An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects

Supportive care of a critically ill child

The goal of pediatric intensive care is early identification, severity assessment and resuscitation of critical patients by utilizing standardized protocols. The primary or precipitating disorder should be the focus of attention and specific intervention. But in order to provide holistic care to a patient, due attention should also be rendered to supportive care. Monitoring of sick children in PICU is an essential part of management. Various monitoring technologies add to the clinical monitoring but cannot replace clinical monitoring. The treating team should follow a checklist to ensure all aspects of supportive care are taken care of in every patient. Due attention should be paid to glucose control, skin and eye care, oral hygiene, prevention of stress ulcer, care of various lines and catheters and prevention of nosocomial infections.

Strategies in the prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.

Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study

INTRODUCTION

In 2005 the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) published guidelines for managing hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP). Although recommendations were evidence based, collective guidelines had not been validated in clinical practice and did not provide specific tools for local implementation. We initiated a performance improvement project designated Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) at four academic centers in the United States. Our objectives were to develop and implement the project, and to assess compliance with quality indicators in adults admitted to intensive care units (ICUs) with HAP, VAP, or HCAP.

METHODS

The project was conducted in three phases over 18 consecutive months beginning 1 February 2006: 1) a three-month planning period for literature review to create the consensus pathway for managing nosocomial pneumonia in these ICUs, a data collection form, quality performance indicators, and internet-based repository; 2) a six-month implementation period for customizing ATS/IDSA guidelines into center-specific guidelines via educational forums; and 3) a nine-month post-implementation period for continuing education and data collection. Data from the first two phases were combined (pre-implementation period) and compared with data from the post-implementation period.

RESULTS

We developed a consensus pathway based on ATS/IDSA guidelines and customized it at the local level to accommodate formulary and microbiologic considerations. We implemented multimodal educational activities to teach ICU staff about the guidelines and continued education throughout post-implementation. We registered 432 patients (pre- vs post-implementation, 274 vs 158). Diagnostic criteria for nosocomial pneumonia were more likely to be met during post-implementation (247/257 (96.1%) vs 150/151 (99.3%); P = 0.06). Similarly, empiric antibiotics were more likely to be compliant with ATS/IDSA guidelines during post-implementation (79/257 (30.7%) vs 66/151 (43.7%); P = 0.01), an effect that was sustained over quarterly intervals (P = 0.0008). Between-period differences in compliance with obtaining cultures and use of de-escalation were not statistically significant.

CONCLUSIONS

Developing a multi-center performance improvement project to operationalize ATS/IDSA guidelines for HAP, VAP, and HCAP is feasible with local consensus pathway directives for implementation and with quality indicators for monitoring compliance with guidelines.

Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review

Introduction

Mechanically ventilated critically ill patients frequently develop ventilator-associated pneumonia (VAP), a life-threatening complication. Proposed preventive measures against VAP include, but are not restricted to, selective decontamination of the digestive tract (SDD), selective oropharyngeal decontamination (SOD) and the use of probiotics. Probiotics are live bacteria that could have beneficial effects on the host by altering gastrointestinal flora. Similar to SDD and SOD, a prescription of probiotics aims at the prevention of secondary colonization of the upper and/or lower digestive tract.

Methods

We performed a literature review to describe the differences and similarities between SDD/SOD and probiotic preventive strategies, focusing on (a) efficacy, (b) risks, and (c) the routing of these strategies.

Results

Reductions in the incidence of VAP have been achieved with SDD and SOD. Two large randomized controlled trials even showed reduced mortality with these preventive strategies. Randomized controlled trials of probiotic strategies also showed a reduction of the incidence of VAP, but trials were too small to draw firm conclusions. Preventive strategies with antibiotics and probiotics may be limited due to the risk of emerging resistance to the locally applied antibiotics and the risk of probiotic-related infections, respectively. The majority of trials of SDD and SOD did not exhaustively address the issue of emerging resistance. Likewise, trials of probiotic strategies did not adequately address the risk of colonization with probiotics and probiotic-related infection. In studies of SDD and SOD the preventive strategy aimed at decontamination of the oral cavity, throat, stomach and intestines, and the oral cavity and throat, respectively. In the vast majority of studies of probiotic therapy the preventive strategy aimed at decontamination of the stomach and intestines.

Conclusions

Prophylactic use of antibiotics in critically ill patients is effective in reducing the incidence of VAP. Probiotic strategies deserve consideration in future well-powered trials. Future studies are needed to determine if preventive antibiotic and probiotic strategies are safe with regard to development of antibiotic resistance and probiotic infections. It should be determined whether the efficacy of probiotics improves when these agents are provided to the mouth and the intestines simultaneously.

