VAP Prevention by Education and Two Combined Bedside Strategies
VAP Prevention by Education and Two Combined Bedside Strategies
Objective The objective of the study was to reduce the ventilator-associated pneumonia (VAP) incidence rates through a rational prevention program.
Design 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).
Setting The study was conducted in a 14-bed medical intensive care unit of private general hospital in Rio de Janeiro, Brazil.
Participants The study included invasively ventilated patients (n = 224; intervention group) compared with 294 controls (historical cohort).
Interventions 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.
Results 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.
Conclusions 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.
Ventilator-associated pneumonia (VAP) remains an important cause of intensive care unit (ICU) morbidity and mortality. Despite advances in antimicrobial therapy, better basic care of intubated patients on mechanical ventilation and a wide variety of preventive measures, VAP continues to complicate the natural history of 8–28% of invasively ventilated patients and its incidence varies from 10 to 30 episodes per 1000 ventilator-days. Strategies aimed at reducing the incidence of this complication may improve clinical outcomes; minimize costs related to health care; and foster patient safety.
Recent data indicate that there is substantial lack of knowledge among ICU professionals on VAP prevention. A European study showed that intensive care nurses scored an average of 45% correct responses in a questionnaire testing evidence-based guidelines for the VAP prevention. On the other hand, it has already been demonstrated that a training program for the ICU staff can promote a decrease in VAP rates. Thus, the involvement of all ICU professionals dealing with mechanically ventilated patients can result in greater attention to every detail of care and greater recognition of the importance of the teamwork. Awareness of prevention and control of VAP also can avoid overdiagnosis and excessive use of antibiotics, mitigating the emergence of multidrug-resistant microorganisms, resulting in better ICU performance.
The VAP bundle, made with the recommendations of the Institute of Healthcare Improvement (IHI) to prevent major complications for patients on mechanical ventilation, may also promote a reduction in its incidence. This bundle may be organized as a checklist and must be verified daily during multidisciplinary ICU rounds at the bedside, avoiding at the bedside, with purpose of avoiding that some checkpoint may be omitted or skipped due to memories failures or inattention. Until 2008, VAP bundle was composed of four key elements: keeping the head of the bed elevated between 30 and 45° degrees, daily interruption of sedation to assess the possibility of extubation and prophylaxis for peptic ulcer disease and for deep vein thrombosis. This approach has been most successful when all elements are executed together, as an 'all or none' strategy. The key points of this approach are to decrease VAP incidence, decrease the time spent on the ventilator and mitigate severe complications, which could prolong the length of stay on mechanical ventilation.
Lastly, organization of a training on oral hygiene protocol, focusing on the nursing and applied daily, aims at standardization of care and is also considered crucial in VAP prevention due to its pathophysiological importance.
The purpose of this study was to implement an educational module for VAP prevention, the use of a daily bundle checklist and a standardized daily oral care, verifying the effect on VAP rates.
Abstract and Introduction
Abstract
Objective The objective of the study was to reduce the ventilator-associated pneumonia (VAP) incidence rates through a rational prevention program.
Design 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).
Setting The study was conducted in a 14-bed medical intensive care unit of private general hospital in Rio de Janeiro, Brazil.
Participants The study included invasively ventilated patients (n = 224; intervention group) compared with 294 controls (historical cohort).
Interventions 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.
Results 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.
Conclusions 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.
Introduction
Ventilator-associated pneumonia (VAP) remains an important cause of intensive care unit (ICU) morbidity and mortality. Despite advances in antimicrobial therapy, better basic care of intubated patients on mechanical ventilation and a wide variety of preventive measures, VAP continues to complicate the natural history of 8–28% of invasively ventilated patients and its incidence varies from 10 to 30 episodes per 1000 ventilator-days. Strategies aimed at reducing the incidence of this complication may improve clinical outcomes; minimize costs related to health care; and foster patient safety.
Recent data indicate that there is substantial lack of knowledge among ICU professionals on VAP prevention. A European study showed that intensive care nurses scored an average of 45% correct responses in a questionnaire testing evidence-based guidelines for the VAP prevention. On the other hand, it has already been demonstrated that a training program for the ICU staff can promote a decrease in VAP rates. Thus, the involvement of all ICU professionals dealing with mechanically ventilated patients can result in greater attention to every detail of care and greater recognition of the importance of the teamwork. Awareness of prevention and control of VAP also can avoid overdiagnosis and excessive use of antibiotics, mitigating the emergence of multidrug-resistant microorganisms, resulting in better ICU performance.
The VAP bundle, made with the recommendations of the Institute of Healthcare Improvement (IHI) to prevent major complications for patients on mechanical ventilation, may also promote a reduction in its incidence. This bundle may be organized as a checklist and must be verified daily during multidisciplinary ICU rounds at the bedside, avoiding at the bedside, with purpose of avoiding that some checkpoint may be omitted or skipped due to memories failures or inattention. Until 2008, VAP bundle was composed of four key elements: keeping the head of the bed elevated between 30 and 45° degrees, daily interruption of sedation to assess the possibility of extubation and prophylaxis for peptic ulcer disease and for deep vein thrombosis. This approach has been most successful when all elements are executed together, as an 'all or none' strategy. The key points of this approach are to decrease VAP incidence, decrease the time spent on the ventilator and mitigate severe complications, which could prolong the length of stay on mechanical ventilation.
Lastly, organization of a training on oral hygiene protocol, focusing on the nursing and applied daily, aims at standardization of care and is also considered crucial in VAP prevention due to its pathophysiological importance.
The purpose of this study was to implement an educational module for VAP prevention, the use of a daily bundle checklist and a standardized daily oral care, verifying the effect on VAP rates.