorial Hospital – Havre de Grace, MD
Availability Status: Available to answer requests
Licensed Beds: 91
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: February 2005
Mentor Contact Name: Nancy Howard, MS, RN   Project Coordinator, Performance Improvement
Mentor Contact Email: nkh.01@ex.uchs.org
Mentor Contact Phone: 443-843-5634

Additional Information:

• Team members at HMH, one of the hospitals in the two-hospital system of Upper Chesapeake Health, rapidly implemented the use of the vent bundle in February, 2005.
• Interdisciplinary goal rounds are conducted two times per day, 7 days per week.  During rounds, all patients on ventilators are discussed and the team focuses on elements of care within the vent bundle and identifies goals to be achieved within the next 24 hours.
• Team members from the Performance Improvement and Medical Information Systems Departments worked together to automate documentation of the vent bundle and report generation in order to provide timely data collection, analysis and feedback to clinicians
• Timely and consistent feedback on the data improved the team members’ understanding of the process and resulted in improved compliance, and consistent implementation of the care elements resulted in improved outcomes.
• Interdisciplinary collaboration by nurses, pharmacists, and physicians improved glycemic control in the vented patient and maintained 38% of glucose levels ≤ 110 mg/dl and 47% of glucose levels within 61-120mg/dl, with the incidence of hypoglycemia occurring at 1% on average for the year.
• HMH spread the culture of safety throughout the organization: all employees view the Josie King video during new team member orientation and Senior Executive Safety Rounds facilitate team member and senior leadership discussion about perceived potential or actual safety issues.
• Patients receiving all elements of the vent bundle averaged 97% during the last 6 months of the year.
• Head of the bed elevated ≥ 30 degrees averaged 99% for the eleven months of 2005 that the vent bundle was in place.
• Achieved 100% peptic ulcer prophylaxis for the last 6 months of 2005 with an average of 99% for the year.
• Deep vein thrombosis prophylaxis averaged 99% for the eleven months of implementation of the vent bundle.
• Rate of VAP decreased by 50% in 2005 and now falls below the CDC median rate per 1000 ventilator days.
• Decreased the ALOS in the ICU by .12 days but the average number of vent days/patient fluctuated month to month due to low volumes.
• When removing the outliers from the data (stays > 10 days) the average number of vent days is unchanged throughout the year and averages 2.8 days.
• Mortality rates trended down in 2005 through Q3 but increased in Q4 as a direct result of palliative patients in the ICU.
[2/14/06]

*                *                  *

Henry Ford Hospital – Detroit, MI
Availability Status: Available to answer requests
Licensed Beds: 904
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: February 2003
Mentor Contact Name: Jack Jordan
Mentor Contact Email: jjordan1@hfhs.org
Mentor Contact Phone: 313-874-3925

Additional Information:

As part of the IHI critical care collaborative, Henry Ford Hospital began an effort to improve ICU care including the implementation of the vent bundle in 2003. Teams were assembled in all four adult ICUs.

Some of the issues that we uncovered while implementing the IHI recommendations included:

• Patients transferred from floors on weekends were not always placed on protocols.
• Head of beds, lowered for procedures, were not immediately returned to 30 degrees.
• Reminders didn’t exist to place sequential compression devices on patients for DVT prophylaxis when heparin was discontinued.
• Daily weaning trials were often conducted after rounds.

After the above issues were identified and corrected, daily “quick rounds” were instituted to verify that vent bundle and glucose protocols were followed.

An average reduction of 1.4 days on a ventilator.
An overall reduction of ICU length of stay by 0.65 days.
[1/31/06]

*                *                  *

Hilo Medical Center – Hilo, HI
Availability Status: Available to answer requests
Licensed Beds: 275
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Gail Rhoades
Mentor Contact Email: grhoades@hhsc.org
Mentor Contact Phone: 808-974-6942

Additional Information:

Hilo Medical Center has been able to implement the Ventilator Bundle rapidly and with success in combination with other strategies, such as a strict oral hygiene program for ventilator patients.

Most notably, we have decreased our ventilator associated pneumonia rate from 3.8 in 2004 to 0.48 in 2005.  We have had only one ventilator associated pneumonia in 12 months.
[2/14/06]

*                *                  *

Huntington Hospital – Huntington, NY
Availability Status: Available to answer requests
Licensed Beds: 289
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: October 2005
Mentor Contact Name: Virginia Smith, RN
Mentor Contact Email: vsmith@hunthosp.org
Mentor Contact Phone: 631-351-2456

Additional Information:

Huntington Hospital developed a standardized approach to manage the process of care and control the incidence of ventilator associated pneumonia. A multidisciplinary team developed policies and procedures to decrease the incidence of Ventilator Associated Pneumonia (VAP) consistent with the recommendations provided by the 100k Lives Campaign.  The goal of this initiative was to develop accountability and change behavior of clinicians at the bedside to reduce VAP. 

