Using New Strategy, Lee County Hospital System Chokes Pneumonia

No ventilator-associated cases in last two years at Cape Coral
FEBRUARY 15, 2009

A few years ago, patients in a hospital intensive care unit on a ventilator could almost bet on their chances of acquiring pneumonia. They had a 20 percent to 30 percent chance of bacteria traveling down the breathing tube and lodging in the lungs, increasing their risk of death and adding extra days — and an estimated $40,000 — to their hospital stays. But increasingly, infection isn’t the case, and one local hospital has made strides against the disease.

Cape Coral Hospital last week announced it has gone two years without a case of ventilator-associated pneumonia, the result of an effort launched 41/2 years ago to use emerging scientific evidence to prevent the disease. On any given day, the hospital has seven to 10 patients on ventilators. As of January, its ICU had gone 3,798 ventilator days without a pneumonia case.
“The numbers are almost unbelievable,” said Dr. Razak Dosani, a pulmonologist. “We knew (the rates) would decrease, but zero came as a surprise.”

Cape Coral is part of Lee Memorial Health System. Other hospitals within the system are making similar strides against pneumonia and other common hospital infections. Lee Memorial’s mortality rate last quarter fell to 1.33 percent — its lowest ever — largely because of interventions that prevent complications such as infections, faster response to changing symptoms and other efforts.

Infection reduction is important. Stephen Streed, Lee Memorial’s lead epidemiologist, said hospital-acquired infections are the nation’s fifth-leading cause of death, taking 103,000 lives a year, according to 2000 data he crunched from the Centers for Disease Control and Prevention.

Of all such infections, ventilator-associated pneumonia is considered to be the worst — the mortality rate for patients on a ventilator jumps from 32 percent to 46 percent if they develop pneumonia, according to The Institute for Healthcare Improvement, a Massachusetts-based organization running a national campaign to reduce incidents of medical harm. Lee Memorial is among the group’s 4,050 participating hospitals.

Cape Coral Hospital adopted the institute’s five-pronged approach, known as a care “bundle,” for caring for ventilated patients. It consists of keeping the patient’s head elevated at 30 degrees at all times; cleaning the mouth every two hours to prevent growth and spread of bacteria; “sedation vacations” — waking up patients at least once a day to assess whether they are ready to be weaned from the ventilator; preventing deep vein thrombosis, a kind of blood clot; and preventing stomach ulcers.

In addition, there were other changes, such as care and handling of the ventilator itself and the tubing that runs into a patient’s body, and a hospitalwide educational push so all departments understand, for example, the importance of head elevation. Multidisciplinary rounds — or teams of caregivers reviewing patient progress daily — also are considered key to the infection-fighting success.

Kelly McCutcheon Adams, who directs one of the institute’s improvement projects and has worked with Cape Coral Hospital, said experts expected the care bundle would improve outcomes for ventilator patients. But no one expected the pneumonia rates to drop dramatically. “It’s absolutely incredible,” she said.

Nationally, the institute knows of 65 hospitals that have gone a year or more without a case of ventilator-associated pneumonia and another 35 going a year or more without a central line-associated bloodstream infection, another serious risk for patients.

Cape’s nursing staff is pushing things one step further. For the first time last week, nurses and other caregivers helped a patient on a ventilator get out of bed to walk. That’s almost unheard of, but may not be much longer. New research has emerged showing the long-term physical and psychological effects of ICU stays, and medical professionals are now looking for ways to keep patients less sedated and more mobile.

“It’s one patient, one day, one change,” said Dr. Marilyn Kole, the system’s medical director for intensive care.

The transition hasn’t been easy. Nurses, who are largely responsible for carrying out the changes, said they believed their managers had “lost it” when they proposed the pneumonia-reducing initiative. Some of what they were asked to do ran counter to their training and longstanding — but newly outdated — care protocols. Many of them left the ICU.

“It was a lot at first. It was overwhelming,” said ICU nurse Dorothy Taylor, who stayed. And Lee Memorial administrators have heard their share of doubters.

“We have had skeptics in our own community who are saying there’s no way we had no VAPs in two years,” said Annette Forlenza, director of the Cape Coral intensive care unit. She and other directors re-examined their data and believe it to be accurate. The system uses the CDC guidelines for defining ventilator-acquired pneumonia.

Results like the Cape’s are spurring a paradigm shift in hospitals, suggested Linda Greene, the director of infection prevention and control at Rochester General Health System in New York. She’s also a lead author of the Association for Professionals in Infection Control and Epidemiology’s position paper on ventilator-associated pneumonia.

Infections are shifting from “the price of doing business” to something that can be prevented. Now, the challenge is not resting on the success. “I think the whole issue now is this issue of sustainability,” Greene said.

Brian Swartz, a North Fort Myers resident, said the Cape Coral Hospital’s staff has impressed him. His 76-year-old father is in intensive care now with a rare form of prostate cancer and pneumonia, which he developed prior to going on a ventilator. Swartz said his dad’s condition has improved since going into the ICU, although he still has a way to go.

The family has been included in the multidisciplinary team’s rounds, so they understand what’s going on, Swartz said.

“The care that he’s getting is superb,” Swartz said. “The passion to make people comfortable is just unbelievable. And the comfort they give the families is unbelievable.”