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

doi:10.1016/j.ajic.2009.03.009

American Journal of Infection Control

Volume 37, Issue 8, October 2009, Pages 619-625

https://doi.org/10.1016/j.ajic.2009.03.009 Get rights and content

Background

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings.

Objective

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).

Methods

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.

Results

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%.

Conclusion

These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.

Section snippets

Setting and study design

A time series study was conducted in a 38-bed, medical-surgical ICU of a tertiary care, private hospital in São Paulo, Brazil. This is an open staffing model ICU where approximately 2200 patients are admitted annually. Because this study was considered a quality improvement project, it was not submitted to our Institutional Review Board. This study was carried out in 3 phases: phase 1 (March 2001 to December 2002), phase 2 (January 2003 to December 2006), and phase 3 (January 2007 to September

Compliance with process measures in each phase

In phase 1, the infection control (IC) process measures for analysis included 710 HOB elevation observations (74.1% compliance) and 304 ventilator circuits without changes (70.4% compliance). In phase 2, there were 267 HOB elevation observations (89.5% compliance), 111 ventilator circuits without changes (60.4% compliance), and 146 heat-and-moisture exchangers changed (71.9% compliance). In phase 3, more intense observations were performed; there were 7264 HOB elevation with 96.8% compliance

Discussion

This study demonstrates that VAP prevention using the majority of evidence-based measures for controlling this HAI in the ICU is a difficult process that involves the accountability of many health care workers who care for ventilated patients. We felt an urgent need to implement a new approach because our rates of VAP were extremely high, although we had been trying to control this infection since 2001. Our experience shows that it is not enough to control HOB or only to implement the IHI

References (22)

P. Youngquist et al.
Implementing a ventilator bundle in a community hospital
Jt Comm J Qual Patient Saf
(2007)
H.M. Babcock et al.
An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects
Chest
(2004)
J.S. Garner et al.
CDC definitions for nosocomial infections
Am J Infect Control
(1988)
S. Assanasen et al.
Impact of 2 different levels of performance feedback on compliance with infection control process measures in 2 intensive care units
Am J Infect Control
(2008)
E. Bouza et al.
Continuous aspiration of subglottic secretions (CASS) in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery
Chest
(2008)
M.H. Kollef et al.
A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients
Chest
(1999)
M.J. Richard et al.
Nosocomial infections in combined medical-surgical intensive care units in the United States
Infect Control Hosp Epidemiol
(2000)
M. Garrouste Orgeas et al.
Impact of adverse events on outcomes in intensive care unit patients
Crit Care Med
(2008)
D.K. Warren et al.
Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center
Crit Care Med
(2003)
Centers for Disease Control and Prevention. Guidelines for preventing healthcare-associated pneumonia, 2003:...

I. Uçkay et al.

Ventilator-associated pneumonia as a quality indicator for patient safety?

Clin Infect Dis

(2008)

Cited by (62)

