Organization: University of Maryland Medical System- Midtown Campus

Background:
Ventilator associated pneumonia (VAP) is defined as a hospital-acquired pneumonia that
develops within 48 to 72 hours after endotracheal intubation; the diagnosis hinges on a lack of
evidence suggesting that the infection developed prior to intubation. VAP is the most common
intensive care unit (ICU)-acquired infection, accounting for 25 percent of all ICU infections and
50 percent of ICU antibiotic use. At least 250,000 VAPs occur in the United States (U.S.) each
year. This condition causes complications in 8 to 28 percent of mechanically ventilated patients
and carries a mortality risk of approximately 10 percent (range 6% to 27%), resulting in a
possible 25,000 VAP-attributable deaths every year. Patients who develop VAP stay, on average,
4 days longer in the ICU. The per-case cost of VAP is estimated to be $23,000, and the total
incremental costs to the U.S. health care system are high: $2.19 to 3.17 billion USD per year.
With a mortality rate approaching 50 percent, VAP has been classified by the Institute for
Healthcare Improvement as one of the most dreadful infections that can strike a patient. VAP is
the leading cause of death amongst the hospital-acquired infections, exceeding the rate of death
due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated
patient (source).
Nationally, Post-Acute Specialty Units pose a challenge because they do not fit the LTAC or SNF
criteria. They are an entity all to themselves. LTAC patients aren’t as acute as our Post-Acute
Specialty Program (PASP) patients. We send our PASP patients to LTACs after they stabilize.
When attempting to compare PASP VAP data to ICU VAP data, one would find that the amount
of data is limited to unavailable. The challenge for the Post-Acute area is that it is held to the
same standard as the acute care areas when the patients are actually more chronic.

Project/Project Description: (problem, how was it identified, baseline data, goals-how do you
know if you were successful)

University of Maryland Medical System- Midtown Campus is a teaching community hospital that
has a dichotomous structure. Its structure has the ability to serve not only acute inpatients but patients
that have Post-Acute Specialty needs. National efforts to reduce VAPs have primarily been focused
around the ICU rather than Post-Acute. Post-Acute care refers to a range of medical care services that
support the individual’s continued recovery from illness or management of a chronic illness or
disability. The PASP Unit is an acute care rehabilitation facility for chronic wound-care patients. We
provide a variety of patient care including a chronic vent weaning program, hemodialysis, wound
care (i.e. post-op fistulas, stage IV, etc.), nutritional support, respiratory support, pain management,
IV antibiotic therapy, or post-surgical care. Physical therapy, occupational therapy, and speech
therapy work with our interdisciplinary team to offer
therapy to any patients who may require the service. Each patient’s care is tailored to their
individualized need as determined by the interdisciplinary team of physicians, nurses, respiratory
therapists, physical and occupational therapists, wound care team, social workers and
pharmacists during our weekly care plan meetings.
PASP had 18 VAPs in 2014 and were up to 8 by April of 2015. February 2015 saw a VAP rate of
8.5/1000 device days. A drill-down on PASP VAP data revealed an increase in device days as
compared to Acute care (See Figure 1). Our team’s goal was to improve the monthly VAP rate to
no more than 2.2/1000 device days by using education, communication, and a strong
collaborative interdisciplinary team based model.
Furthermore, we hypothesized that a reduction in VAPs would coincide with increased patient
and family engagement, patient safety and care, resulting in fewer discharges to acute inpatient
units.

Process:

First, PASP leadership was reviewing a new patient centered care/interdisciplinary team model
with leadership. The patient centered/interdisciplinary team model proposal required additional
resources inclusive, but not limited to staff, education and renovations. Secondly, the department
of Quality and Infection Prevention initiated a root cause analysis with key stakeholders to
determine the root cause and contributing factors that were leading to ventilator associated
pneumonias. The team included: organizational leadership, respiratory therapy, PASP nurse
manager and staff, nurse manager and staff representation from ICU, central sterile processing,
as well as education liaisons. Additional people were included on an as needed basis to
comprehensively explore all facets of VAPs.
The PASP’s average length of stay hovers around 60 days which has the potential to increase the
patient’s susceptibility to infection. The PASP demographic consists of patients that have
multiple co-morbidities and range in age from 24 to 82. Our fishbone diagram and Pareto chart
revealed there were 4 major areas of focus that would assist with our reduction of VAP initiative:
collaboration of care, workflow process, bundle compliance and education.
Solution: (What solution was developed? How was it implemented?)

