Ventilator-associated Pneumonia Prevention Protocol Research Articles

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.

Nebulized hypertonic saline to prevent ventilator associated pneumonia in premature infants, a randomized trial

Background/objectives: Ventilator associated pneumonia (VAP) is a leading cause of death. Nebulized hypertonic saline solution (HSS) has been used to improve pulmonary clearance and reduce infection in intubated patients. This study examines whether nebulized HSS may reduce VAP in intubated premature infants.Methods: We analyzed results of 100 intubated premature infants who completed the study. Infants were divided into: (a) the “Control” group, where VAP prevention protocol was implemented and (b) the “Intervention” group, where nebulized HSS twice daily was added to the package of care. Clinical, radiologic, and laboratory evidence of VAP, endotracheal aspirate and blood cultures, and days on mechanical ventilation were compared between groups.Results: VAP occurred in 18% in the intervention group compared to 52% in the control group, relative risk 0.35 (CI:0.18–0.66, p = .001). VAP incidence density was 16/1000 patient-ventilator days in intervention group versus 30/1000 in control group. There was a significant reduction in the days of mechanical ventilation in the intervention group (10.7 ± 8.6 and 16.9 ± 3.4, p < .001).Conclusions: Nebulized HSS may help preserving lung clearance mechanisms and therefore reduce VAP in premature infants. Multi center, double blinded, randomized, controlled, trial is needed to confirm safety and efficacy of such intervention.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate.

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices. The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients. In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance. In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014. This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU. Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Prevention of ventilator-associated pneumonia.

Ventilator-associated pneumonia is the commonest, yet mostly preventable, infection in mechanically ventilated patients. Successful control of ventilator-associated pneumonia can save hospitalisation cost, and is possible by using a multidisciplinary clinical and administrative approach. The ventilator-associated pneumonia rate should be expressed as the number of ventilator-associated pneumonia days per 1000 ventilator days to take into account the device-utilisation duration for meaningful comparison. Various strategies address the issue, including general infection control measures, body positioning, intubation and mechanical ventilation, oral and gastro-intestinal tract, endotracheal tube, airway pressure, cuff pressure, selective digestive and/or oropharyngeal decontamination, and probiotic or early antibiotic treatment, as well as overall administration at a policy level. The rationale and controversy of these approaches are discussed in this article. The authors suggest that all units treating mechanically ventilated patients should have a ventilator-associated pneumonia prevention protocol in place, and ventilator-associated pneumonia should be seriously considered as a key performance indicator in local intensive care units.

Assessment of the Implementation of a Protocol to Reduce Ventilator-Associated Pneumonia in Intensive Care Unit Trauma Patients

Ventilator-associated pneumonia (VAP) is the primary hospital-acquired infection contracted by critically ill patients who receive mechanical ventilation. This retrospective study evaluated the efficacy of a multifaceted VAP prevention protocol in an adult trauma population. Ventilator-associated pneumonia was defined according to the National Healthcare Safety Network (2009) criteria. The number of days to onset of VAP in the postprotocol period was longer than the preprotocol period despite a concomitant increase in the number of mechanical ventilation days.

The role of total bile acid in oral secretions in ventilator-associated pneumonia

PurposeThe aim of this study was to investigate the role of inflammatory biomarkers and total bile acid (TBA) in oral secretions in the development of ventilator-associated pneumonia (VAP). MaterialsThis prospective study was conducted in an intensive care unit. Oral secretions were collected from mechanically ventilated patients who met the selection criteria for VAP prevention protocol. The levels of interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor α, soluble intercellular adhesion molecule-1, monocyte chemoattractant protein-1, C-reactive protein, surfactant protein D, and TBA in oral secretions were measured and compared between the patients with and those without VAP. ResultsThirty-nine patients with and 39 patients without VAP were studied. The levels of inflammatory biomarkers in oral secretions showed no significant difference between the 2 groups. However, the patients with VAP had significantly higher values of TBA in oral secretions than did those without VAP (median and 25th-75th interquartile range, 9.59 and 1.37-24.66 μmol/L vs 2.74 and 0.00-8.22 μmol/L; P < .003). No significant correlations were found between TBA and inflammatory biomarkers in oral secretions. ConclusionsDuodenogastroesophageal reflux as evidenced by the presence of TBA in oral secretions is common in mechanically ventilated patients and may play a role in the development of VAP.

