Many clinicians and hospital administrators today are anxiously awaiting enactment of CMS "Never Event" regulations governing VAP before they begin planning and incorporating new VAP prevention programs within their facilities. Uneasiness about policy changes that could challenge familiar and long-standing practices can often be a barrier to change, even when it’s evident that change is necessary.

But for Michael Hewitt, RRT-NPS, FAARC, FCCM, director of respiratory, pulmonary, sleep and neurology at Peninsula Regional Medical Center in Salisbury, MD, potential CMS rulings were not a factor back in 2006 when he decided to implement VAP Prevention "Best Practices" within his ICU.

At that time, Hewitt was serving as director of respiratory care and pulmonary diagnostics at a large trauma center in the Southwest U.S. when he became concerned about the rising number of VAP cases and bounce backs to his facility’s intensive care units. Knowing that reducing VAP rates was not only possible, but obligatory, Hewitt took a proactive stance by aggressively augmenting the VAP prevention bundle program recommended by many healthcare organizations such as the CDC, AACN, APIC and others that his facility already had in place.

To ward off VAP before conditions worsened, Hewitt and his respiratory staff began treating vented patients as if they were all at-risk for acquiring VAP. By increasing sigh breathing and vibratory therapy, his ultimate goal was to wean and keep his patients off their ventilators as quickly as possible.

But for those patients required to maintain mechanical ventilation, Hewitt was faced with overcoming the challenge of transforming an organizational culture identified by individualized and sometimes conflicting routines deep-rooted in traditional practices and personal habits. Fortunately, Hewitt was able to obtain support to move forward with his approach from top management, and by his team leading through example, a cultural transformation within the organization began to occur as old habits and behaviors began to be replaced by VAP Prevention "best practices".

Hewitt knew patients depended upon a collaborative sense of consistency and accountability shared among each caregiver responsible for providing patient care, and only through integrating standard VAP preventative "best practices" within their daily routines, would VAP rates began to decrease. From increasing personal hand-washing frequency, to conducting early VAP diagnosis, to providing consistent comprehensive oral care among patients, each caregiver was responsible for tracking and monitoring these and other VAP preventative measures, ensuring protocol standards were met and adhered.

To decrease the opportunity for infection, cross-contamination and alveolar derecruitment, Hewitt stresses the importance of using closed suction catheter systems when clearing a patient’s airway. In addition, early and consistent diagnosis of VAP for nonbronchoscopic bronchoalveolar lavage is an underutilized, but major tool in the fight against VAP. A procedure that can be conducted by trained respiratory therapists, the catheter extends deeper into the lungs for a sample that can help determine if any specific organism is present, allowing for more accurate antibiotic coverage. Along with other VAP preventative measures, an aggressive and comprehensive oral care program must be in place, to prevent the aspiration of oropharangeal pathogens into the lungs.

The results on patient outcomes were significant. Bounce back rates to the ICU were decreased from 3-4 percent to almost zero; length of stay, cost of care, and overall mortality rates were all decreased. In fact, during the 18-month period since he and his staff took a proactive stance against VAP, rates were reduced by 48 percent.

Since recently becoming the director of respiratory, pulmonary and neurology at Peninsula Regional Medical Center, Hewitt is enthused about the successes he and his staff have already experienced by implementing many of the "lessons learned" he gained while at Memorial Hermann.

Revealing a passion and sense of responsibility for his patient’s well-being, Hewitt emphasized the most important improvement a caregiver can make in the prevention of VAP, is frequent hand washing. Although a simple task, Hewitt acknowledges that washing ones hands both before and after every patient contact is not always easy to remember, but incorporating this personal habit is a vital practice all caregivers and hospital staff must strive to achieve.