A Review of Documented Oral Care Practices in an Intensive Care Unit

Oral care is recognized as an essential component of care for critically ill patients and nursing documentation provides evidence of this process. This study examined the practice and frequency of oral care among mechanically ventilated and nonventilated patients. A retrospective record review was conducted of patients admitted to an intensive care unit (ICU) between July 1, 2007 and December 31, 2007. Data were analyzed using bivariate and multivariate analyses to determine the variables related to patients receiving oral care. Frequency of oral care documentation was found to be performed, on average, every 3.17 to 3.51 hr with a range of 1 to 8 hr suggesting inconsistencies in nursing practice. This study found that although oral care is a Center for Disease Control and Prevention (CDC) recommendation for the prevention of hospital-associated infections like ventilator-associated pneumonia (VAP), indication of documentation of the specifics are lacking in the patients’ medical record.

[Prevention and follow-up care of sepsis. 1st revision of S2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V., DSG) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin, DIVI)]

The 1st revision of the S2k guideline on the prevention and follow-up care of sepsis, provided by the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information on the effective and appropriate medical care of critically ill patients with severe sepsis or septic shock. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

Selective decontamination of the digestive tract reduces pneumonia and mortality

Selective decontamination of the digestive tract (SDD) has been subject of numerous randomized controlled trials in critically ill patients. Almost all clinical trials showed SDD to prevent pneumonia. Nevertheless, SDD has remained a controversial strategy. One reason for why clinicians remained reluctant to implement SDD into daily practice could be that mortality was reduced in only 2 trials. Another reason could be the heterogeneity of trials of SDD. Indeed, many different prophylactic antimicrobial regimes were tested, and dissimilar diagnostic criteria for pneumonia were applied amongst the trials. This heterogeneity impeded interpretation and comparison of trial results. Two other hampering factors for implementation of SDD have been concerns over the risk of antimicrobial resistance and fear for escalation of costs associated with the use of prophylactic antimicrobials. This paper describes the concept of SDD, summarizes the results of published trials of SDD in mixed medical-surgical intensive care units, and rationalizes the risk of antimicrobial resistance and rise of costs associated with this potentially life-saving preventive strategy.

Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates

OBJECTIVE

This program was designed to evaluate the effect of morbidity and mortality peer review conferences (MMPRCs) for ventilator-associated pneumonia (VAP) on nurse accountability and compliance with evidence-based VAP prevention practices.

BACKGROUND

Ventilator-associated pneumonia is associated with longer average length of stay (ALOS), greater cost, and increased morbidity and mortality. Traditionally, passive or punitive methods have been used to reduce undesirable outcomes. The MMPRC is not a conventional nursing intervention.

METHODS

Each MMPRC included case history, relevant hospital course, diagnostic comorbidities, and compliance with VAP prevention strategies. The preventability of each VAP was determined by RN peers. Ventilator days, VAP bundle compliance, VAP incidence, ICU ALOS, cost, and satisfaction data were collected.

RESULTS

Nurse accountability improved significantly (chi(2)= 24.041, P < .001), and VAP incidence was reduced. Data demonstrated satisfaction with the MMPRC. Number of ventilator days and ALOS did not change significantly, although VAP bundle compliance improved from 90.1% to 95.2%.

CONCLUSIONS

The nonpunitive MMPRC process was cost-effective and should be considered for other nurse-sensitive indicators to increase nurse accountability and improve outcomes.

Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation

Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.

[Health professionals knowledge about the prevention of pneumonia associated to mechanical ventilation at Intensive Care Unit]

The Pneumonia Associated to Mechanical Ventilation (PAMV) is the more important and more common infection in critic mechanically ventilated patients in the Intensive Care Unit (ICUs). This quantitative research has aimed to assess the knowledge of the health professionals about the prevention of PAMV in two public hospitals of Fortaleza, Ceará State, from June to July, 2006. A questionnaire was applied to 104 professionals, by means of the concept scales of Likert which was used as a parameter and reference to the assessment. It was calculated the average and standard digression and analyzed the knowledge of professionals in relation to the PAMV. It was observed the association between the knowledge about prevention of PAMV and other variables through the chi2 tests from Fisher-Freeman-Halton, fixing the significance level in 5%. The results obtained had suggested that the knowledge of health professionals of the two ICUs about prevention of PAMV was insignificant. We conclude that, in general, despite the professional category, the knowledge about PAMV and risk factors associated to it was only regular lower than expected and, in some cases, the situation was considerably worrying.

