Ventilator-Associated Pneumonia

This guide outlines the steps that managers can follow to prevent Ventilator-Associated Pneumonia (VAP):

Managers’ Meeting Discussion Points:

1. Acknowledge potential challenges in diagnosing and reporting VAP incidences.
2. Emphasize the measurement and reporting of compliance with VAP prevention best practices monthly.
3. Routinely reassess processes/procedures to identify reporting gaps, and ensure integrity of the data collected.
4. Make sure VAP performance and progress are easily visible to frontline/bedside staff, including nurses, respiratory therapists, and environmental service workers.
5. Post VAP longitudinal data prominently in staff areas in an easy-to-understand visual format. Discuss the results frequently and reward improvement.
6. Ensure those on the frontline understand what intervention prompted the improvement.
7. Post daily the amount of time since the last VAP incident.
8. Review data reports at meetings and debriefs.
9. Be transparent about data collection and reporting biases.

If you determine that a performance improvement project is necessary:

1. Gather the right project team—multidisciplinary, engaged, frontline staff and patient/family representatives.
   1. Be sure to involve the right people on the team. You will want:
      1. An oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread.
      2. The actual project team that consists of 5–7 representatives who are most impacted by the process.

• Patients and family members, who should be involved in all improvement projects, as they can make important contributions to safer care.

2. Understand what is currently happening and why.
   1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data, but the most important action here is to go to the point of care and observe.
   2. Even if team members work in the area daily, examining existing processes from every angle is frequently and unexpectedly an informative experience.
   3. The team should question all relevant caregivers and process participants during onsite observations to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
3. Create a process map to identify opportunities for improvement and
   1. Illustrate each step and identify the gaps in best practices.
   2. Use a root cause analysis tool to identify why the gap exists/processes failed.
   3. Review the process map with the advisory team and invite frontline staff to validate accuracy.
4. Prioritize required process changes and implement an accountable, time-limited action plan.
   1. Consider the cost effectiveness, time required, potential outcomes, and realistic possibilities of addressing each gap identified.
   2. Determine which are priorities for the organization to correct.
   3. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers.
   4. Design an experiment to be trialed locally briefly; if successful, create an action plan for broader implementation.
5. Be sure the action plan includes the following steps:
   1. Assess organizational cultural readiness to change and adopt appropriate strategies.
   2. Revise policies and procedures.
   3. Redesign forms and electronic record pages.
   4. Clarify patient and family education sources and content.
   5. Create a plan for changing documentation forms and systems.
   6. Develop the communication plan.
   7. Design the education plan.
   8. Clarify how and when people will be held accountable.
6. Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
   1. Measure both process and outcome metrics.
   2. Compare your outcomes against other related metrics in your organization.
   3. Routinely review all metrics and trends.
   4. Identify barriers to completion of action plans. 

Involve those doing the work in the improvement initiative:

1. Ensure that VAP protocols are embedded in clinical workflows, whether electronic or on paper.
2. Ensure there are enough staff to effectively manage necessary preventive care.
3. Assess which frontline professionals are completing VAP prevention practices and if this responsibility could be more appropriately allocated.
4. Ensure adequate training and documentation of VAP prevention competencies and skills.
5. Understand the barriers to implementation and/or sustainment, such as awareness of the evidence-based practices, buy-in to the practices, ability to implement the intervention easily in their existing workflow, etc.
6. Provide a centralized place for care team planning and communication.
7. Standardize practice across the system (e.g., patient positioning protocols should be the same across each facility).
8. Ensure current policies align with protocols and workflows on the frontline. For example, standardize and align policies, protocols, and procedures around:
   1. Use of noninvasive ventilation equipment
   2. Prevention of aspiration
   3. Early mobility
9. Set up systems (e.g., interdisciplinary rounds) to minimize ventilator exposure. 

Recommended VAP improvement team:

1. Respiratory care practitioners
2. Nurses
3. Physical and occupational therapists
4. Infection control specialists
5. Physicians
6. Pharmacists
7. Clinical educators
8. Dietary staff
9. Environmental service staff
10. Engineering staff
11. Information technology
12. Patient/family members
13. Data analysts
14. Reimbursement and coding personnel
15. IT/EHR specialists 

VAP processes to consider assessing:

1. Organizational coordination
   1. Which groups receive reports/data of VAP prevention compliance, what is done with that data, how is the data analyzed, and with whom is it shared?
   2. Which professionals are reporting to which bodies?
   3. Coordination of post-discharge needs.
2. Respiratory management
   1. Ventilator setting modification and monitoring.
   2. Intubation decision making.
   3. Weaning, sedation vacations, spontaneous awakening trials, and spontaneous breathing trials.
      1. Who is conducting, when and how often, what is their decision-making process, and how do they share information and work with other professionals?
   4. Endotracheal cuff, subglottic suctioning, and tube maintenance.
3. Prophylaxis
   1. Patient positioning.
   2. Use of antibiotics and prophylactic systemic antimicrobials for VAP prevention.
      1. Who is prescribing and what are their justifications for prescribing?
   3. Antibiotic surveillance.

VAP metrics to consider assessing:

1. Antibiotic surveillance
2. Total number of patients on a mechanical ventilator per unit per month
3. Total number of episodes of mechanical ventilation per unit per month
4. Total number of ventilator days per unit per month
5. Hospital days
6. Hand hygiene compliance
7. Percent of patients achieving RASS/SAS target
8. Percent of patient days mobilized out of bed
9. Delirium assessment compliance rate
10. Ventilator length of stay
11. ICU length of stay 

Consider:

1. Hold staff accountable for providing the standard of care and reward success. Nonfinancial incentives may include:
   1. Special titles for champions of the work.
   2. Sharing an individual’s or unit’s efforts with a large group.
   3. Highlighting efforts in an article or newsletter.
   4. Presenting efforts, and calling out individuals or units by name, at conferences or events.
2. Ensure that staff have a simple process to oversee VAP improvement work.
3. Consider how VAP improvement aligns with other initiatives across the organization.