Friday, March 16, 2007

Better grades on VAP

Good progress on implementing steps to reduce ventilator-associated pneumonia. Recall my story in January on this topic.

Our goal is to make sure we are carrying out the five-part Institute for Healthcare Improvement "bundle" to reduce the incidence of this disease. As I noted back then, if you want to reduce VAP, you institute this bundle 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. Here are the monthly stats:

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: 93%
February 07: 98%
March 07: 100% (to date)

In addition, our folks are working on instituting improved oral hygiene for these patients, another aspect of reducing the VAP problem. There we have gone from 58% (in April 06) to 91% (in March 07).

But, I want to make clear that these are process metrics. This differs from the central line infection story I have mentioned elsewhere, where we measure the actual number of cases. My folks tell me that actual VAP rates themselves may not be accurate because it is the most subjective of all nosocomial infections and the most difficult to track. We are currently engaged in refining our methodology for actual VAP surveillance.

Finally, I want to point out that this effort requires a variety of specialties to work together -- several types of doctors, nurses, respiratory therapists, and pharmacists. In this case, 14 people serve in the VAP Working Group. They develop protocols, data monitoring, and training programs and then have to persuade dozens of other people to engage in the program on a sustained basis. As I have noted below, the unique environment of academic medical centers creates interesting challenges in process improvement. These folks deserve a lot of credit for what they have accomplished, but the real test will be to see if they can keep it going. Knowing the people involved, I am optimistic.


Jaz said...

Congratulations on the improvement, it must do wonders for your VAP team to see themselves lauded by the head honcho on a national blog. Kudos. I hope you haven't jinxed March... :o)

Just out of curiosity, you mention a five part bundle, and VAP isn't something we're working on here so I sniffed out the bundle at IHI, I only see four measures. Am I missing something? I don't see "readiness to extuabte" in there.

Just to be even more annoying, you already post your CLABs rate, do you plan on blogging your VAP rate once the surveillance has been duly refined?

Anonymous said...

Here are the five:
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.

Yes, if and when our folks tell me that the actual rates can be measured appropriately. I just don't know when that might be.

Anonymous said...

Dear Dr. Levy:

Glad to see improvements being made in the area of VAP.

Are efforts being made to eliminate cross contamination in spirometry equipment? What exactly is done, to prevent patient to patient, or technician to patient respiratory infection from being spread through unchanged spirometry tubing?

Does a patient have the option to request the filters on the PFT machines changed before testing? If not, why not?

As you know, it would help reduce the number of hospital aquired infections.

This is a hugh concern and I cringe at the thought of what bacteria are lurking in these machines.

Thank you.

Anonymous said...

First, I am not a doctor. That should be evident from my lack of understanding of all these issues!

Yes, the kind of maintenance and cleaning you mention is part of the program.

I don't about the patient request issue, but many of these patients are not in condition to ask themselves. I will inquire further from my folks.

BTW, if you know of highly effective programs in this arena from other hospitals, please feel free to suggest where we might look and learn.

Unknown said...


I am impressed by your honesty on this blog. It takes a very special executive to come forth with information like staff compliance rates with procedures.

I am finishing my training in periodontics at Tufts. I stumbled across your blog because I am doing a research project on dental plaque and its contributions to VAP. I'm convinced that a properly executed oral care program would have a huge impact on the rate of VAP.

It would be great to discuss some of these matters with you.

Good luck on your mission to reduce VAP! I wish you all the best.