Economic burden of ventilator-associated pneumonia based on total resource utilization

OBJECTIVES

To characterize the current economic burden of ventilator-associated pneumonia (VAP) and to determine which services increase the cost of VAP in North American hospitals.

DESIGN AND SETTING

We performed a retrospective, matched cohort analysis of mechanically ventilated patients enrolled in the North American Silver-Coated Endotracheal Tube (NASCENT) study, a prospective, randomized study conducted from 2002 to 2006 in 54 medical centers, including 45 teaching institutions (83.3%).

METHODS

Case patients with microbiologically confirmed VAP (n = 30)were identified from 542 study participants with claims data and were matched by use of a primary diagnostic code, and subsequently by the Acute Physiology and Chronic Health Evaluation II score, to control patients without VAP (n = 90). Costs were estimated by applying hospital-specific cost-to-charge ratios based on all-payer inpatient costs associated with VAP diagnosis-related groups.

RESULTS

Median total charges per patient were $198,200 for case patients and $96,540 for matched control patients (P < .001); corresponding median hospital costs were $76,730 for case patients and $41,250 for control patients (P = .001). After adjusting for diagnosis-related group payments, median losses to hospitals were $32,140 for case patients and $19,360 for control patients (P = .151). The median duration of intubation was longer for case patients than for control patients (10.1 days vs 4.7 days; P < .001), as were the median duration of intensive care unit stay (18.5 days vs 8.0 days; P < .001) and the median duration of hospitalization (26.5 days vs 14.0 days; P < .001). Examples of services likely to be directly related to VAP and having higher median costs for case patients were hospital care (P < .05) and respiratory therapy (P < .05).

CONCLUSIONS

VAP was associated with increased hospital costs, longer duration of hospital stay, and a higher number of hospital services being affected, which underscores the need for bundled measures to prevent VAP.

TRIAL REGISTRATION

NASCENT study ClinicalTrials.gov Identifier: NCT00148642.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI))

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1^st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized, controlled trial

RATIONALE

Enteral administration of probiotics may modify the gastrointestinal environment in a manner that preferentially favors the growth of minimally virulent species. It is unknown whether probiotic modification of the upper aerodigestive flora can reduce nosocomial infections.

OBJECTIVES

To determine whether oropharyngeal and gastric administration of Lactobacillus rhamnosus GG can reduce the incidence of ventilator-associated pneumonia (VAP).

METHODS

We performed a prospective, randomized, double-blind, placebo-controlled trial of 146 mechanically ventilated patients at high risk of developing VAP. Patients were randomly assigned to receive enteral probiotics (n = 68) or an inert inulin-based placebo (n = 70) twice a day in addition to routine care.

MEASUREMENTS AND MAIN RESULTS

Patients treated with Lactobacillus were significantly less likely to develop microbiologically confirmed VAP compared with patients treated with placebo (40.0 vs. 19.1%; P = 0.007). Although patients treated with probiotics had significantly less Clostridium difficile-associated diarrhea than patients treated with placebo (18.6 vs. 5.8%; P = 0.02), the duration of diarrhea per episode was not different between groups (13.2 ± 7.4 vs. 9.8 ± 4.9 d; P = 0.39). Patients treated with probiotics had fewer days of antibiotics prescribed for VAP (8.6 ± 10.3 vs. 5.6 ± 7.8 d; P = 0.05) and for C. difficile-associated diarrhea (2.1 ± 4.8 SD d vs. 0.5 ± 2.3 d; P = 0.02). No adverse events related to probiotic administration were identified.

CONCLUSIONS

These pilot data suggest that L. rhamnosus GG is safe and efficacious in preventing VAP in a select, high-risk ICU population. Clinical trial registered with www.clinicaltrials.gov (NCT00613795).

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

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.

