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Wednesday, June 23, 2010

Ventilator Bundle

Patients used to be left on ventilators too long. If the attending had the day off, the covering doctor was often leery of extubating. The RT on duty wasn't encouraged to "think wean" because there were no protocols. Procedures performed, and sedation, was essentially left to the covering physician, and often varied from patient to patient.

This policy lead to long ventilator stays, increased chance of getting ventilator acquired pneumonia (VAP), and, thus, increased time in hospital, too many poor outcomes, and all this resulting in increased cost to both the patient (or his insurance, or the government) and the hospital.

Studies were done that showed VAP was very high. In fact, every day on the ventilator increased the risk of VAP by 1 percent. Once a patient has VAP, this increases the days on the vent by 4-6 days on average, which increases hospital stays by 4-9 days.

Likewise, fatality rate for VAP is 20-50%, and ultimately costs the hospital an average of $15,000 to $40,000 per patient. Something needed to be done to improve outcomes. The focus was on reducing VAP, and the emphasis was getting all those who cared for the patient on the same page, and thinking the same things.

And if something was missing, or done wrong, others caring for the patient were encouraged to speak up. Studies (like this one) performed showed the following were the best ways to reduce VAP:

1. Good hand washing
2. Ventilator Weaning or extubation Protocols
3. Decrease Ventilator Circuit Contamination:
  • use inline suction catheters
  • change inline suction catheter every 7 days
  • change vent circuit every 30 days (max)
4. Oral Intubations: Studies (as you can see here at show that the risk for acquiring VAP is 75% for nasal intubation as opposed to 29% for orally intubated patients.

5. Patient positioning: Keep HOB 30 degrees or greater to decrease risk of aspiration, and lowers diaphragm to improve ventilation, reducing risk of VAP.

6. ETT cuff pressure 20 or greater (a change from what we learned in RT school)

7. Proper Yankauer care, and replace daily. Contamination can potentially cause VAP.

8. Oral intubation: Studies show the best way to intubate patient s is oral intubation, as orally intubated patients had a 34% chance of developing VAP as opposed to 73% of nasally intubated patients.

9. Swabbing the mouth: Studies show swabbing mouth with chlorhexidine gel 3 times a day reduced the risk of VAP from 66% to 29%.

10. Feedings by gastrostromy or jujunostomy: These have the lowest infection rate according to studies. Long term feedings should be done by these methods. Short term feedings should be done by oral gastric tubes as opposed to nasal gastric tubes.

These have all been proven to greatly reduce the risk of VAP. Poor oral care increases the risk of colonization of the mouth, and this can work it's way to the lungs via secretions. An inflated ETT cuff does not prevent germs from reaching the lungs and cause inflammation and pneumonia.

As you can see from the graph above from the MAYO Clinic, from April through December 2003 there were between 6 and 9 cases of VAP per month. Then, almost by miracle, the number dipped to zero, where it has stayed ever since. So what happened?

In January 2004 the MAYO clinic started what is called the ventilator bundle. This is basically an order form that shows the doctor, nurse and RT what needs to be done to prevent VAP The following are the recommendations for a Ventilator Bundle:
  • Elevation of head 30-40 degrees unless medically contraindicated

  • Continuous removal of subglottic secretions

  • Change ventilator circuit no more often than every 48 hours

  • Washing of hands before and after contact with each patient

  • Daily Sedation Vacation to assess for weaning daily

  • Ventilator Weaning or extubation Protocol (always be thinking wean)

  • Prophylaxis for DVT

  • Prophylaxis for Peptic Ulcer
Here's a copy of our Ventilator Bundle order form from Shoreline Medical. This is a standard sheet that goes in the doctor's orders section for each patient placed on a ventilator:
  • Ventilator Protocol Initiated

  • Sedation Protocol Initiated

  • Peptic Ulcer Protocol Initiated

  • DVT Prophylaxis Protocol Initiated

  • Glucose Control Protocol Initiated

  • Hold Sedation once per day to assess for weanability per ventilator protocol

  • Elevate HOB 30-45 degrees unless contraindicated

  • Chest X-Ray daily

  • ABG daily

  • Sputum C&S ASAP after initiation of vent to rule out colonization at time of vent start

  • Bronchodilator therapy if indicated (MDI only)

  • Dietitian consult if pt. on vent longer than 24 hours to maintain proper nutrition

  • Foley catheter

  • Oral care TID to QID and prn

  • Suction as indicated, or at least once per shift, preferably with inline suction catheter

  • Restraints if approved by physician

  • ISOPTO tears 1-2 drops as needed
Since the MAYO Clinic initiated its Ventilator Bundle, they have had one reported case of VAP. Likewise, since we initiated ours, we have had only one case of VAP.

It's kind of nice, because it pretty much puts the RNs, doctors and RTs on the same page, and it makes sure that every thing that can possibly be done to improve outcomes, and speed up time from intubation to extubation is done.

About five years ago Shoreline Medical established what it calls the Keystone Committee designed to establish protocols and policy to improve patient care and reduce costs. This committe consists of a champion physician and members from each department within the hospital, including critical care, respiratory therapy, surgery, emergency, administration, and quality assessment.

Quality improvement, and new research, is duscussed on a monthly bases, and the ventilator is updated accordingly. And Ventilator Bundle Core measures are assessed to make sure all procedures are being completed and charted accordingly.

An example of a core measures analysis for the Bundle can be seen in the picture. The goal is to obtain 90% or better in each area, and this is indicated by the green. Green ultimately means the goal has been met.

The areas marked by red indicate the goal has not been met, and something needs to be done to make sure the measure is improved. Ovarall, based on this data, the problem area is oral care. So the team would look at why we are only at 85%.

Is this because the nurse or RT forgot to chart? Was it because the procedure is ordered every 2 hours and this is not possible when the patient needs to sleep? What can be done to correct the problem?

These are all things we think of at our Keystone meetings, and then the bundle is changed if needed.

For examle, our initial bundle changes our practice of lavage and suctioning, and we not have inline suction catheters to reduce the risk of infections. We also give Ventolin MDIs to vent patients instead of breathing treatments.

For us RTs, we are thinking wean as soon as the patient is intubated. Length of time on vents has greatly diminished as well. If we notice the HOB is not elevated 30 degrees, we move it up. If the patient is not receiving feedings, we notify the nurse. Vice versal when it comes to clean suction equipment, and assuring that a sputum sample is obtained to make sure the patient didn't have pneumonia at the time of admission. We work together.

So, ultimately the goal of the Ventilator Bundle is to:
  • Reduce VAP

  • Reduce time from intubation to extubation

  • Reduce costs

  • Improve outcomes
Ventilator Bundles work, and one should be initiated at your hospital too.
This topic was also recently discussed at

For studies that show what should be done to reduce VAP check out this post at Critical Care Nurse

1 comment:

Anonymous said...

What about ventilator humidification choice/settings? Wouldn't thick secretions indicate dry respiratory tract with increased likelihood of pneumonia? This seems especially important when patient is getting dried out through diuretics...or is keeps mouth open while on a trach/vent.