Lowering Ventilator-Associated Pneumonia Rates Through a Bedside Dashboard

The dashboard developed at Vanderbilt University Hospital improved ventilator bundle compliance by serving as a "hard-wired reminder at the bedside"

Ventilator bundles—best practices that are grouped together to reduce and prevent ventilator-associated complications, such as pneumonia—are been shown to be effective, but compliance is difficult. Now a team at Vanderbilt University Hospital has developed a method of improving compliance that has lowered ventilator-associated pneumonia substantially.

In 2007, the hospital's ICUs not only developed and implemented a comprehensive ventilator bundle program, but linked it to a real-time computerized dashboard that was developed in-house. The dashboard alerts caregivers to which elements of the bundle need to be addressed for which patient at which time, and also tracks compliance.

Now, research in the journal Infection Control & Hospital Epidemiology shows that full and uninterrupted bundle compliance at the hospital increased from 23% in August 2007 (the first month of implementation) to 83% in June 2011. Additionally, use of the bundle was associated with significant and sustained decreases in ventilator-associated pneumonias (VAPs), with the combined rate in all six of the hospital's ICUs dropping from 19.5 to 9.2 VAPs per 1,000 ventilator-days.

The bundle and dashboard are still in use at the hospital, and researchers are now looking at data to see whether bundle compliance helps with the broader ventilator-associated events measure, too, says Thomas R. Talbot, MD, MPH, chief hospital epidemiologist and lead author of the study.

The dashboard is the screen saver on the bedside computer for every ICU patient, and includes data from the electronic nursing record, the physician order entry system, and respiratory therapy documentation. All vented patients on the unit are shown (de-identified) on the same dashboard.

"We saw a very dramatic uptick in compliance" with the bundle, Talbot says, along with the sustained drop in VAP rates. "It was a hard-wired reminder at the bedside."

The dashboard is divided into columns, each representing a different metric, such head-of-bed elevation. In addition to noting compliance, the dashboard sometimes requires users to input additional information for certain metrics, such as the angle of the bed or the patient's sedation score.

Each of the metrics is color-coded to show whether the metric is in compliance (green), will be out of compliance soon (yellow), or is out of compliance and overdue (red). The color-coded indicator is updated every five minutes.

"It really kind of facilitates that awareness for the need for a task," Talbot says, noting that the awareness extends to a clinician's managers and colleagues as well. If one nurse is too busy with one patient to perform an element of the bundle for another patient, for instance, a manager can easily see that on the dashboard and ask someone else to pick up the slack.

The dashboard "facilitates communication and makes sure the processes were sustained," Talbot says. "We were able to basically, in five-minute increments, to know: Is the patient compliant right now?"

Talbot says the dashboard works well in other respects, too. When it comes to reducing VAP rates, the dashboard shows true compliance with the bundle because it's measured in real-time with constant updates. When using a paper checklist, audits might occur just once a day, and while a patient might technically be in compliance at the moment the caregiver checks off the metric, 10 minutes later the patient might be out of compliance.

"It's more continual," Talbot says of the electronic dashboard.

The dashboard was built in-house with the caregivers' workflow in mind. The system was designed to fit into that workflow, not the other way around. Talbot says the organization's "strong bioinformatics group" worked in partnership with the faculty to develop the tool, kicking off the planning with an all-day, off-campus brainstorming event and implementing clinical input from the start.

"Everybody was onboard from the very beginning and had a shared vision," he says. "It had that input and partnership from the onset."