Five hundred days.
That’s more than 16 months — an eternity in the fast-moving world of health care — but that’s at least how long it has been since an intensive-care patient at Cooley Dickinson Hospital has contracted ventilator-associated pneumonia (VAP), a serious infection that can occur in people who rely on ventilators to breathe.
“Among hospital patients, it’s the number-one cause of death,” said Dr. Daniel Barrieau, director of Respiratory Care Services at Cooley Dickinson, which marked the 500-day milestone as this issue of The Healthcare News went to press in mid-March. “Statistics say that between 15% and 20% of ventilator patients develop pneumonia — but these numbers are changing.”
And changing dramatically at some hospitals, like CDH, that have made tackling VAP a priority. According to the Centers for Disease Control’s National Healthcare Safety Network Report, Cooley Dickinson’s efforts in preventing ventilator-acquired pneumonia place the hospital in the top 10% of the nation’s medical/surgical ICUs.
“When we’re healthy, we have a mechanism that prevents bacteria in our mouths from going down into our lungs,” said Dr. Joanne Levin, medical director of Infection Prevention. “When someone is on a ventilator connecting the mouth and the lungs, there’s an opportunity for bacteria to get into the lungs and cause pneumonia.”
And when it does occur, it’s no small matter, said Barrieau, noting that, while patients on ventilators have a 32% mortality rate in the short term, that rises to 46% when pneumonia is introduced. So, in a very real way, reducing the incidence of VAP is saving lives at Cooley Dickinson.
Barrieau and others characterize the effort a culture shift that started in 2005 when team of respiratory therapists, physicians, nurses, quality-improvement staff, and infection-prevention specialists adopted a set of instructions from the Institute for Healthcare Improvement known as the IHI ventilator bundle. The bundle offers a series of interventions determined to be the best evidence-based practices related to reducing the risk of VAP to patients.
Hospital staff, Barrieau said, took those suggestions into consideration but also developed other strategies to reduce the VAP risk to patients.
Specifically, they scrutinized existing VAP cases to identify patterns and trends. They determined that the most vulnerable patients were those on ventilators for more than 19 days, those with difficult intubations, and those who required transportation within the hospital.
The work has paid off. CDH recorded five VAP cases in 2007, but none since then. In addition to providing safer care to patients, the prevention measures saved an estimated $200,000 in 2007 — and no doubt more since then — by not having to treat pneumonia and also be simply reducing patients’ length of stay in the ICU.
“From the top, everyone in the organization is working on quality,” Levin said. “It’s a priority.”
Ventilator-acquired pneumonia can occur in patients who require mechanical ventilation. When the ventilator tube that pumps air into the lungs becomes contaminated, the tube can act as a pathway for bacteria or secretions to enter the respiratory tract, paving the way for VAP.
“Anyone who is admitted to a hospital is at risk for a hospital-acquired infection,” Levin said. “Our teamwork to eliminate VAP comes from a commitment to providing the best care for each patient. The entire organization is focused on continuously improving patient safety and decreasing hospital-acquired infections.”
“In addition to searching for the best clinical solutions to the VAP problem,” added Barrieau, we asked ourselves, ‘what can we change about our culture and our systems to improve our outcomes?’”
Those steps range from making sure patients’ heads are elevated to heating the ventilator tubing to body temperature before use; if they aren’t heated, the gas that passes through them can turn into water vapor, which is a potential breeding ground for contaminants. Doctors at CDH also use closed-suction catheters, which allow them to clean secretions from a patient’s airway while maintaining ventilation, which also cuts down on the risk of infection.
“All these things are risk-reduction strategies,” Barrieau said. “It’s not any one thing in and of itself, but all these things that reduce the risk of infection.”
In 2006, well before Cooley Dickinson’s 500-day streak began, the Institute for Healthcare Improvement named CDH a mentor hospital in three clinical areas, including VAP prevention. Since then, Barrieau and his colleagues have presented the hospital’s VAP-elimination strategies at professional conferences, and he has served on the Mass. Department of Public Health’s Healthcare Associated Infection Task Force.
Then, in December 2007, Cooley Dickinson was one of three hospitals in Massachusetts to receive the Betsy Lehman Patient Safety Award for its work to eliminate hospital-associated infections, including VAP. In October 2008, CDH was featured in the Joint Commission Journal on Quality and Patient Safety and lauded for breaking new ground in quality improvement.
Also in October, five national health care organizations released a free guide titled A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals to help hospitals prevent the six most common infections (again, including VAP) that affect about 1.7 million patients a year, at an annual cost of $4.5 to $6 billion.
Those honors are backed up with numbers, said Levin, noting that the incidence of hospital-acquired infections at CDH decreased 26% between 2007 and 2008, in procedures ranging from hysterectomies and C-sections to colon surgeries and knee and hip replacements.
And many of these efforts don’t involve high-tech solutions or a hefty price tag, but rather common sense and due diligence, said Linda Riley, Infection Prevention coordinator at CDH.
“It’s basic stuff,” she said. “We use best practices, evidence-based practices. We see how people do their jobs, and that’s how we find out what we need to fix.”
And before you know it, it’s been 500 days.