Objectives used to reach this goal include:
• Implement standardized, evidence-based reduction strategies
• Increase communication, therefore raising consciousness of the caregiver
• Standardize treatment by implementing physician order sets for ventilated patients.
• Providing weekly prevalence studies of the infection prevention practices to increase awareness and compliance.

Partners: Infection control, quality management, nursing, respiratory therapy, medical staff, administration, laboratory, materials management and pharmacy. 

Standardized Tools: 
• Creation of a multidisciplinary rounding tool that incorporated all bundle components.

Educational Resources:
• An IHI 100K Lives Campaign page was created on our intranet that includes educational material regarding bundle components along with a link to IHI. Nurses can earn educational credits by completing a quiz on the 100K Lives Campaign.

Awareness & Recognition: 
• Several articles were written in a publication mailed to all employees to increase awareness of the initiative.
• IHI Awareness Posters are displayed throughout the hospital.
• IHI initiative information was included in the staff training.

Lessons Learned:
• Defined direction and commitment from all leadership made the initiative successful.
• Central approach to defining measures created consistency.
• Involvement of health care providers at every level helped to reduce variation in care.
• Formal education increased understanding of practice.
• Monitoring and objective feedback helped to change behavior not just compliance with documentation. 

Outcomes:  The infection prevention initiative revealed a decrease in VAP.
• From October 2005, VAP bundle compliance remained at 100%.
• From October 2005, the VAP index decreased from 6.13 to 0.
[8/31/06]

*                *                  *

McLeod Regional Medical Center – Florence, SC
Availability Status: Available to answer requests
Licensed Beds: 371
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: 6/2003
Mentor Contact Name: Mark Williams, RN, MBA/HCM, BSN
Mentor Contact Email: mwilliams@mcleodhealth.org
Mentor Contact Phone: 843-777-2449

Additional Information:

McLeod has successfully engaged its physicians in the goal to eliminate VAPs.  McLeod rolled the Vent Bundles and Mouth Care Program out in the Medical Intensive Care, then expanded the program to the three other adult ICU's at McLeod six months later.  A multidisciplinary team consisting of Nursing, Respiratory, Speech Therapy, PT, OT, Pharmacy, and Dietician worked with our physician lead team to develop our program.

A 50% reduction in VAP's from baseline to year one.  That amount was cut by more than half in year two of our program going 244 days without a VAP.  In year three of the program (2005) the MICU had no VAP's.  The MICU is currently sitting at 18 months without a VAP.  For 2005, the four adult ICU's (Surgical ICU, Trauma Surgical Care Unit, and the CCU had no VAP's.
[2/14/06]

*                *                  *

Mercy Health Center – Oklahoma City, OK
Availability Status: Available to answer requests
Licensed Beds: 382
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: April 2005
Mentor Contact Name: Jennifer Perry
Mentor Contact Email: JJPerry@ok.mercy.net
Mentor Contact Phone: 405-752-3602

Additional Information:

Mercy Health Center's VAP team started work in April  2005.  Mercy Health Center was able to implement the complete VAP bundle starting in August, and improved outcomes within 3 months.

As of January 2006, we have experienced a 35% reduction in VAP - from an average of 8.8/1000 ventilator days to an average of 5.7/1000 ventilator days in that short time.
[1/31/06]

*                *                  *

Nebraska Methodist Hospital – Omaha, NE
Availability Status: Available to answer requests
Staffed Beds: 310
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Jackie Thielen
Mentor Contact Email: jackie.thielen@nmhs.org
Mentor Contact Phone: 402-354-3236

Additional Information:

* Began with the vent bundle and drove toward consitency in use using multidisciplinary rounds as a main vehicle to promote compliance with medicine and nursing.
* Added structured oral hygiene at scheduled intervals including brushing teeth with a pre-packaged kit that included antimicrobial components.
* Monitored and facilitated compliance with oral hygiene and all aspects of the vent bundle by including respiratory care providers as key team members.  This was a priority change that greatly facilitated routine sedation vacations and ventilator weaning trials.
* Adding mobility, including ambulation of select ventilated patients, required more teamwork with physical and occupational therapy. 

