• Implementation of a Ventilator Associated Pneumonia Prevention Bundle in the Emergency Department

      Schulz, Cory; Idzik, Shannon (2019-05)
      Background Despite the ability to save lives, mechanical ventilation places patients at an increased risk for adverse events; specifically, ventilator associated pneumonia (VAP). VAP is associated with increased duration of mechanical ventilation, hospital and intensive care unit (ICU) length of stay, hospital costs, and mortality risk. Implementing guideline directed VAP prevention bundles has been shown to reduce hospital VAP rates. Local Problem One specific population at risk for VAP are mechanically ventilated patients in the Emergency Department (ED). Since the risk for VAP begins at the time of intubation, and patients can spend many hours in the ED waiting for bed availability, there is utility in implementing a VAP prevention bundle in this setting. Interventions The purpose of this quality improvement project was to develop, integrate, and evaluate a VAP prevention bundle in the ED at a suburban community hospital system. The long-term goal was to decrease VAP rates in mechanically ventilated patients admitted from the ED. The short-term goal was to have a 100% compliance rate with the bundle during the sixweek implementation period. The bundle was developed based on the recommendations from the Institute for Healthcare Improvement. Then, with help from a multidisciplinary team, it was incorporated into an order-set that was available in the clinical information system. The ED staff was educated during weeks one to four. The order-set was then made available at the beginning of week four and monitoring of compliance occurred from week four to week ten. Results For education, 133 out of 142 ED nurses completed the assigned online learning module (82.1%) and 45 nurses attended the in-services hosted by the project leaders (31.2%). Eleven of the 23 ED physicians attended a formal presentation by the project leader at their departmental meeting (47.8%). During the six weeks following the order-set integration, 16 patients were recorded as being intubated, of which five were excluded because they were terminally extubated in the ED. A total of 11 patient encounters were analyzed for compliance. Sixty-four percent of the patients received all three components of the VAP prevention bundle, 90% for HOB, 64% for CHG mouth care, and 80% for oral care every two hours. There were multiple contextual barriers and limitations to implementation that could have affected the results. These included a high patient census and acuity during project implementation, a cyber-security breach, an accrediting body hospital survey, the annual hospital-wide nursing competency evaluations, a documentation related malfunction, and the process for nurses to obtain the CHG oral solution. Conclusions This quality improvement project demonstrates the feasibility of implementing a ventilator bundle in the ED. The limitations and barriers encountered during this project are a reflection of the challenges associated with translating evidence into practice. There is a need for similar projects in the future and research regarding implementation science in general.
    • Implementation of an Oral Care Protocol on an Acute Geriatric Inpatient Unit

      Jones, Lanaya; Rowe, Gina (2019-05)
      Background: Hospital acquired pneumonia is the second most common hospital acquired infection, and is responsible for 20-33% of mortality rates from infection. Patients with HAP also have higher 30-day hospital readmission rates compared to patients without a hospital acquired infection. Nationwide, hospital acquired pneumonia accounts for 32.5-35.4 million discharges annually. According to the Centers for Disease Control, 5-7% of hospitalizations due to pneumonia end in death. The oral cavity is a high reservoir for infection, and evidence-based practice suggests oral hygiene interventions to prevent hospital acquired pneumonia. Hospital acquired pneumonia is more common in at risk individuals, and there are four routes of transmission: (1) through aspiration of oral contents (food, oropharyngeal secretions, or gastrointestinal contents), (2) from infectious sites, (3), from inhalation of aerosols that are infected, and (4) from extra-pulmonary sites. Aspiration of infectious organisms remains the number one way to acquire hospital acquired pneumonia, so reducing oral bacteria is critical in hospital acquired pneumonia prevention. Local Problem: The focus site had no oral care protocols in place. Oral care supplies that were used were not ones recommended by evidence-based practice. Interventions: This project was implemented over a 12-week time span beginning in September of 2018. Education sessions were provided to staff to ensure appropriate use of oral care equipment. A five-question pre and post education test was administered to measure retention of information. Staff documented each time oral care was performed in addition to documenting all of the supplies that were used. Oral care compliance was measured through point prevalence, and hospital acquired pneumonia incidences was tracked through manual extraction of infection data. Hospital acquired pneumonia percentages was calculated using the number of hospital acquired pneumonia incidences divided by the number of patient visits. Results: Pre-implementation oral care compliance rates were (May-Aug) 36%. Postimplementation rates were (Sep-Dec) 52%. The average pre-pneumonia rate (May-Aug) was 25.8 and average post pneumonia rate (Sep-Dec) was 29.6. In addition, the average pre implementation aspiration pneumonia rate (May-Aug) was 7.3, and the average post aspiration pneumonia (Sep-Dec) was 5.5. The average grade on the pre-test was 77.8% and 82.5% on the post-test. Conclusion: There was a 16% increase in oral care compliance with implementation of this quality improvement project. In addition, there was an appreciative decrease in aspiration pneumonia rates with the increase in oral care compliance. However, there was a surge in nonaspiration pneumonia rates in October in November. From the results of this quality improvement project, one can conclude there is a potential decrease in hospital acquired pneumonia from oral care compliance. The mixed results of this project suggest more research is needed to determine if comorbid conditions (i.e. influenza) affect hospital acquired pneumonia rates.