SummaryColer-Goldwater Specialty Hospital and Nursing Facility modified and expanded the Institute for Healthcare Improvement's inpatient ventilator bundle for use in the long-term acute care setting. Key elements of the modified bundle include early and ongoing evaluation for weaning, pulmonary and dental evaluations, head-of-bed elevation, peptic ulcer disease and deep vein thrombosis prophylaxis, and comprehensive oral care. Pre- and post-implementation analyses suggest that the program has reduced the incidence of ventilator-associated pneumonia by 58 percent, which, in turn, has led to a decline in the overall facility pneumonia rate and use of antibiotics.Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the VAP rate, overall pneumonia rate, and extended antibiotic use.
Developing OrganizationsColer-Goldwater Specialty Hospital and Nursing Facility
Roosevelt Island, NY
Date First Implemented2006
Problem AddressedVentilator-associated pneumonia or VAP (a nosocomial pneumonia that develops in a patient on mechanical ventilator support for more than 48 hours1) is a highly prevalent condition associated with significant morbidity, mortality, and costs. Although use of a set of known-to-be-effective strategies can prevent VAP in the inpatient setting, many hospitals and long-term acute care facilities do not implement all of these strategies in a coordinated fashion.
- High prevalence: VAP develops in 8 to 28 percent of patients on mechanical ventilation, with rates being highest in those patients on ventilators for prolonged periods of time.2 One analysis of Medicare data on almost 14,000 long-term care hospital discharges found that nearly 25 percent of ventilator patients in long-term care facilities acquired VAP.3
- Associated with high mortality, morbidity, and costs: The mortality rate for ventilated patients who develop VAP is 46 percent, compared with 32 percent for ventilated patients who do not develop the condition.4 VAP is associated with longer lengths of stay in the intensive care unit and hospital.5 Although data on the costs of VAP in the long-term care setting are not available, research indicates that one VAP case adds an estimated $40,000 to the cost of a typical acute care admission.6
- Largely preventable through use of known interventions: Known quality improvement initiatives can significantly reduce VAP, leading to fewer deaths and lower costs.7 For example, the Institute for Healthcare Improvement (IHI) has developed a Ventilator Bundle for acute settings, a series of interventions that, if implemented concurrently, lead to significantly better VAP outcomes than when implemented individually.1 Research indicates that these interventions—such as elevation of the head of the bed to 30 to 45 degrees,8 prescribing peptic ulcer disease prophylaxis,1 and implementing deep vein thrombosis (DVT) prophylaxis to reduce the risk of thromboembolism9—can reduce VAP rates. One study conducted in a 200-bed, long-term acute facility with capacity for 42 ventilator patients found that implementing a VAP bundle of initiatives reduced the VAP incidence rate by 56 percent, down to a rate of 14.6 percent.10
- Failure to consistently adopt interventions: Some hospitals and long-term acute care facilities do not implement these initiatives consistently or in a coordinated fashion.
Description of the Innovative ActivityColer-Goldwater Specialty Hospital and Nursing Facility adapted and expanded the IHI inpatient ventilator bundle for use in the long-term acute care setting. The Coler-Goldwater bundle retains three IHI bundle elements—elevation of the head of the bed, peptic ulcer disease prophylaxis, and DVT prophylaxis—and adds newly designed elements relevant to the facility’s population, including a dental evaluation and comprehensive oral care. Key elements of the bundle include the following:
- Early and ongoing evaluation for weaning: All new patients who are on a ventilator are evaluated for extubation by a physician and a pulmonologist. The complete assessment by the pulmonologist includes a clinical assessment, a chest x-ray, an arterial blood gas evaluation, and a review of the weaning parameters of the patients that are measured by a respiratory care practitioner. Criteria considered during this evaluation include ability to trigger the ventilator, minute ventilation, rapid shallow breathing index, dynamic compliance, static compliance, spontaneous tidal volume, respiratory rate, and negative inspiratory pressure. Patients determined to be eligible for extubation are transferred to the facility’s weaning unit, where specially trained staff work to get the patient off the ventilator. Patients initially deemed not eligible are reevaluated on a periodic basis to determine their readiness for weaning.
- Pulmonary and dental evaluations: A respiratory care physician assesses all patients at admission, providing a full evaluation, including for secretion management. A dentist conducts an initial dental evaluation of all ventilator patients within 1 week of admission; the goal is to identify and address any plaque or decayed teeth that can result in patient aspiration of contaminated material, which could increase the risk of VAP.
- Elevation of the head of the bed: The head of each ventilated patient’s bed is kept elevated at 30 to 45 degrees to prevent aspiration, which increases the risk of VAP. Green tape is placed directly on the bed frame to indicate the zone of 30- to 45-degree elevation. The tape enables staff to quickly monitor compliance with the elevation standard and allows all clinicians (e.g., physicians, nurses, physical therapists) to return the bed angle to the appropriate position if it is adjusted during care.
- Peptic ulcer disease and DVT prophylaxis: Peptic ulcer and DVT prophylaxis are initiated for all ventilated patients beginning at admission; the particular medication used depends on the physician's evaluation and recommendation.
- Comprehensive oral care program: Ongoing oral care is provided during each of the three daily shifts. Teeth brushing occurs once a day, while a swab is used to clean the mouth during each of the other two shifts. Oral care kits, including the suction toothbrush, swabs, and other necessary materials, are provided on the units to facilitate compliance with oral care.
- Standardized checkoff form to facilitate ongoing compliance: All elements of Coler-Goldwater’s ventilator bundle are incorporated within the facility’s admission sheet (which is currently being computerized), a standardized form used by physicians and nurses to check off required elements of patient care and trigger automatic referral processes when needed.