* 100% compliance 2008 YTD for sedation vacation, weaning trial, spontaneous breathing trial and 94% or higher for all other bundle components except documentation of HOB elevation at 30 degrees.  Active surveillance verifies that HOB elevation surpasses the documentation of this bundle component.
* The great team effort has resulted in a rate of zero critical care-associated VAPs for the past 14 months.
* Reduction in vent days from 4.0 days 2007 to current 2008 YTD of 3.3 days for non-vent dependent patients.
* YTD VAP rate of 0.0%/1000 ventilator days with consistent decline in rate since 2005.
[10/23/08]

*                *                  *

North Shore University Hospital – Manhasset, NY
Availability Status: Available to answer requests
Licensed Beds: 849
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: October 2005
Mentor Contact Name: Gary Blank, DPM, MBA
Mentor Contact Email: GBlank@nshs.edu
Mentor Contact Phone: 516-465-8345

Additional Information:

North Shore University Hospital developed a standardized approach to manage the process of care and control the incidence of ventilator associated pneumonia. A multidisciplinary Nosocomial Infection Steering Committee ensures that there is “zero tolerance for hospital-acquired infections” by providing oversight to the Ventilator Associated Pneumonia (VAP) Taskforce regarding recommendations for targeted improvement efforts and the establishment of consistent data definitions. The goal of this initiative was to develop accountability and change behavior of clinicians at the bedside to reduce VAP. 

Objectives used to reach this goal include:
• Implement standardized, evidence-based reduction strategies
• Increase communication, therefore raising consciousness of the caregiver
• Establish new educational forums for improvement
• Standardize reporting by creating metrics to demonstrate the results of the infection measures in quality forums

Education, communication, and weekly prevalence studies of the infection prevention practices was key in the success of this initiative.

Partners: Infection control, quality management, nursing, respiratory therapy, medical staff, administration, laboratory, materials management, pharmacy, and safety professionals. 

Standardized Tools: 
• Creation of a multidisciplinary rounding tool that incorporated all bundle components.

Educational Resources:
• An IHI 100K Lives Campaign page was created on our intranet that includes educational material regarding bundle compliance along with a link to the Institute for Health Care Improvement (IHI).

Awareness & Recognition: 
• Several articles were written in a publication mailed to all employees to increase awareness of the initiative.
• IHI Awareness Posters are displayed throughout the hospital.
• IHI initiative information was included in the staff training for Patient Safety Week 2006.
• Members of the VAP Taskforce received a Certificate of Appreciation from senior health system leadership.

Lessons Learned:
• Defined direction and commitment from all leadership made the initiative successful.
• Central approach to defining measures created consistency.
• Involvement of health care providers at every level helped to reduce variation in care.
• Formal education increased understanding of practice.
• Monitoring and objective feedback helped to change behavior not just compliance with documentation.

Outcomes:  The infection prevention initiative revealed a decrease in VAP.
• From October 2005, VAP bundle compliance remained at 100%.
• From October 2005, the VAP index decreased from 6.13 to 0.

[8/4/06]

*                *                  *

Northwestern Memorial Hospital – Chicago, IL
Availability Status: Available to answer requests
Licensed Beds: 811
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: Nov 2003
Mentor Contact Name: Bob Costello
Mentor Contact Email: rcostell@nmh.org
Mentor Contact Phone: 312-926-4714

Additional Information:

Implemented Ventilator Bundle in all ICUs 
• Head of bed elevated    
• RASS Sedation scale and protocol  
• Oral care     
• DVT prophylaxis order set
• Stress ulcer prophylaxis order set

Successful Implementation and Spread Strategies
(1) Infrastructure
• VP leadership support / Physician champion
• Monthly Critical Care Leadership meeting
• Project accountability (Bi-monthly presentations to Executive Leadership)
• Hospital support/resources
(2) Implementation occurred on entire unit at the same time
(3) Nursing staff realized benefits immediately (promoted autonomy)
(4) Efforts were communicated to entire care team (medical staff, nursing, respiratory care and pharmacy)

• 80% compliance with ventilator bundle in all 5 ICUs
• Decreased hospital VAP infection rate by 25% in the first year of implementation
[1/31/06]

*                *                  *

Oconee Memorial Hospital – Seneca, SC
Availability Status: Available to answer requests
Licensed Beds: 160
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: 2003
Mentor Contact Name: Joyce Lawhorne, RN, CIC
Mentor Contact Email: joyce.lawhorne@oconeemed.org
Mentor Contact Phone: 864-885-7305

Additional Information:

• Oconee Memorial Hospital has implemented evidence-based practices to prevent VAP since 2003; mouth care protocol added in October 2004.
• All interventions for the prevention of VAP were integrated into one multidisciplinary policy instead of separate policies by each department in November 2005.
• The success of this project has been celebrated and seen as a process improvement model for other initiatives.

