Ventilator-associated Pneumonia Prevention Measures Research Articles

Design and content validation of a checklist about infection-prevention performance of intensive care nurses in simulation-based scenarios.

To design, develop and validate a new tool, called NEUMOBACT, to evaluate critical care nurses' knowledge and skills in ventilator-associated pneumonia (VAP) and catheter-related bacteraemia (CRB) prevention through simulation scenarios involving central venous catheter (CVC), endotracheal suctioning (ETS) and mechanically ventilated patient care (PC) stations. Simulation-based training is an excellent way for nurses to learn prevention measures in VAP and CRB. Descriptive metric study to develop NEUMOBACT and analyse its content and face validity that followed the COSMIN Study Design checklist for patient-reported outcome measurement instruments. The first version was developed with the content of training modules in use at the time (NEUMOBACT-1). Delphi rounds were used to assess item relevance with experts in VAP and CRB prevention measures, resulting in NEUMOBACT-2. Experts in simulation methods then assessed feasibility, resulting in NEUMOBACT-3. Finally, a pilot test was conducted among 30 intensive care unit (ICU) nurses to assess the applicability of the evaluation tool in clinical practice. Seven national experts in VAP and CRB prevention and seven national simulation experts participated in the analysis to assess the relevance and feasibility of each item, respectively. After two Delphi rounds with infection experts, four Delphi rounds with simulation experts, and pilot testing with 30 ICU nurses, the NEUMOBACT-FINAL tool consisted of 17, 26 and 21 items, respectively, for CVC, ETS and PC. NEUMOBACT-FINAL is useful and valid for assessing ICU nurses' knowledge and skills in VAP and CRB prevention, acquired through simulation. Our validated and clinically tested tool could facilitate the transfer of ICU nurses' knowledge and skills learning in VAP and CRB prevention to critically ill patients, decreasing infection rates and, therefore, improving patient safety. Experts participated in the Delphi rounds and nurses in the pilot test.

Nurse knowledge and confidence in the care of mechanically ventilated patients in the emergency department

Emergency nurses are responsible for the care of mechanically ventilated patients. Evidence-based care to prevent ventilator-associated pneumonia (VAP) must be initiated in the Emergency Department (ED) instead of after arrival in the critical care areas of the hospital. Nurses were surveyed assessing VAP prevention measures education, knowledge, and confidence. Nurses reported seldom to never monitoring patient/ventilator interactions (44.6%) and troubleshooting alarms (seldom/never: 48.9%) with confidence levels minimal (29.1%), moderate (54.1%) and high (14.5%). Nurses are responsible for titrating sedation but report contacting a respiratory therapist (RT) for all other ventilator management. ED nurses may not have the same exposure to VAP prevention education as their counterparts in the critical care areas. Increasing ED nurse knowledge and confidence in VAP prevention is necessary as EDs increasingly care for mechanically ventilated patients.

Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) has traditionally been defined as pneumonia in patients with mechanical ventilation for at least 48 h. Despite advancements in critical care, VAP remains to be a complication resulting in huge financial burden to patients. The limitations to the criteria have resulted in an urge to redefine VAP by the Centers for Disease Control and Prevention. Ventilator-associated event (VAE) has been well categorized in adult population; however, in pediatric cohort, while surveillance enhances the detection of infectious and noninfectious complications which can influence patient outcomes, there are many gaps in its classification and management. Establishing a diagnosis of VAP/VAE is crucial in management of a critically ill patient. The role of clinical criteria in concordance with laboratory evidence of inflammatory markers along with chest X-ray helps in supplementing the diagnosis. The presence of culture positivity aids in diagnosis with minimally invasive bronchoalveolar lavage providing a reasonable and safe method. Early empiric antibiotic treatment in suspected patients is beneficial. The role of antibiotic stewardship will help in prevention of antimicrobial resistance in treatment of VAP. More emphasis on VAP prevention measures with multidisciplinary approach is the way forward in overcoming this morbid condition in the intensive care units.

