AACN News—January 2007—Association News
Vol. 24, No. 1, JANUARY 2007
Leading Critical Care Societies Partner to Advance Healthy Work Environment Standards
The leading critical care societies have joined AACN in a cooperative effort to promote healthy work environments that foster safe, quality care. In making the announcement, the American College of Chest Physicians, American Thoracic Society and Society of Critical Care Medicine, as well as the Society of Hospital Medicine, all endorsed the AACN Standards for Establishing and Sustaining Healthy Work Environments as essential in overcoming circumstances and conditions that, among other things, contribute to medical errors and put patients at risk.
AACN established the six evidence-based, relationship-centered standards—skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition and authentic leadership—to cultivate healthy work and care environments. The standards were announced in conjunction with the release of the 2005 Silence Kills report. Sponsored by AACN and VitalSmarts, the report found that 84 percent of physicians and 62 percent of nurses and other clinical care providers have seen co-workers taking shortcuts that could be dangerous to patients; however, less than 10 percent of healthcare workers voiced these concerns. Those who do voice concerns have reported observing better patient outcomes, working harder and feeling more satisfied and committed to staying in their jobs. AACN’s Healthy Work Environments effort is an in-depth and continued effort to engage nurses, their colleagues and employers to recognize the urgency and importance of changing behaviors and creating systems to improve the environments in which nurses and others provide patient care. ACCP, ATS, SCCM and SHM will now work jointly with AACN to raise awareness among their members and constituents of their roles as individual healthcare providers in using the Standards to drive cultural change in America’s hospitals.
“To empower healthcare professionals to deliver the best quality care and ensure patient safety, we must create healthy work environments that foster effective communication and true collaboration. Meeting this goal is a priority that requires the effort and leadership of nurses and doctors,” said Wanda Johanson, RN, MN, CEO of AACN. “We are thrilled the leading organizations in this field will be working hand-in-hand with us to support this vital endeavor.”
“Medical errors and poor decision making can occur anywhere in the healthcare delivery system, but critical care environments have significant patient safety challenges that put patients and the healthcare team at a greater risk for these errors," said Mark J. Rosen, MD, FCCP, ACCP president. "Patient-focused environments that emphasize safety standards, team collaboration and effective communication are essential to provide optimal care.”
Additionally, John E. Heffner, MD, ATS president, explained, "Nurses are the backbone of our healthcare system and deserve not only professional respect but a work environment that allows them to provide their skills, compassion, and leadership abilities in caring for patients. Critical care physicians within the ATS are committed to making this standard a reality not only because it is the right thing to do but because our patients’ lives depend on it.
“These standards are increasingly important, considering that nurses are now in dangerously short supply, especially in our nation’s ICUs. Achieving the standards’ goals will improve patient care and create a work environment that more nurses will want to join."
Charles G. Durbin Jr., MD, FCCM, SCCM president, said, "Clear, direct communication is the heart of true collaboration, and the SCCM welcomes the opportunity of advancing this important agenda forward together."
Laurence D. Wellikson, MD, FACP, CEO of SHM, added, "The Society of Hospital Medicine and our nation’s more than 15,000 hospitalists are proud to join with AACN in this effort to create the 21st century healthcare that will be patient centered, based on evidence with quality outcomes and delivered by teams of dedicated health professionals. Together we can create the best and safest hospital experience for the patients we serve."
The AACN Standards for Establishing and Sustaining Healthy Work Environments is available at www.aacn.org/hwe. More than 125,000 copies of the standards have been downloaded since their release in early 2005.
November Was a Good Month for the Member-Get-A-Member Campaign
Diana Lane, RN, MSN, of Hermitage, Tenn., held her lead in AACN’s Member-Get-A-Member campaign as of the end of November.
But several member recruiters debuted in the campaign in November with strong numbers, including Virginia C. Macko, RN, of Alliance, Ohio, with 16 new members recruited; Fredrecker P. Adams, RN, BSN, of Bowie, Md., with 12; and Katherine L. McElderry, RN, BSN, of Shawnee, Kan., with 10.
