Improving Care for Some of the Sickest Patients at Small, Community Hospitals

Jul 16, 2013, 9:00 AM, Posted by

Deverick J. Anderson, MD, MPH, is an alumnus of the Robert Wood Johnson Foundation Physician Faculty Scholars program and an associate professor of medicine at Duke University School of Medicine. He recently led a study, published in the July issue of Infection Control and Hospital Epidemiology, that finds small, community hospitals have higher rates of ventilator-associated pneumonia than larger hospitals, even though they use ventilators less frequently.


Human Capital Blog: Why did you decide to look at this particular topic?

Deverick Anderson: Our group is very interested in infectious diseases and hospital epidemiology in community hospitals. Despite the fact that more than half of the health care provided in the United States is provided in this setting, data are rarely, if ever, published from small, community hospitals.

HCB: What did your study look at?

Anderson: We analyzed prospectively collected surveillance data on ventilator-associated pneumonia (VAP) from 31 community hospitals over a five year period (2007-2011).

HCB: What did you find? 

Anderson: As expected, VAP led to significant morbidity and mortality. The most common cause of VAP was methicillin-resistant Staphylococcus aureus, or MRSA.  Most surprisingly, however, we noted that the incidence of VAP was inversely associated with hospital size. In other words, the smallest community hospitals in our network (with less than 30,000 patient-days per year) had the highest rates of VAP.

HCB: Why do you think small community hospitals experience more cases of ventilator-associated pneumonia? 

Anderson: This is a great question … and one that I don’t have a definitive answer for! I suspect that the trend is likely related to resources and experience. Smaller community hospitals may not have experts in ventilator management, such as respiratory therapists or intensivists, readily available to care for these incredibly sick patients. In addition, staff in these smaller hospitals are less experienced in caring for patients on ventilators. For example, the smaller community hospitals had an average of one patient on a ventilator each day. In contrast, the larger community hospitals had more than eight per day. Together, these two issues may lead to patients on ventilators not receiving important evidence-based interventions to prevent the occurrence of VAP.

HCB: What kind of implications do your findings have for patients, providers and/or policy-makers? What do you hope happens as a result of these findings? 

Anderson: I hope our findings lead to an increased awareness of the issue of critical illness and infection in community hospitals. Critically-ill patients don’t have much say in where they receive their care (ambulances go to the nearest hospital!), so it’s important that we ensure adequate and appropriate care in all ICU settings. Perhaps our data can stimulate policy-makers to pursue different methods for resource allocation for small community hospitals and/or investigate policies for transfer of critically ill patients to larger hospitals.

HCB: Do you plan to look at this subject further?

Anderson: Absolutely. Our group just finished a large, multicenter study investigating methods for improving the care of ventilated patients using protocols to implement best practices. We hope to perform a similar study in the small community hospitals described above.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.