Action of mouthwashes on Staphylococcus spp: isolated in the saliva of community and hospitalized individuals

The use of mouthwashes in critical patients has been a source of concern for health professionals due to the diverse range of products, causing uncertainty about which is the most indicated. This study aimed to assess the susceptibility of Staphylococcus spp. isolated in the saliva of individuals from the community and patients in Intensive Care Units (ICU) as to antiseptic mouthwashes. The following oral antiseptics were assessed: cetylpyridinium chloride solution, Listerine® and Neen®. Calcium alginate swab was used for saliva collection to isolate Staphylococcus spp. Microbiological processing involved growth, isolation, strain identification and determination of MID (maximum inhibitory dilution). MID was considered the greatest dilution that completely inhibited the strains. The products efficacy was analyzed by a two-factor ANOVA repeated measures and by Bonferroni adjustments in multiple comparisons, considering a significance level of α=0.05. In total, 80 strains of Staphylococcus spp. were isolated, 40 from ICU patients and 40 from community individuals. MID results revealed that cetylpyridinium chloride solution presented better results in comparison to other products, that is, 39 (97.5%) strains from hospital patients with MID 1:128, and 37 (92.5%) of individuals from the community had MID 1:64. Neen® inhibited all strains in both groups at a dilution from 1:2 to 1:4. Listerine® presented the worst MID results, 65% of the strains from individuals from the community and 10% of hospital strains were not inhibited at a dilution of 1:2.

Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults

BACKGROUND

Ventilator-associated pneumonia is associated with increased morbidity and mortality.

OBJECTIVE

To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation.

METHODS

Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS).

RESULTS

The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS >or=6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS >or=6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine.

CONCLUSIONS

Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

Infection control education: impact on ventilator-associated pneumonia rates in a public sector intensive care unit in Pakistan

We describe efforts towards introducing infection control (IC) practices and establishment of antimicrobial resistance (AMR) surveillance in a public sector hospital in Pakistan. The study was conducted in an eight-bed intensive care unit. IC principles, introduced through interactive sessions, were used as an intervention and their impact was observed by conducting surveillance for ventilator-associated pneumonia (VAP) before and after the intervention. Respiratory isolates of VAP patients in the period after intervention were screened for AMR, and empiric antibiotic at the time of admission was compared with the antimicrobial sensitivity pattern reported. VAP rates were high in general and declined in the period after intervention, although the difference was not significant. Of 37 VAP patients in the period after intervention, 68% had more than one clinically significant organism isolated from the respiratory specimen. Acinetobacter spp. were isolated from 76% of patients and Pseudomonas aeruginosa from 43%. All Acinetobacter spp. and 72% P. aeruginosa were multidrug resistant. The mean stay of the nosocomially infected patients was significantly higher than for the uninfected group (6.5 vs. 2.1 days, P<0.001). Our study suggests IC education needs to be supplemented by a hospital system that facilitates IC practices and development of surveillance programmes.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Occurrence of VAP in acute care facilities.

a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).

i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.

2. Outcomes associated with VAP

a. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.

i. The mortality attributable to VAP may exceed 10%.

ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.

SMART approaches for reducing nosocomial infections in the ICU

Nosocomial infections are problematic in the ICU because of their frequency, morbidity, and mortality. The most common ICU infections are pneumonia, bloodstream infection, and urinary tract infection, most of which are device related. Surgical site infection is common in surgical ICUs, and Clostridium difficile-associated diarrhea is occurring with increasing frequency. Prospective observational studies confirm that use of evidence-based guidelines can reduce the rate of these ICU infections, especially when simple tactics are bundled. To increase the likelihood of success, follow the specific, measurable, achievable, relevant, and time bound (SMART) approach. Choose specific objectives that precisely define and quantify desired outcomes, such as reducing the nosocomial ICU infection rate of an institution by 25%. To measure the objective, monitor staff adherence to tactics and infection rates, and provide feedback to ICU staff. Make objectives achievable and relevant by engaging stakeholders in the selection of specific tactics and steps for implementation. Nurses and other stakeholders can best identify the tactics that are achievable within their busy ICUs. Unburden the bedside provider by taking advantage of new technologies that reduce nosocomial infection rates. Objectives should also be relevant to the institution so that administrators provide adequate staffing and other resources. Appoint a team to champion the intervention and collaborate with administrators and ICU staff. Provide ongoing communication to reinforce educational tactics and fine-tune practices over time. Make objectives time bound; set dates for collecting baseline and periodic data, and a completion date for evaluating the success of the intervention.

Prevention of hospital-acquired infections: review of non-pharmacological interventions

Hospital-acquired (nosocomial) infections (HAIs) increase morbidity, mortality and medical costs. In the USA alone, nosocomial infections cause about 1.7 million infections and 99 000 deaths per year. HAIs are spread by numerous routes including surfaces (especially hands), air, water, intravenous routes, oral routes and through surgery. Interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator management, use of coated urinary and central venous catheters and use of high-efficiency particulate air (HEPA) filters have all been associated with significantly lower nosocomial infection rates. Multiple infection control techniques and strategies simultaneously ('bundling') may offer the best opportunity to reduce the morbidity and mortality toll of HAIs. Most of these infection control strategies will more than pay for themselves by saving the medical costs associated with nosocomial infections. Many non-pharmacological interventions to prevent many HAIs will also reduce the need for long or multiple-drug antibiotic courses for patients. Lower antibiotic drug usage will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire infections.

