Hospital checklist helps pneumonia rates tumble by 70%

A quality system in Michigan ICUs provides physicians and other medical staff with data that show how their efforts lower infections.

By Tanya Albert Henry — Posted March 11, 2011

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Ventilator-associated pneumonia rates plummeted 70% at Michigan hospitals when physicians and other medical staff members improved communication and followed a checklist designed to prevent lethal lung infections.

Hospital staffs in more than 100 intensive care units in Michigan were able to maintain that lowered rate during the 2½ years that researchers tracked data, according to a study published online Feb. 17 in Infection Control and Hospital Epidemiology.

With nearly 250,000 U.S. patients developing ventilator-associated pneumonia annually, reductions like this on a national scale could reduce health care costs by millions, researchers said. It also could prevent the vast majority of the 36,000 deaths linked to such infections each year.

"Up until now, these infections have been viewed as an inevitable part of patient care because the patients are sick to begin with," said study lead author Sean M. Berenholtz, MD, MHS, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine in Baltimore. "This study is creating a paradigm shift. It shows these are preventable and not inevitable."

The Agency for Healthcare Research and Quality, which funded the project, also was encouraged by the findings.

"This initiative is a terrific candidate for taking nationwide," said AHRQ Director Carolyn M. Clancy, MD. "One thing that is impressive is the dramatic reduction in the pneumonia rates and the fact that they linked the outcomes with the practices."

Medical staff members were asked to follow a five-step checklist:

  • Elevate the head of the bed to more than 30 degrees to prevent bacteria from migrating into the lungs.
  • Give antacids or proton pump inhibitors to prevent stomach ulcers.
  • Provide anticoagulants to prevent blood clots.
  • Reduce sedation so patients could follow commands.
  • Assess readiness to remove the breathing tube on a daily basis.

More than a checklist

Drs. Berenholtz and Clancy emphasized that this improvement was not just about printing out a checklist and telling people to follow it.

"People have to believe in these tools," Dr. Berenholtz said. "You need to get people to communicate better." That included making data that showed how patients were being harmed more visible to physicians and others, and asking front-line health professionals to identify how they believed the situation could be improved.

Physicians and other health professionals received feedback on how their efforts were working. That was done by distributing data on a regular basis.

"If there is one thing I've seen physicians ... get excited about is the data that is directly linked to what they are doing," Dr. Clancy said.

It allowed doctors and others to connect the dots of how their efforts made a difference, she said. "The feedback is important for everyone. You are asking people to change their routines."

The ventilator-associated pneumonia project is part of a larger AHRQ initiative to reduce health care-associated infections. The initiative, known as the Comprehensive Unit-based Safety Program, commonly referred to as CUSP, includes tools such as a checklist to improve communication and teamwork among ICU staff teams. An earlier effort, which has been rolled out nationwide, showed that the CUSP approach reduced catheter-related bloodstream infections by 66% in Michigan ICUs.

"However, we did not know if it could be applied to other types of preventable harm," said Peter J. Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and the pneumonia study's senior author. "This study demonstrates that it is equally effective at reducing pneumonia."

Dr. Pronovost led development of the AHRQ-sponsored Keystone Intensive Care Unit Project that is aimed at reducing health care-associated infections in Michigan and implemented it with the Michigan Health & Hospital Assn. The ventilator-associated pneumonia and catheter-related bloodstream infection studies were part of the Keystone project.

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Changes in treatment

Over time, physicians and other health professionals improved how often they used five therapies designed to prevent ventilator-associated pneumonia in the intensive care unit. Here are the percentages of ventilator days when there was compliance with a checklist item.

Component Baseline 16-18 months after implementation 28-30 months after implementation
Head of bed elevated 30 degrees 81% 98% 98%
Stress ulcer prophylaxis administered 93% 99% 99%
Deep venous thrombosis prophylaxis administered 90% 98% 99%
Patients followed commands 65% 87% 92%
Ability to extubate assessed 66% 92% 97%
Performed all 5 therapies 32% 75% 84%

Source: "Collaberative Cohort Sutdy of an Interventiont on Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit," Infection Control and Hospital Epidemiology, Feb. 17

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