Reduction In Ventilator-associated Pneumonia Rate Research Articles

Ventilator-associated pneumonia: approaching the horizon

Ventilator-associated pneumonia (VAP) continues to be a disturbing problem in the care of intensive care unit (ICU) patients. Although much progress has been achieved in the past two decades, many issues remain unresolved, and mortality still reaches 30–40% 1, 2. In this issue of the European Respiratory Journal , two contributions are devoted to VAP. Although quite divergent in scope, they all reflect the many difficulties researchers must face when approaching this issue. After all, it seems that tremendous efforts have to be made to even recognise how such difficulties could be avoided in future, more sophisticated study designs. The first contribution approaches the question of whether prone positioning reduces the incidence of VAP and its mortality 3. The authors investigated the effect of prone positioning on the incidence of VAP in a large cohort of 2,409 patients admitted over a 9-yr period to 12 French ICUs. They found that prone positioning had no effect on the risk of VAP. Also, they were unable to detect a decrease in mortality, although in patients receiving prone positioning for more than 1 day, mortality may have in fact been reduced. However, mortality was not reduced in patients with acute respiratory distress syndrome (ARDS) at admission. Positioning as a means to decrease the risk of VAP is continuously attracting much interest. In the 1990s, semi-recumbent positioning was shown to reduce VAP rates 4, 5. This was explained by a reduction of aspiration of contaminated gastric juice 4, 6. Since then, it has become the standard of care in most instances; however, its application in clinical practice continued to be difficult 7. Prone positioning was primarily introduced as a measure to improve oxygenation. It may, however, also have use as a preventive tool based on better secretion …

Ventilator-associated pneumonia rate and ventilator bundle compliance in a district general hospital

An observational study to establish the incidence of ventilator-associated pneumonia (VAP), and ventilator care bundle (VCB) compliance. Neither has previously been quantified at our institution. VAP is a nosocomial pneumonia presenting in patients mechanically ventilated for ≥48 hours [1]. Use of microbiological data in conjunction with the Clinical Pulmonary Infection Score (CPIS) improves VAP diagnostic specificity [1]. VCBs reduce VAP rates, in some cases to zero. The Department of Health VCB is one such collection of evidence-based interventions [2].

Evidence-Based Review and Discussion Points

Evidence-Based Review and Discussion Points

Successful prevention of ventilator-associated pneumonia in an intensive care setting

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings. Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU). A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions. The incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P=.05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%. These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.

Bundles to prevent ventilator-associated pneumonia: how valuable are they?

To review the value of care bundles to prevent ventilator-associated pneumonia (VAP). The Ventilator Bundle contains four components, elevation of the head of the bed to 30-45 degrees, daily 'sedation vacation' and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis, aimed to improve outcome in mechanically ventilated patients, but not all are associated with VAP prevention. Daily spontaneous awakening and breathing trials are associated with early liberation from mechanical ventilation and VAP reduction. Although a small prospective, randomized clinical study documented that the semirecumbent position was associated with a significant reduction in VAP, more recent studies have documented that the semirecumbent position is difficult to maintain in mechanically ventilated patients and may not impact VAP reduction. Prophylaxis for peptic ulcer disease and deep venous thrombosis do not directly impact VAP reduction. Other methods to reduce VAP, such as oral care and hygiene, chlorhexidine in the posterior pharynx, and specialized endotracheal tubes (continuous aspiration of subglottic secretions, silver-coated), should be considered for inclusion in a revised Ventilator Bundle more specifically aimed at VAP prevention. The Ventilator Bundle is an effective method to reduce VAP rates in ICUs. The ventilator bundle should be modified and expanded to include specific processes of care that have been definitively demonstrated to be effective in VAP reduction or a specific VAP bundle created to focus on VAP prevention.

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.

Role of chlorhexidine gluconate in ventilator-associated pneumonia prevention strategies in ICU patients: where are we headed?

