A multidisciplinary approach towards the reduction of ventilator-associated pneumonia (VAP)

Abstract

ISSUE: VAP is the second most frequent healthcare-acquired infection and contributes to significant morbidity and mortality, with an added cost of up to $40,000 per patient. Multiple studies have been published that show significant reduction in VAP rates with a multidisciplinary team approach targeted on risk-reduction strategies. Infection control (IC) surveillance for April-June 2004 (Q2) showed high VAP rates in the 25-bed medical-surgical intensive care unit (ICU), 19-bed neuro-critical care unit (NCCU), and 16-bed coronary care unit (CCU), as compared to the National Nosocomial Infection Surveillance System (NNIS) used for benchmarking at our 478-bed acute care level II trauma facility. PROJECT: As part of a multidisciplinary taskforce, IC worked collaboratively with the critical care committee and the respiratory therapy (RT) department toward implementation of a ventilator bundle. This included a comprehensive oral care protocol (OCP) along with other evidence-based practices, including elevation of the head of the bed to >30 degrees, daily sedation holiday, and daily assessment of readiness to extubate. In September 2004, RT assumed responsibility for performing 2-hourly OCP using a dilute hydrogen peroxide solution, oropharyngeal suctioning every 6 hours, and sharing responsibility for brushing every 12 hours with nursing. Steps were taken to ensure bedside availability of the OCP kit. A comprehensive education campaign was undertaken to disseminate the practice recommendations and to emphasize hand hygiene, adherence to contact precautions, and proper disinfection measures. Compliance was assessed and reinforced during daily multidisciplinary rounds by the nurse managers and random rounds by IC, with frequent feedback to nursing and medical staffs. RESULTS: Our performance improvement initiatives resulted in significant reduction in VAP rates, from 21/1523 ventilator days in Q2 to 3/1734 ventilator days for October-December 2004 (Q4), a decrease of 26% (range 18-100%; p < 0.05). From Q2 to Q4, the unit-specific VAP rates per 1000 ventilator days decreased from 13.18 to 2.36 for ICU, from 17.24 to 0.0 for CCU, and from 12.01 to 2.96 for NCCU (p < 0.001 for all three units), all well below the 2003 NNIS benchmark (p < 0.001). LESSONS LEARNED: Implementation of a collaborative effort led to a significant VAP rate reduction in our three adult critical care units, especially after RT assumed ownership for implementation of the OCP.