Much like the popular CBS show CSI: Crime Scene Investigation, the Duke Infection Control Outreach Network (DICON) plays detective to figure out how to prevent infections, such as ventilator-associated pneumonia, in the hospital setting. But for these infection investigators, it’s more common for the culprit to be a chance event rather than a systematic error. “The reality is that most of the time there isn’t any smoking gun,” said Deverick J. Anderson, MD, MPH, assistant professor of medicine at Duke University School of Medicine and a participating member in DICON. “What we often find is several little things.” For example, they’ll use ultraviolet light emitters to objectively assess whether a room is clean or review hand-washing protocols with staff.
DICON’s goal is to break down guidelines from professional organizations, the Institute for Healthcare Improvement’s ventilator bundle, and the latest available research into steps easy to implement in small community hospitals. They also benchmark each hospital against all network members and share best practices reported by each hospital’s local infection control teams.
The latest research shows that attention to those details can add up to big savings. The 41 member hospitals in DICON saved about $100,000 each annually, in part because they’ve reduced VAP rates by 40 percent over the last three years.1 Each VAP case is estimated to cost up to $40,000 and to increase hospitals stays by 25 days.2
Take a look at the cases below, which challenged the DICON team to think outside the box on infection control.
Nash Healthcare Systems of Rocky Mount, N.C., had a small outbreak of VAP cases. Three ventilator-dependent patients in their intensive care unit developed an infection after they were placed on ventilators with heated humidity ventilator circuits. Pulmonary and Neurodiagnostics Director Steven Pinyan, RRT, RCP, turned to DICON to help him deduce the problem.
The infection control team zeroed in on air conditioning vents located in the ceilings above patient beds. Although intended to blow cool air around the patients in a protective “air curtain,” the air vents were blowing directly onto the heated wire ventilator circuits laid across the patients’ beds, causing rainout in the tubing. Nurses were breaking the circuits more frequently to remove the excess moisture and sometimes doused the patient with water from the tube, thereby introducing bacteria into the circuit and increasing the patient’s risk of developing VAP.
To reduce the incidence of this event, Pinyan rewrote the department’s protocol with stricter parameters for using heated humidity ventilator circuits. Patients are screened to determine their need for either heated humidity or heat moisture exchangers that do not require heated ventilator circuits.
In another case, a ventilator-dependent patient tested positive for a bacteria strain already infecting another patient in the intensive care unit. All fingers pointed to the respiratory therapist, because he was the only person treating both patients. The RT claimed to have followed all hand hygiene protocols and used cleaned and sterilized equipment, so DICON was called in to uncover the cause.
What they discovered was that intubated patients who complained of being hot and sweaty were given portable fans. “(They were) pulling air outside of the room into the room and keeping bacteria particles stirred up in the room,” said Pinyan, whose hospital is not the one discussed in this case. Removing all fans from the unit eliminated this cross-contamination risk.
Like any good investigator, DICON is digging up new evidence to help prevent ventilator-associated pneumonia. The network is involved in a multi-center study, sponsored by the Centers for Disease Control and Prevention, to improve compliance with the ventilator-associated pneumonia bundles, in particular sedation vacations and breathing trials, and to determine what additional patient populations could benefit. “People believe that we’re doing a good enough job in weaning sedation,” said Dr. Anderson. But “we’re just scratching the surface.”
1. Anderson DJ, Miller BA, Chen LF, et al. The Network Approach for Prevention of Healthcare-Associated Infections: Long-Term Effects of Participation in the Duke Infection Control Outreach Network. Infection Control and Hospital Epidemiology. 2011 Apr; 32(4): 315-22. Available from: www.jstore.org/stable/10.1086/658940.
2. Tablan OC, Anderson LJ, Besser R, et al. CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing healthcare-associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar 26;53(RR-3):1-36.
Kristen Ziegler can be reached at firstname.lastname@example.org.