Multifaceted interventions are likely to be more effective to increase adherence to the ventilator care bundle: A systematic review of strategies to improve care bundle compliance
2023, Intensive and Critical Care Nursing
The implementation of ventilator care bundles has remained suboptimal. However, it is unclear whether improving adherence has a positive relationship with patient outcomes.
To identify the most effective implementation strategies to improve adherence to ventilator bundles and to investigate the relationship between adherence to ventilator bundles and patient outcomes.
A systematic review followed the PRISMA guidelines. A systematic literature search from the inception of ventilator care bundles 2001 to January 2021 of relevant databases, screening and data extraction according to Cochrane methodology.
In total, 6035 records were screened, and 24 studies met the eligibility criteria. The implementation strategies were provider-level interventions (n = 15), included educational activities, checklist, and audit/feedback. Organizational-level interventions include (n = 8) included change of medical record system and multidisciplinary team. System-level intervention (n = 1) had motivation and reward. The most common strategies were education, checklists, audit feedback, which are probably effective in improving adherence. We could not perform a meta-analysis due to heterogeneity of the strategies and types of adherence measurement. Most studies (n = 7) had a high risk of bias. There were some conflicting results in determining the associations between adherence and patient outcomes because of the poor quality of the studies.
Multifaceted interventions are likely to be effective for consistent improvement in adherence. It remains uncertain whether improvements in adherence have positive outcomes on patients due to limited evidence of low to moderate uncertainty. We recommend the need for robust research methodology to assess the effectiveness of implementation strategies on improving adherence and patient outcomes.
Critical care nurses' compliance and barriers toward ventilator-associated pneumonia prevention guidelines: cross-sectional survey
2021, Journal of Taibah University Medical Sciences
This study aims to determine the compliance of critical care nurses with the ventilator-associated pneumonia prevention guidelines and the factors that affect their compliance. We also explored the barriers faced by the nurses in the implementation of these guidelines.
A cross-sectional descriptive survey was conducted using a self-administered questionnaire containing 17 recommended strategies to prevent ventilator-associated pneumonia and 15 possible barriers. All critical care nurses of varying qualifications, levels of experience, and nationalities working in adult ICUs were invited. Between January and March 2018, the questionnaire was distributed to 283 nurses at eight ICUs in five public hospitals in Almadinah Almunawwarah, KSA.
A total of 229 invitees responded to the questionnaire. The mean compliance score was 85.9%. More than half (54%) of the sample had a high or acceptable compliance level. The lowest compliance rate was reported for the suctioning of subglottic secretions. The main reported barriers were the shortage of nursing staff, forgetfulness, and hospital cost control policies. Working in general ICUs with the capacity of 10–15 beds or prior education related to ventilator-associated pneumonia prevention influenced the nurses’ compliance.
In our study, the overall compliance of the critical care nurses with the ventilator-associated pneumonia prevention guidelines is acceptable. Shortage of nursing staff, forgetfulness, and cost control policies were the main reported barriers to compliance.
Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization
2017, Brazilian Journal of Infectious Diseases
Citation Excerpt :
Ventilator associated pneumonia rates differ according to the centers and wards and the ratio of VAP is reported between 10 and 25% in the studies.10 Prevention of VAP has become the priority of ICUs all around the world, and in America in particular.11–13 Since 2005, the rate of VAP had a significant decline as a result of the implementation of VAP prevention bundles.9,13–16
The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p < 005). On average, VAP occurred 17.33 ± 21.09 days in the case group and 10.43 ± 7.83 days in the control group (p = 0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.
Nursing job satisfaction, certification and healthcare-associated infections in critical care
2015, Intensive and Critical Care Nursing
Citation Excerpt :
This finding was consistent with other studies that have examined the relationship between workplace characteristics and VAP (Manojlovich et al., 2009). Nurses have the greatest influence over reducing the incidence of VAP in the ICU by performing diligent oral care and assessing for readiness for extubation (IHI, 2012; Marra et al., 2009). Units with nurses expressing a more positive perception of organisational policies tended to have a lower incidence of both VAP and CLABSI.
The purpose of this study was to examine the relationship between nursing job satisfaction and healthcare-associated infections (HAIs) in adult critical care.
Multilevel modelling was used to examine the relationship between nursing job satisfaction and two HAIs, ventilator-associated pneumonia (VAP) and central-line associated bloodstream infections (CLABSI).
