Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia

The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit

OBJECTIVE

The purpose of this study was to determine the effects of a simple low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit.

DESIGN

Preintervention and postintervention observational study.

SETTING

Twenty-four bed surgical/trauma/burn intensive care units in an urban university hospital.

PATIENTS

All mechanically ventilated patients that were admitted to the intensive care unit between June 1, 2004 and May 31, 2005.

INTERVENTIONS

An oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients' teeth with sodium monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent application of a 0.12% chlorhexidine gluconate chemical solution done twice daily at 12-hour intervals.

MEASUREMENTS AND MAIN RESULTS

During the preintervention period from June 1, 2003 to May 31, 2004, there were 24 infections in 4606 ventilator days (rate = 5.2 infections per 1000 ventilator days). After the institution of the oral care protocol, there were 10 infections in 4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days. This 46% reduction in ventilator-associated pneumonia was statistically significant (P = .04). Staff compliance with the oral care protocol during the 12-month period was also monitored biweekly and averaged 81%. The total cost of the oral care protocol was US$2187.49. There were 14 fewer cases of ventilator-associated pneumonia, which led to a decrease in cost of US$140 000 to US$560 000 based on the estimated cost per ventilator-associated pneumonia infection of US$10 000 to US$40 000. There was an overall reduction in ventilator-associated pneumonia without a change to the gram-negative or gram-positive microorganism profile.

CONCLUSIONS

The implementation of a simple, low-cost oral care protocol in the surgical intensive care unit led to a significantly decreased risk of acquiring ventilator-associated pneumonia.

Bile acid aspiration in suspected ventilator-associated pneumonia

AIMS

The aims of this study were to measure the levels of bile acids in patients with suspected ventilator-associated pneumonia (VAP) and provide a possible pathway for neutrophilic inflammation to explain its proinflammatory effect on the airway.

METHODS

Bile acid levels were measured by spectrophotometric enzymatic assay, and liquid chromatography mass spectrometry was used to quantify the major bile acids. Alveolar cells were grown on modified air-liquid interface culture inserts, and bile acids were then employed to stimulate the cells. Reverse transcriptase polymerase chain reaction and Western blots were used to determine the involved gene expression and protein levels.

RESULTS

The mean (+/- SE) concentration of total bile acids in tracheal aspirates was 6.2 +/- 2.1 and 1.1 +/- 0.4 mumol/L/g sputum, respectively, for patients with and without VAP (p < 0.05). The interleukin (IL)-8 level was significantly higher in the VAP group (p < 0.05). The major bile acid, chenodeoxycholic acid, stimulated alveolar epithelial cells to increase IL-8 production at both the messenger RNA and protein level through p38 and c-Jun N-terminal kinase (JNK) activation. The selective p38 and JNK inhibitors, as well as dexamethasone, successfully inhibited IL-8 production.

CONCLUSION

These data suggest that early intervention to prevent bile acid aspiration may reduce the intensity of neutrophilic inflammation in intubated and mechanically ventilated patients in the ICU.

Prevention of nosocomial infections in the intensive care unit

Infections are considered nosocomial if they occur 48 hours or more after hospital admission or within 30 days after discharge. One third of these infections are considered preventable. Many studies have shown that with proper education and use of strict guidelines, we can prevent nosocomial infections in the intensive care unit. In this article, we will review the literature on preventing catheter-associated urinary tract infection, central line-associated blood stream infection, and ventilator-associated pneumonia.

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.

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.

Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy

These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention, diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues, equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated pneumonia.

Cost of hospital-wide activities to improve patient safety and infection control: a multi-centre study in Japan

OBJECTIVE

The aim of this study was to assess the financial costs to hospitals for the implementation of hospital-wide patient safety and infection control programs.

METHODS

We conducted questionnaire surveys and structured interviews in seven acute-care teaching hospitals with an established reputation for their efforts towards improving patient safety. We defined the scope of patient safety activities by use of an incremental activity measure between 1999 and 2004. Hospital-wide incremental manpower, material, and financial resources to implement patient safety programs were measured.

RESULTS

The total incremental activities were 19,414-78,540 person-hours per year. The estimated incremental costs of activities for patient safety and infection control were calculated as US$ 1.100-2.335 million per year, equivalent to the employment of 17-40 full-time healthcare staff. The ratio of estimated costs to total medical revenue ranged from 0.55% to 2.57%. Smaller hospitals tend to shoulder a higher burden compared to larger hospitals.