Context of the InnovationColer-Goldwater Specialty Hospital and Nursing Facility is a public, 2,000-bed facility located on two campuses on Franklin D. Roosevelt Island in New York City. Coler-Goldwater is part of the New York City Health and Hospitals Corporation, the largest municipal hospital and health care system in the country, with 11 acute care hospitals, 4 skilled nursing facilities, 6 large diagnostic and treatment centers, and more than 80 community-based clinics. Each day, approximately 110 Coler-Goldwater patients are on long-term mechanical ventilation. A 2005 analysis conducted by infection control staff found that approximately 40 percent of pneumonia cases in 2005 occurred in Coler-Goldwater's ventilator population. When the IHI released its ventilator bundle, Coler-Goldwater administrators decided to review and adapt the IHI bundle in an effort to reduce the facility’s already low VAP rate.
ResultsPre- and post-implementation analyses suggest that the program has reduced the incidence of VAP by 58 percent, which, in turn, has led to a decline in the overall facility pneumonia rate and use of antibiotics.
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the VAP rate, overall pneumonia rate, and extended antibiotic use.
- Lower rates for VAP and all pneumonia: The VAP rate (defined as the number of VAPs per 1,000 ventilator days) decreased by 58 percent, from 2.4 in early 2006 (before program implementation) to 1 by the fourth quarter of 2007. The VAP rate remained at this level through the second quarter of 2008. Because 40 percent of pneumonia cases were related to ventilator use, the facility’s overall pneumonia rate also fell, from 1.5 per 1000 patient days in 2006 to 0.8 per 1000 patient days in 2007. The pneumonia rate by the second quarter of 2008 was 0.6 per 1,000 patient days.
- Less antibiotic use: The decline in VAP prompted a reduction in the percentage of patients on extended antibiotic regimens (defined as longer than 2 weeks), from 64 percent in 2007 to 40 percent in 2008.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Convening an interdisciplinary team: A core group from Coler-Goldwater’s Infection Prevention and Control Committee had been studying VAP rates at the facility. This group was expanded to include representatives from hospital administration and the departments of medicine, infectious disease, pulmonary care, nursing, respiratory care, dentistry, and materials management. The resulting team was charged with developing a ventilator bundle based on the IHI bundle.
- Adapting and expanding the bundle: The team reviewed the IHI bundle elements and recognized that they were not completely applicable to the facility's long-term care patients (because they had been developed for an acute care population). The team decided to retain three IHI bundle elements—elevation of the head of the bed, peptic ulcer disease prophylaxis, and DVT prophylaxis. The team also designed new elements relevant to the facility’s population, including a dental evaluation and comprehensive oral care.
- Creation of oral care kit: The team invited frontline staff members to develop a list of necessary supplies for an oral care kit. The facility then ordered supplies and asked central supply staff members to create customized oral care kits that were stocked on units where ventilator patients receive care.
- Pilot test and training: The team piloted its ventilator bundle on one unit for approximately 6 months in early 2006. Members of the interdisciplinary team met with pilot unit staff on each shift for 60 to 90 minutes to explain the bundle and introduce the changes to the admission process. The team also introduced a monitoring form to collect data on bundle compliance.
- Expansion to other units: The facility expanded the bundle to the other units in the fourth quarter of 2006. Infection control staff participated in scheduled weekly unit meetings to introduce the program and shared the prize-winning poster about the VAP bundle that was created for a corporation-wide patient safety fair/contest.
- Incorporation into new employee orientation: The VAP bundle was incorporated into new employee orientation sessions and materials, in the section related to pneumonia prevention.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: Costs incurred in the development of this initiative were minimal; ongoing operating expenses include the cost of the green tape, suction toothbrushes, and disposable oral care supplies. Although no specific cost estimates are available, facility representatives think that the expenses associated with the oral care kit and tape are negligible compared with the savings generated through the avoidance of even one VAP case.
Funding SourcesColer-Goldwater Specialty Hospital and Nursing Facility
Tools and Other ResourcesInformation about the IHI ventilator bundle is available at: http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx.
Getting Started with This Innovation
- Involve senior leadership in bundle development: Securing buy-in from frontline staff will be easier if senior leaders are involved in bundle development, which allows them to describe and support the initiative at unit/department meetings.
- Empower staff to become involved and encourage creativity: Staff often provide excellent suggestions. For example, a Coler-Goldwater staff member recommended a simple, effective, and inexpensive strategy for marking the appropriate bed elevation with green tape. Frontline staff also designed the customized the oral kit based on their knowledge of what supplies would be needed.
- Consider how to manage limited resources: For example, instead of buying prepackaged oral care kits from vendors, Coler-Goldwater buys toothbrushes and other oral care supplies in bulk, and then has its own central supply staff pack them into kits and distribute the kits to the units. This approach ensures that the kits include the exact supplies needed, with no waste.
Sustaining This Innovation
- Track and share data: Performance data should be tracked over time and shared with staff. Seeing positive results will motivate staff to maintain compliance with the bundle.
Contact the InnovatorJocelyn Juele-Cesareo, RN, BSN, MN, CIC
Director, Infection Prevention and Control
Coler-Goldwater Specialty Hospital and Nursing Facility
900 Main Street
Roosevelt Island, NY 10044
Phone: (212) 848-6980
Innovator DisclosuresMs. Juele-Cesareo has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesInstitute for Healthcare Improvement. Improvement report: reducing VAP for long-term mechanical ventilation patients using the ventilator bundle. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories
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Rello J, Ollendorf DA, Oster G, et al. VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115-21. [PubMed]
Tablan OC, Anderson LJ, Besser R, et al. CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36. [PubMed]
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Original publication: August 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 16, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.