Ventilator-associated pneumonia (VAP) has been a constant headache for hospitals around the country, and on the list of IHI interventions since the inception of the 100,000 Lives Campaign in 2006. It is one of the most-acquired conditions by intensive care unit (ICU) patients on ventilators and its presence exacerbates existing conditions, as well as adds costly days spent in the ICU.
UPenn Health System (UPHS) in Philadelphia utilized an electronic ICU (eICU), which uses telemedicine to monitor patients, already in place to help lower its rates of VAP and realized a cost savings of more than $138,000 over a two-year span.
An eICU can add an extra level of monitoring for ICU patients. Not only does it provide visual surveillance, but it offers a level of data and analysis that simply utilizing bedside caregivers cannot.
"Telemedicine receives alerts and alarms through a software package," says Joseph DiMartino, BSN, RN, outcomes coordinator for UPHS. The eICU monitors different quality initiatives at the Hospital at The University of Pennsylvania, Presbyterian Hospital, and Pennsylvania Hospital. "That allows us to see and detect alerts for patients earlier than maybe the bedside nurse might see."
He explains that often bedside caregivers set patient alarms so that they only go off in an extreme emergency and are not ringing all day, as a distraction. The eICU's system is set to be alerted whenever there is a 20% or higher change in a vital sign and the eICU staff members can alert the bedside caregiver if it is necessary.
The UPHS eICU was started in 2005, and the VAP initiative began in 2006. The eICU contains three surveillance stations—two for each of the nurses monitoring patients and one for the doctor monitoring patients. There is a smaller setup for the data coordinator as well.
A surveillance station contains six computer screens, each displaying pertinent data, pictures, or video, mounted on a desktop. Additionally, a phone and any alarms necessary are attached. Currently, the eICU is staffed by two nurses from 11 a.m. to 11 p.m. and one nurse 11 p.m. to 11 a.m. Additionally, a physician monitors the eICU from 7 p.m. to 7 a.m. The data coordinator's shifts vary.
If the eICU staff members recommend a change to the ICU bedside caregivers in the morning, the eICU staff members look to see that the change has taken place by that night.
Data from the original ICU show that in 2006 there were 17 cases of VAP. That number dropped to nine in 2007 because of the eICU surveillance. The program has been expanded to ICUs at all three UPHS hospitals and continues to reduce VAP numbers.
Integrating eICU technology with VAP prevention
DiMartino's team originally approached the bedside team at a specific ICU at Presbyterian Hospital to discuss using telemedicine to lower the rate of VAP. Although the idea was accepted overall, some staff members needed to warm up to the idea.
"There are always individuals who aren't really accepting of the eICU and what we do, people might think we're spying on them, another set of eyes," says DiMartino. "We're trying to show them how we can help them." Staff members really needed to be educated about what telemedicine actually is, as well as the eICU’s responsibilities.
The eICU surveillance team was trained to watch for the care techniques identified in the IHI's bundle of care for preventing VAP. This means head of bed elevation between 30 and 45 degrees, stress ulcer prophylaxis, and DVT prophylaxis. The bedside caregivers are responsible for measuring whether daily sedation holidays have been implemented and the patient's readiness to extubate.
To adequately estimate a patient's head of bead elevation, the data coordinators working at the eICU underwent a two-week training period that helped them become accustomed to identifying this.
"We have the ability to go in and visualize what's going on in the room, so we trained the data coordinators to figure out where the head of the bed is elevated based on visual cues behind the bed—if the bed is flat, or at 10, 20, 30, or 40 degrees elevated," says DiMartino.
Additionally, eICU staff members check each patient's documentation to ensure adequate prophylaxis has been ordered, and is being delivered. Is the patient taking an anticoagulant? Does that patient have compression boots, and are they being worn properly? The same goes for stress ulcer prophylaxis—has an acid blocker been prescribed and administered?