Educational interventions for prevention of healthcare-associated infection: a systematic review

BACKGROUND

Healthcare-associated infections (HCAIs) are associated with considerable morbidity and mortality. Education of healthcare providers is a fundamental measure to prevent HCAI.

OBJECTIVE

To perform a systematic review to determine the effect of educational strategies of healthcare providers for reducing HCAI.

DATA SOURCE

Multiple computerized databases for the years 1966 to November 1, 2006, supplemented by manual searches for relevant articles.

STUDY SELECTION

English-language controlled studies and randomized trials that included an educational intervention and provided data on the incidence of one or more kinds of HCAIs were included.

DATA EXTRACTION

Data were extracted on study design, patient population, type of intensive care unit, details of the educational intervention, target group for intervention, incidence of HCAI, duration of follow-up, and costs of intervention. Both investigators abstracted data using a standard data abstraction form; study quality was also assessed.

DATA SYNTHESIS

A total of 26 studies used a number of different educational programs targeting varied study populations of healthcare providers to determine their effect on HCAI rates. Most were pre-post intervention studies and were implemented in the intensive care setting. There was a statistically significant decrease in infection rates after intervention in 21 studies, with risk ratios ranging from 0 to 0.79. The beneficial effect of education was apparent in teaching and nonteaching institutions and in lesser-developed countries and developed nations.

LIMITATIONS

Only English language studies were included. Because of the study designs and limitations of the individual studies, a causal association between educational interventions and reduced HCAI rates cannot be made.

CONCLUSIONS

The implementation of educational interventions may reduce HCAI considerably. Cluster randomized trials using validated educational interventions and costing methods are recommended to determine the independent effect of education on reducing HCAI and the cost-savings that may be realized with this approach.

Impact of a multidisciplinary approach to guideline implementation in diabetic ketoacidosis

Background. Faculty members developed diabetic ketoacidosis (DKA) guidelines based on the current American Diabetes Association guidelines. Objectives. To evaluate the impact of a multidisciplinary approach to implementing DKA guidelines on residents' knowledge, guideline compliance, and patient outcomes. Design. Longitudinal case-control study with 2 arms. Setting. University-affiliated teaching hospital in Fresno, California. Methods. A Web-based testing software (TestWare) was used for educational/ assessment testing before and after DKA guidelines implementation. Patients' charts were reviewed to determine the degree of guideline compliance, patient care charges, and length of stay before and after DKA guidelines introduction. Results. Testing scores improved from 48% to 54% correct answers after implementation of the guidelines (P = .06). Overall, guidelines compliance improved from 67% to 88% (P < .05). Conclusion. A multidisciplinary intervention including knowledge assessment, individualized education, and formal didactic teaching was effective at improving knowledge and guideline compliance in DKA for internal medicine residents.

Ventilator-associated pneumonia: prevention is better than cure

BACKGROUND

The prevention of ventilator Assisted Pneumonia (VAP), a hospital acquired infection, among intensive care patients is a major clinical challenge. It is a condition that is associated with high rates of morbidity, mortality, length of stay and hospital costs.

AIM

The aim of this paper is to critically review the available literature and identify current evidence based nursing and medical interventions to support practitioners in preventing VAP in their patients.

METHODS

A literature search using keywords, including 'ventilator-associated pneumonia' were entered into a search engine. A number of highly pertinent papers relevant to the aims of the review were identified, however only a small sample came from nursing journals. Only those papers, which discussed specific strategies for managing VAP were selected for analysis and inclusion in this review.

DISCUSSION

We identified a number of practical and evidence based strategies that nurses can incorporate into their practice to prevent VAP and to reduce its incidence. In addition, the introduction of newer techniques, advances in equipment and use of multidisciplinary care bundles can further support and improve the quality and delivery of safe patient care.

CONCLUSION

Targeted strategies aimed at preventing VAP, should be implemented to improve patient outcome and reduce length of intensive care unit stay and costs. Front-line critical care nurses need to understand the factors which place their patients at risk of developing VAP and, institute evidence-based interventions that will compromise the patients' survival and recovery.