Reducing V.A.P.: SYSTEM Tracer Begin with Large Group General Questions: 1. Describe your surgical and then medical process related to the prevention of V.A.P. 2. The Team Leader will create questions that come from synthesized Strengths, Weaknesses, Opportunities, Threats (S.W.O.T.) analysis related to the adverse events (A.E). 3. Can you share current state policies, protocols, standards specific to the prevention of V.A.P? 4. Describe the critical care areas in your hospital that have high volume of V.A.P. 5. What education is provided to all surgical/medical staff disciplines? Physicians, Nursing, Respiratory Therapy (R.T.), Anesthesia, etc. 6. Describe the patient care areas that you would like to trace. (For example, emergency department [E.D.] to operating room [O.R.] to Surgical and Medical intensive care units [S.I.C.U. and M.I.C.U.]). 7. Do you have all staff involved in the tracer or group sessions that you would like to have? (Infection Control, Epidemiologist, Microbiology Laboratory, I.C.U. nurses, Surgical and Anesthesia staff, Respiratory, Internal Medicine, Hospitalist) V.A.P data over last three years 1. What is your baseline data? 2. What solutions have been tried to achieve this data? 3. Ask the team to describe their performance improvement process: Stakeholder analysis, High Level Map, Defining the Problems: Root Cause/s for Infections, Data Collection Process, Solutions generated that target root cause, 1
Monitoring and Reporting Process, Leadership strategic priority, Accountability Pre-Hospital Care Portable Ventilation Equipment (E.M.S, S.N.F.s, Assisted Care, Home) (The hospital should be encouraged to seek prehospital input into the following questions) 1. Describe your process for ventilator decision. 2. Describe your training regarding prevention of V.A.P. 3. Do you use a standardized protocol for V.A.P prevention? 4. Does the protocol describe routine maintenance and care? 5. Does the protocol describe when to discontinue the ventilator? 6. Do you receive information or feedback about your patients who experience a V.A.P? How does that happen? 7. Are your patients put on antibiotics prophylactically? 8. What would you recommend that your team do differently to avoid V.A.P? 2
Patient Entry Points to the Hospital (The team will identify all patient entry points and ascertain transfer pneumonia rates clinics, P.C.P. offices, inter hospital transfers, air transport, ground transport, other hospital related entry points) 1. Describe your process for ventilator decision. 2. Describe your training regarding prevention of V.A.P. 3. Do you use a standardized protocol for ventilator use? 4. Does the protocol describe routine maintenance and care? 5. Does the protocol describe when to discontinue the ventilator? 6. Do you receive information or feedback about your patients who experience a V.A.P? How does that happen? 7. What would you recommend that your team do differently to avoid V.A.P? I.C.U. Care and Treatment 1. Describe your process for ventilator decision. 2. Describe your training re V.A.P. 3. Do you use a standardized protocol for the prevention of V.A.P? (Head of Bed, Oral Hygiene, Suctioning, Readiness to extubate, Daily Necessity?) 4. Does the protocol describe routine maintenance and care? 3
5. Does the protocol describe when to discontinue the ventilator? 6. What do you do to prevent V.A.P? 7. Do you receive information or feedback about your patients who experience a V.A.P? How does that happen? 8. What would you recommend that your team do differently to avoid V.A.P? Policies and Procedures 1. What policies and procedures are in place to prevent V.A.P? 2. Describe the management and updating of policies. When was the policy last updated? 3. Are evidence based strategies applied? 4. Has Respiratory Care been involved in the policy redesign? Infection Control 1. Describe the hospital data for V.A.P. 2. Describe the hospital reporting process. 3. How is feedback provided to the disciplines? 4. What collaborative work has been done to standardize care, treatment and prevention strategies? 4
5. What recommendations for change do you have? 6. Describe your hand washing process, data collection and data results. Respiratory Care Services 1. What is the V.A.P rate across I.C.U.s in this hospital? 2. What is your involvement in the prevention of V.A.P.? 3. Describe your ventilator change out process cleaning, maintenance of airways, etc. 4. What causes V.A.P in your patient populations? What data do you have to support this? 5. Are device related pressure ulcers present? (Positioning of E.T. tube.) 6. What recommendations for change do you have? Patient 1. How is the patient prepared for the ventilator both conscious and unconscious? 2. How is the patient positioned while on the ventilator? 3. What are additional complicating factors to consider while the patient is ventilated and identify the associated actions to minimize the risks? 5
4. How, who, and what are done to prepare visitors? The team will complete key findings and themes from the tracer and then begin building a high level process map inclusive of risk points for each step in the process. Please refer to the How To guides on the J.C.R. H.E.N. s website in the toolkit section and talk with your JCR consultant about the team s tracer. 6
Reducing V.A.P.: PATIENT Tracer First complete the System tracer. The purpose of the Patient tracer is to assess whether the related protocols and policies are actually in use with patients. Reducing V.A.P. Patient Tracer Sample Tracer Observations/Questions: Comments/Notes while tracing: Patient on a ventilator Observe the patient: 1. Is the head of the bed elevated? And are there visual cues used to indicate if patient and bed are in correct position? 2. Where is the endotracheal tube placed? Nasal or Oropharyngeal? 3. Describe how the E.T. is secured and stabilized. 4. Ask a respiratory therapist about standardized procedure for E.T. placement. 5. Ask a nurse about nurse s role in E.T. care, treatment, suctioning procedures, etc. Review the medical record: 1. Is a flow sheet used to prompt staff to check bed and patient position? If yes, is it completed and included in patient record? Does it match the hospital s 7
Reducing V.A.P. Patient Tracer Sample Tracer Observations/Questions: Comments/Notes while tracing: policy and protocol? 2. Is there evidence of the patient having a break or lightening of sedation on a daily basis (e.g. sedation vacation strategy)? 3. If a sedation scale is part of the hospital s protocol, is it used and documented? 4. Is the patient receiving peptic ulcer prophylaxis? 5. Is the patient receiving V.T.E. prophylaxis? 6. Is the patient receiving daily oral cleansing with chlorhexidine? 8