Smarter Risk Identification and Prevention Around Key Respiratory Care Challenges

Patient safety and financial efficiency are not incompatible goals. In fact, they are often complementary. One goal of risk management is to reduce the probability that adverse outcomes will occur and lead to liability exposure. Accomplishing this mission will likely lead not only to improved patient outcomes, but also to a safer and a more financially solvent healthcare facility.

Generally, risk identification and prevention include mitigation of circumstances that may contribute to potential liability. From a purely financial point of view, avoidance of negative outcomes is vital, since in most cases the cost of preventing liability claims is far less than the cost of resolving them. Hospital-acquired conditions (HACs) alone accounted for 12.2 percent of total legal liability costs incurred by healthcare facilities in 2007, according to Aon Corporation in its 2008 Hospital Professional Liability and Physician Liability Benchmark Analysis, released in conjunction with the American Society for Healthcare Risk Management (ASHRM).

HACs related to respiratory care, such as ventilator-associated pneumonia (VAP) and infectious outbreaks, clearly demonstrate the importance of risk identification and prevention programs to both patients and healthcare facilities. A holistic approach to address these HACs can improve both clinical and financial outcomes in respiratory care. This can be accomplished by increasing the efficacy and functionality of medical devices used in respiratory care.

Prevention of respiratory infection requires provider education, employment of best practices and the adoption of effective technology. To achieve this, clinicians and administrators should consider:

• Focused orientation of new employees including medical staff, residents and nurses

• Continuing education regarding techniques to optimize clinical outcomes and to minimize clinical and medical legal risks

• Seminars or conferences for target audiences to illuminate particular risk management problems such as VAP

• Critical analysis of the impact that equipment, technology and best practices can have on outcomes

One effective way to assess the impact of current practices on clinical outcomes is to review pertinent literature demonstrating best practices.

For example, an eight-month randomized clinical trial1 published in the peer-reviewed journal American Journal of Respiratory and Critical Care Medicine (Vol. 176, 2007) reveals that use of an endotracheal tube (ETT) with a polyurethane (PU) cuff and a capability for subglottic secretion drainage (SSD) reduced the incidence of late-onset VAP by 62 percent, compared with a conventional endotracheal tube with polyvinyl cuff without SSD. In this study, patients were intubated with the Mallinckrodt™ SealGuard Evac™ endotracheal tube, which incorporates a unique, tapered-shape cuff made from an ultrathin material. This PU cuff is designed to reduce micro-aspiration past the inflated cuff by at least 95 percent, compared with current high-volume, low-pressure cuffs,2 reducing the risk for complications associated with aspiration.

Additionally, the Mallinckrodt device offers an improved SSD system design that offers a 200 percent improvement in suction efficiency, compared with early SSD tubes.3 SSD, also known as continuous aspiration of subglottic secretions (CASS), is acknowledged globally as an effective intervention in the fight against VAP and is recommended by the Centers for Disease Control, the American Thoracic Society and the American Association of Critical Care Nurses. In a 2008 study,4 Emilio Bouza, MD, PhD, of the Gregorio Marañón University General Hospital in Madrid, Spain, demonstrated that CASS significantly decreased antibiotic usage and reduced ICU length of stay and duration of mechanical ventilation in patients intubated for more than 48 hours.

Public reporting rates and discussions of changes in reimbursement for avoidable events by the Centers for Medicare & Medicaid Services have led to increased focus on VAP prevention. This heightened awareness creates the need for a better understanding of prevention methodologies. This is especially important given that:

• VAP is the second most common nosocomial infection in the United States. It is estimated to occur in 9 percent to 25 percent of ICU patients.5-7

• VAP is associated with increasing ICU stays by up to 22 days and hospital stays by up to 25 days.8

• Mortality that is directly attributable to VAP is estimated to be as high as 27.1 percent.9

• VAP is associated with more than $40,000 in increased hospital costs per patient and may be higher in certain types of patient care units.9

• A study in a shock trauma ICU found that VAP costs $57,000 per occurrence.10

• Late-onset VAP has been associated with a 65 percent attributable mortality rate and more than $60,000 in increased costs per patient.1

• Often caused by multi-drug resistant organisms, late-onset VAP is associated with significantly higher antibiotic usage than early-onset VAP.