Development of a Tool for Measuring Ventilator-Associated Pneumonia Prevention Behaviors of Intensive Care Unit Nurses.

Introduction: Ventilator-associated pneumonia (VAP) lengthens intensive care unit (ICU) stays and increases medical expenses and mortality risk. Aim: We aimed to develop and validate a tool for measuring VAP prevention behaviors among ICU nurses. Method: This is a methodological study that included a tool development step, based on the procedure suggested by DeVellis, and a tool verification step. Results: Through a literature review and focus interviews, 35 preliminary items were selected. After a content validity examination by experts and a pre-test, 30 items were chosen for this study. In the testing phase of the main survey, the final version tool was used on 452 ICU nurses to assess validity and reliability. From factor analysis, 7 factors and 17 items were selected. The factors included aspiration prevention, ventilator management, oral care, suction system management, subglottic suction, spontaneous awakening trials and spontaneous breathing trials, and standard precautions. The total determination coefficient was 71.6%. These factors were verified using convergent, discriminant, and concurrent validity tests. Internal consistency reliability was acceptable (Cronbach’s α = 0.80); thus, the VAP prevention behavior measurement tool was proven valid and reliable. Conclusions: This tool can be used with ICU nurses to measure behaviors associated with VAP prevention and, in turn, VAP prevention measures can be improved.

Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus.

Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period. We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme. There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n=198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n=184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n=217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017. The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.

Attributable Mortality of Ventilator-associated Pneumonia. Replicating Findings, Revisiting Methods

Rationale: Estimating the impact of ventilator-associated pneumonia (VAP) from routinely collected intensive care unit (ICU) data is methodologically challenging.Objectives: We aim to replicate earlier findings of limited VAP-attributable ICU mortality in an independent cohort. By refining statistical analyses, we gradually tackle different sources of bias.Methods: Records of 2,720 adult patients admitted to Ghent University Hospital ICUs (2013–2017) and receiving mechanical ventilation within 48 hours after admission were extracted from linked Intensive Care Information System and Computer-based Surveillance and Alerting of Nosocomial Infections, Antimicrobial Resistance, and Antibiotic Consumption in the ICU databases. The VAP-attributable fraction of ICU mortality was estimated using a competing risk analysis that is restricted to VAP-free patients (approach 1), accounts for VAP onset by treating it as either a competing (approach 2) or censoring event (approach 3), or additionally adjusts for time-dependent confounding via inverse probability weighting (approach 4).Results: A total of 210 patients (7.7%) acquired VAP. Based on benchmark approach 4, we estimated that (compared with current preventive measures) hypothetical eradication of VAP would lead to a relative ICU mortality reduction of 1.7% (95% confidence interval, −1.3 to 4.6) by Day 10 and of 3.6% (95% confidence interval, 0.7 to 6.5) by Day 60. Approaches 1–3 produced estimates ranging from −0.7% to 2.5% by Day 10 and from 5.2% to 5.5% by Day 60.Conclusions: In line with previous studies using appropriate methodology, we found limited VAP-attributable ICU mortality given current state-of-the-art VAP prevention measures. Our study illustrates that inappropriate accounting of the time dependency of exposure and confounding of its effects may misleadingly suggest protective effects of early-onset VAP and systematically overestimate attributable mortality.

ADHERENCE TO VENTILATOR-ASSOCIATED PNEUMONIA PREVENTION MEASURES IN INTENSIVE CARE

Introduction: Ventilator-Associated Pneumonia (VAP) is a frequent infection in patients admitted to intensive care units. The occurrence of VAP prolongs hospital stay and increases health care costs. The objective of this study is to assess adherence of health professionals to a VAP prevention package of interventions (Bundle). Outline: Retrospective, documentary study performed in an intensive care unit of a university hospital. The sample consisted of patients hospitalized in the period from January to June 2014, who met the inclusion criteria. The data collection was carried out through examination of medical records. Results: Increase in hospital stay of patients with VAP and low adherence to Bundle items were verified. Proper cuff pressure and oral hygiene with standardized antiseptic were the items with lower adherence. Implications: The adherence to some Bundle VAP prevention measures was not different between groups of patients (with or without VAP) and showed low values of adherence.

