In January 2005, the Institute for Healthcare Improvement (IHI) launched an ambitious campaign aimed at preventing unnecessary patient deaths and improving U.S. healthcare. Since then, IHI estimates that more than 122,300 lives have been saved.
Known as the “100,000 Lives Campaign,” the movement encourages hospitals to use evidence-based clinical interventions with the goal of preventing 100,000 avoidable deaths by June 2006. These interventions focus on six areas, one that includes the prevention of ventilator-associated pneumonia (VAP).
According to the IHI Web site, VAP occurs in up to 15% of patients receiving mechanical ventilation, making it a relatively common problem. Although data vary on how many fatalities result directly from VAP, it is widely agreed that those patients who are the sickest and using mechanical ventilators the longest run the greatest risk of dying from VAP or its related complications.
“If someone is on the ventilator one day, their risk is relatively low, but for each additional day they’re on the ventilator there’s a small increasing percentage that they will develop pneumonia,” says Greg Martin, MD, a pulmonary and critical care specialist at Atlanta’s Grady Memorial and Crawford Long hospitals. For the sickest patients who are on the respirator longest (for days or even weeks), the risk can add up quickly and become “quite substantial,” says Dr. Martin.
This risk is why IHI has encouraged hospitals to use what is known as a “ventilator bundle” to reduce the incidence of VAP in all mechanically ventilated patients unless the bundle is contraindicated. The ventilator bundle includes four components. The first two seek to prevent VAP, and the latter two seek to prevent VAP-related complications through prophylaxis of peptic ulcer disease (PUD) and deep vein thrombosis (DVT), unless contraindicated.
The first preventative component calls for elevating the head of the patient’s bed to 30 to 45 degrees, thereby reducing aspiration of gastric secretions. “If you look at all the interventions, it’s probably the most effective and simplest of them all—and costs nearly nothing,” says Dr. Martin.
Not quite as simple but proven effective, the IHI’s second component calls for sedation vacations; that is, interrupting or reducing the amount of sedation patients receive each day so they can be evaluated daily for extubation. Dr. Martin says studies show that sedation vacations allow many patients to come off the respirator more quickly and spend less time in the ICU, thereby saving money, time, and lives.
Vicki Spuhler, nurse manager of the respiratory ICU at Latter Day Saints Hospital, part of Intermountain Healthcare in Salt Lake City, says, “When the bundle is consistently applied, we consistently see a significant drop in VAP. Each element is important. But it’s the bundling and consistent, reliable application of the elements that make it effective.”
Joe McCannon, “100,000 Lives Campaign” manager, says several of the more than 3,100 participating hospitals have gone six months (some a year) with no reports of VAP.
“What that kind of result says to hospitals around the country is there are no more excuses,” explains McCannon. “You can’t say because of the type of facility we are, because of the type of resources we have, we can’t make this change.”
If using the ventilator bundle is proving effective, why is the bundle not used more often? “People don’t do it (use the bundle) for whole host of reasons,” says John P. Kress, MD, director of pulmonary and critical care procedure service at the University of Chicago’s Department of Medicine. “Those reasons run the spectrum from lack of awareness of the literature to skepticism about the quality of the studies to skepticism about the widespread applicability.”
Yet, these healthcare providers may want to carefully consider why they’re not using the ventilator bundle—or at least parts of it, he says. Sometimes hospitals aren’t in the position to apply all of the components; they’re not practical. But if that’s the case, institutions or individuals who claim there are difficulties may very well want to look long and hard at those problems. “They should think about ways to change the landscape so they can apply these things,” says Dr. Kress. “We need to take the evidence we have and apply it in a careful, thoughtful way to individual patients, and see what happens, and then respond in a careful way. You can’t blindly follow a protocol. You have to modify the individual protocol depending on the circumstances. A protocol is not a mindless cookbook. It’s a starting point, a launch pad.” TH
Robin Tricoles is managing editor of the Journal of Hospital Medicine.