Breathing Better
Problem: Pneumonia in patients who breathe with mechanical ventilators Proposal: Raise the head of the bed, stop ventilation earlier, other measures Possible lives saved: 10,000
Any person in an intensive care unit, or ICU, is very sick indeed. Many patients in medical ICU s (as distinguished from surgical ICU s, where patients spend time after an operation) are on mechanical ventilators to help them breathe, and up to 15 percent of them develop pneumonia from one of the many bugs that roam hospitals. The relationship is so strong that it has a name: VAP, for ventilator-associated pneumonia.
VAP is a killer, the No. 1 cause of death from hospital-acquired infections. The VAP death rate is 44 percent higher than it is for ventilated ICU patients who don't get pneumonia. Practices that reduce the toll have been published, but hospitals have been slow to adopt them. IHI packaged four of the measures into a "bundle" and made VAP reduction part of the 100K campaign.
At Hackensack, medical ICU nurse-manager Courtney Cook's first response to the bundle was, "Are you kidding me? We do this stuff all the time." But after thinking about it, "I realized we didn't do all of the things all of the time." The four components of the VAP-reduction program are deceptively simple:
Raise the head of the bed. Possibly it's because a patient is less likely to inhale stomach contents or mucus. Or because it helps the patient breathe more deeply. Whatever the reason, putting the head of the bed at an angle of 30 to 45 degrees cuts VAP--by nearly 80 percent in one trial.
Impose a "sedation vacation" as part of ventilator weaning. Ventilated patients are generally sedated to keep them free from pain (and so they won't try to remove the ventilator). To see if they can breathe on their own, the ventilator is removed every day and sedation lightened or halted briefly. "Right now we have three patients on ventilators out of 20 beds," reported Hackensack's Joe Capone, supervisor of the ICU's respiratory therapists, in late June. "Before, we probably would have had 12."
Medicate to prevent stomach ulcers. These anti-ulcer drugs lower stomach acidity, a particular benefit to ventilated patients because the more acidity, the worse the consequences if a nauseated patient inhales some stomach contents into the lungs.
Prevent clots in leg veins. Deep vein thrombosis, or DVT, poses a risk that a clot will travel from a vein in the leg to the lungs, heart, or brain and is more common in bedridden patients. Steps to prevent DVT, such as blood thin-ners and compression sleeves, also seem to lower the risk of VAP.
How well does this collection of measures work? The last case of VAP at McLeod, says Mark Williams, nursing director of the medical ICU, was logged on July 26, 2004.
This story appears in the July 18, 2005 print edition of U.S. News & World Report.
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