A clinical trial of silver-coated and tapered cuff plus supraglottic suctioning endotracheal tubes in preventing ventilator-associated pneumonia

PurposeNovel designs of the endotracheal tube (ETT) are emerged to reduce the risk of ventilator-associated pneumonia (VAP). We evaluated the effect of two different types, namely silver-coated (Bactiguard) and subglottic suctioning (Taperguard) ETTs, on the incidence of VAP in critically-ill patients. MethodsA total of 90 patients, mechanically ventilated for >72 h, were randomly assigned to Bactiguard and Taperguard groups. They otherwise received routine care, including VAP prevention measures during their intensive care unit (ICU) stay. Subglottic suctioning was performed in Taperguard group. Statistical analyses were performed using SPSS 25 for iMacs. ResultsBoth groups had similar demographics and did not differ in the prevalence of comorbidities and the severity of underlying illness. There was no difference in the frequency of reintubation (P = .565), the duration of ventilation, ICU and total hospital length of stay. VAP developed in 31% of the Bactiguard group and 20% of the Taperguard group (P = .227). Nearly twice the number of patients died in the Bactiguard group compared to the Taperguard group. This difference was not significant either (P = .352). ConclusionsThe use of Bactiguard or Taperguard ETTs was not associated with any difference in the incidence of VAP or ICU mortality.

Financial burden of ventilator associated pneumonia among patients in intensive care unit: Kosovo case study

Background and objective: Ventilator-associated pneumonia (VAP) is a predominant type of healthcareassociated infection (HAI) in intensive care units (ICU), associated with increased length of stay(LOS), mortality rates, and costs. We aimed to assess the financial burden of VAP in terms of direct medical costs incurred by the patients treated in ICU. Methods: A local surveillance dataset was used to perform the assessment of direct medical costs incurred by the patients while being treated for VAP in the ICU at University Clinical Centre of Kosovo (UCCK). Results: Overall, incidence rate of HAIs in the ICU at UCCK was 62.1% with VAP dominating the infection account (73.2%). The LOS in ICU ranged from 2–44 days with a median time of six days, while the distribution between VAP affected and unaffected patients ranged between 13.5 and 5.4 days, respectively. The mean cost to patients with VAP is estimated as €647±487, which is significantly higher than in patients without VAP (€227±174). Conclusion: An immediate action is required to introduce better VAP prevention and control measures in the ICU. Evidence-based practices confirm that compliance to hand-hygiene practices, ICU staff education, introduction of regular surveillance, and adequate antibiotic therapy can significantly decrease VAP incidence, save lives, decrease LOS, and reduce costs.

Preventing ventilator-associated pneumonia-a mixed-method study to find behavioral leverage for better protocol adherence.

Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence. Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs). The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.Patients and participantsAdherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians. Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component 'reflective motivation' (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to 'physical capability' (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, 'restructuring environment' and 'enabling HCP') emerged as means to overcome these barriers. Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

Effectiveness of Electronic Learning Module in Implementing VentilatorAssociated Pneumonia Prevention Measures of Intensive Care Unit Nurses

Effectiveness of Electronic Learning Module in Implementing VentilatorAssociated Pneumonia Prevention Measures of Intensive Care Unit Nurses

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU "Pneumonia Zero" Program.

The "Pneumonia Zero" project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU. Prospective, interventional, and multicenter study. A total of 181 ICUs throughout Spain. All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012. Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April-June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status. The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42-11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22-5.84) after 19-21 months of participation. Implementation of the bundle measures included in the "Pneumonia Zero" project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.