• No cases of ventilator associated pneumonia from August 2004 through December 2005

[4/28/06]

*                *                  *

Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Availability Status: Available to answer requests
Licensed Beds: 267
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: October 2004
Mentor Contact Name: Susan Fuchs, RN Director of ICU
Mentor Contact Email: sfuchs@lourdes.com
Mentor Contact Phone: 607-798-5420

Additional Information:

Our ICU Team learned about the ventilator bundle from IHI. A member of our team had been introduced to the bundle when working at another facility. The team began to test the ventilator bundle January 2004. We implemented within a couple of weeks. Eventually we incorporated the bundle into the pre-printed physician orders, the ICU nursing flow sheet and the patient daily goals forms used during rounds.

Prior to implementing the ventilator bundle, our VAP rate was 5.53 per 1000 ventilator days.
After implementing the ventilator bundle our VAP rate decreased 66% to 1.85 per 1000 ventilator days.
We monitor our average ventilator days per month and have seen a decrease. We developed and implemented a Respiratory Therapy driven Weaning protocol.
The first 6 months of 2005 our average ventilator days were 3.9 days.
The last 6 months of 2005 our average ventilator days were 2.8 days.
We have had 4 VAPs in 2005, however during case review it was discovered that all of these patients, due to being hypotensive and inability to raise the head of the bed, had an increased risk of aspiration. We have tested and implemented the CASS endotracheal tube in an effort to avoid VAP in this patient population.

[1/31/06]

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Overlake Hospital Medical Center – Bellevue, WA
Availability Status: Available to answer requests
Licensed Beds: 257
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: October, 2004
Mentor Contact Name: Stephanie Crow
Mentor Contact Email: Stephanie.crow@overlakehospital.org
Mentor Contact Phone: 425-688-5310

Additional Information:

Culture of Critical Care:
• Staff improved critical thinking and planning for patient care
• Staff are able to take view from 10,000 feet rather than what is taking highest priority at that moment
• Infections are not inevitable
Great patient saves: not just reducing VAP & CL – found pts on meds that could have been dangerous to them and many safety risks that may not otherwise have been discovered.
• Found that a renal failure patient was on full dose Lovinox
• Found many patients that needed to have their antibiotics DC’d
• Found a patient that went into renal failure was on too much Digoxin and was becoming toxic

12 m Baseline average CA-BSI rate 2.84
12 m project average CA-BSI rate .73= 74% Reduction
10 out of 12 months with zero infections
[1/31/06]

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Palmetto Health Baptist – Columbia, SC
Availability Status: Available to answer requests
Licensed Beds: 489
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: September 2004
Mentor Contact Name: Brown Cantrell, Nurse Manager ICU/CCU
Mentor Contact Email: Baptist_Zaps_VAP@palmettohealth.org
Mentor Contact Phone: 803-296-3050

Additional Information:

Palmetto Health Baptist, Columbia initiated a Failure Mode Effects Analysis (FMEA) with an interdisciplinary team approach on Ventilator Associated Pneumonia (VAP) in Summer, 2004. The following practice changes occurred as a result:

1. Hand washing of nurses, physicians, and ancillary personnel was monitored. An opportunity for improvement was indicated.
2. Education on “germs around us” & hand hygiene was presented. On subsequent monitoring, the results demonstrated much improvement.
3. The Hi- Lo Evac Endotracheal tube (epiglottal suctioning) was introduced into the hospital with the policy that any patient intubated greater than 48 hours would be switched to this ET tube.
4. An oral mouth care kit designed for every 2-4 hour mouth care was initiated in ICU & IICU. The kit included toothbrushes with suctioning to prevent plaque build-up, a covered oral suctioning catheter and suctioning swabs.
5. Policy was initiated that the head of the bed will be elevated 30- 45 degrees on all patients (unless contraindicated).
6. Education on numbers 3, 4, & 5 was presented and competency check-offs were completed with all the ICU & IICU staffs.

Our success is credited to our Nursing Champions and the Interdisciplinary Team who worked and continues to work with the nursing staff in maintaining the goal.

The ICU/CCU and Intermediate ICU at Palmetto Health Baptist in Columbia SC has been free of VAP for 15 months.

The speed at which