CONCLUSIONS

Our study provides a framework for measuring hospital-wide activities for patient safety. Study findings suggest that the total amount of resources is so great that cost-effective and evidence-based health policy is needed to assure the sustainability of hospital safety programs.

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.

Pneumonie

nach dem ursächlichem Agens (virale, bakterielle, mykotische oder atypische)

nach klinischem Verlauf (akut, chronisch)

nach dem Ort, an dem die Infektion erworben wurde:

ambulant, außerhalb des Krankenhauses erworbene Pneumonie („community acquired pneumonia“; CAP)

nosokomial erworbene Pneumonie („hospital acquired pneumonia“; HAP); hierzu zählen die

beatmungsassoziierte Pneumonie („ventilator associated pneumonia“; VAP ) und die

Pneumonie bei Patienten, welche aus dem Alten- oder Pflegeheim stammen („health care acquired pneumonia“; HCAP)

3.

Pneumonien bei immunsupprimierten Patienten

•

primäre und sekundäre Pneumonien (als Folge bestimmter Grunderkrankungen, Bronchiektasien, Aspiration, Inhalationsintoxikation, Lungeninfarkt etc.)

Improved extubation rates and earlier liberation from mechanical ventilation with implementation of a daily spontaneous-breathing trial protocol

BACKGROUND

Daily spontaneous-breathing trials (SBTs) are promulgated as the best method for assessing readiness for discontinuation of mechanical ventilation. SBT protocols have also been shown to improve outcomes as opposed to wild-type implementation of daily SBT recommendations. Here we determine whether implementation of a mandatory, protocol-driven daily SBT on all ventilated patients in the ICU improves extubation rates and accelerates liberation from mechanical ventilation.

STUDY DESIGN

A daily 30-minute SBT protocol was introduced into an academic surgical ICU in July 2005 and followed through September 2006. Decisions about next steps (continued mechanical support versus liberation) after each trial were recorded. Owing to the low liberation rate, physicians began (in January 2006) recording the reasons for continuing mechanical ventilation after a passing SBT. Differences in patient outcomes were compared for the first and last 8 weeks of the study period, corresponding to similar times in the academic and calendar years.

RESULTS

Four hundred eighty-eight patients experienced 547 mechanical ventilation episodes from July 2005 to September 2006. A total of 2,835 safety evaluations for SBTs were completed. Rate of extubations of passing patients after the first 8 weeks of implementation (n = 73 patients) was 27% (35 extubations of 131 passed trials). This rate improved in the last 8 weeks to 42% (42 of 101) (p < 0.02) (n = 57 patients). Reintubation rate was similar at 6% for the first 8 weeks and 8% for the final 8 weeks (p = 0.65), including self-extubations.

CONCLUSIONS

Implementation of a daily SBT protocol resulted in improvement of extubation rates during the year of implementation without a change in the reintubation rate. Requesting that physicians enumerate reasons for continuing mechanical ventilation in the face of a passing breathing trial was associated with a sustained improvement in extubation rate.

Nosocomial pneumonia in the ICU: a prospective cohort study

Ventilator-associated pneumonia (VAP) is the most common intensive care unit (ICU)-acquired infection among patients requiring mechanical ventilation. A prospective surveillance programme of all patients has been implemented at the ICU, Karolinska University Hospital, Sweden since 2001. Within this programme, incidence and risk factors for ICU-acquired pneumonia and associated death over a 2-y period have been studied. Of 329 patients enrolled in the study, 221 required mechanical ventilation. 33 of 221 patients (15%) developed VAP, corresponding to a rate of 29 VAP/1000 ventilator d. Risk factors for VAP were aspiration (hazard ratio 3.79; 95% CI 1.48-9.68), recent surgery (HR 3.58; 95% CI 1.15-11.10) and trauma (HR 3.00; 95% CI 1.03-8.71). 11 patients of 33 (33%) with VAP died within 28 d compared to 46 of 288 (16%) without ICU-acquired pneumonia (odds ratio 2.73; 95% CI 0.97-7.63). We conclude that: 1) incidence of VAP was 15% and the most important risk factor was aspiration; 2) APACHE II score > or = 20 is a stronger predictor for poor outcome than VAP; 3) a minority of patients with APACHE II score > or = 20 develop VAP; and 4) continuous surveillance programmes are feasible and provide valuable data for improvement of quality of care.

