Cardiac Intensive Care Unit reaches rare milestone

In April, the Cardiac Intensive Care Unit (CICU) at UNC Hospitals reached a rare milestone: going four years without a single case of ventilator-associated pneumonia (VAP). The achievement, unheard of among CICUs nationwide, is the result of teamwork, dedication, and passion for safe patient care.

Cardiac Intensive Care Unit reaches rare milestone click to enlarge Five of the more than 50 nurses who make the VAP streak possible: (from L-R) Cristie Dangerfield, Sue Copeland-Upchurch, Kisa Wilson, Tabitha Linville, and Kim Mears.

by Zach Read - zread@unch.unc.edu

Great improvement often requires significant cost--not so with the CICU at UNC Hospitals. Rather, the CICU’s tremendous strides in reducing VAP can be traced to embracing new thinking.

Several years ago, in response to the problems caused by VAP, the CICU made a push to reduce infections by implementing recommendations from the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign.

“It didn’t take a lot of fancy equipment, additional supplies, or anything like that,” says Jacci Harden, director of the Heart & Vascular Center. “It took a change in culture and the adoption of this new way of taking care of our patients.”

The IHI’s series of interdependent, scientifically grounded steps for improving patient care called for oral care every four hours, head elevation at 30 degrees, and spontaneous breathing trials, among other critical points of emphasis.

In addition to incorporating IHI guidelines, the CICU instituted a system of auditing that ensured that each point of care was being done on time, and that if any steps were missed, then physicians, residents, and nurses would be educated on the importance of sticking to the routine.

Cristie Dangerfield, RN, BSN, has worked closely with CICU nurses since the implementation of the guidelines.

“It’s pretty simple,” says Dangerfield. “We’ve followed the literature on the evidence-based practice that was available. That’s how we started six years ago and how we’ve gotten better since. We held each other accountable, and as the days ticked by, everyone got very excited and recognized the importance of it.”

The widespread use of mechanical ventilation to support the critically ill puts patients at a particularly high risk for developing healthcare-associated pneumonia, usually called ventilator-associated pneumonia (VAP).

Such infections can have serious consequences for patients, leading to death in some cases and extending hospital stays in others. From the perspective of the provider—and of the CICU at UNC Hospitals—VAP keeps patients stuck in the intensive care unit when they could be preparing for the next phase of their treatment or recovery.

For the CICU, the no-VAP streak comes on the heels of a two-year streak without a VAP, meaning the unit has only had one VAP in the past six-plus years. CICU nurses, in particular, are very proud of the achievement. They’ve embraced the components that have led to the success and have committed themselves to safe patient care.

“They’re passionate about what they’re auditing and what they’re seeing in bedside practice,” says Tracey Blevins, interim nurse manager of the CICU and coordinator of the Chest Pain Center. “They mentor and teach on the spot when something isn't done properly. Their passion leads them to have strong conversations with somebody who doesn’t see quality as important. It really is amazing to watch. It’s infectious, in a good way.”

Dangerfield also emphasizes the importance of getting complete buy-in to the goals set more than six years ago. The buy-in begins with finding the right people to work in the CICU.

“The type of nurses we look for are people who are very much family- and patient-centered-care-oriented, and that has a lot to do with it,” says Dangerfield. “Because if that’s important to you, this effort will be important to you, and those quality and infection risk issues will be important to you.”

According to Blevins, it takes a special type of person to work in the CICU--and in any ICU throughout the hospital.

“The person has to be extremely dynamic to survive in an ICU setting because of the intense world that it is,” said Blevins. “We not only have lots of patients, but we have high acuity and a lot of patient movement. We stabilize patients, those patients leave, and we get sicker patients. So there are a lot of dynamics that go on in an ICU environment, and you have to find really good people who can do that every day. It’s tough, but I think we’ve done really well building our CICU team.”

Leadership in the Heart & Vascular Center—and throughout the hospital—has been especially proud of the total commitment they’ve seen from every care provider who enters the CICU.

“It’s such a collaborative effort among the nursing staff, the physicians, the respiratory therapists, and epidemiology,” says Harden. “Without that collaboration and teamwork, there's no way success of this magnitude happens.”

William Rutala, PhD, director of hospital epidemiology, attended the four-year, no-VAP celebration held in the spring.

“The Cardiac Intensive Care Unit has reached the pinnacle of preventing VAP,” said Rutala. “….This is a remarkable achievement that is unequaled in the health care literature. The staff in the CICU is congratulated on its exceptionally safe patient care.”

To many, such an achievement seemed unlikely, even unattainable. Harden recalls the thinking at the time the unit began its effort to reduce VAP.

“I can remember at the beginning people saying that it’s not possible to eliminate VAP,” says Harden. “When the IHI first came out with its campaign, there were folks that thought it was a long shot. There was ‘no way you’d eliminate VAP,’ they said. ‘No way you’d eliminate central line infections. No way you’d eliminate catheter-associated UTIs’….But now that we’ve accomplished this, there’s no one who can tell me that there’s no way you can eliminate these infections, because I know otherwise.”

Harden believes that the achievement can have an impact throughout the hospital.

“The CICU has inspired me as a leader—inspired all of us as leaders—that you absolutely can eliminate infections,” she says.  “You can accomplish things you think you can’t just by doing what the CICU is doing every day.”