Reduction In Ventilator-associated Pneumonia Rate Research Articles

G222 Does the implementation of a ventilator associated pneumonia (vap) care bundle reduce incidence of vap in picu?

Ventilator associated pneumonia (VAP) is pneumonia that develops 48 h after intubation. VAP is the second most common nosocomial infection in PICU patients and is associated with increased duration of ventilation, ICU stay, hospital stay, and cost. VAP is a preventable healthcare acquired infection and a Department of Health (1999) Saving Lives initiative. This poster aims to discover whether the introduction of a VAP care bundle (VCB) is effective at reducing VAP rates in PICU. A search of various databases was undertaken, including MedLine, Pubmed, CINHAL, EBSCO, using relevant PICO key words. 3 paediatric research studies were found and 4 published presentations of data. Due to the limited amount of paediatric data the search was extended to include adult studies, producing 12 valid studies. Results conclusively showed a decrease in VAP following the introduction of a VAP care bundle. Paediatric studies showed a reduction ranged from 76%–100% (91% average), with 210 days – 3 years VAP free with associated decreases in length of stay and cost. Adult studies found a 62% average decrease in VAP, with higher reduction in VAP associated with increased compliance. Due to limitations of the observational designs used, various implementation strategies, and lack of consistency in VCB elements, it is difficult to determine what is responsible for the measured outcomes. However the weight of evidence showing VAP reduction with VCB use suggests a strong relationship. And although the evidence is not at the highest experimental level, it is at the highest ethically acceptable level. It should also be taking into consideration that each individual bundle component is supported by its own breadth of high level experimental evidence. Routine use of VCB is widespread in adult ICUs, and the adult and paediatric literature agree that care bundles are an effective method for reducing the incidence of ventilator associated pneumonia. Therefore in absence of any contradictory data, care bundles should be adopted in paediatric intensive care practice. Further research is required to examine individual elements of the paediatric VCB; but with a synchronised team approach, VCB can result in continued reductions in VAP, length of stay, and costs.

How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients.

Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH2O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5–8 cmH2O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of gastric residual volumes in mechanically ventilated patients receiving enteral nutrition cannot be recommended.

The effect of a nurse-led multidisciplinary team on ventilator-associated pneumonia rates.

Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown. Methods. A retrospective study of the trend in VAP rates in a community-hospital's open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates. Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days, P < 0.001 (CI: −0.40–−0.13). Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively.

Preventing Ventilator-Associated Pneumonia (VAP) in a Pediatric Intensive Care Unit using a Modified Ventilator-Associated Pneumonia Bundle: Pre-interventional and Post-interventional Trial

Background: Ventilator-associated pneumonia increases in-hospital stay, morbidity and mortality of ventilated pediatric patients. It prolongs time spent on the ventilator and length of Pediatric Intensive Care Unit stay. Methods: This is a pre-interventional and post-interventional trial of 57 and 50 pediatric patients, respectively, which started in March 2011 to decrease the rate of ventilator-associated pneumonia in Pediatric Intensive Care Unit after initiation of a modified pediatric VAP bundle compared with the ventilator-associated pneumonia rate for the preceding 12 months. The study was conducted at Makassed General Hospital in Beirut, Lebanon. It included pediatric patients that were on mechanical ventilation from March 2010 to March 2012. An interdisciplinary performance improvement team was formed, who implemented a modified pediatric VAP bundle. Results: The implementation of the pediatric VAP bundle resulted in the reduction of ventilator-associated pneumonia rates from 52% (March 2010-2011) to 6% (March 2011-2012) (P

Efficacy of an infection control program in reducing ventilator-associated pneumonia in a Chinese neonatal intensive care unit

