MICU Nurses Work to Decrease the Incidence of VAP

Critically ill patients intubated for more than 24 hours are at 6 to 21 times the risk of developing ventilator-associated pneumonia, or VAP. In addition to mechanical ventilation, other risk factors for VAP include decreased level of consciousness, gastric distention, presence of gastric or small intestine tubes, and a trauma or COPD diagnosis.

The nursing staff in the Medical Intensive Care Unit (MICU), in collaboration with the multidisciplinary team, have launched an initiative aimed at decreasing the incidence of VAP in patients admitted to McClure 4. This is one of many patient care initiatives begun in both adult intensive care units at Fletcher Allen over the past several months.

The evidence-based strategies used by the MICU nursing staff to combat VAP come in part from the recent practice alert published by the American Association of Critical Care Nurses (AACN). AACN issues these practice alerts in order to close the research/practice gap, provide guidance, standardize practice, and identify and inform nurses about new advances and trends in practice. The practice alerts summarize the supporting evidence and identify clinical interventions that can help reduce the incidence of VAP. One of the key nursing interventions implemented by the MICU staff is elevation of the head of the bed.

All mechanically ventilated patients, as well as those at high risk for aspiration, now have the head of the bed elevated at an angle of 30-45 degrees at all times, unless medically contraindicated. According to the literature, this simple positioning of the HOB can reduce the incidence of VAP by as much as 34%. This has a significant effect on patient outcome since VAP increases ventilator days, critical care days and length of stay. All of these factors can result in more than $40,000 in increased costs for each case of VAP.

As recommended by AACN, critical care practitioners at Fletcher Allen have formed a multidisciplinary task force to address VAP practice changes. The team included nurses, physicians, respiratory therapists, data collection specialists and clinical pharmacists. Data collection is currently being conducted in the MICU on a monthly basis. The multidisciplinary team then reviews and analyzes the data at its monthly meeting. The MICU nursing staff hope to report on the results of their efforts related to these and other patient care initiatives in future editions of "Notes on Nursing."