Elsevier

Journal of Critical Care

Volume 17, Issue 3, September 2002, Pages 161-167
Journal of Critical Care

Prevention of ventilator-associated pneumonia: Current practice in Canadian intensive care units,☆☆

https://doi.org/10.1053/jcrc.2002.35814Get rights and content

Abstract

Objective: To evaluate the current use of strategies to prevent ventilator-associated pneumonia (VAP) and to identify interventions to target for quality-improvement initiatives. Design: Cross-sectional national survey. Setting: Canadian intensive care units (ICUs) with at least 8 beds. Patients: Seven hundred and two patients in 66 ICUs in 10 provinces in Canada. Interventions: None. Measurements and Results: The Canadian Critical Care Trials Group recently developed VAP prevention guidelines. Before these guidelines were disseminated, we documented the extent to which these recommendations were followed in practice by using 3 methods: survey of ICU directors, prospective observation of patients on one day, and retrospective review of patient charts for a 12-day period. According to ICU directors, ventilator circuits were changed only for new patients or if the circuit was soiled in 7 of 66 ICUs (10%), heat and moisture exchangers were used routinely in 53 of 66 ICUs (80%), and closed-suction catheter systems were used in 58 of 66 ICUs (88%). Neither subglottic secretion drainage tubes nor prophylactic antibiotics for VAP were used at all. Of the entire cohort of 702 patients, the average degree of elevation of the head of the bed was 29.9° (range, 0°−90°) and 22 of 702 (3.1%) were observed to be on a kinetic bed. Of the 459 patients receiving any form of mechanical ventilation, 56 (12.2%) were receiving noninvasive or mask ventilation, 262 (57.1%) were orally intubated, 9 (1.9%) were nasally intubated, and 132 (28.8%) had received a tracheostomy. Of the 423 patients who received nutrition support, 373 (88.2%) received enteral nutrition. Small bowel feeding tubes were used during 16.4% of study days on enteral feeds and sucralfate was prescribed for 1.7% of study days. Conclusions: Significant opportunities exist to improve VAP prevention practices in Canada. These strategies include decreasing the frequency of ventilator circuit changes, and increasing the use of non-invasive ventilation, subglottic secretion drainage endotracheal tubes, kinetic bed therapy, small bowel feedings, and elevation of the head of the bed. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Methods

We conducted a cross-sectional observational study of Canadian ICUs that had at least 8 beds. According to the Canadian Hospital Directory, 144 hospitals had more than 8 critical care or coronary care unit beds. We excluded hospitals that had less than 8 critical care beds because these units typically do not care for ventilated patients for more than 24 hours. An additional criterion for inclusion of participating ICUs was availability of a dietitian who consulted in the ICU (excluding

Results

Of the 79 dietitians who were sent study materials, 66 returned completed case report forms for a response rate of 83.5%. Questionnaires from Unit Directors were included in all 66 returned surveys. Characteristics describing the 66 participating ICUs are found in Table 2; 29 (44.0%) were university-affiliated ICUs and 47 (71.2%) were closed units.

. Characteristics of participating ICUs

University-affiliated29 (44%)
Community12 (18%)
Community with occasional medical residents25 (38%)
Type of ICU
 Open

Discussion

Recent guidelines have been developed for the prevention of VAP in critically ill patients.11, 13, 14, 15 However, there are no Canadian studies that document the gap between current practice and optimal practice by using these guidelines. In this study, we surveyed Canadian ICUs to determine the current practice related to VAP prevention and found a low rate of use of noninvasive ventilation and poor compliance with recommendations to decrease the frequency of ventilator circuit changes,

Acknowledgements

The authors would like to thank Rupinder Dhaliwal and Andrew Day for helping with the data analysis, and the dietitians who collected data for this study: John Pilgrim, Thunder Bay Regional Hospital; Gigi Farrell and Kim Fisher, Sault Area Hospital; Joy Hoard, William Osler Health Centre; Natalie Seurralt, Hotel Dieu Hospital, a division of R. H. S. J. Health Centre of Cornwall; Elizabeth Chan, The Scarborough Hospital, Grace Division, Nutrition and Food Services; Diana Calligan, Hamilton

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D.K.H. is a Career Scientist with the Ontario Ministry of Health. D.J.C. is a Canada Institute for Health Research Chair.

☆☆

Address reprint requests to Daren K. Heyland, MD, FRCPC, MSc, Angada 3, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, Canada K7L 2V7. E-mail: [email protected].

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