Measures employed in preventing ventilator-associated pneumonia (VAP) in developing countries are rarely reported. This study evaluates the efficacy of an infection control program in reducing VAP in a neonatal intensive care unit (NICU) in China. All neonates who received mechanical ventilation for at least 48 hours and were hospitalized in the NICU for ≥5 days during 3 epochs were included. The hospital relocated to a new site during phase 2 and a bundle of comprehensive preventive measures against VAP were gradually implemented using the evidence-based practice for improving quality method. Research physicians recorded associated information of patients diagnosed with VAP. Of 491 patients receiving mechanical ventilation, 92 (18.7%) developed VAP corresponding to 27.33 per 1,000 ventilator-days. The rate decreased from 48.84 per 1,000 ventilator-days in phase 1 to 25.73 per 1,000 ventilator-days in phase 2 and further diminished to 18.50 per 1,000 ventilator-days in phase 3 (P < .001). Overall mortality rate of admitted neonates significantly decreased from 14.0% in phase 1 to 2.9% in phase 2 and 2.7% in phase 3 (P= .000). Gram-negative bacteria (95.5%) were the predominant organisms in VAP and Acinetobacter baumannii (65.2%) was the most frequently isolated microorganism. Implementing a multifaceted infection control program resulted in a significant reduction in VAP rate with long-term effects. Such interventions could be extended to other low-income countries.

Ventilator-associated pneumonia prevention by education and two combined bedside strategies

The objective of the study was to reduce the ventilator-associated pneumonia (VAP) incidence rates through a rational prevention program. The study was a non-controlled clinical trial with a set of interventions in mechanically ventilated patients from April 2006 until June 2008. Pneumonia rates were analyzed as time series and their mean risks of development were compared before and after the interventions with a non-concurrent cohort using the same time frame (January 2004-March 2006). The study was conducted in a 14-bed medical intensive care unit of private general hospital in Rio de Janeiro, Brazil. The study included invasively ventilated patients (n = 224; intervention group) compared with 294 controls (historical cohort). An educational module about VAP prevention was introduced at the start of the trial (April 2006). A bundle checklist was used daily concomitantly with a standardized oral care in all patients afterwards. Main outcome measure The main outcome measure was reduction in VAP incidence rates. The observed mean rate before the intervention was 18.6 ± 7.8/1000 ventilator-days (95% CI 8.7-14.9), decreasing to 11.8 ± 7.8/1000 ventilator-days (95% CI 15.5-21.7) (P = 0.002) after the interventions. Under the adoption of non-informative prior distributions for the parameters of the proposed statistical model, there was a 70% posterior probability in favor of the hypothesis of risk reduction associated with the interventions, regardless their seasonality or secular trends. There was a 38% relative risk reduction. A reduction in VAP rates and on their risk after a set of preventive tools was observed. However, some other co-interventions not related to the primary interventions may have contributed to these results.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC)

We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

Oral Care Education in the Prevention of Ventilator-Associated Pneumonia: Quality Patient Outcomes in the Intensive Care Unit

Ventilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates in mechanically ventilated patients in the United States. Routine oral care has been shown to have a direct effect on reducing VAP rates. Intensive care unit registered nurses attended educational sessions about oral care and also used online education modules. Nursing care involving 180 intubated patients was observed, and changes were noted in practices related to oral care. After the education intervention, the frequency of oral care increased significantly (p = .001) to tooth brushing every 4 hours and swabbing every 12 hours with 0.12% chlorhexidine solution. The evidence-based practice education intervention decreased VAP rates by 62.5%. Significant reductions in VAP rates may be achieved through improved education and implementation of oral care protocols with 0.12% chlorhexidine solution.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey. A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach. In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.) The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Implementation of Clinical Practice Guidelines for Ventilator-Associated Pneumonia

Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting

BackgroundVentilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality.MethodsA quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement’s (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation.ResultsWe evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%.ConclusionThese results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part II: Impact of a Multidimensional Strategy to Reduce Ventilator-Associated Pneumonia in Neonatal Intensive Care Units in 10 Developing Countries

