Thursday, January 25, 2007

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.


Anonymous said...

Wow, that is an eye opener to the non clinical readers of your blog.

Note to self to make a list of these kind of things so when I get hospitalized I can do my own self checks...

Anonymous said...

As a non-MD, I feel the same way!

Unfortunately, in this case you are just as likely to be unconcious -- and of, course, you couldn't talk with a tube down your throat anyway; but it is a good thing for your relatives to know, so they can inquire of the nurses and doctors. The most important part of being a patient in a hospital is to have a good advocate (friend, relative) who accompanies you.

Anonymous said...


You should be congratulated for your leadership in both reducing infection rates, VAP rates and providing transparency about your results and progress. Hopefully, other hospital CEO's will emulate your efforts if they are not already doing so. My question relates to the impact on your financial results. To the extent that you are successful in reducing infection rates and improving patient safety and outcomes, does your revenue decline more than your incurred costs given the high fixed cost nature of the hospital business model? Or, are insurers negotiating case rate or per diem payments that already incorporate infection rates lower than what BIDMC (and other hospitals) are actually experiencing? At the very least, best in class or well above average performance on these metrics is likely to be rewarded with more patients. It would be helpful if those patients are profitable and your occupancy rate can be sustained at a satisfactory level.

Anonymous said...


Terrific blog and kudos to you and others like Donald M. Berwick who are working these issues.

It is refreshing to see leadership at a hospital willing to engage on the issue of performance metrics and to talk about it openly both within the "safe" environs of the clinical setting and to the "outside world". As a non-physician who works with medical professionals dedicated to alleviating human suffering I am sometimes surprised at the reluctance of those professionals to accept critical (constructive) review from non-physicians.

This experience leads me to ponder two questions: 1) would your blog, and its candid public engagement on issues that some might feel are the exclusive province of physicians, ever be written by a physician CEO, and 2) do you find any discomfort arising within your institution as you publicly engage on these issues?

Anonymous said...

Dear BC,

I don't think we lose money by avoiding complications, especially where the complications are the result of our own treatment. In fact, we save money.

Dear Anon,
(1) Dunno.
(2) Actually, people here seem pretty excited by this kind of public disclosure in that it (1) validates their efforts, (2) reinforces a culture of safety, disclosure, and improvement rather than blame, and (3) makes them proud to be part of an institution where this is at the forefront. I am sure, knowing this place very well, that anyone who objected would be sure to tell me!! (We do not have shy people here.)

Anonymous said...

Mr. Levy has no basis for self-flagellation on the point about quarterly results masking month-to-month variations. If you graph the data he provided, the success at BIDMC is even more stunning.

Mr. Levy thinks and acts as though he lived in a perfectly rational world. I only hope that CEO Levy reaps the rewards of both that world and this one.

Anonymous said...

Don't worry, Mr. B. I have no illusions about rationality!

(Thanks for writing.)

Anonymous said...

I have another point to add about VAP. I think that patients are sometimes intubated too readily, and that if we avoided intubating people who do not really need it we could save a lot of money and possibly some lives as well.

As a neurologist, I am thinking of the stroke patient population, who often look to an ED doc as if they need intubation, but almost always do not. The part of the brain that controls breathing is in such a place that if it is damaged on both sides of the brain so that you need a ventilator, there is not much chance you are ever going to recover anyway.

As you might imagine, this is not a popular point of view with ED docs and ICU attendings, who feel they should intubate everyone who breathes irregularly. They have a point, because often they are not in a position to determine which ones have a neurological problem that does not require intubation, so they intubate everyone. But this creates problems for neurologists because once they intubate the patient, they also load them with drugs to sedate the patient, so that we also cannot get an accurate neurological exam.

I am not sure that there is a real solution for this problem, other than sensitizing the ED and ICU docs to being a bit slower in rushing to intubate neuro cases…

Anonymous said...

Wow, what a fascinating and difficult dilemna. It sounds like good communication between doctors at that moment is the key, something that can be hard in the rushed environment of the emergency room. I'd welcome observations from other doctors about this.

Anonymous said...

