Reducing Risk of Ventilator Associated Events During Ventilated Transports

Abstract

Background: Ventilated transport procedure changes and increased infection prevention has reduced the risk of Ventilator Associated Events from occurring during transport. Ventilator Associated Events (VAE) cost an estimated 48,000.00 per event, according to the US Department of Health and Human Services. As a larger goal of reducing VAE, ventilated transports were identified as a high risk procedure due to risk of; aspiration, multiple disconnections from the ventilator and possible circuit contamination while not in use. Methods: The transport procedure was revised in collaboration with the Infection Prevention Department to include more stringent infection control procedures. Procedural steps were added to ensure airway care was performed prior to transport. This included cuff pressure management, completing above and below cuff as well as oral suctioning and confirming tube placement. Additional steps were added to ensure proper infection control of the ICU ventilator circuit while not in use. Bacterial filters or circuit caps were required on all ventilator circuits while not in use in order to reduce the risk of contamination if not sealed properly. A transport audit tool was created to evaluate transport procedure and perform corrective action in real time. Transport audits helped identify points of improvement for staff. The primary deficiencies found were in regards to the pre transport airway management. Along with real time corrective education, deficiency information was reported in staff meetings, leadership meetings and communicated to staff as points of education. Results: After revising transport procedures and staff education, transport audits showed that the number of deficiencies decreased dramatically. Transport procedures with no deficiencies increased from 33% to 75% in a 3-month period. Conclusions: The creation of an audit tool in tandem with revised ventilated transport procedures allowed for identification of points of needed improvement and staff reeducation. This has increased the awareness and quality of patient care during ventilated transport therefore reducing the risk of ventilator-assoicated events.