While shopping at a craft store, Jacqueline Juele-Schuster, was not thinking about how to prevent ventilator-associated pneumonia (VAP) for her patients at Coler-Goldwater Specialty Hospital and Nursing Facility. But, when she saw rolls of different colored tape, she suddenly realized she may have found an unlikely tool to improve patient safety.
"Patients who are on respirators need to have their heads elevated 30° to 45° above their stomachs to prevent them from aspirating or vomiting, which can cause VAP," according to Juele-Schuster, Nurse Practitioner at the hospital. "When I saw the green tape I thought I could use it to mark the proper angle of the head of the bed elevation to allow staff to instantly spot potential problems and prevent infections."
The use of green tape has now become an effective self-monitoring tool for clinical staff at Coler-Goldwater who use it as a visual reminder to keep proper bed elevation for ventilator patients who are at high risk of VAP. Coler-Goldwater's VAP infection rate in the last quarter of 2008 has dropped 63% to 0.9 infections per 1,000 ventilator days from 2.4 in 2006.
The green tape is affixed to the bed frame to clearly mark the location where the adjustable frame must be positioned to achieve the correct angle for patient safety and comfort. The green tape marking became known as the unit's "VAP Buster" and was adopted in all the other ventilator units in the hospital. But, why green? "Because green is a positive color and for many people it means ‘go,'" added Juele-Schuster.
Reducing VAP rates has been a major focus of HHC's patient safety program. By consistently observing a set of evidence-based procedures for preventing VAP infections, rates for ICU patients in HHC hospitals have reduced by 90%. (See the separate story Public Hospital ICUs See Big Drop in Infection Rates.)
"The idea is simple, ingenuous and resourceful," said Claude Ritman, Executive Director of Coler-Goldwater. "She found a common item and used it to resolve a life-threatening dilemma. It reminded me of MacGyver," he says, referring to the popular TV hero, famous for solving dire problems using every-day items.
"I'm no MacGyver," said Juele-Schuster, "but it was nice to find an inexpensive solution that works."
For her commitment to patient safety -- and her ingenuity -- Juele-Schuster was recognized by HHC as a 2009 Patient Safety Champion and was honored by HHC President Alan Aviles at an awards ceremony to recognize individuals and teams throughout HHC that have served as change agents for patient safety.
March 2009
