ICU cuts hospital-acquired pneumonia by 43%

Kinetic therapy, early nutrition key to improvement

When Cheryl McKay, RN, MSN, CNS, took over as the trauma coordinator at Western Medical Center in Santa Ana, CA, she found good practice patterns with few variances and appropriate care in high-volume, high-cost procedures — not much room for quality improvement. But then she discovered a hospital-acquired pneumonia (HAP) rate that seemed a little high.

After doing some benchmarking, she discovered that Western’s HAP rate was indeed high — consistently 10% to 15% higher than the 12.7% median rate for a medical-surgical ICU established by the National Nosocomial Infection Surveillance Report from the Centers for Disease Control and Prevention in Atlanta.

A little more research revealed that most of the cases were trauma (33%) and neurosurgical (48%) patients and that aggressive treatment usually came after the patients had already contracted pneumonia. "We knew that we could do better," McKay says. "We decided that we were going to be very aggressive and do things in terms of earlier intervention."

A multidisciplinary team was formed to study the issue and recommend practice pattern changes. The team hoped to reduce the HAP rate as well as cut length of stay in the ICU and number of days on a ventilator. What team members didn’t expect was that their improvements would also enhance patients’ nutrition, make more cost-effective use of specialty beds, and improve communication among physicians, nurses, and respiratory therapists. In fact, all of those things happened, she says.

These results were achieved:

- 43% overall reduction in HAP in the ICU.

- 100% of patients placed on kinetic therapy, one of the new practice patterns, for pneumonia prevention did not develop HAP.

- 75% of patients placed on kinetic therapy showed improvement in pulmonary status within 48 hours.

- Ventilator days decreased by 20%.

- ICU length of stay decreased by one day.

- HAP median rate decreased to 9.2% in the second quarter of 1998.

How did the team do it? For starters, the improvement team discovered that there was no formal system in place to evaluate patients for risk factors known to contribute to HAP. Physicians lacked a standardized approach to identification and treatment, and nurses and respiratory therapists were unaware of the practice patterns that led to increased rates of HAP in high-risk patients. To correct those problems, educational sessions were held for nurses and therapists on appropriate hand washing, suctioning, assessment techniques, and circuit changes, as well as the modes of transmission and pathogenesis of the most common bacteria causing HAP.

Also, the team chose the patient identification for rotational therapy (PIRT) tool that was developed from the APACHE II patient classification scoring system to identify patients at high risk for pneumonia. A respiratory therapist uses the PIRT tool, which measures 14 variables relating to pulmonary status, to evaluate patients within 24 hours of the time they come into the unit intubated. The tool provides quantifiable data that help physicians and nurses make decisions, McKay says.

Within 48 hours, patients who score between 20 and 30 on the PIRT scale are placed on kinetic therapy, which involves a special bed that rotates the patient at a minimum of 40 degrees to either side for at least 18 hours a day. The movement redistributes pulmonary blood flow and improves mucous transport to help prevent and treat pulmonary complications in immobile patients. "We’ve always known in nursing since Florence Nightingale that we need to turn the patients, that they need to move," she says. "And we’ve proven here that it works."

Patients identified as high-risk also start nutritional therapy within 48 hours, and long-term ventilated patients have a tracheostomy and peg inserted by day seven. Patients are scored using the PIRT tool every 48 hours, and kinetic therapy is automatically stopped after five days unless a physician orders continued treatment.

One by-product of the quality improvement project has been useful discussion on ethical treatment at the end of life. "A lot of patients change their trajectory of illness," she says. "Let’s say a trauma patient ends up with multisystem failure and all of the sudden his PIRT score is over 30. Now you’re talking do-not-resuscitate status instead of when the patient will recover. When patients reach 30 on the PIRT tool, we really look at quality-of-life issues."

While many providers don’t consider nutrition or kinetic therapy to be treatments, many families do. That’s why it helps to have a well-articulated policy on withdrawing treatment and an ethics committee to deal with conflicts, she says.

"We feel much better about these patients going into the unit, knowing that they’re not going to come out with a complication that we inflicted," McKay says.

For more information on this project, connect to the Best Practice Network Web site at best4health.org. A complete report is available under the best practices section.