Objective Ventilator-associated events (VAE) are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the NIH and AHRQ funded a two-state collaborative to reduce VAEs. We describe the collaborative’s impact on VAE rates in 56 ICUs. Design Longitudinal quasi-experimental study. Setting 56 intensive care units (ICUs) at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. Interventions We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multi-disciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a web-based portal. Measurements and Results ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of VAE data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean VAE rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p=0.007). During the same time period, infection-related ventilator-associated complication (IVAC) and possible and probable ventilator-associated pneumonia (PVAP) rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p=0.018, p=0.012), respectively. Conclusions A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in VAE, IVAC and PVAP. Our study is the largest to date affirming that best practices can prevent VAEs.

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Objective. To develop and field test an Implementation Assessment Tool for assessing progress of hospital Units in implementing improvements for prevention of ventilator associated pneumonia (VAP) in a two-state collaborative, including data on actions implemented by participating teams and contextual factors that may influence their efforts. Using the data collected, learn how implementation actions can be improved, and analyze effects of implementation progress on outcome measures. Design. We developed the tool as an interview protocol that included quantitative and qualitative items addressing actions on CUSP and clinical interventions, for use in guiding data collection via telephone interviews. Setting/Participants/Patients. We conducted interviews with leaders of improvement teams from Units that participated in the two-state VAP prevention initiative. Methods/Interventions. We collected data from 43 hospital Units as they implemented actions for the VAP initiative, and performed descriptive analyzes of the data with comparisons across the two states. Results. Early in the VAP prevention initiative, most Units had made only moderate progress overall in using many of the CUSP actions known to support their improvement processes. For contextual factors, a relatively small number of barriers were found to have important negative effects on implementation progress, in particular, barriers related to workload and time issues. We modified coaching provided to the participating Unit teams to reinforce training in weak spots the interviews identified. Conclusion. These assessments provided important new knowledge regarding the implementation science of quality improvement projects, for feedback during implementation and to better understand which factors most affect implementation.

Objective: The Centers for Disease Control and Prevention has called for an interdisciplinary approach to antibiotic stewardship implementation that includes front-line nurses. The literature to date has identified key factors preventing uptake by nurses: lack of education, poor communication among providers, and unit culture. Three e-learning modules were developed to address the nurses’ education regarding the roles nurses play in antibiotic stewardship, antibiotic resistance, allergy assessment, medication side effects and interactions, pharmacokinetics–pharmacodynamics, culture interpretation, specimen collection, and the antibiogram. A survey was used to assess whether nurses felt more prepared to participate after finishing the modules. Setting: Front-line staff nurses in acute care were assigned e-learning modules as part of their pharmacy’s introduction of an antibiotic stewardship program for nurses. Methods: Nurses viewed the modules and completed a survey designed to rank their usefulness and to assess their attitudes. Results: Overall, 81% of nurses felt that they should be part of the antibiotic stewardship team. After completing the modules, 72% felt more empowered to participate in stewardship discussions and an additional 23% requested more education. Also, 97% felt that the information they learned could be utilized in everyday work regardless of the new program. The most cited barriers to stewardship activities were lack of education (45%) and hospital and/or unit culture (13%). Conclusion: Education and culture need to be addressed to overcome the barriers to nurses’ involvement in antimicrobial stewardship. E-learning can provide a simple and effective first step to educate nurses, with minimal time investment.

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