Pneumonia Rate Plummets in Adult ICU

By consistently implementing a series of simple steps, staff in Strong Memorial Hospital's Medical Intensive Care Unit (ICU) have discovered a solution to a deadly problem that plagues hospitals throughout the U.S. In less than a year, Strong's team has virtually eliminated ventilator-associated pneumonias, a complication that drives up ICU length-of-stay and mortality.

National studies estimate that between 10 and 65 percent of patients on ventilators contract ventilator-associated pneumonias, with mortality reported as high as 55 percent.

"This is a persistent and difficult issue in our ICU and in those throughout the nation," said Michael Apostolakos, M.D., director, Adult Critical Care. "Yet, there are specific practices that have been shown to improve patient outcomes. We set out to make those practices standard of care, and to vigorously ensure compliance with those standards."

Those standards include elevating the head of a patient's bed more than 30 degrees, using gastrointestinal bleeding and deep venous thrombosis prophylaxis, and giving patients sedation holidays. Apostolakos' team incorporated these and other measures into a checklist that is now completed by medical residents during daily rounds on the unit. Meanwhile, staff from throughout the unit was educated as to the importance of complying with the standards. Issues are ironed out at the team's weekly health team rounds.

Participating in an ICU quality improvement collaborative led by Berwick's Institute for Health Care Improvement (IHI), the group carefully monitored compliance with the standards using the daily checklists. After just one year, the results have been dramatic.

• The percent of patients having head-of-bed elevation increased from less than 15 percent to more than 80 percent.
• The number of patients being allowed to awaken periodically from sedation increased from zero to 75 percent.
• The frequency of ventilator-associated pneumonia fell from 6 percent at the start of the initiative to zero in June of 2003.
• The amount of time patients spent on ventilators decreased from 7.7 days to 6.47 days, a 16 percent increase.
• On average, patients spent two days less in the unit once the standards were implemented.
• Mortality decreased from 20 percent to 15 percent in the unit.

While the 14-bed unit involved in Strong's pilot project admits 1,100 patients per year (60 percent of whom require ventilators), Apostolakos believes that his checklist system is easily translatable to other ICUs. "We would be delighted to share our process, checklist and our lessons-learned with other hospitals," he adds.

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