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Vent team effort drives rates, costs to bottom line

Vent team effort drives rates, costs to bottom line

Family conferencing aspect well-received

A multidisciplinary effort to reduce ventilator-associated pneumonia has resulted in sharply reduced infection rates and $1 million in projected cost savings over three years in a medical-surgical intensive care unit, reports Marjorie O’Connor, RN, infection control practitioner at Dominican Hospital in Santa Cruz, CA.

"I’ve been doing infection control for 20 years, and I know that we are not a revenue-generating department," she tells Hospital Infection Control. "The idea that you could save [by preventing] an infection is sort of an abstract thought. I always felt that there was value in that, but I didn’t know how to show it."

As a key member of the process improvement team charged with reducing ventilator-associated pneumonias in the 16-bed ICU, O’Connor saw both costs and infection rates fall sharply as series of interventions were introduced over a four-year period. "When I had over 1,100 patients in the database for the four years that we were doing this [performance improvement program], I separated out the patients that developed ventilator-associated pneumonia vs. those that didn’t," she says. "There were definite, big differences in the number of days on the ventilator, the number of days in the hospital, and the number of days in the ICU."

Infection rate dropped fivefold

Those differences translated to roughly $71,000 in additional costs per ventilator-associated pneumonia patient when all factors were considered. (See chart, p. 82.) Overall, the infection rate dropped more than fivefold over the period, going from 17.5 per 1,000 ventilator days in 1996 to 3.1 per 1,000 vent days in 1999. The sharp reduction in infections led to substantial cost savings because O’Connor found, for example, that patients that developed vent-associated pneumonia stay some three weeks longer in the hospital than those who did not acquire the infection.

"I was really surprised at the cost savings," she says. "It was very substantial. But that does include all costs. We looked at the total hospital cost — not charges but actual costs. That includes everything: room charges, medication charges, radiology studies, laboratory [work]."

The program began in 1996 when O’Connor implemented surveillance measures using device-day denominators in the ICU. In doing so, she found that the vent-associated pneumonia rate was significantly higher than the 11.5 mean rate in the Centers for Disease Control and Prevention’s National Nosocomial Infections Surveillance system. The facility formed a multidisciplinary process improvement team to develop and implement strategies to reduce the rates. In 1997, heat moisture exchange was introduced to reduce moisture and possible aspiration from the ventilator circuit tubing. "We put heat-moisture exchange circuits on the ventilator tubing, and that had a dramatic [effect]," she says. "Our vent-associated rate fell something like 60% just based on that."

The team also extended ventilator-tubing changes because frequent handling of the tubing has been linked with aspiration of moisture into patients’ lungs. "Like we’ve learned with a lot of the other procedures, the less you manipulate, the better off you are," she says. Other aspects of the ongoing effort include instituting new sedation and ventilator weaning protocols, performing naso-jejunostomy feedings, elevating the head of the bed to minimize aspiration, and conducting family conferences. The latter has proven to be one of the more novel aspects of the program, as clinicians hold regular family conferences to review the status of ventilated patients with relatives. A form was developed to address various aspects of the patient’s condition as well as the family’s concerns and expectations. (See form, p. 81.)

"Our plan — and it was kind of an aggressive plan — was to hold a family conference on the fourth ventilator day," she says. "We have had some patients who have actually been able to participate, but usually it is [just] a family conference. We get as many of the physicians and caregivers as we can present who can discuss where the patient is and what they think will happen."

While increasing communication across the board, the meeting has been so well-received by families that the approach has been extended to non-ventilated patients, she adds. "We feel that we want to give the family something that they can look back on, as well as having something in the chart so there would be some continuity," she says. "Because what happens is that you have many members of the family, and one member may talk to Dr. A and get one picture and another member may talk to Dr. B and get another picture. There is a lot of confusion as to what is really going on with their loved one."