ZAPPING VAP at MCCG

Purpose:
Beginning with >100 VAP/ year, ICU nurses, RRT, MDs and Infection Prevention identified the need to dramatically reduce VAP incidence while improving compliance with process measures such as oral care, PUD and DVT prophylaxis, readiness to extubate, feeding tubes, among others.

Significance:
According to IHI, the estimated cost for VAP is $40,000 per hospital stay. In addition, mortality and morbidity increases substantially as well. With 7 adult and pediatric ICU's and 142 beds, decreasing to ZERO VAP, in light of NDNQI, NHSN and APACHE IV comparative data, was an imperative.

Strategy and Implementation:
As early adopters for VAP bundles, adult ICUs had a head start on reducing VAP. Mandatory education and “vent fairs” were held and additional components added to the bundle as evidence grew in the literature. Driven by our root cause and process flowcharting, we have uncovered many opportunities for improvement as we kept attention focused on ZAPPING VAP. Analysis of NHSN, NDNQI and APACHE IV data by MD, RN, RRT, Infection Preventionists, and Dieticians revealed lack of compliance with professional guidelines. While building an incremental action plan, we also attended to hardwiring VAP prevention; job descriptions, competency checklists, RRT shadowing, leading/ process indicator monitoring 3x weekly, interdisciplinary and family involvement and adequate equipment and supplies were also key. We embedded our VAP bundle into the E.M.R. and assured peer review and regular feedback. Small tests of change and pilots were conducted, as well as nutritional and pediatric SBT/ SAT research.

Evaluation:
Excellent results have occurred in the past 12 quarters; out-performing NDNQI and NHSN with 0 VAP in all but one ICU. Our ventilator mortality vs. predicted, vent LOS vs. predicted and vent utilization all outperform APACHE. These results reflect the strong interdisciplinary commitment to ZAP VAP.

Implications for Practice:
In many ways, a unilateral approach to QI is simpler; however, to ZAP VAP all voices must be heard. All disciplines must keep current with best practices and participate in research. We have hardwired our VAP processes into shared roles, shared data analysis and action planning and joint RCA.