Other leading recruiters as of the end of November were Kathleen Richuso, RN, MSN, Chapel Hill, N.C., with 31; Ann Brorsen, RN, MSN, CCRN, CEN, of Sun City, Calif., with 29; Deborah L. Erickson, RN, MA, CCRN, of Augusta, Ga., with 23; Diana Pryer, RN, MS, MSN, CCRN, of St. Louis, Mo., and Kara Bader, RN, of Burleson, Texas, both with 21; and Debra A. Skrajewski, RN, BS, CCRN, CEN, of Downingtown, Pa., with 20.
In the chapter campaign, the Houston Gulf Coast Chapter edged into the lead with 51 new members recruited. That overtook by one the Greater Richmond Area Chapter, which had held the top spot at the end of October.
Other top chapters in the campaign at the end of November were the Southeastern Pennsylvania Chapter with 44 new members, the Greater Cincinnati Chapter with 35 new members, and the Atlanta Area Chapter and Greater Portland Chapter, both with 25 new members.
They are among the 917 individuals and chapters that have recruited 3,312 new members since the campaign began May 1. The campaign ends Aug. 31, 2007. The recruitment period was extended for this year’s campaign to move the program to a 12-month cycle in the future.
Participation in the Member-Get-A-Member drive offers the opportunity for recruiters to receive valuable rewards, including a $1,000 American Express gift check that will be awarded to the top individual recruiter. The top recruiter is also eligible for three Grand Prize drawings for $500 gift certificates. Every recruiter who enrolls five new members during the program will be entered into the drawing.
In addition, as individuals recruit new members, they are entered into a drawing for a $100 American Express gift check each month they recruit. Adoracion Yap, RN, BS, BSN, MS, MSN, CCRN, of Sugarland, Texas, won the gift certificate in November.
After recruiting their first five new members, participants will receive a $25 gift certificate toward AACN products and services, and $50 after recruiting their first 10 new members.
The chapter recruiting the most new members during the campaign will receive a $1,000 honorarium check.
The winning chapter is also eligible for Grand Prize drawings for three $500 honorarium checks for their chapter treasuries. In addition, chapters are eligible for monthly drawings for a free NTI registration any month they recruit a new member. The winner for November was the San Diego Area Chapter.
To see the full list of recruiters and their totals through October, visit the AACN Web site at www.aacn.org > Membership.
Morris Named New AJCC Physician Co-editor
Morris Dracup Bryan-Brown
Peter E. Morris, MD, FACP, FCCP, has accepted an appointment as physician co-editor of AJCC, the American Journal of Critical Care, AACN’s official interdisciplinary evidence-based journal. With this appointment, Christopher Bryan-Brown, BM, BCh, MA (Oxon), DA, FRCA, transitions to the role of founding co-editor.
Morris is an associate professor in the pulmonary, critical care, allergy and immunologic diseases section of the Department of Medicine at Wake Forest University School of Medicine. Since 2002 he has been the medical director of the intermediate care unit at Wake Forest University Baptist Medical Center (WFUBMC).
He brings a wealth of clinical and academic experience to this new role. Leader of the interdisciplinary early ICU mobility project at WFUBMC, a position that involves close collaboration with nursing colleagues, he also participates in numerous hospital clinical committees and project teams. Morris holds an undergraduate degree summa cum laude from St. John’s University and an MD from Cornell University, which included a fourth-year elective in the National Institutes of Health Division of Critical Care. Following a medical residency and fellowship in pulmonary medicine at Vanderbilt University, he served on the faculty of the University of Kentucky Division of Pulmonary Medicine.
Morris holds active membership in three of AACN’s collaborating medical societies, namely the American College of Chest Physicians, the Society of Critical Care Medicine and the American Thoracic Society. He is board certified in pulmonary and critical care medicine and has been a reviewer for numerous journals, authoring more than two dozen peer-reviewed articles, two book chapters and 30 abstracts.
