Cost Implications of VAP

It would be utopia if quality patient care was the only engine driving healthcare today. The reality is a facility must generate profit to keep its doors open. But what if you could do both?

Some expenditures can’t be avoided, but reducing hospital-acquired infections could be a big cost saver – especially now that the Centers for Medicare and Medicaid will not reimburse for many of these preventable complications.

One of the most common hospital-acquired infections is ventilator-associated pneumonia (VAP), affecting about 250,000 people annually. It is also one of the most expensive, costing anywhere from $12,000 to $40,000 to treat one hospital case and with a 60 percent mortality rate.1,2 Each year in the U.S. a conservative estimate of collective VAP infections costs a whopping $3 billion.

Any way you approach it, reducing VAP could markedly impact the bottom line and, most importantly, improve patient care.

Problems & Solutions
Understanding the problem is the first step to elimination. VAP is defined as pneumonia that occurs more than 48 hours after a patient has been intubated and has been receiving mechanical ventilation. For every day on a ventilator, the risk of VAP increases from 1 to 3 percent, said Sean M. Berenholtz, MD, MHS, FCCM, physician director of Inpatient Quality and Safety, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore.

Before expensive treatment for VAP can even begin, diagnosis itself can be costly, including aggressive patient surveillance, bedside examination, X-rays and laboratory analysis of respiratory secretions.

Believing prevention is achievable, researchers at the Armstrong Institute decided to tackle the issue head-on. The result: a five-point initiative that has virtually eliminated VAP in numerous hospitals, including 65 Michigan facilities that were part of the Keystone ICU project which tested the program. Zero incidence means zero dollars spent on treatment.

The five-point program incorporates basic patient care tasks based on the premise most VAP occurs as a result of contamination of the lungs from oral bacteria. And it offers tools and strategies created by the Armstrong Institute group to achieve reduction, such as CUSP (Comprehensive Unit-based Safety Program) and TRiP (Translating Research into Practice). The five points include:

1. Head of bed elevation – use of a semi-recumbent position (≥ 30ø) keeps the bacteria from migrating into the lungs;
2. Spontaneous awakening and breathing trials – daily assessment of sedation and readiness to wean;
3. Oral care – at least 6 times per day to decrease bacterial load;
4. Oral care with chlorhexidine – should be included in the oral care regimen twice per day;
5. Subglottic suctioning endotracheal tubes (ETTs) – use subglottic suctioning ETTs in patients expected to be mechanically ventilated for >72 hours. “This allows care providers to suction any pooling saliva that collects in the trachea before it reaches the lungs,” Berenholtz explained.

“Actually, the ventilator bundle from which VAP reduction occurred wasn’t developed to reduce VAP as much as it was to reduce complications in patients with mechanical ventilation,” Berenholtz said. “But we saw that by initiating interventions in the bundle it reduced VAP incidence.”

Weighing Costs
The cost of eliminating VAP depends on the region. But what is the cost of equipment and staff training for these five interventions?

From Berenholtz’s experience the training required is minimal and is typically done by existing nurse educators or infection control personnel. And since oral care has become a standard of care per most guidelines for VAP reduction, many facilities are already doing it.

“Subglottic tubes cost around $7 versus $1 for a standard breathing tube,” Berenholtz explained. “A few cost-effectiveness analyses suggest the extra cost of the subglottic tube is more than paid for by reductions in VAP, antibiotics and ICU length of stay.”

Bed-turnover is critical to the bottom line. “Most hospitals are able to increase revenue by turning over beds, the same as a restaurant would tables,” Berenholtz said of the benefits of the program. “With more open beds, the hospital can admit additional patients and increase their revenue.”

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Prove It
Critical to the entire VAP reduction process is administrative buy-in. What better way to achieve that than to show the bottom line benefits from adopting these research-based practices?

“Part of the challenge of these initiatives is that administrators need to be engaged,” Berenholtz told Executive Insight. “Often there is no traditional way to do this. But we felt a tool that could track ventilator rates and convert those rates into deaths, dollars and days would help staff and administration translate the information into the number of preventable deaths, number of ICU days and the cost of their performance.”
With an unrestricted educational grant from Sage Products, Inc., Johns Hopkins Armstrong Institute developed a free, easy-to-use equation called the VAP Opportunity Estimator ( The Estimator helps calculate the potential number of avoidable deaths, excess ICU days and excess costs based on a facility’s total number of VAPs. The tool uses published estimates of VAP case fatality, cost per VAP and additional LOS per VAP to get real-time figures on what VAP costs a facility. Those figures can be applied to estimate what potential savings can be gained by implementing a VAP reduction program.
“Presenting the data as potentially avoidable deaths, dollars and days rather than traditional VAP rates makes it more meaningful for patients and staff,” Berenholtz said. “It especially helps staff understand how their performance and level of care impacts patients.”

1. Berenholtz SM, Pham JC, Thompson DA, et al. An intervention to reduce ventilator- associated pneumonia in the ICU. Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
2. Tablan OC, Anderson LJ, Besser R, et al. CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health care-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.

Gail O. Guterl is a freelance writer.

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