Effectiveness of an Educational Program to Reduce Ventilator-Associated Pneumonia in a Tertiary Care Center in Thailand: A 4-Year Study

BACKGROUND

Ventilator-associated pneumonia (VAP) is considered to be an important cause of infection-related death and morbidity in intensive care units (ICUs). We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU (MICU).

METHODS

A 4-year controlled, prospective, quasi-experimental study was conducted in an MICU, surgical ICU (SICU), and coronary care unit (CCU) for 1 year before the intervention (period 1), 1 year after the intervention (period 2), and 2 follow-up years (period 3). The SICU and CCU served as control ICUs. The educational program involved respiratory therapists and nurses and included a self-study module with preintervention and postintervention assessments, lectures, fact sheets, and posters.

RESULTS

Before the intervention, there were 45 episodes of VAP (20.6 cases per 1000 ventilator-days) in the MICU, 11 (5.4 cases per 1000 ventilator-days) in the SICU, and 9 (4.4 cases per 1000 ventilator-days) in the CCU. After the intervention, the rate of VAP in the MICU decreased by 59% (to 8.5 cases per 1000 ventilator-days; P=.001) and remained stable in the SICU (5.6 cases per 1000 ventilator-days; P=.22) and CCU (4.8 cases per 1000 ventilator-days; P=.48). The rate of VAP in the MICU continued to decrease in period 3 (to 4.2 cases per 1000 ventilator-days; P=.07), and rates in the SICU and CCU remained unchanged. Compared with period 1, the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 (P<.001) and by 8.9 days in period 3 (P<.001). The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50% (P<.001) and 37%-45% (P<.001), respectively.

CONCLUSIONS

A focused education intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of hospitalization.

Impact of a protocol for prevention of ventilator-associated pneumonia

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Critical Care Nurses’ Knowledge of Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia: An Evaluation Questionnaire

Background Nurses’ lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia.

Objective To develop a reliable and valid questionnaire for evaluating critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia.

Methods Ten nursing-related interventions were identified from a review of evidence-based guidelines for preventing ventilator-associated pneumonia. Selected interventions and multiple-choice questions (1 question per intervention) were subjected to face and content validation. Item difficulty, item discrimination, and the quality of the response alternatives or options for answers (possible responses) were evaluated on the test results of 638 critical care nurses.

Results Face and content validity were achieved for 9 items. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.10 to 0.65. The quality of the response alternatives led to the detection of widespread misconceptions among critical care nurses.

Conclusion The questionnaire is reliable and has face and content validity. Results of surveys with this questionnaire can be used to focus educational programs on preventing ventilator-associated pneumonia.

The methodological quality of economic evaluations of guideline implementation into clinical practice: a systematic review of empiric studies

OBJECTIVES

Despite the emphasis on efficiency of health-care services delivery, there is an imperfect evidence base to inform decisions about whether and how to develop and implement guidelines into clinical practice. In general, studies evaluating the economics of guideline implementation lack methodological rigor. We conducted a systematic review of empiric studies to assess advances in the economic evaluations of guideline implementation.

METHODS

The Cochrane Effective Professional and Organisational Change Group specialized register and the MEDLINE database were searched for English publications between January 1998 and July 2004 that reported objective effect measures and implementation costs. We extracted data on study characteristics, quality of study design, and economic methodology. It was assessed whether the economic evaluations followed methodological guidance.

RESULTS

We included 24 economic evaluations, involving 21 controlled trials and three interrupted time series designs. The studies involved varying settings, targeted professionals, targeted behaviors, clinical guidelines, and implementation strategies. Overall, it was difficult to determine the quality of study designs owing to poor reporting. In addition, most economic evaluations were methodologically flawed: studies did not follow guidelines for evaluation design, data collection, and data analysis.

CONCLUSIONS

The increasing importance of the value for money of providing health care seems to be reflected by an increase in empiric economic evaluations of guideline implementation. Because of the heterogeneity and poor methodological quality of these studies, however, the resulting evidence is still of limited use in decision-making. There seems to be a need for more methodological guidance, especially in terms of data collection and data synthesis, to appropriately evaluate the economics of developing and implementing guidelines into clinical practice.

