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.