Weakened by critical illness or surgical trauma, many patients in hospital intensive care units (ICUs) are unable to breathe without the aid of mechanical ventilators. These machines pump air into struggling lungs through tubes inserted into airways, giving severely stressed patients time to regain the energy and strength to breathe on their own. Though often vital and life-sustaining, ventilators can turn into a hazard for patients when the tubes delivering air also allow bacteria or secretions to enter the lungs. As many as 15 percent of ICU patients on breathing machines develop ventilator-associated pneumonia (VAP). Already debilitated by their medical conditions, patients often have little ability to fight off the added assault. The hospital mortality rate for ventilator patients who develop VAP is 46 percent, compared to 32 percent for ventilator patients who do not develop VAP.
As part of the 100,000 Lives Campaign, the Institute for Healthcare Improvement (IHI) has targeted VAPs and other problems that cause unnecessary hospital deaths. IHI-sponsored Breakthrough Series Collaboratives have provided critical evidence to support the Campaign’s six interventions.
Results from the most recent IHI Collaborative on Reducing Complications from Ventilators and Central Lines in the ICU, which ran from September 2004 to May 2005, have been especially encouraging, with some hospital teams reporting no VAPs at all for several months.
“There’s just no reason to tolerate VAPs, when they can be drastically reduced or eliminated with a few simple, low-tech procedures,” insists Collaborative participant Kerry Eaton, RN, Vice President for Patient Outcomes at St. Vincent’s Medical Center. Before Eaton implemented the procedures she learned in the Collaborative, staff at the 397-bed hospital serving greater-Bridgeport, Connecticut, and Westchester County, New York, couldn’t recall a month without a VAP. Since November 2004, St. Vincent’s medical ICU has had no VAPs, and in the surgical ICU there’s been less than one case per month. The key to eradication, says Eaton, is that “you have to use all the procedures with every patient, every time.”
In fact, the Ventilator Bundle, as the required procedures are collectively known, is effective against more than VAPs. It also protects ventilator patients from developing two other frequent complications of respiratory failure: peptic ulcers (erosion of the stomach lining) and deep vein thrombosis (blood clots in the lower limbs). When implemented as a set of interdependent steps, the Ventilator Bundle, which is based on the latest clinical evidence, substantially improves clinical outcomes for ventilator patients.
Eaton explains the protocols this way:
Patient position: While the patient is on the ventilator, the head of the bed must always be raised 30 to 45 degrees to allow the lungs to expand more easily and to discourage the pooling of secretions. “The patient’s head has to be elevated 24 hours a day,” says Eaton. “The angle can’t be lowered at night for sleeping.”
Ventilator weaning: The best way to avoid VAP is to be off the vent, says Eaton, so patients must be evaluated every day for readiness to breathe on their own. Assessment can be complex. Because breathing tubes are uncomfortable, most patients require sedatives to help their bodies accept the intrusion. However, explains Eaton, “Sedation works against breathing on your own,” so the first step in ventilator weaning is a “sedation vacation” — cutting back sedation to see how well a patient does. Depending on the results, says Eaton, the respiratory therapist may lower the ventilator settings to allow the patient to take over more breathing work or even to take the patient off the machine. “The sooner, the better,” says Eaton.
Peptic ulcer prevention: “Desperately sick people are under enormous stress,” says Eaton, “and the constant lights and noise and intrusions of the ICU just make things worse. No wonder their stomachs are churning out acid.” To prevent the formation of peptic ulcers, ventilator patients receive intravenous antacids.
Deep vein thrombosis prevention: Prolonged immobility increases the odds that blood clots will form in the lower extremities and, possibly, break off and travel to a vital organ. “So, unless contra-indicated, we give all ventilator patients a blood thinner, either intravenously or by injection,” says Eaton.
Other hospital teams that participated in the recent IHI Collaborative also report impressive results. Swedish Hospital Medical Center, the Pacific Northwest’s largest hospital, with 1,300 beds on three campuses in the greater Seattle area, used to average two or three VAPs per month in its 80-bed ICUs. Once June Altaras, RN, BSN, Swedish’s Clinical Manager of Adult ICUs, began enforcing the procedures emphasized in the Collaborative, the number of VAPs plummeted, and since October 2004 there have been none at all.
Swedish Medical Center ICU Dashboard (Providence Campus)
Altaras credits the transformation to more than clinical improvements. “There’s been a cultural improvement,” she says. “We were already doing all the things in the Ventilator Bundle, but we weren’t doing them consistently and we didn’t really connect that factor to poor outcomes. We just thought that very sick people were very vulnerable and that’s the way it was.”
In the Collaborative, says Altaras, she learned that following all the procedures at least 95 percent of the time — preferably 100 percent — could lead to zero VAPs. “I’ve been a nurse for 20 years and no one ever held up ‘zero’ bad outcomes as a goal. We were always told to compare our performance to the average. As long as we were doing as well or better than average, we were fine. It’s a whole new way of looking at our jobs.”
If Altaras needs any encouragement that her hospital’s VAP-free record can continue indefinitely, she can look to Community Hospital East in Indianapolis, which hasn’t had a VAP in its medical ICU since December 2003 and just had the first one in its coronary ICU since March 2003. Infection Control Practitioner Laurie Fish, RN, says the secret is that “we never let up.” Community Health Network, the five-hospital system parent of Community East, first began a concerted effort to reduce VAPs in 1998. Since that time, Fish says that she and other infection control specialists have scrutinized every VAP case to find the root cause and eliminate it. “If things look fine on the surface, we just dig deeper,” says Fish.
Throughout Community Health Network, the Ventilator Bundle constitutes standing orders for the care of ventilator patients. “In other words,” explains Fish, “each protocol is on a default setting. It’s followed unless a physician issues a specific order saying not to follow it.” That makes it easier for the staff to take responsibility, so they do, says Fish. “It’s not fair to expect people to always do the right thing without giving them a clear way to know what that is. Once you do, you tap into their sense of accomplishment and pride. They know they are saving lives.”