Ventilator-associated pneumonia improvement program

Ventilator-associated pneumonia (VAP) is a significant clinical problem associated with increased intensive care unit and hospital length of stay and substantial increases in delivery cost and associated morbidity and mortality. With system changes and management of the environment of care, the incidence of VAP was reduced in seven of our intensive care units across the system. Steps necessary to reduce VAP were identified and put into place in all the intensive care units. Patient positioning, oral care, nutrition, and management of comfort drugs are a few of the processes addressed to reduce VAP. Standardization of these essential care practices can reduce the incidence of this nosocomial infection and its associated increases in the cost of care delivery and mortality.

Economic implications of an evidence-based sepsis protocol: can we improve outcomes and lower costs?

OBJECTIVE

To determine the financial impact of a sepsis protocol designed for use in the emergency department.

DESIGN

Retrospective analysis of a before-after study testing the implications of sepsis protocol.

SETTING

Academic, tertiary care hospital in the United States.

PATIENTS

Persons with septic shock presenting to the emergency department.

INTERVENTIONS

A multifaceted protocol developed from recent scientific literature on sepsis and the Surviving Sepsis Campaign. The protocol emphasized identification of septic patients, aggressive fluid resuscitation, timely antibiotic administration, and appropriateness of antibiotics, along with other adjunctive, supportive measures in sepsis care.

MEASUREMENTS AND MAIN RESULTS

We compared patients treated before the protocol with those cared for after the protocol was implemented. Overall hospital costs represented the primary end point, whereas hospital length of stay served as a secondary end point. All hospital costs were calculated based on charges after conversion to costs based on department-specific cost-to-charge ratios. We also attempted to measure the independent impact of the protocol on costs through linear regression. We conducted a sensitivity analysis assessing these end points in the subgroup of subjects who survived their hospitalization. The total cohort included 120 subjects (evenly divided into the before and after cohorts) with a mean age of 64.7 +/- 18.2 yrs and median Acute Physiology and Chronic Health Evaluation II score of 22.5 +/- 8.3. There were more survivors following the protocol's adoption (70.0% vs. 51.7%, p = .040). Median total costs were significantly lower with use of the protocol ($16,103 vs. $21,985, p = .008). The length of stay was also on average 5 days less among the postintervention population (p = .023). A Cox proportional hazard model indicated that the protocol was independently associated with less per-patient cost. Restricting the analysis to only survivors did not appreciably change our observations.

CONCLUSIONS

Use of a sepsis protocol can result not only in improved mortality but also in substantial savings for institutions and third party payers. Broader implementation of sepsis treatment protocols represents a potential means for enhancing resource use while containing costs.

Article Commentary: Strategies in the Prevention and Management of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in the intensive care unit. Prevention of VAP is possible through the use of several evidence-based strategies intended to minimize intubation, the duration of mechanical ventilation, and the risk of aspiration of oropharyngeal pathogens. Current data favor the quantitative analysis of lower respiratory tract cultures for the diagnosis of VAP, accompanied by the initiation of broad-spectrum empiric antimicrobial therapy based on patient risk factors for infection with multi-drug-resistant pathogens and data from unit-specific antibiograms. Eventual choice of antibiotic and duration of therapy are selected based on culture results and patient stability, with an emphasis on minimization of unnecessary antibiotic use.

[Diagnosis and therapy of sepsis]

A recent survey conducted by the publicly funded Competence Network Sepsis (Sep- Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change

BACKGROUND

Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost.

CONTEXT

Our hospital is located in Northern Mississippi and has a 28 bed Medical-Surgical ICU unit with 95% occupancy. We joined the ICU collaborative with the IMPACT initiative of the Institute of Healthcare Improvement (IHI) in October 2002. A preliminary prospective before (fiscal year (FY) 2001-2) and after (FY 2003) hypothesis generating study was conducted of outcomes resulting from small tests of change in the management of ICU patients.

KEY MEASURES FOR IMPROVEMENT

Nosocomial infection rates, adverse events per ICU day, average length of stay, and average cost per ICU episode.

STRATEGY FOR CHANGE

Four changes were implemented: (1) physician led multidisciplinary rounds; (2) daily "flow" meeting to assess bed availability; (3) "bundles" (sets of evidence based best practices); and (4) culture changes with a focus on the team decision making process.