We read with interest the recent study by Scannapieco and colleagues [1], which concluded that twice-daily oral rinse with 0.12% chlorhexidine failed to reduce the number of potential respiratory pathogens in dental plaque, mortality, the incidence of ventilator-associated pneumonia (VAP), the length of intensive care unit (ICU) stay and the duration of mechanical ventilation in trauma ICU patients. Trauma ICU patients are similar to mixed ICU patients with respect to risk factors for developing VAP, unlike patients undergoing elective cardiac surgery. Use of 0.12% chlorhexidine decreases the incidence of VAP in patients undergoing elective cardiac surgery. In mixed ICU patients, chlorhexidine at concentrations less than 0.2% has consistently been shown to have no benefit [2]. A randomized trial using 2% chlorhexidine has, however, demonstrated a reduction in VAP rates in these patients [3]. A previous study showed that 12-hourly application of chlorhexidine has a sustained preventive effect on biofilm formation [4]. The lack of benefit from twice-daily oral cleansing with chlorhexidine in the present study may be due to the lower concentration of chlorhexidine. The authors' recommendation for investigation into mechanical plaque removal with chlorhexidine would conceptually have some added benefit. Mechanical plaque removal with chlorhexidine, however, has not affected outcomes in ICU patients in two studies [5,6]. We therefore suggest that further studies using oral chlorhexidine in ICU patients should be conducted using higher concentrations (2%) to test the most appropriate frequency of use, since oral cleansing is a nursing-driven intervention and clinical trials with chlorhexidine are yet to demonstrate a mortality benefit.

Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and Implementing a Sustainable Solution

To characterize ventilator-associated pneumonia (VAP) in our pediatric intensive care unit (PICU), implement an evidence-based pediatric VAP prevention bundle, and reduce VAP rates. The setting is a 25-bed PICU in a 475-bed free-standing pediatric academic medical center. VAP was diagnosed according to Centers for Disease Control and National Nosocomial Infections Surveillance System definitions. A pediatric VAP prevention bundle was established and implemented. Baseline VAP rates were compared with implementation and post-bundle-implementation periods. VAP is significantly associated with increased PICU length of stay, mechanical ventilator days, and mortality rates (length of stay VAP 19.5+/-15.0 vs non-VAP 7.5+/-9.2, P< .001; ventilator days VAP 16.3+/-14.7 vs non-VAP 5.3+/-8.4, P< .001; mortality VAP 19.1% vs non-VAP 7.2%, P= .01). The VAP rate was reduced from 5.6 (baseline) to 0.3 infections per 1000 ventilator days after bundle implementation; P< .0001. Subglottic/tracheal stenosis, trauma, and tracheostomy are significantly associated with VAP. PICU VAP is associated with increased morbidity and mortality rates. A multidisciplinary improvement team can implement a sustainable pediatric-specific VAP prevention bundle, resulting in VAP rate reduction.

Ventilator-associated pneumonia in adults in developing countries: a systematic review

Ventilator-associated pneumonia (VAP) is a leading cause of death in hospitalized patients, but there has been no systematic analysis of the incidence, microbiology, and outcome of VAP in developing countries or of the interventions most applicable in that setting. We reviewed MEDLINE (January 1966-April 2007) and bibliographies of the retrieved articles for all observational or interventional studies that examined the incidence, microbiology, outcome, and prevention of VAP in ventilated adults in developing countries. We evaluated the rates of VAP using the National Healthcare Safety Network (NHSN) definitions and the impact of VAP on the intensive care unit (ICU) length of stay (LOS) and mortality, and the impact of interventions used to reduce VAP rates. The rates of VAP varied from 10 to 41.7 per 1000 ventilator-days and were generally higher than NHSN benchmark rates. Gram-negative bacilli were the most common pathogens (41-92%), followed by Gram-positive cocci (6-58%). VAP was associated with a crude mortality that ranged from 16% to 94% and with increased ICU LOS. Only a small number of VAP intervention studies were performed; these found that staff education programs, implementation of hand hygiene, and VAP prevention practice guidelines, and/or implementation of sedation protocol were associated with a significant reduction in VAP rates. Only one interventional study was a randomized controlled trial comparing two technologies, the rest were sequential observational. This study compared a heat and moisture exchanger (HME) to a heated humidifying system (HHS) and found no difference in VAP rates. Based on the existing literature, the rate of VAP in developing countries is higher than NHSN benchmark rates and is associated with a significant impact on patient outcome. Only a few studies reported successful interventions to reduce VAP. There is a clear need for additional epidemiologic studies to better understand the scope of the problem. Additionally, more work needs to be done on strategies to prevent VAP, probably with emphasis on practical, low-cost, low technology, easily implemented measures.

Ventilator-Associated Pneumonia as a Quality Indicator for Patient Safety?

The economic and clinical burden of ventilator-associated pneumonia (VAP) is uncontested. In many hospitals, VAP surveillance is conducted to identify outbreaks and to monitor infection rates. Here, we discuss the concept of benchmarking in health care as modeled on industry, and we contribute personal arguments against considering the VAP rate as a potential candidate for benchmarking or for monitoring the quality of patient care. Accurate benchmarking of VAP rates currently seems to be unfeasible, because the patient case mix is often too diverse and complicated to be adjusted for, and diagnostic criteria and surveillance protocols vary. Thus, the risk of drawing inaccurate comparisons is high. In contrast, some risk factors for VAP are modifiable and can be monitored and used as quality indicators. Process-oriented surveillance permits bypass of case-mix and diagnostic constraints. A well-defined interhospital surveillance system is necessary to prove that interventions on procedures do really lead to a reduction of VAP rates.

