Broadening ventilator surveillance measures improves care

Scott & White Healthcare infection prevention specialists used to debate at length whether intensive-care patients had ventilator-associated pneumonia.

There was good reason to put ventilator-associated pneumonia, or VAP, on the watch list at the Temple, Texas, hospital. The dangerous lung infection hits an estimated 1 in 11 critically ill patients on ventilators nationwide. VAP is associated with longer hospital stays, higher mortality rates and steeper healthcare costs.

Over the past decade, hospitals have focused increased attention on VAP. The Centers for Disease Control and Prevention added surveillance protocols for VAP in its National Healthcare Safety Network, an online healthcare-associated infection reporting system.

But the definition for VAP was notoriously subjective. It required, for instance, interpretation of a chest X-ray. Just getting infection-prevention staff and clinicians to agree that a patient actually had VAP was very difficult, said Bill Schreier, an infection prevention practitioner at Scott & White.

The struggle to correctly identify pneumonia cases took time away from medical staff's ability to maintain surveillance of other complications related to ventilator care, such as edema, blood clots and adverse drug reactions. Clinical experts began arguing for protocols that looked more broadly at all ventilator-related adverse events.

“Conventional VAP surveillance could take as long as 30 to 40 minutes per case,” said Dr. Michael Klompas, an infectious-disease physician and associate hospital epidemiologist at Brigham and Women's Hospital in Boston. “It was a paradox: It took an enormous amount of time to see if a patient had pneumonia, and then that determination was still subjective.”

In 2011, the CDC convened a work group to develop an easier-to-use algorithm for a broader category: ventilator-associated events, or VAEs. Hospitals across the country welcomed the new criteria as a way to more accurately measure adverse ventilator events, gauge ICU quality and improve patient care.

Schreier and his colleagues were pleased with the criteria, but unsure what changes the new VAE surveillance methods required. They were anxious to move beyond measurement and adopt new evidence-based ventilation practices.

So in June 2012, six months before the CDC's new VAE surveillance definitions were scheduled to take effect, Scott & White Healthcare joined the Texas Wake Up and Breathe Improvement Collaborative, an initiative led by the Texas Center for Quality and Patient Safety, part of the state's hospital association.

The collaborative's 19 member hospitals shared evidence-based practices for ventilated ICU patients, while also preparing to implement the CDC's new reporting protocols, said Rachel Hardegree, a respiratory therapist and the quality center's director of program management.

The two-prong initiative focuses on waking ICU patients up daily, and then testing whether they can breathe on their own. This paired, coordinated intervention has been shown to significantly reduce lengths of stay and improve outcomes for ventilated patients.

Bolstered by its work with the collaborative, Scott & White also markedly reduced the amount of sedation drugs given to its ventilated patients. Heavy sedation is not only associated with adverse events such as delirium, but makes it more difficult to wake patients and test independent breathing, Schreier said.

“Many of us were afraid that by reducing sedation, we would have patients waking up and taking their breathing tubes out,” Schreier said. “We learned from the success other hospitals had that that didn't really happen.”

Scott & White also charged a physical therapy team with getting hospital ICU patients up and walking around far sooner, another intervention linked to shorter lengths of stay and fewer complications.

Through the Wake Up and Breathe collaborative, Scott & White adjusted its data-collection processes to align with the CDC's new ventilator-associated event requirements.

Those VAE protocols and definitions, which went into effect in January 2013, use a clearly defined, tiered algorithm to identify all ventilator-associated conditions—not just VAP—and to determine whether those conditions are infection-related.

Klompas, who provided professional guidance for the Texas Wake Up and Breathe collaborative, developed a related calculator that hospitals can use to enter data—such as the percentage of oxygen a patient is inhaling—that provide specific measures for making a VAE determination. “With the new definitions, there's no room to argue about whether something is a VAE or not,” Schreier said. “It just is what it is.”

As of Feb. 1, roughly 1,500 hospitals are now voluntarily reporting VAEs to the CDC's National Healthcare Safety Network, federal officials said.

Although the new VAE definition makes it hard to compare data from before and after Scott & White's improvement efforts, Hardegree identified Scott & White as a standout among the collaborative's hospitals, and said the hospital did see fewer VAEs than it expected.

“We have been very pleased with the results of this project,” said Charlotte Wheeler, Scott & White's director of infection prevention. “It has really helped us make improvements to patient care.”

The Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, Baltimore, has invited Scott & White to participate in a federally funded project that will study and measure early adopters' VAE interventions. They plan to develop ventilator-care solutions that can be implemented at the national level.

Follow Maureen McKinney on Twitter: @MHMMcKinney