The Infection Preventionist/Performance Improvement liaison collaborated with PASP leadership

and staff to develop an action plan to reduce the number of VAPs, specifically related to the
Pareto chart analysis. In addition to the current evidence-based practice guidelines, our team
introduced supplemental approaches to achieve our goal of 2.2 VAP/1000 device days.
Buy-in to the process was initiated by allowing all staff to participate in the process and
assist with developing strategies to improve VAP rates.
Employee engagement and satisfaction was enhanced with full implementation and re-
education with organizational philosophy- RITE touch behaviors: respect, integrity,
teamwork, and excellence. Employees were provided resources to use to facilitate patient
and family involvement in the patient centered care model.
The initial stages of the patient centered care model were implemented with executive
leadership’s support. This approach encourages the staff to work as a team of 2 nurses
and 1 patient care technician per every 10 patients. This approach decreased the nurse to
patient ratio from 1:7 to 1:5. A charge nurse will oversee all 4 teams (40 patients) to help
facilitate any patient transfers, admissions, and discharges, as well as ensure a smooth
shift for all patients and staff and increased communication with families.
The floor’s patient capacity was reduced from 60 to 40 beds. This eliminated semi-
private rooms that reduced the spread of infection/cross-contamination as well as
increased patient safety and privacy.
The PASP staff was educated on their roles and the newly developed PDSA action plan.
All staff received competency training in all aspects of ventilator associated pneumonia
evidence-based practice and maintenance care.
Central Sterile Supply was integrated in the process and SAGE is now continuously
stocked on the floor as part of the par.
Physician change in practice was implemented to ensure CHG mouth wash is ordered
every 12 hours to facilitate compliance
An audit tool that incorporated evidence-based practice methodologies was developed
and implemented by the RCA team, and concurrent audits were performed daily by the
charge nurse from May to October, then decreased to weekly. This allowed for point of
care corrective course action and for staff to be held accountable.
Respiratory actions: to ensure patients are pulled up in the bed prior to respiratory
treatments, suction patients prior to trach cuff deflation and immediately post cuff
deflations
PCTs to trial placing tube feeding on hold as soon as they enter the room to allow time to
pass before lowering the bed as per evidence based bundles
Unit clerks added mouth care intervention on all vented patients and nurse to follow-up
when unit clerk is not available.
Evaluating current specialty mattress for proper inflation. A representative from the
vendor comes onsite daily to ensure appropriate practice is followed and condition of
mattress is intact.
To improve patient engagement and satisfaction, customer service rounds are completed
by management and/or a patient care coordinator. The rounds assist in identifying any
areas where improvement is needed, and prompt immediate feedback on areas of
strength. The findings are discussed in the monthly staff meetings, to highlight and keep
staff informed of any key focus areas.
Measurable Outcomes:
Fewer patients are being discharged from Post-Acute and admitted to ICU because of the
coordination of care model as indicated by increased PASP length of stay.

Fig. 1

Total # VAPs by Month: University of Maryland Medical Center‐

Midtown
VAPs

Days
5 600
4 500

eDevic
300
PASP Number of VAPs
Total Number of

3 400

of
200
2 Rest of House Number of VAPs

Total Number
1
100
PASP Number of Device Days
0 0

Rest of House Number of Device

Days
Month

Fig. 2

VAP Rate/1000 device days: University of Maryland Medical

Center ‐ Midtown
device days

9
8
7
6
5
4
RateofVAPs/1000

3
2
1
0

Month

PASP Rest of House

Sustainability (What measures are being taken to ensure that results can be sustained and
spread?)
Concurrent audits are compiled and analyzed by the Quality Improvement/Infection
Prevention Team and all staff are informed of progress during monthly staff meetings.
The PDSA plan is reinforced during monthly staff meetings.
Aggregated data is shared monthly at the Organizational Infection Prevention Committee,
Quality Improvement Committee, and Medical Executive Committee.
Our rates are discussed monthly at Nursing Quality Improvement Committee and shared
as a part of the shred governance model.
Daily rounds are performed as a team by leadership, PASP staff and infection prevention
to ensure compliance.

Role of collaboration and leadership

Our team includes a core set of physicians, the PASP nurse manager, the Director of PASP,
Quality and Infection Prevention, leadership and patient families. Hospital leadership is notified
when there are investigations. This process has led to other areas being identified as
opportunities for improvement and lessons learned are shared with other clinical areas. Executive
leadership is fully aware of the progress in reduction of VAPs and their instrumental buy-in and
support has helped to implement the patient centered care model as well as increase patient
safety and clinical outcomes. Patient satisfaction has improved as evidenced by the unit earning
the most improved patient satisfaction scores for FY15. The staff are excited and proud of their
accomplishment. The nurse manager has received compliments from other physicians across the
organization about the decrease in discharges and readmissions to the ICU as well as the
decrease in calls. Their excitement has fueled the team to look at other areas of opportunity that
can be shared to improve patient safety across the organization. The units’ success was
recognized during 2015 National Quality and Infection Week.

Innovative attributes
University of Maryland Medical System- Midtown Campus’s PASP unit has the privilege to care for
patients that have an unusually high acuity. PASP is a chronic hospital within an acute hospital. We
maintain our core values that remind us that our hands can either help to heal or hurt.
Our data shows that although our patient population presents with challenges, our compassion and
vigor propels us to seek better ways to increase safety and provide the best care possible for our
patients. This initiative was successful because it involved a holistic approach that included the hands
of our executive leadership, management, clinical and ancillary staff as well as our patients. Although
we are in the initial stages of implementation with our patient centered care model, we recognize that
the unique attributes of this model along with using employee engagement, restructuring of the unit
for better workflow allows for consistent communication and timely
feedback. Fostering and building relationships internally and externally, support from leadership,
continuous monitoring and sharing our success lends itself to continued success.