With a mortality rate approaching 50 percent, ventilator-associated pneumonia (VAP) is one of the most dreaded infections that can strike a hospital patient. It afflicts up to 15 percent of those in intensive care units (ICUs) so weakened by illness or trauma that they need mechanical help to breathe. When the ventilator tube that pumps life-saving air into vulnerable lungs becomes contaminated, it can act as a pathway for bacteria or secretions to enter the respiratory tract, paving the way to a deadly VAP.
In February 2004, Catholic Healthcare West (CHW), a San Francisco-based system with 41 hospitals in California, Arizona, and Nevada, launched an internal Critical Care Collaborative, modeled on an earlier IHI Collaborative in which one of its hospitals — Dominican in Santa Cruz, California — had participated. With advice and support from IHI, 26 hospitals in the CHW system achieved a 55 percent system-wide reduction in VAPs in their intensive care units by July 2006. Seven hospitals have been VAP-free in their ICUs for between 16 and 27 months.
Dominican has had no VAPs in its 16-bed medical-surgical ICU since mid-October 2004. When asked the secret of success, Lee Vanderpool, Vice President in charge of Quality and Performance Improvement, Clinical Operations and Hospital Support, likes to quote business guru Jack Welch about the value of “the monotonous, maniacal drumbeat of improvement that makes you sick until it makes you better.” In hospital terms, says Vanderpool, this means never letting up on daily multidisciplinary rounds
that are, above all, interactive. “It’s the information from caregivers with varying perspectives that trigger the ‘aha’s,’ ‘oh really’s,’ and ‘well then’s’ that produce subtle but steady improvements in patient care.” For example, based on the overnight team’s report, the respiratory therapist may declare a patient ready to wean off the ventilator. This information stimulates not only the extubation order from the physician, but also the nurse’s order for a swallowing evaluation, the clinical pharmacist’s order to discontinue certain antibiotics, and the dietician’s order for a new nutrition plan.
Another element in Dominican’s success, says Vanderpool, is that the caregiver teams are led by four intensivists
— physicians who are board-certified in intensive care. “They stay current on best practices and pass along that cutting-edge knowledge informally every day and, formally, on Skills Days, when we conduct staff training,” says Vanderpool. Once a week, members of Dominican’s Performance Improvement Team — the leaders of individual improvement initiatives — meet to share ideas, and an annual Critical Care Summit recognizes exceptional efforts and individuals.
Tracy Sklar, CHW’s Vice President for Quality and Service Improvement, says that adopting the IHI collaborative learning approach
was key in reducing the system-wide VAP rate by more than half. “We took what one hospital learned during one IHI Collaborative and leveraged it across 26 hospitals in our system. We then continued the learning process and indeed found that Dominican Santa Cruz was also able to learn from sister hospitals.” In addition to providing tools and resources, CHW made sure there was organizational alignment. “Because the goal to improve care in our ICUs was a component of our strategic plan, this made achievement not just a goal for the ICU leaders and staff, but a goal for senior leadership as well and this helped focus attention and resources on this project.” Roger Resar, MD, a Senior Fellow at IHI and Assistant Professor of Medicine at the Mayo Clinic School of Medicine who worked with CHW on the project, also praises the partnership. “I’ve never seen such a focused effort from such a large organization.” Supportive management structures like CHW’s are crucial in sustaining improvement gains, says Resar.
“Quality improvement is not a project you sign up for, dedicate a certain time period to, then collect your data and you’re done. It’s a long-term commitment,” adds Sean Townsend, MD, IHI critical care faculty member, and Assistant Professor at Brown University Medical School. Building a culture that achieves and sustains improvement takes years, says Townsend: “It takes at least five years to carve the inroads that make quality of care a value inherent throughout a culture, in my estimation.” Commitment at the top, while vital, isn’t nearly enough, says Townsend. “To create a well-tiered structure that holds up over time, the QI department needs strong relationships with all its clinical partners. It takes time to make improvement a system-wide value.” Elements such as constant feedback and celebrating and rewarding improvement are also critical, but each organization finds its own path.
