4 VAP VAE Gap Analysis

A ttachment H: VAP/VAE Gap Analysis

VAP/VAE Gap Analysis

The purpose of this assessment is to understand current ventilator-associated pneumonia (VAP) and ventilator-associated event (VAE) prevention practices, policies, and procedures in order to identify areas of strength and opportunities to focus team actions. This assessment can be repeated over time to monitor any changes and support continued actions. Changes that might initiate a repeat of the assessment would be events like changes in the number of outcomes, such as meeting goals of lowered infections or after a significant staff turnover.

This form should be completed by the individuals from your CUSP team (or unit patient safety team) who are or will be leading VAP/VAE prevention initiatives. This should include at least the physicians/advanced practice practitioner lead(s), nurse lead(s), a respiratory therapist, and the infection preventionist assigned to the unit. This form will take approximately 60 minutes to complete.

Current Infection Prevention Practices

For each question below, select the appropriate response.

Institution of Mechanical Ventilation

Question	Yes	No	Don’t know
Does your unit consistently consider using non-invasive ventilation (e.g., BiPAP, high flow nasal cannula etc.) when appropriate to reduce the use of invasive mechanical ventilation?	O	O	O
Do you use subglottic suctioning endotracheal tubes (SGSETTs) consistently for intubations where the patient is expected to be ventilated >48-72 hours	O	O	O

During mechanical ventilation

Question	Yes	No	Don’t know
When used, are the SGSETTs set to intermittent suction?	O	O	O
Does your unit have a protocol to guide a minimal sedation strategy?	O	O	O
4a. Do you consistently minimize sedation of ventilated patients whenever possible?	O	O	O
4b. Does your unit consistently avoid benzodiazepines for sedation?	O	O	O
Is the head of bed consistently maintained between 30-45 degrees?	O	O	O
Does your unit consistently exercise or mobilize ventilated patients?	O	O	O
Does you unit consistently consider early tracheostomy in appropriate patients?	O	O	O
Does your unit consistently perform oral care with toothbrushing (without CHG) in mechanically ventilated patients?	O	O	O
Does your unit preferentially provide enteral (to the gut) as opposed to parenteral (intravenous) nutrition?	O	O	O
9a. Does your unit consistently attempt to perform post- pyloric feeding tube placement in patients with gastric feeding intolerance at high risk for aspiration		O	O
Does your unit consistently avoid changing ventilator circuits unless visibly soiled/fouled or malfunctioning or when dictated by the manufacturer?	O	O	O
Does your unit consistently use closed suctioning systems as opposed to open systems?	O	O	O
Does your unit have a low prevalence of resistant organisms?	O	O	O
12a. If you answered yes to 12, does your unit perform selective decontamination of the oropharynx and/or gut?	O	O	O
12b. If you answered yes to 12a, does your unit maintain a robust surveillance program for the development of antimicrobial resistance?	O	O	O

Discontinuing Mechanical Ventilation

Question	Yes	No	Don’t know
Does your unit use a ventilator liberation bundle?	O	O	O
Does your unit use a rounding checklist to consider if the patient is a candidate for discontinuation of mechanical ventilation?	O	O	O
14a. Are orders for a Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) consistently placed?	O	O	O
Does your unit empower nurses to perform a daily SAT in appropriate patients based on a conditional or standing order?	O	O	O
Are Respiratory Therapists empowered to perform a spontaneous breathing trial (SBT) when a patient passes a SAT using a conditional order?	O	O	O

Policies and Feedback

Question	Yes	No	Don’t know
When you have identified elevated VAP/VAE rates, do you implement standardized workflows for a member of the infection prevention team and a unit member to observe and audit VAP/VAE prevention interventions?	O	O	O
Do you have ventilator rounds at least monthly?	O	O	O
Do you systematically review each VAP/VAE to determine gaps in evidence-based practice and opportunities for improvement?	O	O	O
Does your team meet at least once a month to discuss progress towards VAP/VAE goals?	O	O	O
Does your unit receive regular reports from the infection prevention and control program on your VAP/VAE rates?	O	O	O
Does your unit receive regular reports from the infection prevention and control program on process measures related to VAP/VAE prevention?	O	O	O
With whom do you share your VAP/VAE surveillance data? Select all that apply.	Unit managers All unit nursing staff All physicians providing care to patients in the unit Respiratory Therapists None of these Don’t know
Are patient education handouts about VAP/VAE quality improvement efforts available in your unit (e.g., on paper or in EHR or another website readily available for download)?	O	O	O
Is a safety climate survey completed at least annually by individual healthcare providers on your unit?	O	O	O
In the past 30 days, has a senior leader/executive conducted patient safety rounds on the unit?	O	O	O
Has your unit experienced > 25% nursing staff turnover in the past year?	O	O	O
What is your unit’s usual registered nurse-to-patient ratio?	1:1 1:2 1:3 1:4 or greater

Self-Reported Change in HAI Rates and HAI Prevention Processes will be administered with the endline Gap Analysis. One unit lead and one infection preventionist will self-report change in HAI rates and HAI prevention processes per unit at the end of implementation.

• “Since the beginning of the implementation, have your units' HAI rates improved?"

• “Since the beginning of the implementation, have your units' HAI prevention processes improved?"

Public reporting burden for the collection of information is estimated to average 60 minutes per response, the estimated time required to complete this assessment. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-XXXX), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857.

The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.