EFFECTS OF CHANGE

Between baseline and re-measurement periods, nosocomial infection rates declined for ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) and bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), with a downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode. From FY 2002 to FY 2003 the cost per ICU episode fell from $3406 to $2973.

LESSONS LEARNED

A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs.

Bringing quality improvement into the intensive care unit

BACKGROUND

During the last several years, many governmental and nongovernmental organizations have championed the application of the principles of quality improvement to the practice of medicine, particularly in the area of critical care.

OBJECTIVE

To review the breadth of approaches to quality improvement in the intensive care unit, including measures such as mortality and length of stay, and the use of protocols, bundles, and the role of large, multiple-hospital collaboratives.

RESULTS

Several agencies have participated in the application of the quality movement to medicine, culminating in the development of standards such as the intensive care unit core measures of the Joint Commission on Accreditation of Healthcare Organizations. Although "zero defects" may not be possible in all measurable variables of quality in the intensive care unit, several measures, such as catheter-related bloodstream infections, can be significantly reduced through the implementation of improved processes of care, such as care bundles. Large, multiple-center, quality improvement collaboratives, such as the Michigan Keystone Intensive Care Unit Project, may be particularly effective in improving the quality of care by creating a "bandwagon effect" within a geographic region.

CONCLUSION

The quality revolution is having a significant effect in the critical care unit and is likely to be facilitated by the transition to the electronic medical record.

Évaluation de la prescription antibiotique dans un service de réanimation pédiatrique

The antibiotic prescription in intensive care units is frequent using often broad-spectrum antibiotics; its quality has never been evaluated in paediatric intensive care units.

OBJECTIVES

To describe the modalities of antibiotic prescriptions in a paediatric intensive care unit and confront them to the literature guidelines and bacteriological data.

METHODS

From January 1st to March 31st 2005, 52 consecutive prescriptions regarding 45 children, with a total of 47 hospitalisations were prospectively analysed.

RESULTS

Confirmed diagnosis of bacterial infection was retained for 50 of the 52 patients: community acquired infection in 35 cases (70%) and a nosocomial infection in 15 cases. Ten children died during the antibiotic treatment (22%), with 5 deaths related to the infection (11%). Monotherapy represented 56% of the prescriptions of antibiotics. The initial antibiotic treatment was empirical in 42 of 52 cases (81%). The empirical prescriptions were documented afterward in 48% of cases. One or more microorganisms were isolated for 60% of the initial prescriptions. Misuses in antibiotic doses (in excess [10%] or by insufficiency [13%]), number of daily administration (4%), and way of administration and/or length of treatment were observed. Seventy-seven percent of the initial prescriptions seemed to be adapted to the identified or suspected bacteria, but only 63% adequate to recommendations.

CONCLUSION

Almost 2/3rd of the antibiotic prescriptions were adequate to the recommendations. The implementation of standardized and specific protocols should contribute to improve the quality of these prescriptions.

Evidence-Based Practice: Use of the Ventilator Bundle to Prevent Ventilator-Associated Pneumonia

• Purpose To examine critical care nurses’ knowledge about the use of the ventilator bundle to prevent ventilator-associated pneumonia.

• Method Published reports were reviewed for current evidence on the use of the ventilator bundle to prevent ventilator-associated pneumonia, and education sessions were held to present the findings to 61 nurses in coronary care and surgical intensive care units. Changes in the nurses’ knowledge were evaluated by using a 10-item test, given both before and after the sessions. Changes in the nurses’ practices related to ventilator-associated pneumonia, including elevation of the head of the bed to 30° to 45°, were observed in 99 intubated patients.

• ResultsAfter the education sessions, the nurses performed better on 8 of the 10 items tested (P from .03 to &lt;.001). The areas of most significant improvement were elevation of the head of the bed (P &lt; .001), charting of the elevation of the head of the bed (P= .009), oral care (P= .009), checking of the nasogastric tube for residual volume (P = .008), washing of hands before contact with patients (P &lt; .001), and limiting the wearing of rings (P &lt; .001) and nail polish (P = .04). Even after the education sessions, the nurses’ compliance with hand-washing recommendations before contact with patients was low, though statistically some improvement was apparent. Contraindications to elevation of the head of the bed did not appear to affect the nurses’ practices (P= .38).

• Conclusion Education sessions designed to inform nurses about the ventilator bundle and its use to prevent ventilator-associated pneumonia have a significant effect on participants’ knowledge and subsequent clinical practice.

