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

Abstract

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.