February 13, 2009

ICU teams drastically reduce vent-related pneumonia rates

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Karen Adamson, R.T., and team members in Vanderbilt’s adult intensive care units are improving prevention of pneumonia in patients on mechanical ventilators. (photo by Dana Johnson)

ICU teams drastically reduce vent-related pneumonia rates

The mechanical ventilator is a lifesaver with a drawback — its breathing tube tends to circumvent respiratory tract defenses and increase the risk of lung infection. Ventilator-associated pneumonia, or VAP, is a common contributing cause of death in Intensive Care Unit patients.

Drawing on Vanderbilt's strength in clinical information technology, intensive care teams in all six adult ICUs have standardized preventive measures for their ventilator patients.

As hoped, standardization has resulted in decreased complications, most notably a sharp reduction in VAP.

In the 10 months following the October 2007 adoption of consistent preventive measures, the VAP rate across the six adult ICUs decreased 41 percent compared with the rate in the preceding nine months.

That equaled 86 fewer cases of VAP during that time. Using published data on VAP mortality and cost, Jack Starmer, M.D., assistant professor of Biomedical Informatics, calculates that those 86 fewer VAPs represent 13 fewer deaths and a cost reduction of between $1.9 and $3.5 million.

Innovation fuels the ventilator initiative.

Clinical information systems were adapted to allow ICU teams to self-monitor their performance and correct deficiencies before they occurred.

Also, periodic reports on performance and outcomes are available to support ongoing adjustment of care standards and processes.

“It's gratifying to see our people, processes and technology come together so effectively to advance our system of care,” said C. Wright Pinson, M.D., M.B.A., associate vice chancellor for Health Affairs and chief medical officer.

“As we continue to improve patient safety and clinical quality, the ventilator initiative can help serve as a model.”

With prompting from VMC leaders, medical directors and managers of the six adult ICUs adopted a ventilator care “bundle” in early 2007 that included detailed processes and schedules including:

• head of the bed elevated at least 30 degrees;
• every two hours, mouth swabbed with mouthwash;
• every four hours, suctioning to clear the throat;
• every 12 hours, teeth brushed;
• every 12 hours, physician orders a target sedation level;
• every four hours, nursing assesses patient's sedation level;
• every 24 hours, respiratory therapy assesses patient readiness for a spontaneous breathing trial; and
• preventive measures for deep vein thrombosis and gastric ulcers.

Orders and patient care documentation at VUH figure as keystrokes entered in fields within electronic records — keystrokes entered directly by doctors, nurses, respiratory therapists and others in the course of work.

From this database, programmers channeled information relevant to the ventilator bundle into a single “dashboard” screen for each adult ICU that continually updates itself, giving teams their performance status with just a glance.

With the dashboard, and with periodic reports to leaders and unit managers showing performance patterns, compliance with the bundle went from 27 percent in November 2007 to 90 percent by March 2008.

“You realize that at the end of your 12 hours you're part of an initiative that saved lives,” said Lee Parmley, M.D., J.D., professor of Anesthesiology and director of the Division of Critical Care Medicine.

“As leaders we can agree about how something should be done, but the thing I've learned is that it needs to be important to the people doing the bedside work.
“Until then, we've got nothing,” Parmley said.

This type of “closed-loop,” IT-supported team process will increasingly shape quality and safety improvements at VMC, leaders say.

The next projects will include prevention of catheter-associated urinary tract infection, blood stream infection, surgical site infection, pressure ulcers and patient falls.

The ventilator initiative was organized by Pinson; Bill Stead, M.D., associate vice chancellor for Strategy and Transformation; Larry Goldberg, CEO of Vanderbilt University Hospital; Marilyn Dubree, M.S.N., R.N., executive chief nursing officer; and other leaders.

The core team includes Starmer; Parmley; Devin Carr, R.N., M.S.N., administrative director, surgery and trauma patient care centers; Sharon Mullins, health information systems project manager; Anna Ambrose, director, Respiratory Care; Tom Talbot, M.D., M.P.H., chief hospital epidemiologist; and Debianne Peterman, Ph.D., M.S.N., director, Nursing Education and Development.