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.

Efficacy of a Pneumonia Prevention Protocol in the Reduction of Ventilator-Associated Pneumonia in Trauma Patients

We hypothesized that implementing evidence-based ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP, and that VAP affects patient outcomes. A prospective study was performed with 331 consecutive ventilated trauma patients in a level one university teaching hospital. The VAPP protocol was modified to include elevation of the head of the bed more than 30 degrees , twice-daily chlorhexidine oral cleansing, a once-daily respiratory therapy-driven weaning attempt, and conversion from a nasogastric to an orogastric tube whenever possible. Ventilator days were compared with occurrences of nosocomial pneumonia, as defined by the U.S. Centers for Disease Control National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to discern the effect VAP has on outcome. In 2003, there were 1,600 days of ventilator support with 11 occurrences of VAP (6.9/1,000 ventilator days). In 2004, there were two occurrences of VAP in 703 days of ventilation (2.8/1,000 ventilator days). In the analysis of outcomes of the patients with and without VAP, there was a statistically significant difference in total hospital days (38.7 +/- 26.2 vs. 13.3 +/- 15.5), ICU days (27.8 +/- 12.6 vs. 7.5 +/- 9.7), ventilator days (21.1 +/- 9.8 vs. 6.0 +/- 10.3), Functional Independence Measures (7.25 +/- 2.3 vs. 10.8 +/- 1.8), and hospital charges ($371,416.70 +/- $227,774.31 vs. $138,317.39 +/- $208,346.64)(p < 0.05 for all). The mortality rate did not decrease significantly (20% vs. 7.5%; p = NS). The difference in the mean Injury Severity Score in the two groups was not significant (21.9 +/- 9.6 vs. 16.7 +/- 11.4 points) and thus could not account for the differences in outcomes. These data suggest that a VAPP protocol may reduce VAP in trauma patients. Ventilator-associated pneumonia may result in more hospital, ICU, and ventilator days and higher patient charges.

Impact of a Protocol for Prevention of Ventilator-Associated Pneumonia

Several interventions have been shown to be effective in reducing the incidence of ventilator-associated pneumonia (VAP), but their implementation in clinical practice has not gained widespread acceptance. To determine the impact of a protocol that incorporates evidence-based interventions shown to reduce the frequency of VAP on the overall rate of VAP, early-onset VAP, and late-onset VAP in the intensive care unit (ICU) of a tertiary care adult teaching hospital. This pre- and postintervention observational study included mechanically ventilated patients admitted to the Montreal General Hospital ICU between November 2003 and May 2004 (preintervention) and between November 2004 and May 2005 (postintervention). A multidisciplinary prevention protocol was developed, implemented, and reinforced. Rates of VAP per 1000 ventilator-days were calculated pre- and postprotocol implementation for all patients, for patients with early-onset VAP, and for those with late-onset VAP. In the pre- and postintervention groups, 349 and 360 patients, respectively, were mechanically ventilated. Twenty-three VAP episodes occurred in 925 ventilator-days (crude incidence rate 25 per 1000) in the preintervention period. Following implementation, the VAP rate decreased to 22 episodes in 988 ventilator-days (crude incidence rate 22.3 per 1000), corresponding to a relative reduction in rate of 10.8% (p < 0.001). The incidence of early-onset VAP decreased from 31.0 to 18.5 VAP per 1000 ventilator-days (p < 0.001), while the incidence of late-onset VAP increased from 21.9 to 24.1 VAP per 1000 ventilator-days (p < 0.001). However, when all covariates were adjusted, the impact of the prevention protocol was not statistically significant. Implementation of a VAP prevention protocol incorporating evidence-based interventions reduced the crude incidence of VAP, early-onset VAP, and late-onset VAP. However, when covariates were adjusted, the beneficial effect was no longer observed. Further research is needed to assess the impact of such measures on VAP, early-onset VAP, and late-onset VAP.

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