Effectiveness of electronic learning module in implementing ventilator-associated pneumonia prevention measures among intensive care unit nurses

Effectiveness of electronic learning module in implementing ventilator-associated pneumonia prevention measures among intensive care unit nurses

Nursing workload and adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia. A pilot study

ObjectiveTo analyse whether adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia (VAP) is associated with nursing workload. MethodsA prospective observational study performed in a single medical-surgical ICU. Nurses in charge of patients under ventilator support were assessed. Variables: knowledge questionnaire, application of non-pharmacological VAP prevention measures, and workload (Nine Equivalents of Nursing Manpower Use Score). Phases: 1) the nurses carried out a educational programme, consisting of 60-min lectures on non-pharmacological measures for VAP prevention, and at the end completed a questionnaire knowledge; 2) observation period; 3) knowledge questionnaire. ResultsAmong 67 ICU-staff nurses, 54 completed the educational programme and were observed. A total of 160 observations of 49 nurses were made. Adequate knowledge was confirmed in both the initial and final questionnaires. Application of preventive measures ranged from 11% for hand washing pre-aspiration to 97% for the use of a sterile aspiration probe. The Nine Equivalents of Nursing Manpower Use Score was 50±13. No significant differences were observed between the association of the nurses’ knowledge and the application of preventive measures or between workload and the application of preventive measures. ConclusionsNurses’ knowledge of VAP prevention measures is not necessarily applied in daily practice. Failure to follow these measures is not subject to lack of knowledge or to increased workload, but presumably to contextual factors.

Carga de trabajo y cumplimiento por parte de las enfermeras de las medidas no farmacológicas para la prevención de la neumonía asociada a la ventilación mecánica. Estudio piloto

ObjectiveTo analyse whether adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia (VAP) is associated with nursing workload. MethodsA prospective observational study performed in a single medical-surgical ICU. Nurses in charge of patients under ventilator support were assessed. Variables: knowledge questionnaire, application of non-pharmacological VAP prevention measures, and workload (Nine Equivalents of Nursing Manpower Use Score). Phases: 1) the nurses carried out a educational programme, consisting of 60-minute lectures on non-pharmacological measures for VAP prevention, and at the end completed a questionnaire knowledge; 2) observation period; 3) knowledge questionnaire. ResultsAmong 67 ICU-staff nurses, 54 completed the educational programme and were observed. A total of 160 observations of 49 nurses were made. Adequate knowledge was confirmed in both the initial and final questionnaires. Application of preventive measures ranged from 11% for hand washing pre-aspiration to 97% for the use of a sterile aspiration probe. The Nine Equivalents of Nursing Manpower Use Score was 50±13. No significant differences were observed between the association of the nurses’ knowledge and the application of preventive measures or between workload and the application of preventive measures. ConclusionsNurses’ knowledge of VAP prevention measures is not necessarily applied in daily practice. Failure to follow these measures is not subject to lack of knowledge or to increased workload, but presumably to contextual factors.

Evaluating the Accuracy of Sampling Strategies for Estimation of Compliance Rate for Ventilator-Associated Pneumonia Process Measures.

BACKGROUND Measuring processes of care performance rates is an invaluable tool for quality improvement; however, collecting daily process measure data is time-consuming and burdensome. OBJECTIVE To evaluate the accuracy of sampling strategies to estimate monthly compliance rates with ventilator-associated pneumonia prevention measures. SETTING AND PARTICIPANTS A total of 37 intensive care units affiliated with 29 hospitals participating in a 2-state 35-month ventilator-associated pneumonia prevention collaborative. Analysis was limited to 325 unit-months with complete data entry rates. METHODS We calculated unit-month level actual and sample monthly compliance rates for 6 ventilator-associated pneumonia prevention measures, using 4 sampling strategies: sample 1 day per month, sample 1 day per week, sample 7 consecutive days per month, and sample 7 consecutive days per month plus additional consecutive days as necessary to obtain at least 30 ventilator-days for that month whenever possible. We compared sample versus actual rates using paired t test and χ2 test. RESULTS Mean sampling accuracy ranged 84%-97% for 1 day per month, 91%-98% for 1 day per week, 92%-98% for 7 consecutive days per month, and 96%-99% for 7 consecutive days with at least 30 days per month if possible. The most accurate sampling strategy was to sample 7 consecutive days with at least 30 ventilator-days per month if possible. With this strategy, sample rates were within 10% of actual rates in 88%-99% of unit-months and within 5% of actual rates in 74%-97% of unit-months. CONCLUSION Sampling process measures intermittently rather than continually can yield accurate estimates of process measure performance rates. Infect Control Hosp Epidemiol 2016;37:1037-1043.