His clinical and research interests align directly with high acuity and critical care nursing. These include early ICU mobility and clinical trials with emphasis on severe sepsis, shock and acute lung injury. He is a frequent speaker, with invited presentations for the Critical Care Nurses Seminar on Sepsis at the University of North Carolina, Chapel Hill, and the Association of Healthcare Pharmacists to his credit.
“I am humbled by the opportunity of succeeding Dr. Bryan-Brown, which warrants a very special level of attention and diligence,” Morris said. “AJCC is well respected among our specialty’s peer-reviewed journals. I especially look forward to collaborating with Kathy Dracup in positioning the journal as the primary source of interdisciplinary evidence-based knowledge in high acuity and critical care.”
“I look forward to forging a mutually rewarding partnership with Pete Morris,” said Kathy Dracup, RN, DNSc, FAAN, who continues as AJCC’s nurse co-editor. “He is a superb clinician and researcher with a strong commitment to interdisciplinary practice. Chris Bryan-Brown and I anticipate a seamless transition.”
Outgoing physician co-editor Bryan-Brown is professor of anesthesiology and vice chair in the Department of Anesthesiology at Albert Einstein College of Medicine as well as director of critical care anesthesiology at New York’s Montefiore Medical Center. Continuing an interdisciplinary collaboration that began when they were co-editors of AACN’s first scientific journal, Heart & Lung, Bryan-Brown and Dracup were tapped to launch AJCC as the association’s new scientific journal in 1992.
“AJCC’s physician co-editor should have a track record in publishing and research, and at the same time should not be too bound up with the medical establishment to have no sense of humor or ability to critique the status quo,” Bryan-Brown wryly observed. A long-standing champion of AACN, he reflects that throughout his professional career his association with AACN “has afforded many extraordinary tutors in the values of nursing. Among them, my collegial relationship with Kathy Dracup has been one marked by the trust and moral support that are hallmarks of genuine collaboration.” A thoughtful retrospective titled “My First 50 Years of Critical Care (1956-2006)” appears in the January 2007 issue of AJCC.
Bryan-Brown’s transition to founding co-editor took place Jan. 1, 2007, when Morris assumed his new role. Morris will attend the May 2007 National Teaching Institute & Critical Care Exposition in Atlanta, where he also will be an Advanced Practice Institute speaker on early ICU mobility. He can be reached at firstname.lastname@example.org.
Scene and Heard
Our Voice in the Media
Nursing Spectrum (Sept. 25, 2006)—“Time for Us All to Act Boldly” was the title of an article about Critical Care Nurses’ Work Environment: A Baseline Status Report, a national survey of critical care nurses conducted by the Bernard Hodes Group, Nursing Spectrum and AACN, which found that nurses continue to work in disrespectful and even unsafe environments, but the majority reported being very satisfied with their career. Indicating that “AACN has long been a leader in many aspects of nursing,” the article also referenced the National Critical Care Survey, which AACN released early last year.
MarketWatch (Sept. 25, 2006)—“New Survey Finds 87% of Critical Care Registered Nurses Committed to Staying in Field Despite Serious Challenges.” This article also discussed Critical Care Nurses’ Work Environment: A Baseline Status Report and included the following quote from CEO Wanda Johanson, RN, MN. “A healthy work environment is not only the most critical component of retaining and recruiting nurses, it is vital to assuring patient safety. That is why our top advocacy priority is AACN’s Healthy Work Environment Initiative, an in-depth and continued effort to engage nurses, their colleagues and employers to recognize the urgency and importance of changing behaviors and creating systems to improve the environments in which nurses provide patient care.”
The article appeared in many other outlets, including Yahoo News, MSN, CNN, Los Angeles Times and Kiplinger.com.
University Hospitals Health System News (Sept. 27, 2006)—“University Hospitals Case Medical Center’s Medical ICU Earns Beacon Award for Second Consecutive Year.” Ron Dziedzicki, RN, senior vice president and CNO at the medical center, said, “Once again the nurses at University Hospitals demonstrate that high-tech can be combined with high-touch, compassionate care.”
