1. Murray, Theresa MSN, RN, CCRN

Article Content

Problem and Significance

The Centers for Disease Control and prevention (CDC) defines ventilator associated pneumonia (VAP) as pneumonia in patients who have been on mechanical ventilation for more than 48 hours. VAP falls under the umbrella of hospital-acquired pneumonia, and accounts for 10% to 15% of all nosocomial infections. VAP is the most common of the infections seen in the ICU and is associated with the highest mortality rate.



This project was designed to implement evidence-based interventions aimed at preventing VAP, including the system-level changes that support implementation of the selected interventions.


Description of Project

This project involved creating goal-directed, multifocused, evidence-based interventions for reducing/eliminating VAP in an integrated health network with several ICUs.



The implementation of many evidence-based and overlapping systems, called independent redundancies, was used. The concept of independent redundancies involves putting multiple triggers in the system to help ensure that a particular activity will take place with high reliability. Some examples of these interventions are protocols for mobility, enteral nutrition, weaning the ventilator, and pain and anxiety management; education of all caregivers on key principles of VAP prevention; changes in the equipment used and the process for caring for this equipment and the patient receiving mechanical ventilation. Multiple environmental reminders were used to insure that each patient, each day, receives interventions to prevent VAP.



Within several months, each ICU was at an internal benchmark of "green light" status on each of the identified process measures targeted at the preventing VAP. Green light status is attained when 95% of the time each patient has every intervention. Each ICU now has gone over 60 days without a VAP, the longest has been 314 days, and one unit currently has had no VAP for the entire year of 2004.


Conclusions and Nursing Implications

Systematic implementation of independent redundancies in a clinical arena can ensure significant clinical performance improvement. These system improvements have added evidence to the notion that VAP is a nurse-sensitive outcome and can be prevented in most patients. By implementing the interventions using a multiple redundancies strategy, a CNS can help reduce or eliminate VAP in a critical care unit, significantly improving the quality of care in the critical care unit, and potentially reducing cost and mortality.


Section Description

This year's annual NACNS conference is planned for Orlando, Fla, March 9-12, 2005. Over 300 clinical nurse specialists (CNSs) are expected to attend, and as with past conferences, attendees will also include graduate faculty from CNS programs, nurse administrators, and nurse researchers. The theme of the conference, CNS Leadership: Navigating the Healthcare Environment Toward Excellence, was selected to showcase the many ways CNSs acquire and disseminate knowledge and innovative practices in their specialty areas. Two preconference sessions are scheduled. One session, sponsored by NACNS Legislative/Regulatory Committee, targets information for CNSs interested in understanding the legislative/regulatory process as it deals with the practice of nursing, and will also help build skills CNSs need to engage in the process. The second session, sponsored by NACNS Education Committee, focuses on CNS education issues, and as with the education preconferences of past years, anticipates informative dialogue and much sharing among CNS educators around curriculum design, teaching strategies, and indicators of quality in the curriculum that link to the NACNS education standards to program review and excellence. The conference planning committee is proud and pleased to have Jeanette Ives Erickson, MS, RN, CNA, Senior Vice President for Patient Care Services and Chief Nurse Executive of Massachusetts General Hospital as the opening keynote speaker. She will begin the conference by highlighting the importance of CNS practice on patient safety. The planning committee is equally proud and pleased to have NACNS past-president Rhonda Scott, PhD, RN, Chief Nursing Officer of Grady Health System as the closing speaker. Dr Scott will challenge attendees to use the information from the conference to shape quality care delivered in a safe environment and to advance the profession of nursing through direct care to clients, influencing standards of care delivered by other nurses, and influencing the healthcare delivery system to be to support innovative, cost-effective, quality nursing care. A total of 64 abstracts for podium and poster presentations were selected in addition to graduate student posters. The abstracts address the 3 spheres of CNS practice with a strong emphasis on clinical practice improvements. As you will note from the abstracts published in this issue of the journal, specialty practice areas represented in the abstracts include children, adults, and gerontological patient groups; hospital, outpatient, and home care settings, and community health. In addition, a wide variety of specialty topics including smoking cessation programs, end-of-life care issues, and protocols outlining nursing approaches to improved diabetes, cardiovascular and ventilator management. A number of the abstracts described hospital and healthcare system level innovations that resulted from CNS practice. Collectively, these abstracts reflect the breadth, depth, and richness of CNS contributions to the well-being of individuals, families, groups, and communities. The following abstracts are from those presenters who elected to have their work published in the journal so those who are unable to attend this year's conference can share in the knowledge of the conference. As you read each abstract, consider the talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to improved outcomes for patients and healthcare organizations. You may want to contact individual presenters to network, collaborate, consult, or share your own ideas about these topics. Watch for next year's call for abstracts and consider submitting an abstract for presentation at NACNS's next conference in Salt Lake City, Utah, March 15-18, 2006.