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Checklist could stop thousands of pneumonia deaths

The system could prevent most deaths from respirator-associated pneumonia

Louise Prime

Friday, 18 February 2011

A simple checklist could prevent the vast majority of deaths from ventilator-associated pneumonia, say US researchers. The research, published online today in Infection Control and Hospital Epidemiology, showed a ‘dramatic and unprecedented reduction’ of more than 70% in cases of infection in Michigan hospitals after they implemented the checklist.

About 36,000 people in the US die every year from ventilator-associated pneumonia. Researchers at Johns Hopkins University assessed the effectiveness of a group of five evidence-based interventions, known as the ventilator bundle, in combating the infection. The relatively simple checklist was implemented, along with an education programme for caregivers, in 127 intensive care units (ICUs) in 82 hospitals in Michigan State. It included:

  • elevating the head of the bed more than 30º to keep bacteria from migrating into the lungs
  • giving antacids or proton pump inhibitors to prevent stomach ulcers
  • giving anticoagulants to prevent blood clots
  • lessening sedation to allow patients to follow commands
  • daily assessment of readiness to remove the breathing tube

The study’s authors explain that although only the first intervention acts directly against infection, the others help to shorten a patient’s time on the ventilator, which in itself is key to reducing infection risk.

“If we evaluate patients every day with objective tests to see how well they are breathing on their own, patients will come off ventilators sooner,” they point out. “And the less time they spend on the ventilator, the lower their risk of developing an infection.”

At the same time as the checklist was implemented, ICU staff were also encouraged to foster a culture of good communication and of learning from mistakes, and to focus on achieving the earliest possible freedom from respirators, all which the authors say were important in the programme’s great success.

Data from 112 of the ICUs, in 72 of the hospitals, showed that within 30 months of the programme starting, the proportion of ventilator days on which patients received all five interventions in the ventilator bundle had risen to 84%, from just 32% at the beginning of the study.

The authors report that during the same period, there was “a dramatic and unprecedented reduction” of up to 71% in the rates of ventilator-associated pneumonia in Michigan – and half of ICUs reported no such infections at all, within months of the programme beginning. These improvements were sustained for up to 2½ years.

“We hope that we can replicate these results nationally, reducing ventilator-associated pneumonia just as we have reduced bloodstream infections,” say the authors.

“Far too many patients continue to suffer preventable harm from these respirator-linked pneumonias. Health care organisations need to be held accountable for ensuring that patients get safe and effective treatments to prevent these infections. Broad use of this intervention could prevent the vast majority of those 36,000 deaths.”

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