Anonymous -

Let me start off by saying that I definitely agree with you that this is a complicated problem and that many patients are intubated who might be safely managed without intubation. However, I might also suggest that there are other factors in play.

It turns out that (as a practicing ICU doc with lots of ER buddies) many of my colleagues and I would actually like to intubate FEWER of these patients … but many of us feel constrained by the neurology professional societies’ recommendations. For example, the American Stroke Association’s Guidelines say:
(1)“[U]rgent management of patients with acute ischemic stroke should begin with the assessment and treatment of the airway …”

(2)“Maintaining adequate tissue oxygenation is of great importance during periods of acute cerebral ischemia in order to prevent hypoxia and potential worsening of the neurological injury…. Patients with a decreased level of consciousness or brain stem stroke have an increased risk of airway compromise…”

(3) And the ASA summarizes it like this: “Recommendations: There is general agreement to strongly recommend airway support and ventilatory assistance in the treatment of patients with acute stroke who have depressed levels of consciousness or airway compromise.”

In my practice, the vast majority of stroke patients in the ICU have either altered mental status or apparent trouble with their airway (or both) – otherwise they would be in a different unit. So, the American Stroke Association’s recommendations would clearly apply to them. My own bias turns out to be the same as yours – it seems likely that many of these patients might be managed without intubation. Still, it’s just my opinion … at least to my knowledge there are no definitive trials on the subject.

So … even though we might doubt the correctness of the recommendation, many of us feel uncomfortable not intubating stroke patients with tenuous respiratory status, since the national neurology organization specializing in stroke comes down “strongly recommending” intubation and ventilation in the types of stroke patients who tend to wind up in our ICUs.

- michael

Amy said...

The "self-flagellation" comment only confuses me, where your article made sense to me, so I think a more detailed explanation of the point made would be beneficial??

Anonymous said...

Frankly, I didn't understand the self-flagellation point either. For my part, I was just suggesting that the progress has not been monotonic in direction, i.e, there are some monthly up's and down's. Maybe the observer thought I was being too hard on us.

Richwlf said...

Neurologists are understandably concerned about unnecessary airway management in stroke victims for the reasons mentioned. However, they usually are involved only after other causes have been excluded and the patient is proven to be stable. Hindsight is 20/20 but not a luxury available when the decision for airway management needs to be reached on patients with altered mental status and focal findings – in the minutes following presentation to the emergency department. A patient suffering from a stroke can be very difficult to distinguish from intracerebral bleeding and other “non stroke” disorders. With only one point on the curve to make a call on patient stability, not taking control of the airway can be disastrous for a good number of patients. Protecting the airway is reversible, holding off in these other patients can result in permanent neurologic damage or death. Non stroke patients with these presentations may need protection from pulmonary aspiration while undergoing CT scan as their neurologic deterioration continues to progress. Surging intracranial pressure in patients with hemorrhage can be controlled with artificial ventilation, delaying cerebral herniation until the diagnostic studies lead to the needed surgical intervention. When airway management I truly unnecessary, it is a simple matter to withdraw it.

Anonymous said...

For those of us who are not MDs, this has been a fascinating interchange. Thanks so much!

Anonymous said...

I don't sense self-flagellation rather clear, reality thinking that even when we're good we have to strive to be better.

We can't rest on our laurels when the numbers get good.

I also like the all or nothing rule here in regards to the "bundle".

Keep up the great work BI !

Emily DeVoto, Ph.D., said...

Paul, thank you so much for starting this discussion. My question: how about your health outcomes? Are you diagnosing less VAP, or pressure ulcers?

Unknown said...

My dad checked in one of the best hospital in India for normal follow up coronary angiography on 11 May 2007 .he had a preventive open heart surgery in 2003).
They messed up big time & a clot got stuck in his basal artery .
thereafter he was put on ventilator , here he developed VAP.
Now he is really critically .
I am just worried he might get into the vicious cycle of ventilator -infection-ventilator-infection-...........
please if u may suggest some steps.

Anonymous said...

Very hard from long distance. I am so sorry. There are excellent doctors there who should be able to help.