Rhinelander Daily News (Sept. 26, 2006)—“Eggman Earns Critical Care Credentials” noted that “CCRN certification is one of the most advanced professional credentials that can be achieved by a nurse in the field of critical care … Most importantly, the CCRN credential signals that these individuals have been acknowledged by their peers as being among the very best in the critical care nursing profession.”
Our Voice at the Table
Mary Fran Tracy, RN, PhD, CCRN, CCNS, FAAN, AACN board president, attended Trends in Critical Care in King of Prussia, Pa., which was co-sponsored by the Southeast Pennsylvania (SePA) Chapter and AACN. She presented her keynote, “Powered by Insight.” Tracy also participated in a Town Hall meeting with Janet Riggs, RN, CNS, MN, CCNS, SePA chapter president.
Dana Woods, MBA, AACN’s director of marketing and strategy integration, also attended Trends and gave a presentation on findings from the recent Critical Care Nurses’ Work Environment Survey, with Beth Ulrich, EdD, RN, CHE, FAAN, vice president of professional and editorial services of Nursing Spectrum, co-investigator of the study. The survey of more than 4,000 critical care RNs was conducted by AACN, Nursing Spectrum and the Bernard Hodes Group. The findings are available in the October 2006 issue of Critical Care Nurse at http://ccn.aacnjournals.org.
Dave Hanson, MSN, RN, CCRN, CNS, AACN president-elect, presented a national AACN update at the Greater Louisville (Ky.) Chapter’s Annual Symposium: Gizmos, Gadgets & Code Stroke. He also visited with chapter members at the Education Center, Baptist Hospital East.
Hanson was invited to participate in the AACN Region 15 (Okla. and Texas) meeting. He opened the program with the keynote address, “Powered by Insight: The Unique Contributions of Acute and Critical Care Nurses.” Hanson was later joined by fellow AACN board member, Julie Miller, BSN, RN, CCRN, to update participants on the various programs and initiatives in which AACN is involved. Miller presented “Healthy Work Environments” and John Dixon, RN, MSN, immediate past AACN board member, presented the “AACN Synergy Model.”
Tracy gave her keynote, “Powered by Insight,” at Critical Care Updates 2006, sponsored by the Greater Milwaukee Area Chapter. Approximately 175 people attended the conference, which also offered a CCRN review track.
Tracy, Hanson and CEO Wanda Johanson, RN, MN, attended the American College of Chest Physicians’ annual meeting in Salt Lake City, Utah. Tracy attended the Board of Regents meeting and also presented “Medical Accidents and Errors: What Happens When Things Go Wrong: Organizational Response,” as part of the Presidents’ Panel (ACCP, SCCM, AACN and ATS representatives).
Miller presented a “12 Lead ECG Interpretation Course” at the University of Texas Health Center, Tyler, Texas, sponsored by the Greater East Texas Chapter. Chapter President Anna Taylor, RN, BS, BSN, Treasurer Mary Haislet, RN, BSN, and Secretary Erni Jimenez, RN, AAS, discussed the benefits of national and local AACN membership. Miller also presented AACN’s standards for healthy work environments.
Nancy Blake, RN, MN, CCRN, CNAA, immediate past AACN board member, gave a lecture at the Sigma Theta Tau Southern California Research Odyssey conference on Versant’s RN Residency and on using AACN’s standards for a healthy work environment to improve retention.
Patricia Gonce Morton, RN, PhD, ACNP, FAAN, AACN board member, attended the semiannual fall meeting of deans and directors of schools of nursing sponsored by the American Association of Colleges of Nursing, in Washington, D.C.
Implementing Evidence-Based Practice Guidelines to Minimize Ventilator-Associated Pneumonia
Maureen Seckel, RN, MSN, APRN-BC, CCRN, CCNS
Ventilator-associated pneumonia (VAP) typically begins between 48 and 72 hours after endotracheal intubation, and it is estimated to occur in 9% to 27% of all intubated patients. Mortality rates are significant, ranging between 33% and 50% in affected patients.