Units with nurses that reported satisfaction with organisational policies were associated with a 6.08 decrease in VAP (p = 0.013) and units with nurses reporting favourable perception of task requirements were associated with a 7.02 decrease in VAP (.014). Positive perception of organisational policies was associated with lower rates of CLABSI (p = 0.002). Unexpected findings include a positive relationship between perception of pay and autonomy and CLABSI as well as perception of interactions and VAP. Units with a higher proportion of Critical Care Registered Nurse (CCRN) certified nurses were associated with lower rates of both CLABSI (p < 0.001) and VAP (p = 0.037).
This study provides preliminary evidence to support the relationship between nursing job satisfaction and HAIs in critical care, although some relationships were counterintuitive. A secondary finding included significant relationships between CCRN certified nurses and HAIs.
Managing hyperactive delirium and spinal immobilisation in the intensive care setting: A case study and reflective discussion of the literature
2014, Intensive and Critical Care Nursing
The management of ventilated patients on intensive care has, at its core, a care bundle; an evidence based group of actions designed to reduce the risk of ventilator-associated pneumonia. One of these is the daily cessation of sedation medication to expedite weaning from ventilatory support. A reflection-on-action exercise was carried out when a spinally injured patient became physically active during a sedation hold. This was attributed to hyperactive delirium. The concern was the conflict between providing evidence based Intensive Care Unit (ICU) therapy care and maintaining spinal immobility.
Reflection on this incident led to a literature search for guidance on the likelihood of delirium causing secondary spinal injury in patients with unstable fractures. There was plentiful research on delirium and its consequences but very little examining the link between spinal injury and delirium. In order to be able to provide evidence-based care to future trauma patients the research supporting spinal immobilisation was also examined.
The research showed that compliance with ventilator care bundles reduced the risks of acquiring ventilator-associated pneumonia. Research surrounding spinal immobilisation was conflicting and there were no studies linking the consequences of immobilised patients experiencing hyperactive delirium.
Through a case study approach the research was reviewed in relation to a particular patient and although literature was lacking some implications for practice could be identified to promote the best possible outcomes.
Sedation cessation episodes are an essential part of patient care on intensive care. For spinally injured patients’ these may need to be modified to sedation reductions to prevent sudden wakening and uncontrolled movement should the patient be experiencing hyperactive delirium. This case study clearly highlights the need for further research in this area as the consequences of both ventilator associated pneumonia and extending spinal injuries is costly for both patients and hospitals.
Antimicrobial resistance among Enterobacteriaceae in South America: History, current dissemination status and associated socioeconomic factors
2014, Drug Resistance Updates
South America exhibits some of the higher rates of antimicrobial resistance in Enterobactericeae worldwide. This continent includes 12 independent countries with huge socioeconomic differences, where the ample access to antimicrobials, including counterfeit ones, coexists with ineffective health systems and sanitation problems, favoring the emergence and dissemination of resistant strains. This work presents a literature review concerning the evolution and current status of antimicrobial resistance threats found among Enterobacteriaceae in South America. Resistance to β-lactams, fluoroquinolones and aminoglycosides was emphasized along with description of key epidemiological studies that highlight the success of specific resistance determinants in different parts of the continent. In addition, a discussion regarding political and socioeconomic factors possibly related to the dissemination of antimicrobial resistant strains in clinical settings and at the community is presented. Finally, in order to assess the possible sources of resistant bacteria, we compile the current knowledge about the occurrence of antimicrobial resistance in isolates in South American’ food, food-producing animals and off-hospitals environments. By addressing that intensive intercontinental commerce and tourism neutralizes the protective effect of geographic barriers, we provide arguments reinforcing that globally integrated efforts are needed to decelerate the emergence and dissemination of antimicrobial resistant strains.

View all citing articles on Scopus

: Conflicts of interest: None to report.

View full text

Major ArticleSuccessful prevention of ventilator-associated pneumonia in an intensive care setting

Background

Objective

Methods

Results

Conclusion

Section snippets

Setting and study design

Compliance with process measures in each phase

Discussion

Jt Comm J Qual Patient Saf

Chest

Am J Infect Control

Am J Infect Control

Chest

Chest

Nosocomial infections in combined medical-surgical intensive care units in the United States

Infect Control Hosp Epidemiol

Impact of adverse events on outcomes in intensive care unit patients

Crit Care Med

Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center

Crit Care Med

Ventilator-associated pneumonia as a quality indicator for patient safety?

Clin Infect Dis

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