Assessment of a training programme for the prevention of ventilator‐associated pneumonia

BackgroundVentilator-associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICUs). Most published studies have analysed nurses' theoretical knowledge about a specific procedure; however, the transfer of this knowledge to the practice has received little attention.AimTo assess the impact of training session on nurses' knowledge regarding VAP, compliance with VAP preventive measures, VAP incidence and determining whether nursing workload affects compliance.MethodA prospective, quasiexperimental, pre- and post-study of the nursing team in a 16-bed medical/surgical ICU. Pre-intervention phase: a questionnaire to assess nurses' knowledge of VAP prevention measures, direct observation and review of clinical records to assess compliance. Intervention phase: eight training sessions for nurses. The post-intervention phase mirrored the pre-intervention phase.FindingsNurses answered more questions correctly on the post-intervention questionnaire than on the pre-intervention (17·87 ± 2·69 versus 15·91 ± 2·68, p = 0·002). Compliance with the following measures was better during the post-intervention period (p = 0·001): use of the smallest possible nasogastric tube, controlled aspiration of subglottic secretions and endotracheal tube cuff pressure, use of oral chlorhexidine and recording the endotracheal tube fixation number. VAP incidence remained unchanged throughout the study. However, a trend towards lower incidence of late (>4 days after intubation) VAP was observed (4·6 versus 3·1 episodes/1000 ventilation days, p = 0·37).ConclusionThe programme improved both knowledge of and compliance with VAP preventive measures, although improved knowledge did not always result in improved compliance.

Prevention and care of ventilator-associated pneumonia in critically ill patients

Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs in patients usually 48 hours or more after mechanical ventilator intubation. VAP is the most common nosocomial infection in critically ill patients. Mechanical ventilators are critical oxygenation and ventilation systems for patients. However, there is a close relationship among self-use efficacy, system settings, and VAP infection rate. VAP not only results in higher mortality, longer hospital stays, and higher medical costs, but also negatively affects patient outcomes and medical care quality. The purpose of this article was to provide reference information on VAP risk factors and prevention measures.

The Importance of a Multidisciplinary Approach to VAP Prevention: The Role of the Respiratory Therapist

Ventilator associated pneumonia (VAP) is one of the most common hospital acquired infection among patients in the ICU, with an estimated incidence of 10–20% in some institutions.[1][1] Despite extensive research, the implementation of VAP prevention measures or “bundles” in acute care

The paradox of ventilator-associated pneumonia prevention measures

There is a striking paradox in the literature supporting high-profile measures to reduce ventilator-associated pneumonia (VAP): many studies show significant reductions in VAP rates but almost none show any impact on patients' duration of mechanical ventilation, length of stay in the intensive care unit and hospital, or mortality. The paradox is largely attributable to lack of specificity in the VAP definition. The clinical and microbiological criteria for VAP capture a population of patients with an array of conditions that range from serious to benign. Many of the benign events are manifestations of bacterial colonization superimposed upon pulmonary edema, atelectasis, or other non-infectious processes. VAP prevention measures that work by decreasing bacterial colonization preferentially lower the frequency of these mislabelled, more benign events. In addition, misclassification obscures detection of an impact of prevention measures on bona fide pneumonias. Together, these effects create the possibility of the paradox where a prevention measure may have a large impact on VAP rates but minimal impact on patients' outcomes. The paradox makes changes in VAP rates alone an unreliable measure of whether VAP prevention measures are truly beneficial to patients and behooves us to measure their impact on patient outcomes before advocating their adoption.