W E D N E S D A Y, J U N E 2 3 , 2 0 1 0

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 Medscapes.com) 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 rtmagazine.com