As Patient Safety First Week takes place from 21 September, one trust outlines how it implemented the ventilator care bundle to improve patient care
Keywords: critical care, ventilated patient, care bundles
Patient Safety First, a campaign to make patient safety everyone’s top priority, was launched in June 2008. It currently consists of four clinical and one leadership intervention, and is sponsored by the NPSA, the NHS Institute for Innovation and Improvement and The Health Foundation.
The University Hospitals of Leicester NHS Trust was one of the first large acute trusts to sign up to Patient Safety First. While we have signed up to every intervention, the one we have particularly focused on is on reducing harm in critical care. This consists of two care bundles – one on mechanical ventilation and the other on central lines.
We implemented the ventilator bundle, with the aim of avoiding ventilator-acquired pneumonia (VAP), which occurs in up to 15 per cent of patients receiving mechanical ventilation. Risk factors include tracheostomy, multiple central line insertions, reintubation and the use of antacids. The hospital mortality rate for patients on ventilators who develop VAP is 46 per cent, compared with 32 per cent for those who do not develop it (Ibrahim et al, 2001).
The ventilator bundle
There are four key components in this bundle:
- Elevation of the head of the bed to between 30º and 45º;
- Daily ‘sedative interruption’ and assessment of readiness to extubate;
- Peptic ulcer disease (PUD) prophylaxis;
- Venous thromboembolism (VTE) prophylaxis (unless contraindicated).
All the measures implemented lead to patients being on ventilators for a shorter time.
Elevating the head of the bed
The first change is to ensure patients are sitting up at an angle of at least 30º. Drakulovic et al (1999) found that lying at an angle of 30-45º reduced the risk of aspiration of gastrointestinal contents or oropharyngeal and nasopharyngeal secretions. This would, in turn, help to reduce the risk of VAP. Nurses therefore constantly monitor patients’ position.
In the past when patients were put on a ventilator, they would be kept asleep. However, evidence shows sedation can slow down recovery and in some cases cause patients to become more dependent on medication (Kress et al, 2000). If sedation is stopped at regular intervals patients generally need fewer days on a ventilator. While we sedate patients when they are first put on a ventilator, we stop their sedation every day to prevent the accumulation of sedation.
Sedation holds have been the most difficult element of the care bundle to implement consistently. Timing is the key factor, ensuring it is done by the start of the ward round so patients’ consciousness level can be checked.
Patients on ventilators are at increased risk of developing stomach ulcers so it is important to reduce gastric acidity by giving medication to protect against PUD and GI bleeding, and continually monitor for ulcers.
Doctors prescribe gut protection when patients are first admitted to ICU. A standard dose of ranitidine is prescribed and so pH levels do not need to be measured. The medication is given enterally, unless this route cannot be used.
A key component of the ventilator bundle is prevention of VTE. We monitor patients carefully and give them anticoagulants regularly.
Ensuring the right patients receive VTE prophylaxis every day has been more complicated than introducing some of the other care bundle elements, as some may be actively bleeding post surgery or be on anticoagulants for dialysis. Despite this, using protocols and multidisciplinary working, we ensure the right patients receive VTE prophylaxis.
Nurses are crucial to ensuring the ventilator bundle is a success. They are responsible for:
- Ensuring that bed heads are elevated between 30-45º;
- Making sure that a sedation hold occurs regularly and recording this for the next nurse on shift;
- Ensuring that anticoagulants for VTE prophylaxis are administered properly;
- Recording each element of the care bundle.
Patient Safety First has helped us become much more aware of how to reduce harm from treatment and we have already seen a difference. Since joining the campaign care bundle compliance has increased significantly, from just over 75 per cent on average in June 2008 to 95 per cent in March 2009.
- Patient Safety First Week, which runs from 21-27 September, urges healthcare professionals and leaders to take “one new step” to improve patient safety. See www.patientsafetyfirst.nhs.uk for more.
AUTHORS Sanjay Agrawal is assistant medical director for infection prevention and control; Amy Williams is ward sister on the ICU; both at University Hospitals of Leicester Trust.
Drakulovic, M.B. et al (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet; 354: 9193, 1851-1858.
Ibrahim, E.H. et al (2001) The occurrence of ventilator associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest; 120: 2, 555-561.
Kress, J.P. et al (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New EnglandJournal ofMedicine; 342: 20, 1471-1477.