VAP may be caused by a wide spectrum of bacterial pathogens or multiple organisms and is rarely due to viral or fungal sources in patients with intact immune systems.2 Aerobic gram-negative bacilli (eg, Pseudomonas aeruginosa), gram-positive cocci (eg, Staphylococcus aureus), and particularly methicillin-resistant Staphylococcus aureus (MRSA) have been rapidly emerging in the United States. More than 50% of Staphylococcus aureus isolates in cultures from intensive care patients are resistant to methicillin. VAP due to multidrug-resistant organisms has also increased dramatically in the United States.
The primary source of bacterial entry into the respiratory tract is colonization of the oral cavity, trachea, stomach, or sinuses with pathogenic bacteria (see Figure). Within 48 hours of hospital admission, the oropharyngeal flora changes from the usual gram-positive streptococci and dental pathogens, to predominantly gram-negative organisms, which constitute a more virulent flora.3 Additionally, the stomach contents can become colonized, particularly when stress ulcer prophylaxis alters the pH balance. Gross aspiration or microaspiration carries these bacteria-rich secretions into the lower respiratory tract. Colonies of bacteria on the endotracheal tube, known as biofilms, are thought to contribute to VAP in some cases. Additionally, although less common, bacteria can gain entry through direct inhalation.
VAP results in increased lengths of stay, reported to be as much as 22 days at a cost of more than $40,000 per patient, per infection.7 With approximately 5 to 10 cases per 1000 admissions, the estimated 300,000 annual cases of VAP could cost healthcare systems more than $12 billion annually.
RISK FACTORS AND RATES OF INFECTION
The National Nosocomial Infection Surveillance (NNIS) system was developed in 1970 to monitor the incidence of healthcare-associated (nosocomial) infections and their associated risk factors and patho-gens. This voluntary reporting system today includes approximately 300 hospitals that report their data to the Centers for Disease Control and Prevention (CDC).10
An NNIS report published in 2004 in the American Journal of Infection Control indicated that the highest rates of VAP were most likely to be seen in the trauma, burn, neurosurgical, and surgical intensive care units (ICUs).11 Infection rates were calculated by taking the number of ventilator patients with pneumonia, multiplying by 1000, and then dividing by the number of ventilator days. For example:
2 patients with VAP x 1000
500 ventilator days
4 (VAP infection rate)
Risk factors can be modifiable or nonmodifiable. Nonmodifiable factors that increase the risk of acquiring VAP include chronic obstructive pulmonary disease, coma, patient’s age greater than 60 years, male sex, transport out of the ICU, and re-intubation. Modifiable risk factors that affect the occurrence of VAP include ventilator circuit changes every 24 hours, supine positioning of patients, and endotracheal cuff pressures less than 20 cm H2O.
CLINICAL PRACTICE GUIDELINES TO REDUCE VAP
Multiple organizations have issued evidence-based guidelines to reduce and prevent VAP. In 2004, the American Association of Critical-Care Nurses (AACN) issued the VAP Practice Alert. These measures include head-of-bed (HOB) elevation between 30° and 45°, continuous aspiration of subglottic secre-tions (CASS), and the elimination of routine changes to the patient’s ventilator circuit.13 These guidelines are also supported by the American Thoracic Society (ATS)1 and the CDC14 (see Table below).
VAP Practice Alert: All patients receiving mechanical ventilation, as well as those at high risk for aspiration (eg, decreased level of consciousness, with enteral tube in place), should have the head of the bed (HOB) elevated at an angle of 30°–45° unless medically contraindicated.
HOB elevation reduces the risk of aspiration and the incidence of VAP. In a study by Drakulovic et al,15 clinical evidence indicated dramatic reductions in VAP rates with HOB elevation to between 30° and 45°. ATS and CDC also recommend this intervention on the basis of their review of clinical evidence. However, despite multiple evidence-based guidelines supporting HOB elevation, a recent study by Grap et al16 has shown that the mean HOB elevation in patients receiving mechanical ventilation was consistently lower than the recommendations of 30° to 45°.
