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VAP Bundle Changes

Existing VAP Bundle HOB at 30 ˚ or > (unless contraindicated) Sedation Protocol Ordered Oral Care Q4 DVT Prophylaxis PU Prophylaxis Methods to Track Compliance with Existing VAP Bundle: Weekly Audits on Unit to Monitor Compliance with the Bundle

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VAP Bundle Changes

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  1. Existing VAP Bundle HOB at 30˚ or > (unless contraindicated) Sedation Protocol Ordered Oral Care Q4 DVT Prophylaxis PU Prophylaxis Methods to Track Compliance with Existing VAP Bundle: Weekly Audits on Unit to Monitor Compliance with the Bundle Audits have not been completed consistently on all units Current Compliance with Existing VAP Bundle by Unit: CCU - 96% (N=127/132) CTICU - 100% (N=203/203) MICU - 84% (N=181/216) NSICU - 100% (N=130/130) SICU - 97% (N=173/178) New VAP Prevention Bundle HOB at 30˚or > ( unless contraindicated) Oral Care Q4 Hours Chlorhexidine Rinse Q12 Hours Sedation Protocol Ordered Sedation Holiday Documented Daily Readiness to Wean Assessed Cuff Pressure Documented BID Daily Methods to Track Compliance with New VAP Prevention Bundle: Weekly Compliance Report for Oral Care and Chlorhexidine Rinse Compares number of Oral Care Kit utilized to Total Vent Days (each vent day should utilize one oral care kit) Continue Weekly Audits on the Unit to Monitor Compliance with the entire Prevention Bundle until EDW Reports are Created Develop a VAP Prevention Bundle Compliance Report in the EDW Develop an Exception Report to identify all areas of Non-Compliance with the VAP Prevention Bundle to provide feedback to the staff VAP Bundle Changes New VAP Prevention Bundle is scheduled to Go Live on December 1st

  2. Central Line Insertion Checklist and Maintenance Requirements • Central Line Insertion Checklist • Clean hands • Wear sterile gloves during catheter insertion • Wear hat, mask and sterile gown • If present, assisting physician follows same precautions (hand hygiene, mask, gloves, gown) • All staff in room wear mask • Prep procedure site with Chlorhexidine (30 sec for dry site, 2 min for moist) • Large drape to cover patient in sterile fashion • Maintain sterile field • If appropriate, use ultrasound/sonasite • Sterile technique maintained when applying dressing • Dressing dated • Maintenance Requirements • Tubing changed every 96 hours • Dressing changed every 6 days • Lines changed within 24 hours if placed emergently or from an outside hospital

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