Design. Before-after prospective surveillance study to assess the efficacy of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control program to reduce the rate of occurrence of ventilator-associated pneumonia (VAP). Setting. Neonatal intensive care units (NICUs) of INICC member hospitals from 15 cities in the following 10 developing countries: Argentina, Colombia, El Salvador, India, Mexico, Morocco, Peru, Philippines, Tunisia, and Turkey. Patients. NICU inpatients. Methods. VAP rates were determined during a first period of active surveillance without the implementation of the multidimensional approach (phase 1) to be then compared with VAP rates after implementation of the INICC multidimensional infection control program (phase 2), which included the following practices: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices. This study was conducted by infection control professionals who applied National Health Safety Network (NHSN) definitions for healthcare-associated infections and INICC surveillance methodology. Results. During phase 1, we recorded 3,153 mechanical ventilation (MV)-days, and during phase 2, after the implementation of the bundle of interventions, we recorded 15,981 MV-days. The VAP rate was 17.8 cases per 1,000 MV-days during phase 1 and 12.0 cases per 1,000 MV-days during phase 2 (relative risk, 0.67 [95% confidence interval, 0.50-0.91]; [Formula: see text]), indicating a 33% reduction in VAP rate. Conclusions. Our results demonstrate that an implementation of the INICC multidimensional infection control program was associated with a significant reduction in VAP rate in NICUs in developing countries.

Impact of a multidimensional approach on ventilator-associated pneumonia rates in a hospital of Shanghai: Findings of the International Nosocomial Infection Control Consortium

PurposeThe aim of this study was to analyze the impact of a multidimensional infection control approach on the reduction of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) patients of one hospital in China. Materials and MethodsWe conducted a before-after study from January 2005 to July 2009, which was divided into baseline (phase 1) and intervention (phase 2) periods. During phase 1, active prospective outcome surveillance of VAP was performed by applying the definitions of the Centers for Disease Control and Prevention/National Health Safety Network, and the methodology of the International Nosocomial Infection Control Consortium. During phase 2, the multidimensional approach was implemented. Ventilator-associated pneumonia rates obtained in phases 1 and 2 were compared in yearly periods. ResultsWe recorded data from 16 429 patients hospitalized in 3 ICUs, for a total of 74 116 ICU bed days. The VAP baseline rate was 24.1 per 1000 ventilator-days. During phase 2, the VAP rate significantly decreased to 5.7 per 1000 ventilator-days in 2009 (2009 vs 2005: relative risk, 0.31; 95% confidence interval, 0.16-0.36; P = .0001), amounting to a 79% cumulative VAP rate reduction. ConclusionsImplementing a multidimensional infection control intervention for VAP was associated with a significant cumulative reduction in the VAP rate in our ICUs.

The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia

Ventilator-associated pneumonia (VAP) prevention is an important patient safety initiative. We describe the impact of a multidisciplinary surveillance program on VAP rates in a tertiary medical-surgical-trauma intensive care unit (ICU). An epidemiologic surveillance program was established in 2003 as a joint project between ICU and Infection Prevention and Control Department to regularly report VAP rates to guide evidence-based VAP preventive strategies. VAP cases were diagnosed according to predefined criteria and prospectively recorded by a research physician. VAP microbiology, risk factors, and outcomes were noted. Of 2,812 ventilated patients, 433 (15.4%) developed VAP corresponding to 15.9 episodes per 1,000 ventilator-days. The rate decreased from 19.1 in 2003 to 6.3 per 1,000 ventilator-days in 2009. On multivariate analysis, VAP was associated with accidental extubation (hazard ratio [HR], 4.11; 95% confidence interval [CI]: 1.93-8.73), trauma versus medical diagnosis (HR, 2.59; 95% CI: 2.07-3.23), chronic obstructive pulmonary disease (HR, 1.55; 95% CI: 1.08-2.22), and neuromuscular blockade (HR, 1.39; 95% CI: 1.07-1.81). The most common isolated pathogens were Gram-negative organisms. VAP patients had longer mechanical ventilation duration, ICU and hospital length of stay, but similar ICU and hospital mortality compared with non-VAP patients. The study showed a reduction in VAP rates with active surveillance, reporting and evidence-based preventive strategies and identified several modifiable risk factors, which should be the focus of additional interventions.

Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries. This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology. During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P= .02), demonstrating a 31% reduction in VAP rate. Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.

Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis*

Aspiration of secretions containing bacterial pathogens into the lower respiratory tract is the main cause of ventilator-associated pneumonia. Endotracheal tubes with subglottic secretion drainage can potentially reduce this and, therefore, the incidence of ventilator-associated pneumonia. New evidence on subglottic secretion drainage as a preventive measure for ventilator-associated pneumonia has been recently published and to consider the evidence in totality, we conducted an updated systematic review and meta-analysis. We searched computerized databases, reference lists, and personal files. We included randomized clinical trials of mechanically ventilated patients comparing standard endotracheal tubes to those with subglottic secretion drainage and reporting on the occurrence of ventilator-associated pneumonia. Studies were meta-analyzed for the primary outcome of ventilator-associated pneumonia and secondary clinical outcomes. We identified 13 randomized clinical trials that met the inclusion criteria with a total of 2442 randomized patients. Of the 13 studies, 12 reported a reduction in ventilator-associated pneumonia rates in the subglottic secretion drainage arm; in meta-analysis, the overall risk ratio for ventilator-associated pneumonia was 0.55 (95% confidence interval, 0.46-0.66; p < .00001) with no heterogeneity (I = 0%). The use of subglottic secretion drainage was associated with reduced intensive care unit length of stay (-1.52 days; 95% confidence interval, -2.94 to -0.11; p = .03); decreased duration of mechanically ventilated (-1.08 days; 95% confidence interval, -2.04 to -0.12; p = .03), and increased time to first episode of ventilator-associated pneumonia (2.66 days; 95% confidence interval, 1.06-4.26; p = .001). There was no effect on adverse events or on hospital or intensive care unit mortality. In those at risk for ventilator-associated pneumonia, the use of endotracheal tubes with subglottic secretion drainage is effective for the prevention of ventilator-associated pneumonia and may be associated with reduced duration of mechanical ventilation and intensive care unit length of stay.

Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate

ObjectiveVentilator-associated pneumonia (VAP) is associated with significant morbidity and mortality. Measures to reduce the incidence of VAP have resulted in institutions reporting a zero or near-zero VAP rates. The implications of zero VAP rates are unclear. This study was done to compare outcomes between two intensive care units (ICU) with one of them reporting a zero VAP rate. Design, Setting and PatientsThis study retrospectively compared VAP rates between two ICUs: Utah Valley Regional Medical Center (UVRMC) with 25 ICU beds and American Fork Hospital (AFH) with 9 ICU beds. Both facilities are under the same management and attended by a single group of intensivists. Both ICUs have similar nursing and respiratory staffing patterns. Both ICUs use the same intensive care program for reduction of VAP rates. ICU outcomes between AFH (reporting zero VAP rate) and UVRMC (VAP rate of 2.41/1000 ventilator days) were compared for the years 2007-2008. Measurements and Main ResultsUVRMC VAP rates during 2007 and 2008 were 2.31/1000 ventilator days and 2.5/1000 ventilator days respectively compared to a zero VAP rate at AFH. The total days of ventilation, mean days of ventilation per patient and mean duration of ICU stay per patient was higher in the UVRMC group as compared to AFH ICU group. There was no significant difference in mean age and APACHE II score between ICU patients at UVRMC and AFH. There was no statistical difference in rates of VAP and mortality between UVRMC and AFH. ConclusionsDuring comparisons of VAP rate between institutions, a zero VAP rate needs to be considered in the context of overall ventilator days, mean durations of ventilator stay and ICU mortality.

New tracheal tubes to prevent ventilator-associated pneumonia: where is the evidence?