Following are notable examples of hospitals that have gotten cases of VAP down to zero and some of the factors that contributed to it.
Williamsburg Community Hospital, in Williamsburg, Virginia, has had no VAPs in its 12-bed ICU for the last 30 months; Norfolk General Hospital, its affiliate in the Sentara Healthcare system, based in Norfolk, has gone as long as two years without a VAP in its three ICUs.
“We audit ourselves constantly,” says William Brock, MD, Sentara’s Medical Director for Critical Care Improvement, “and once we hit zero, we didn’t just move on to something else. We still check every step, every time.” In fact, says Brock, keeping the rate down has cleared the way for looking more closely at root causes. “VAPs are so rare now that we view one as a sentinel event that we analyze in minute detail, which helps us learn even more about avoiding them. Then we pass along the lesson to our other units.”
Indeed, the push to eliminate VAPs is part of a system-wide Critical Care Initiative begun three years ago with major support from Sentara’s management, whose year-end bonuses are partly tied to the results. “Williamsburg and Norfolk were our early adopters of the new processes, but now we’ve taken our show on the road,” says Brock. He and Sarah Darwin, RN, MSN, CCRN, his partner in the Initiative, conduct monthly site visits to Sentara’s seven acute-care hospitals, participate in multidisciplinary rounds, and teleconference with medical leaders to share best practices.
Community Health Network
Two hospitals in Community Health Network, a five-hospital network headquartered in Indianapolis, Indiana, have maintained VAP-free ICUs for 32 months. Community Hospital in Anderson has had no cases of VAP in its ICU since early 2004, and 2 South Tower of Community Hospital East has mirrored this accomplishment in its ICU. Dan Kidwell, RRT, RCP, the Network Cardiopulmonary Clinical Practice Specialist who oversees the effort, mainly credits success to the dedication and skills of bedside caregivers, but adds, “We put a lot of focus on getting patients off the ventilator right from day one, rather than attending to it later.”
That factor was a key element in Kidwell’s choice of new equipment earlier this year: “Our first priority was finding the machines that were most efficient at helping us wean patients off of them.” Working with the manufacturer, Kidwell obtained new ventilators with “closed loop” technology that constantly measure a patient’s pulmonary mechanics against customized settings and step-down the ventilation automatically. “The machines practically do the weaning for us,” says Kidwell. In 2005 Community Hospital ventilator patients spent an average of just 4.3 days on the machine, as compared to a more common five to seven days nationwide, and the hospital believes the new ventilators will drive the numbers down still further.
Once a patient is placed on a ventilator, only staff with washed and gloved hands
can touch the equipment. Ventilator tubing and suction catheters are rarely replaced, which is another key to infection control, notes Kidwell. “Any time you disturb the interface between the machine and the patient, it puts the patient at risk.”
Baptist Memorial Hospital
Checking for pre-existing infections is one way the Critical Care Unit at Baptist Memorial Hospital in Columbus, Mississippi, has avoided VAPs for 23 months, says Sherry Elmore, RN, CCRN, Director for Critical Care. Intubated patients on her 18-bed unit, which includes open-heart surgery patients, get an immediate sputum culture to find out whether they’re harboring pathogens that might make them especially vulnerable, “so we can treat that infection before it leads to more trouble.”
But it’s the continuity among staff that makes the biggest difference, insists Elmore. “Our turnover is incredibly low. I only needed three replacements this year among our 46 RNs.” And promoting job satisfaction does far more than just retain workers, says Elmore; it sets up a dynamic that affects the way everyone does their work. For example, she says, “We let the nurses schedule themselves, which encourages them to take personal control and personal responsibility. At the same time, self-scheduling fosters cooperation and team spirit. Those habits and attitudes are reflected right back in patient care.”