Control of multi-resistant bacteria and ventilator-associated pneumonia: is it possible with changes in antibiotics?

Potent antimicrobial agents have been developed as a response to the development of antibiotic-resistant bacteria, which especially affect patients with prolonged hospitalization in Intensive Care Units (ICU) and who had been previously treated with antimicrobials, especially third-generation cephalosporins. This study was to determine how changes in the empirical treatment of infections in ICU patients affect the incidence of Gram-negative bacteria species and their susceptibility to antimicrobials, and examine the impact of these changes on nosocomial infections. A prospective interventional study was performed in a university hospital during two periods: 1) First period (September 1999 to February 2000); and 2) Second period (August 2000 to December 2000); empirical treatment was changed from ceftriaxone and/or ceftazidime in the first period to piperacillin/tazobactam in the second. ICU epidemiological and infection control rates, as well as bacterial isolates from upper airways were analyzed. Ceftazidime consumption dropped from 34.83 to 0.85 DDD/1000 patients per day (p=0.004). Piperacillin/tazobactam was originally not available; its consumption reached 157.07 DDD/1000 patients per day in the second period (p=0.0002). Eighty-seven patients and 66 patients were evaluated for upper airway colonization in the first and second periods, respectively. There was a significant decrease in the incidence of K. pneumoniae (p=0.004) and P. mirabilis (p=0.036), restoration of K. pneumoniae susceptibility to cephalosporins (p<0.0001) and reduction of ventilator-associated pneumonia rates (p<0.0001). However, there was an increase in P. aeruginosa incidence (p=0.005) and increases in ceftazidime (p=0.003) and meropenem (p<0.0001) susceptibilities. Changing antimicrobial selective pressure on multi-resistant Gram-negative bacteria helps control ventilator-associated pneumonia and decreases antimicrobial resistance.

A Two–Hospital Multidiscinary Approach towards the Reduction of Ventilator Associated Pneumonia (VAP)

ISSUE: VAP is the second most frequent health-care acquired infection and contributes to significant morbidity and mortality. Many studies have shown the cost of a VAP to be at or above $40,000 per patient. Other published studies have shown a significant reduction in VAP rates when a multidisciplinary approach to established risk-reduction strategies is taken. Infection control surveillance from January-December of 2004 showed a low rate of VAP in the two hospitals below the NNIS pooled mean for benchmarking. Both hospitals had a 10 bed Med/Surg ICU with 1785 vent device days combined in 2004. While both institutions had low VAP rates, the taskforce felt that the numbers could be even lower. Download : Download full-size image Head of the Bed at 30 Degrees Daily Sedation Vacation/Assessment of Rea diness to Extubate PUD Prophylaxis DVT Prophylaxis Use of Oral Care Product Compliance to All Components Baseline n = 129 (May-July 2005) 79% 82 87% 64% 95% 48% Post-training/Education n = 127 (Aug.-Nov.2005) 95% 95% 83% 86% 96% 68% PROJECT: As part of a multidisciplinary taskforce, IC worked collaboratively with the ICU nurses and the RT department towards the implementation of a ventilator bundle that included all components outlined by CDC and IHI recommendations. This includes elevation of the head of the bed by >30 degrees, daily sedation vacations, DVT & PUD prophylaxis, oral care every 4 hours with deep oral pharyngeal suctioning and tooth-brushing every 12 hours, and assessment of readiness to extubate. Both ICU nurses and RT staff received one-hour VAP education with training and rationales in the form of a video. The oral care kits and laminated protocols were affixed to the ICU wall for easy access for staff. Additional education emphasized hand hygiene, adherence to aseptic technique and oral cavity assessments. Compliance was measured using a daily protocol check-sheet. RESULTS: Our performance improvement initiatives resulted in a significant reduction in VAP rates from 7 infections at both sites in 2004 to 0 infections at both sites for 2005. These VAP rates are all well below the CDC benchmark for a med/surg ICU. Significant improvement was also achieved for the head of the bed and daily sedation vacation components with continued compliance to the oral care standards (see Figure 1 and Table 1). LESSONS LEARNED: Implementation of a collaborative effort lead to a significant reduction in VAP rates in two 10-bed ICU units when ICU nurses and respiratory therapists consistently implemented all CDC guidelines.

