Reducing the rare event: lessons from the implementation of a ventilator bundle.

The ventilator-associated event (VAE) is a potentially avoidable complication of mechanical ventilation (MV) associated with poor outcomes. Although rare, VAEs and other nosocomial events are frequently targeted for quality improvement efforts consistent with the creed to 'do no harm'. In October 2016, VA Greater Los Angeles (GLA) was in the lowest-performing decile of VA medical centres on a composite measure of quality, owing to GLA's relatively high VAE rate. To decrease VAEs, we sought to reduce average MV duration of patients with acute respiratory failure to less than 3 days by 1 July 2017. In our first intervention (period 1), intensive care unit (ICU) attending physicians trained residents to use an existing ventilator bundle order set; in our second intervention (period 2), we updated the order set to streamline order entry and incorporate new nurse-driven and respiratory therapist (RT)-driven spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) protocols. In period 1, the proportion of eligible patients with SAT and SBT orders increased from 29.9% and 51.2% to 67.4% and 72.6%, respectively, with sustained improvements through December 2017. Mean MV duration decreased from 7.2 days at baseline to 5.5 days in period 1 and 4.7 days in period 2; statistical process control charts revealed no significant differences, but the difference between baseline and period 2 MV duration was statistically significant at p=0.049. Bedside audits showed RTs consistently performed indicated SBTs, but there were missed opportunities for SATs due to ICU staff concerns about the SAT protocol. The rarity of VAEs, small population of ventilated patients and infrequent use of sedative infusions at GLA may have decreased the opportunity to achieve staff acceptance and use of the SAT protocol. Quality improvement teams should consider frequency of targeted outcomes when planning interventions; rare events pose challenges in implementation and evaluation of change