Why are patients being kept with the HOB elevated less than 30° to 45°, despite clinical evidence to support elevation? One reason may be conflicting recommendations for the prevention of skin shearing or breakdown. The Agency for Healthcare Research and Quality recommends maintaining the elevation at the lowest degree consistent with the medical condition or restrictions to prevent pressure ulcers.17 Another reason may be a simple misjudg-ment of the angle. Most critical care beds now come with angle devices in the bed rail, but elevation can also be measured with a separate angle device or protractor, to ensure compliance with the AACN guidelines. Additionally, HOB elevation may be below recommended guidelines because of a patient’s hemodynamic instability. However, researchers in several studies found that decreased HOB elevation was not related to lower or unstable blood pressure in ICU patients receiving mechanical ventilation.
Continuous Aspiration of Subglottic Secretions
VAP Practice Alert: Use an endotra-cheal tube with a dorsal lumen above the endotracheal cuff to allow drainage by continuous suctioning of tracheal secretions that accumulate in the subglottic area.
First described in 1992, subglottic suction involves the use of a specialized endotracheal tube, sometimes known as a CASS tube, which has a dorsal lumen opening above the cuff in the subglottic region. The suction lumen can be attached to low continuous suction at -20 mm Hg or intermittent suction at -100 to -150 mm Hg.
In a meta-analysis of 110 different randomized controlled trials comparing standard care of endotracheal tubes with drainage of subglottic secretions, Dezfulian et al19 reported that draining subglottic secretions reduced the incidence of VAP by nearly half. Additionally, drainage of subglottic secretions reduced length of stay in the ICU by 3.1 days compared with standard endotracheal care.
In addition to the AACN, the CDC and ATS currently support use of an endotracheal tube with subglottic secretion drainage.
Minimal Changes of Ventilator Circuit
VAP Practice Alert: Do not routinely change, on the basis of duration of use, the patient’s ventilator circuit.
Historically, ventilator circuits were changed as frequently as every 8 hours. This recommendation was based on early studies showing a relationship between respiratory equipment and VAP. Practices were changed in the 1980s after a land-mark study by Craven et al20 showed that rates of VAP did not change when circuits were changed every 48 hours rather than every 24 hours. In 1995, Kollef et al21 extended the body of evidence to recommend circuit changes on an as-needed basis by demonstrating no differences in VAP rates with or without 7-day circuit changes in a randomized controlled trial of 300 patients.
Current guidelines indicate that circuits should be changed only when visibly soiled or malfunctioning. The American Association of Respiratory Care (AARC) joins the AACN, ATS, and CDC in support of this guideline.
In a recent study of critically ill long-term-care residents, El-Solh et al23 investigated the association between dental plaque colonization and the lower respiratory tract. Their findings suggested that dental plaque can serve as a reservoir for microorganisms; regimens that improve oral health should reduce the risk of VAP.
The AACN Procedure Manual for Critical Care24 includes the following procedure: brush teeth with a pediatric or soft toothbrush twice daily; use oral swabs and apply mouth moisturizer to the oral mucosa and lips every 2 to 4 hours; and suction the oral cavity and pharynx frequently, changing oral suction equipment and tubing every 24 hours.
In a 2005 study, Hanneman and Gusick25 found that nurses self-report more frequent oral care than is documented. The mean documented frequency of oral care in intubated patients was 3.3 episodes during a 24-hour period; the self-reported frequency was 4.2 episodes. The most recent statement by the CDC recommends implementation of a comprehensive oral hygiene program for patients who are at high risk for healthcare-associated pneumonia, although specific practices such as chlorohexidine rinses or oral decontamination with topical antimicrobials are not recommended for routine use. The current AACN and ATS guidelines do not address oral care strategies to prevent or reduce the risk of VAP, and additional research is needed.
Education is a critical factor in the decrease of VAP rates. The implementation of educational programs reduced one facility’s VAP rate by more than 57%,26 and a multidisciplinary performance improvement team in another institution was able to decrease its VAP rate by 95% over a period of 6 years.
