Reducing Ventilator-Associated Pneumonia

Some patients go to the hospital because they have pneumonia. Other people go to the hospital for other reasons (e.g, stroke), are put on ventilators, and get pneumonia. We call this ventilator-associated pneumonia, or VAP. It is a big problem:

• It is common, with 10 to 20% of patients ventilated for two or more days;
• It is lethal, roughly doubling the risk of death;
• It is expensive, adding $20,000 to $40,000 in extra costs per case.

The good news is that it is often preventable, and we could be pretty good at preventing it if we took the right steps all the time. Our good friends at the Institute for Healthcare Improvement suggest the following "bundle" of steps to help avoid VAP:

1. Elevation of the head of the bed;
2. Daily "sedation vacation", i.e., some removal of sedation medication;
3. Daily assessment of readiness to extubate, i.e, don't keep the breathing tube in longer than necessary;
4. Stress ulcer disease prophylaxis, to reduce the risk of upper GI bleeding;
5. Deep venous thrombosis prophylaxis, to prevent formation of embolisms.

So, if you want to reduce VAP, you institute this bundle of of steps. But, like your toughest sixth grade teacher would say, "There is no partial credit!" Unless you carry out all five steps, you do not get a perfect score.
We started working hard on this problem last year at BIDMC. Why? Because we looked at our rate of this disease, and we were not pleased. Here are our compliance scores on the IHI bundle, after lots of analysis, training, and follow-up:

FY06 Q3: 79%
FY06 Q4: 81%
FY07 Q1: 88%
FY07 Q2: 92% (only includes January, through today)

This looks pretty good, right? It appears that we are making constant improvement. Not so. Unfortunately, the quarterly figures mask monthly variations:

April 06: 83%
May 06: 74%
June 06: 82%
July 06: 80%
August 06: 76%
September 06: 86%
October 06: 92%
November 06: 85%
December 06: 87%
January 07: 92%

Still, the trend is good, but the difficulty of carrying out the full bundle for all patients is real. For example, we have virtually 100% compliance with stress ulcer disease prophylaxis; but we do not always carry out a daily assessment of the readiness to extubate. On that metric, we have ranged from 88% to 98%. Sometimes, even when you know what you would like to do, the patient's condition or other exigencies make it impossible. Sometimes, even when you know what you should do, it doesn't get done -- for a variety of reasons: training, follow-up, schedules, competing demands of other patients.

Sometimes, there are unexpected reasons. At one point, we could not elevate some beds properly because other patient-related equipment was in the way! (We fixed that. And, yes, we bought contractors' protractors, the same ones used in construction to measure the angle of a pipe bend. How else will you know if the bed angle is correct?)

IHI has published stories of places with great success in this arena. Congratulations to those hospitals. We hope to be in one of those stories some day.

Why can't we do that?

A recent note from our chief operating officer to several of our clinical chiefs:

I came across the NEJM from 12/28/06 and the article and editorial on catheter-associated blood stream infections done in Michigan (my medical school alma mater!)

In that study of 108 ICU’s in Michigan, the institution of a set of evidence-based interventions reduced the median rates of infection per 1000 catheter days from 2.7 to 0 and the mean rates from 7.7 to 1.4. These impressive gains were held through 18 months of follow-up. If more than half of these ICU’s can virtually eliminate these infections, it seems that we should be able to do so as well. We had 2 months in the last year when we achieved this goal, but the last two months showed a sizable bump. Are we doing everything possible to eliminate these on a sustainable basis? What will we do differently going forward to hold the ‘zero rate’ for every month?

For the record, here are the numbers for BIDMC, updated from my posting of December 17, below.

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87

We are serious about this and, like Michigan, we will share any lessons learned with others in the medical community. Recall that we engaged in an intensive training and improvement program in this arena, and the result we want is tantalizingly within reach. Nonetheless, as noted by our COO, we are not yet "best in class," which is our goal.

Here is what we are doing for now: Every single infection is now viewed as a sentinel event, for which we conduct a root cause analysis and from which we learn how to do better. Stay tuned to see how we progress over the coming months.

What Works -- Part 5 -- Team Training

We have all heard stories of cockpit behavior in an airplane that causes a crash. The navigator or first mate says to the pilot, "Watch out for that mountain." The pilot ignores the advice, and the aircraft ends up in flames. This kind of thing can happen in a hierarchical environment.

The same kind of thing can happen in an operating room, where the surgeon is the "pilot" and the nurses and anaesthesiologists are the support crew. Doctors, like pilots, are trained to be in charge and to make split-second decisions.

A few years ago, a series of errors and bad communication in our obstetrics department resulted in the loss of a baby and almost resulted in the death of the mother. For a department that had always prided itself on providing extraordinary care, the event was a shock and caused an intense self-evaluation.

Using the experience of the military -- indeed from those cockpit situations --the Department proceeded on a full-fledged series of courses in team training.

This was not a simple seminar or two. It was a process that took many months. After all, it had to break down barriers and behaviors that had taken years to develop. Nurses had to feel comfortable offering suggestions to doctors, and doctors had to learn how to hear the nurses' comments.

Here's an article that describes the whole thing. I urge you to take the time to read it. Our OB staff would tell you that it has changed their view of practicing medicine. They would also tell you that it has created unusual bonds of collaboration and friendship in their department, even for a group that had always had a strong group ethic. Most important, the program has actually had a measurable difference in clinical results. Our folks now participate in programs across the country to spread the word.

I wish I could tell you that we have taken this experience and have infused it throughout our own hospital. We have not, at least to the extent I would like. Not that we are not trying, but it turns out that the culture of each department and each division is a bit different, even within the same hospital. So it takes longer than you might expect. What might work in OB needs to be modified to work in surgery or orthopaedics. Even within surgery, what might work for the pancreatic surgery group -- see the November 27 discussion below on Whipple procedures (What Works -- Part 2) -- might not be quite right for the transplantation group. Like other medical centers, we are still feeling our way through this issue of the diffusion of practice improvements.