ADVANCE for Executive Insight 1 ADVANCE for Executive Insight

VAP
which tested the program. Zero incidence means
zero dollars spent on treatment.
The five-point program incorporates basic patient
care tasks based on the premise most VAP
occurs as a result of contamination of the lungs
from oral bacteria. And it offers tools and strategies
created by the Armstrong Institute group
to achieve reduction, such as CUSP (Comprehensive
Unit-based Safety Program) and TRiP
(Translating Research into Practice). The five
points include:
n Head of bed elevation — use of a semi-recumbent
position (≥ 30°) keeps the bacteria from
migrating into the lungs
n Spontaneous awakening and breathing trials
— daily assessment of sedation and readiness
to wean
n Oral care — at least 6 times per day to decrease
bacterial load
n Oral care with chlorhexidine — should be included
in the oral care regimen twice per day
n Subglottic suctioning endotracheal tubes (ETTs)
— use subglottic suctioning ETTs in patients
expected to be mechanically ventilated for >72
hours. “This allows care providers to suction any
pooling saliva that collects in the trachea before
it reaches the lungs,” Berenholtz explained.
“Actually, the ventilator bundle from which VAP
reduction occurred wasn’t developed to reduce
VAP as much as it was to reduce complications in
patients with mechanical ventilation,” Berenholtz
said. “But we saw that by initiating interventions in
the bundle, it reduced VAP incidence.”
WEIGHING COSTS
The cost of eliminating VAP depends on the region.
But what is the cost of equipment and staff
training for these five interventions?
From Berenholtz’s experience the training required
is minimal and is typically done by existing
nurse educators or infection control personnel.
And since oral care has become a standard
of care per most guidelines for VAP reduction,
many facilities are already doing it.
“Subglottic tubes cost around $7 versus $1
for a standard breathing tube,” Berenholtz explained.
“A few cost-effectiveness analyses suggest
the extra cost of the subglottic tube is more
than paid for by reductions in VAP, antibiotics
and ICU length of stay.”
Bed turnover is critical to the bottom line.
VAP is defined as
pneumonia that
occurs more than
48 hours after a
patient has been
intubated and has
been receiving
mechanical ventilation.
For every
day on a ventilator,
the risk of VAP
increases from 1
to 3 percent.
On the Web
A study by the Agency
for Healthcare Research
and Quality (AHRQ)
offers evidence that
nurse-to-patient staff
ratios has been linked
with patient outcomes.
Read more at http://
healthcare-executive-insight.advanceweb.com/
News/Daily-News-Watch/
Evidence-Based-Staffing-Helps-Eliminate-Nurse-Burnout-and-Hospital-Acquired-Infections.aspx
“Most hospitals are able to increase revenue
by turning over beds, the same as a restaurant
would tables,” Berenholtz said of the benefits of
the program. “With more open beds, the hospital
can admit additional patients and increase
their revenue.”
PROVE IT
Critical to the entire VAP reduction process is administrative
buy-in. What better way to achieve
that than to show the bottom line benefits from
adopting these research-based practices?
“Part of the challenge of these initiatives is that
administrators need to be engaged,” Berenholtz
told Executive Insight. “Often there is no traditional
way to do this. But we felt a tool that could
track ventilator rates and convert those rates into
deaths, dollars and days would help staff and administration
translate the information into the
number of preventable deaths, number of ICU
days and the cost of their performance.”
With an unrestricted educational grant from
Sage Products, Inc., Johns Hopkins Armstrong
Institute developed a free, easy-to-use equation
called the VAP Opportunity Estimator (http://
www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html).
The Estimator
helps calculate the potential number of avoidable
deaths, excess ICU days and excess costs
based on a facility’s total number of VAPs. The
tool uses published estimates of VAP case fatality,
cost per VAP and additional LOS per VAP to
get real-time figures on what VAP costs a facility.
Those figures can be applied to estimate what
potential savings can be gained by implementing
a VAP reduction program.
“Presenting the data as potentially avoidable
deaths, dollars and days rather than traditional
VAP rates makes it more meaningful for patients
and staff,” Berenholtz said. “It especially helps
staff understand how their performance and level
of care impacts patients.”
References
1. Berenholtz SM, Pham JC, Thompson DA, et al. An intervention
to reduce ventilator- associated pneumonia in the
ICU. Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
2. Tablan OC, Anderson LJ, Besser R, et al. CDC Healthcare
Infection Control Practices Advisory Committee. Guidelines
for preventing health care-associated pneumonia,
2003: Recommendations of CDC and the Healthcare Infection
Control Practices Advisory Committee. MMWR
Recomm Rep. 2004 Mar 26;53(RR-3):1-36.
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