A recent report by Lawson28 highlighted the efforts of one hospital to reduce VAP rates through evidence-based medicine. The 6 steps of the program are detailed below.
The project began with a comparison of that hospital’s VAP rates against similar units in other hospitals, as reported through the NNIS system. The hospital’s VAP rates were higher than the national threshold.
Assembling a Team
A multidisciplinary team was assembled, including the critical care director, nursing director, director of respiratory therapy, infectious disease nurse, progressive unit care manager, and critical care educator. Additionally, the hospital librarian contributed by doing extensive literature research for the project.
Developing an Action Plan
After a careful review of the literature, the team developed a list of multiple changes, including the following procedures.
• HOB elevation 30° to 45°
• CASS endotracheal tube
• Oral care
• Draining ventilator circuits away from the patient
• Additional changes, including hand washing, appropriate use of gowns and gloves, ventilator protocols, eliminating saline lavage, and continuous lateral rotation therapy.
The implementation process was incremental, involving staff development sessions, formal and video taped lectures, self-learning packets, e-mails, flyers, and colorful storyboards, all reinforcing the importance of VAP prevention and the methods for reducing the risk of infections.
The results of the program were quickly evident, with an immediate and drastic reduction in VAP rates. Compliance with individual elements of the program was tracked (HOB elevation, documentation of oral care) through records and nursing interviews.
Dissemination of Results
The results of the project were disseminated to all ICU nurses, as well as administrative, medical, and nursing committees. The results were celebrated and highlight-ed as an example of how working together could help to achieve positive results.
Using Evidence-Based Guidelines to Decrease VAP
As healthcare providers, we work hard to give our patients the best care we can give; as direct caregivers at the bedside, our impact can be huge. The statistics on VAP are staggering. Pneumonia remains the sixth leading cause of death in the United States29 and VAP, as a hospital-acquired infection, has a 33% to 50% mortality rate.1,14 We know from solid research and the publication of evidence-based guidelines that there are steps we can take for our patients that will decrease the risk of this deadly infection.
The AACN Practice Alert offers succinct information, provides tools and education to guide bedside care, and is readily available at the AACN Web site. Yet we know from research that despite published guidelines, practice lags behind the evidence, and HOB elevation below 30° can still be found.
You can make a difference and affect your patients’ outcomes. Read the evidence, bring the guidelines to work, and discuss them with your peers, nurse manager, or unit director. Find out what your unit’s VAP rate is so that you can measure your success. Use a monitoring tool to measure your ICU’s compliance with the guidelines for HOB elevation.
In 2004, I was part of a team that developed and implemented a clinical practice guideline for VAP at my hospital. The team measured HOB compliance in our 12-bed medical intensive care unit and saw that we improved over time. The VAP rate for our unit was posted in the break room; barriers and successes were discussed as a standing agenda item for the medical ICU staff meetings. The VAP rate in the medical ICU steadily decreased from 8.4 infections per 1000 ventilator days at the start of the clinical practice guideline to zero infections in the last two quarters of 2005. The process was driven by persistence, patience, teamwork, and a united goal to improve pa-tients’ outcomes. After all, it really is all about the patient.
Maureen Seckel is a critical care medicine/pulmonary clinical nurse specialist at Christiana Care Health Services, Newark, Del. This article was written with the sup-port of Nellcor Puritan Bennett, as part of a course in development for their continuing education Web site: www.nellcor.com
1. American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated and healthcare-associated pneumonia. Am J Respir Care Med. 2005;171:388-416.
2. Rello J, Diaz E, Rodriguez A. Etiology of ventilator-associated pneumonia. Clin Chest Med. 2005;26:87-95.
3. Abele-Horn M, Dauber A, Bauernfeind A, et al. Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination SOD. Intensive Care Med. 1997;23:187-195.