Blue Ribbon Abstract Award

BACKGROUND/OBJECTIVES: Ventilator associated pneumonia (VAP) is the leading cause of nosocomial infection in the ICU with mortality rates as high as 50%. Evidence suggests that control of oral colonization, plaque removal, prevention of aspiration, and removal of subglottic secretions may reduce the incidence of VAP. METHODS: This study describes the impact of a VAP prevention protocol on VAP rates for a 40 bed Level I Trauma/Regional Burn intensive care unit. Evidence based protocols were developed and implemented to target the causative mechanisms of VAP: colonization of the oropharynx and aspiration of contaminated secretions. Educational modules were used to educate staff on ventilator care, aspiration prevention measures, and specific oral care interventions derived from the literature. Patient outcomes were monitored for two years. Chart audits were performed to determine compliance with VAP prevention measures. Data were collected from 876 patient days. RESULTS: The percentage of mechanically ventilated ICU patients who develop VAP decreased 68% during the study period. Results suggest there is a significant relationship between head of bed (HOB) positioning and VAP rate (p = 0.0001). As staff compliance with HOB positioning at ≥30 degrees increased, the VAP rate decreased (See Figure 1). Multiple regression analysis revealed that the interventions of covered Yankauer use, toothbrushing, subglottic suctioning, oral care, and monitoring the ETT cuff pressure independently did not significantly impact VAP rates (p > 0.05). The combined interventions of HOB elevation, toothbrushing, subglottic suctioning and checking the ETT cuff pressures was nearly significant (p = 0.07) explaining 46.28% of the variance in VAP rates for the study period (See Table 1). Surprisingly, HOB elevation alone explained 52.52% of the variance in VAP rates and accounted for the single most significant factor in reducing VAP rates for this sample. CONCLUSIONS: Initial data suggests that patient positioning is the most effective intervention in significantly reducing the VAP rate in a 40 bed Level One Trauma Center ICU with a heterogeneous population at high risk for developing VAP. Further research is necessary to determine which nursing interventions are the most effective in reducing VAP. I have given four lectures for SAGE Products which manufactures the oral care items used in our study. Multiple Regression Analysis - Nursing Interventions & VAP Rate Nursing Interventions Sum of Squares R Squared F LOS HOB > 30 degrees 181.14 0.52 22.12 0.0001 ∗ Toothbrushing & Subglottic Suctioning 174.69 0.29 3.11 0.07 HOB > 30 degrees, Toothbrushing, Subglottic Suctioning and ETT cuff check 132.71 0.46 2.80 0.07 ∗ p Download : Download full-size image

The Use of Oral Care Kits as a Strategy To Reduce Ventilator Associated Pneumonia Rates in a Surgical Intensive Care Unit

ISSUE: Despite educational efforts and enforcement of CDC guidelines for the prevention of hospital acquired ventilator associated pneumonia, including attention to oral care, infection rates remained elevated above the established acceptable threshold. A multidisciplinary team, including physicians, nurses and respiratory therapists examined the practices of the unit. An analysis of risk factors that contributed to the elevated rates concluded that nursing and respiratory therapy staff had difficulty providing meticulous attention to oral care due to inconvenience of oral care supplies and difficulty remembering to perform oral care at the recommended time intervals of every four hours. PROJECT: A study utilitzing prepackaged oral care kits in the SICU as a measure to increase compliance with oral care protocol as a strategy to reduce VAP was designed and initiated. No other practice was changed. Education and orientation on the use of the prepackaged oral care kit was provided to all nursing and respiratory therapy staff prior to starting the project. In November 2004, oral care kits were placed at patient bedsides in the SICU. The kits were packaged in bundles which contained all cleansing and suctioning tools necessary for complete oral care for a twenty-four hour period. The bundles were divided into sections which were detached every four hours, used, and discarded. Compliance with use of the kits was monitored and documented by unit personnel. Infection Control personnel also monitored and encouraged compliance during frequent rounds. Purchasing records were tracked by the Infection Control Department. RESULTS: A comparison of rates was made over a sixteen month period, including eight months prior to and after introduction of the oral care kits. A sixty-nine percent reduction of nosocomial VAP rates was demonstrated after introduction of the kits, from 13.2 per 1000 ventilator days to 5.0 infections per 1000 ventilator days.Use of the kits rsulted in $265,155.00 in cost avoidance (cost to treat VAP minus the cost of the kits). LESSONS LEARNED: Improving compliance with CDC and institutional guidelines regarding care of the ventilated patient through education and provision of convenient, innovative tools, with emphasis on aseptic technique resulted in a significant decrease in nosocomial ventilator associated pneumonia and a significant financial savings.

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

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.