Zolfaghari and Wyncoll [1] propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given the weight of evidence supporting the use of newer tube designs to prevent ventilator-associated pneumonia (VAP). There is strong evidence supporting the use of subglottic aspiration to prevent VAP [2]. However, other new tracheal tubes, such as polyurethane cuffed, silver-coated, or low-volume low-pressure tubes, could not be recommended to prevent VAP in routine practice. Although recent studies found polyurethane-cuffed tracheal tubes to be associated with significantly reduced VAP rate, major limitations of these studies preclude definitive conclusions; these limitations include the use of subglottic aspiration [3], before/after study design [4], and clinical criteria to define pneumonia [4,5]. One large multicenter study found the use of silver-coated tracheal tubes to be associated with significant reduction in VAP rate [6]. However, limitations of this study should be taken into account, such as the significant difference in the proportion of patients with chronic obstructive pulmonary disease between the two groups, and the small rate of late-onset VAP. Low-volume, low-pressure tracheal tubes were found to be associated with significantly reduced leakage of blue dye in a randomized controlled study performed in a single ICU [7]. Similarly, some in vitro studies suggested beneficial effects of conical shaped and guayule latex double-layered cuffs [8]. However, to date no randomized controlled study has evaluated the effect of these tubes on VAP prevention [9]. Therefore, further well designed studies are required before recommending the use of new tracheal tubes in every critically ill patient requiring mechanical ventilation for longer than 24 hours.

Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle

Ventilator-associated pneumonia (VAP) increases in-hospital mortality of ventilated patients to 46%, compared with 32% for ventilated patients who do not develop VAP. In addition, VAP prolongs time spent on the ventilator, length of intensive care unit (ICU) stay, and length of hospital stay. In this study, we implemented VAP bundle to decrease the rate of VAP infection. This is a pre- and postintervention trial beginning in 2006 to decrease the rate of VAP in adult ICUs after initiation of the Institute for Healthcare Improvement (IHI) VAP bundle compared with the VAP rate for the preceding 12 months. The study was conducted at a private general hospital in Saudi Arabia. The study included all adult patients who were on mechanical ventilation from 2006 to 2008. An interdisciplinary performance improvement team was formed. The team implemented an evidence-based VAP bundle adopted from the IHI. The implementation of the VAP prevention bundle resulted in the reduction of VAP rates from a mean of 9.3 cases per 1000 ventilator-days in fiscal year 2006 to 2.3 cases per 1000 ventilator-days in 2007 and to 2.2 in 2008 (P < .001). It is estimated that each VAP case increases the hospital length of stay attributable by 10 days and the mean hospital cost by $40,000. Thus, the potential decrease in hospital cost is $780,000 annually. Implementing the IHI VAP bundle significantly resulted in the reduction of the VAP rate with potential great cost avoidance.

Significant Reduction of Ventilator-Associated Pneumonia Rates Associated With the Introduction of a Prevention Protocol and Maintained for 10 Years

Objective: To determine if the institution of a ventilator-associated pneumonia (VAP) prevention protocol was associated with VAP decrease in mechanically ventilated patients at a long-term acute care (LTAC) hospital over time. Introduction: VAP is the most common serious nosocomial infectious disease in mechanically ventilated patients. It has a high mortality and morbidity and significantly increases the cost of care. Design: A prospective preintervention and postintervention observational study comparing the number of episodes of VAP per 1000 patient ventilator-days in the 16 months preceding and 120 months (10 years) after the introduction of a VAP prevention protocol. Setting: A 73-bed, university-affiliated LTAC hospital. Methods: The implementation of a VAP prevention protocol included the following: (1) head of bed raised at 30°; (2) twice-weekly whole-body chlorhexidine-based bath with mupirocin 2% ointment applied to nares; (3) adequate hand washing; (4) adequate nutrition; (5) early tracheotomy by Day 7 if patients had endotracheal tubes; (6) monitor staff compliance; (7) infection control–run campaign involving posters, handouts, small group education events, positive reinforcement of good infection control practices, and focus on hand washing and universal precautions. Results: The initial VAP rate of 6.1 fell to 1.98/1000 ventilator-days within 5 months ( P &lt; .001), and this was maintained. Relative risk was 0.32 ( P = .001) (68% relative risk reduction). Conclusion: The institution of a VAP prevention protocol showed a significant reduction in VAP episodes after the first 5 months of implementation. This rate was sustained for 10 years.