Friday, March 13, 2009

The ventilator bundle---going beyond performance to real quality

The effectiveness of the ventilator bundle in preventing ventilator associated pneumonia (VAP) is not known. According to a systematic review just published in Critical Care Medicine (emphasis mine):

Conclusion: Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundle's effectiveness or cost-effectiveness. To assure efficient allocation of the limited healthcare resources, rigorous evaluation of optimal strategies for VAP prevention is needed to 1) establish best practices and 2) create a benchmark against which new technologies' value can be assessed. The vent bundle is not a viable quality measure in the intensive care unit at this time.

The publicly reported components of the ventilator bundle are these:

Elevation of the head of the bed
Daily "sedation vacations" and assessment of readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis

Although commonly referred to as the “VAP bundle” only two of these four measures directly target pneumonia.

A recent quality improvement effort at Vanderbilt to reduce VAP is another example of what I have previously described as going beyond performance to real quality. Here are their measures, most of which are off the public radar screen:

head of the bed elevated at least 30 degrees;
every two hours, mouth swabbed with mouthwash;
every four hours, suctioning to clear the throat;
every 12 hours, teeth brushed;
every 12 hours, physician orders a target sedation level;
every four hours, nursing assesses patient's sedation level;
every 24 hours, respiratory therapy assesses patient readiness for a spontaneous breathing trial; and preventive measures for deep vein thrombosis and gastric ulcers.

Vanderbilt’s IT system tracked adherence in real time, which went from 20% to 90%.

They saw a 41% decrease in VAP rates (note it wasn’t 100%) at an estimated cost saving in the millions and an estimated 13 lives saved over 10 months!

That, my friends, is the difference between performance and quality.

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