In the realm of pandemic preparedness, infection control professionals must address a question that is pertinent to all areas of hospital operation: “What is the most cost-effective way to prepare for the implications of an outbreak?” The impact of a pandemic on a healthcare facility is potentially massive. However, the Healthcare Financial Management Association (HFMA) believes the exposure can be managed using sound planning.11

Reviewing the recommendations of key healthcare organizations, agencies and healthcare facilities that faced the recent SARS and avian flu outbreaks, it becomes clear that hospitals should not delay planning in order to minimize financial impact and increase patient safety:

• In March 2008, Secretary Michael O. Leavitt, U.S. Department of Health and Human Services, released Pandemic Planning Update V with the following message: “Forty million died when the last major influenza pandemic swept the world in 1918. We have had two less severe pandemics since then. We will no doubt see another sometime in the future. We don’t know when...but we know it will happen sooner or later and that what we do now will save lives.”12

• In a pandemic situation, the U.S. Department of Health and Human Services holds medical professionals responsible for stockpiling medical countermeasures, such as respirators, ventilators and face masks.13

• The Joint Commission and American Association of Respiratory Care (AARC) include maintenance and standardization of ventilators, as well as staff training, in their recommendations and 2008 guidelines. Standardization of ventilator fleet technology helps protect clinical, patient and staff safety, as well as the legal position of your hospital, in everyday situations and pandemic preparedness.

• The inspiratory and expiratory filters on the Puritan Bennett 840 ventilator helped contain Vancouver Hospital’s SARS outbreak in 2003. Heated expiratory filters help protect caregivers, patient visitors and any ancillary personnel from undue exposure to infectious contagions, such as SARS, TB and avian flu, and are becoming the standard of care.14

There is a compelling financial argument supporting the value of risk identification and prevention in these areas. Translated into dollars, the cost of key infection-related incidents includes:

Reacting to Avian Flu $1 million-plus/episode

Managing Ventilator Asynchrony $72,000/case

Treating Ventilator-Associated Pneumonia (VAP) $40,000/case

Managing MRSA $36,000/case

Managing TB $20,000/case

Ventilation Days $4,000/day

Financial and clinical drivers related to VAP and pandemic preparedness are complicated and interrelated. However, hospitals that invest in risk identification and reduction can realize better clinical and financial outcomes. In order to achieve these improvements, healthcare organizations must commit resources, time and specialized expertise in respiratory care so they may complete an objective. Thorough analysis of which tools and technology would have the greatest yield is a critical component of that process.

Roger Mecca, MD, is vice president of medical affairs for Covidien Respiratory and Monitoring Solutions. Covidien manufactures, distributes and services a diverse range of industry-leading product lines in four segments: Medical devices, imaging solutions, pharmaceutical products and medical supplies.


1. Lorente L. Influence of an endotracheal tube with polyurethane cuff and subglottic drainage on pneumonia. Am J Resp Criti Care Med. 2007.

2. 510(k) clearance letter.

3. Internal testing.

4. Bouza E. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. CHEST. 5;134. 2008.

5. Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator-associated pneumonia in a community hospital: Risk factors and clinical outcomes. Chest. 120;555-561. 2001.

6. Craven D E and Steger KA. Nosocomial pneumonia in mechanically ventilated adult patients: Epidemiology and prevention in 1996. Semin Respir Infect. 11;32-53. 1996.

7. Rello J, Ollendorf DA, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large U.S. database. Chest. 122:2115-2121. 2002.

8. Warren D, Shukla S, Olson M, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 31;1312-1317. 2003.

9. Fagon JY, Chastre J, et al. Nosocomial pneumonia in ventilated patients: A cohort study evaluating attributable mortality and hospital stay. Am J Med. 94, 281-288. 1993.

10. Cocanour C, Ostrosky-Zeichner L, Peninger M, et al. Cost of a ventilator-associated pneumonia in a shock trauma intensive care unit. Surg Infections. 6,; 65-72. 2005.

11. Healthcare Financial Management Association (2007). Managing unfunded liabilities: Will your hospital be prepared? Retrieved from the HMFA Web site:

12. Leavitt M. (2008). Pandemic planning update V, Retrieved from U.S. Department of Health and Human Services Pandemic Flu Web site:

13. Gerberding JL. (2005) Pandemic planning and preparedness. Retrieved from U.S. Department of Health and Human Services Web site:

14. Thiesen RJ. (2007). Heated expiratory filtration: Lessons from the SARS experience. Retrieved from Future Healthcare Web site:

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