Guidelines for the validation and application of typing methods for use in bacterial epidemiology

For bacterial typing to be useful, the development, validation and appropriate application of typing methods must follow unified criteria. Over a decade ago, ESGEM, the ESCMID (Europen Society for Clinical Microbiology and Infectious Diseases) Study Group on Epidemiological Markers, produced guidelines for optimal use and quality assessment of the then most frequently used typing procedures. We present here an update of these guidelines, taking into account the spectacular increase in the number and quality of typing methods made available over the past decade. Newer and older, phenotypic and genotypic methods for typing of all clinically relevant bacterial species are described according to their principles, advantages and disadvantages. Criteria for their evaluation and application and the interpretation of their results are proposed. Finally, the issues of reporting, standardisation, quality assessment and international networks are discussed. It must be emphasised that typing results can never stand alone and need to be interpreted in the context of all available epidemiological, clinical and demographical data relating to the infectious disease under investigation. A strategic effort on the part of all workers in the field is thus mandatory to combat emerging infectious diseases, as is financial support from national and international granting bodies and health authorities.

[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Epidemiology of intensive care unit (ICU)-acquired infections in a 14-month prospective cohort study in a single mixed Scandinavian university hospital ICU

BACKGROUND

Our aim was to evaluate the epidemiology of intensive care unit (ICU)-acquired infections in a prospective cohort study.

METHODS

Patients with longer than a 48-h stay in an adult mixed medical-surgical ICU in a tertiary level teaching hospital were included. The incidence (per cent) and incidence density (per 1000 patient days) of ICU-acquired infections and the device-associated infection rates per 1000 device days were analysed prospectively in a 14-month study.

RESULTS

Eighty (23.9%) of 335 patients, whose ICU stay was longer than 48 h, acquired a total of 107 infections (1.3 per patient) during their ICU stay, with an infection rate of 48 per 1000 patient days. The most common infections were ventilator-associated pneumonia (VAP) [33.8% (18.8 per 1000 respiratory days)], other lower respiratory tract infections (LRTIs) (20%) and sinusitis (13.8%). The rate of central catheter-related (CRI) or primary bloodstream infections was 6.3% (2.2 per 1000 central venous catheter days), and the rate of urinary tract infections was 1.3% (0.5 per 1000 urinary catheter days). The first ICU infection was observed in 58.8% (47/80) of cases within 6 days after admission. The median time from admission to the diagnosis of an ICU-acquired infection was 4 days (25th-75th percentiles, 4.0-6.0) for VAP, 6.0 days (4.5-7.0) for LRTIs and 9.5 days (6.5-13.0) for CRIs.

CONCLUSIONS

The rates of urinary tract infections and bloodstream infections were lower than reported previously, differentiating our results from the classic pattern of ICU-acquired infections, with the exception of the predominance of VAP.

Using Evidence and Process Improvement Strategies to Enhance Healthcare Outcomes for the Critically Ill: A Pilot Project

• Background Although the value of evidence-based practice may seem obvious, the process needed to produce more effective delivery of evidence-based healthcare is not obvious. Furthermore, the continuing escalation of healthcare costs fuels the desire of providers and consumers to undertake only those treatments that have benefit. One way to effect necessary changes in healthcare organizations is through focused, interdisciplinary, collaborative projects related to evidence-based practice.

• Objectives To reduce rates of ventilator-associated pneumonia and catheter-related bloodstream infection in patients in the medical intensive care unit of a large, urban tertiary referral hospital in the Southwest.

• Methods The theory of planned behavior served as the basis for providing staff members with research-based, easily controllable strategies that “fit” with the usual methods of care delivery. Implementation of the strategies and data collection were accomplished through routine rounds on patients and regular reporting of objective information.

• Results During a 15-month period, use of the selected strategies resulted in a 54% reduction in ventilator-associated pneumonia, a 78% reduction in catheter-related bloodstream infections, and a 18% reduction in mean length of stay in the unit. Use of a multidisciplinary, environmentally tailored approach to concerns about patients’ care resulted in estimated cost savings of $1.0 million to $2.3 million.

• Conclusions Early, consistent communication about the project’s rationale, expected behavior, and outcomes enhanced the manageability and effectiveness of this change in an adult intensive care unit.

Ventilator-associated pneumonia: diagnosis, treatment, and prevention

While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.