4. Osmon SB, Kollef MH. Prevention of pneumonia in the hospital setting. Clin Chest Med. 2005;26:135-142.
5. Kollef NH. Prevention of hospital-acquired pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004;32:1396-1405.
6. Grap MJ, Munro CL. Preventing ventilator-associated pneumonia: evidence-based care. Crit Care Nurs Clin North Am. 2004;16:349-358.
7. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 2003;31:1312-1317.
8. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122:2115-2121.
9. McEachern R, Campbell GD. Hospital-acquired pneumonia: epidemiology, and treatment. Infect Dis Clin North Am. 1998;12:761-779.
10. National Nosocomial Infections Surveillance System (NNIS). Available at: http://www/cdc.gov/ncidod/dhqp/nnis
_pubs.html. Accessed March 29, 2006.
11. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004. Am J Infect Control. 2004;32:470-485.
12. Bonten MJ, Kollef MH, Hall JB. Risk factors for ventilator-associated pneumonia: from epidemiolgy to patient management. Clin Infect Dis. 2004;38:1141-1149.
13. American Association of Critical-Care Nurses. AACN practice alert: ventilator-associated pneumonia. 2004. Available at: http://www.aacn.org/AACN/practiceAlert
.nsf/Files/VAPi. Accessed March 29, 2006.
14. Centers for Disease Control and Prevention. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53:1-36.
15. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354:1851-1858.
16. Grap MJ, Munro CL, Hummel RS III, Elswick RK, McKinney JL, Sessler, CN. Effect of backrest elevation on the development of ventilator-associated pneumonia. Am J Crit Care. 2005;14:325-332.
17. U.S. Department of Health and Human Services. Pressure Ulcers in Adults: Prediction and Prevention. 1992. Rockville, Md: U.S. Department of Health and Human Services. AHCPR Publication No. 92-0047.
18. Grap MJ, Munro CL, Bryant S, Ashtiani B. Predictors of backrest elevation in critical care: a pilot study. Intensive Crit Care Nurs. 2003;19:68-74.
19. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med. 2005;118:11-18.
20. Craven DE, Connolly MG Jr, Lichtenberg DA, Primeau PJ, McCabe WR. Contamination of mechanical ventilators with tubing changes every 24 or 48 hours. N Engl J Med. 1982;306:1505-1509.
21. Kollef MH, Shapiro SD, Fraser VJ, et al. Mechanical ventilation with or without 7-day circuit changes. Ann Intern Med. 1995;123:168-174.
22. Hess D. Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Resp Care. 2003;48:869-879.
23. El-Solh AA, Pietrantoni C, Bhat A, et al. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest. 2004;126:1575-1582.
24. Scott JM, Vollman KM. Endotracheal tube and oral care. In: Lynn-McHale DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 5th ed. St. Louis, Mo: Elsevier; 2005.
25. Hanneman SK, Gusick GM. Frequency of oral care and positioning of patients in critical care: a replication study. Am J Crit Care. 2005;14:378-386.
26. Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30:2407-2411.
27. Keith DD, Garrett KM, Hickox G, Echols B, Comeau E. Ventilator-associated pneumonia: improved clinical outcomes. J Nurs Care Q. 2004;19:328-333.
28. Lawson P. Zapping VAP with evidence-based practice. Nursing 2005. 2005;35:66-67.
29. Anderson RN, Smith BL. Deaths: leading causes for 2002. Natl Vital Stat Rep. 2005;53:1-89.
Free CE Webcast Supported by an Educational Grant From Edwards Lifesciences
A new, free CE webcast, “Implementing Nurse-Driven Protocols: Using Arterial Pressure-Based Cardiac Output Technologies,” has been posted on AACN’s Web site. The online course has been approved for 2.0 contact hours of CE credit and is supported by a grant from Edwards Lifesciences, a Bronze member of the AACN Corporate Circle. Program presenters include Jan M. Headley, RN, AD, BHS; Barbara A. McLean, RN, MSN, CCRN, ACNP, APN-C, FCCM; and Albert Minjock, RN, MS. To view the webcast, visit www.aacn.org/ELLC.