IMPROVING CARE FOR PATIENTS RECEIVING MECHANICAL VENTILATION

In this section, we demonstrate how we applied the principles of quality measurement and improvement to improve the care of mechanically ventilated patients (see Chapter 71 , Chapter 74 , and Chapter 75 ). There is a rapidly growing body of evidence to guide our practice in critical care, and we focused on the evidence to support interventions for patients that require mechanical ventilation because mechanical ventilation is common in the ICU and is associated with significant morbidity, mortality, and costs of care.^[74] Several therapies or processes can reduce this burden, including head-of-bed elevation, ^[75] peptic ulcer prophylaxis,^[76] deep venous thrombosis prophylaxis,^[77] and holding sedation such that patients can follow commands once each day.^[78] This evidence is derived from well-done randomized, controlled trials, and the results suggest that if we provide these therapies to our patients, we can expect to see improvements in patient outcomes, including reductions in morbidity, mortality, and costs of care.

Despite this evidence, a gap exists between available evidence and best practice.^[79] We found that performance for each of these process measures varied widely in our ICU, and although our performance on some measures was good, on only 30% of ventilator days did patients receive these four processes. Similar results were found as part of a collaborative including 11 hospitals and 13 medical and surgical ICUs sponsored by the Institute for Healthcare Improvement (IHI) and Volunteer Hospital Association (VHA); during less than 65% of ventilator days did patients receive these four processes.^[85] Performance at some hospitals was more than 90% for each process, but significant variation in practice existed among hospitals. Based on the median performance from the collaborative and using estimates of efficacy for each of these care processes from the literature, an average ICU with 1000 admissions per year may be able to prevent 27 deaths and save an additional 825,000 dollars annually by ensuring that patients receive these four evidence-based processes.^[85] If we assume an average mortality rate of 10% for U.S. ICUs,^[80] preventing 27 deaths represents a 27% reduction in mortality for an average ICU with 1000 admissions per year, which is a larger impact than for newer and more expensive therapies to treat sepsis.^[81] These results suggest that the most cost-effective opportunity to improve patient outcomes in the ICU over the next quarter century probably will not come from discovering new therapies but from discovering how to deliver therapies that are known to be effective.