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The Impact of a Multidisciplinary Education Program for Intensive Care Unit Staff Regarding Ventilator Care Bundle on the Frequency of Ventilator-Associated Events. Dimens Crit Care Nurs 2021; 40:210-216. [PMID: 34033440 DOI: 10.1097/dcc.0000000000000484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Ventilator bundles have been reported to reduce the risk of ventilator-associated pneumonia. However, data concerning the role of the education of the intensive care unit (ICU) staff regarding the items in the bundle and the importance to adhere to its items on the development of ventilator-associated events (VAEs) are limited. This study aimed to compare the frequency of VAEs in subjects admitted to the ICU before and after the education of the ICU staff. METHODS A total of 105 subjects were enrolled in this retrospective study. The ICU staff, including the physicians, respiratory therapists, and nurses, received a 2-day educational lecture regarding items in the bundle as well as the need to adhere to its items. The study population was divided into two according to the admission date: subjects who were admitted before the education of the ICU staff regarding the ventilator bundle (preeducation) and subjects who were admitted after the education of the ICU staff regarding the ventilator bundle (posteducation). The difference in VAE rate in subjects admitted before and after bundle training was the primary outcome measure of this study. RESULTS The bundle compliance rates presented by days were significantly higher in the posteducation group compared with the preeducation group. Moreover, the frequency of VAEs was significantly lower in posteducation subjects compared with preeducation subjects (4.7% vs 19.0%, P = .042). Ventilator-associated event rate was also lower in posteducation subjects compared with preeducation subjects (2.5/1000 vs 9.8/1000 ventilator days). There were no significant differences among the groups with respect to ICU mortality. CONCLUSION The educational intervention performed in this study not only increased the adherence to the ventilator care bundle but also led to a significant reduction in the rate of the VAEs in patients receiving mechanical ventilator support in the ICU.
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Sole ML, Talbert S, Yan X, Penoyer D, Mehta D, Bennett M, Emery KP, Middleton A, Deaton L, Abomoelak B, Deb C. Impact of deep oropharyngeal suctioning on microaspiration, ventilator events, and clinical outcomes: A randomized clinical trial. J Adv Nurs 2019; 75:3045-3057. [PMID: 31241194 PMCID: PMC8331062 DOI: 10.1111/jan.14142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/18/2019] [Accepted: 06/13/2019] [Indexed: 12/12/2022]
Abstract
AIMS To evaluate a deep oropharyngeal suction intervention (NO-ASPIRATE) in intubated patients on microaspiration, ventilator-associated events and clinical outcomes. DESIGN Prospective, two-group, single-blind, randomized clinical trial. METHODS The study was conducted between 2014 - 2017 in 513 participants enroled within 24 hr of intubation and randomized into NO-ASPIRATE or usual care groups. Standard oral care was provided to all participants every 4 hr and deep oropharyngeal suctioning was added to the NO-ASPIRATE group. Oral and tracheal specimens were obtained to quantify α-amylase as an aspiration biomarker. RESULTS Data were analysed for 410 study completers enrolled at least 36 hr: NO-ASPIRATE (N = 206) and usual care (N = 204). Percent of tracheal specimens positive for α-amylase, mean tracheal α-amylase levels over time and ventilator-associated events were not different between groups. The NO-ASPIRATE group had a shorter hospital length of stay and a subgroup with moderate aspiration at baseline had significantly lower α-amylase levels across time. CONCLUSION Hospital length of stay was shorter in the NO-ASPIRATE group and a subgroup of intervention participants had lower α-amylase across time. Delivery of standardized oral care to all participants may have been an intervention itself and possibly associated with the lack of significant findings for most outcomes. IMPACT This trial compared usual care to oral care with a deep suctioning intervention on microaspiration and ventilator-associated events, as this has not been systematically studied. Further research on the usefulness of α-amylase as an aspiration biomarker and the role of oral suctioning, especially for certain populations, is indicated. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT02284178.
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Affiliation(s)
- Mary Lou Sole
- University of Central Florida College of Nursing, Orlando, Florida
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, Florida
| | - Steven Talbert
- University of Central Florida College of Nursing, Orlando, Florida
| | - Xin Yan
- Department of Statistics, University of Central Florida College of Sciences, Orlando, Florida
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, Florida
| | - Devendra Mehta
- Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando, Florida
| | - Melody Bennett
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, Florida
| | | | - Aurea Middleton
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, Florida
| | - Lara Deaton
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, Florida
| | - Bassam Abomoelak
- Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando, Florida
| | - Chirajyoti Deb
- Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando, Florida
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van Mourik MSM, Perencevich EN, Gastmeier P, Bonten MJM. Designing Surveillance of Healthcare-Associated Infections in the Era of Automation and Reporting Mandates. Clin Infect Dis 2019. [PMID: 29514241 DOI: 10.1093/cid/cix835] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Surveillance and feedback of infection rates to clinicians and other stakeholders is a cornerstone of healthcare-associated infection (HAI) prevention programs. In addition, HAIs are increasingly included in public reporting and payment mandates. Conventional manual surveillance methods are resource intensive and lack standardization. Developments in information technology have propelled a movement toward the use of standardized and semiautomated methods.When developing automated surveillance systems, several strategies can be chosen with regard to the degree of automation and standardization and the definitions used. Yet, the advantages of highly standardized surveillance may come at the price of decreased clinical relevance and limited preventability. The choice among (automated) surveillance approaches, therefore, should be guided by the intended aim and scale of surveillance (eg, research, in-hospital quality improvement, national surveillance, or pay-for-performance mandates), as this choice dictates subsequent methods, important performance characteristics, and suitability of the data generated for the different applications.
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Affiliation(s)
- Maaike S M van Mourik
- Department of Medical Microbiology and Infection Control, University Medical Center Utrecht, The Netherlands
| | - Eli N Perencevich
- Department of Internal Medicine, University of Iowa Carver College of Medicine and Iowa City VA Health Care System
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | - Marc J M Bonten
- Department of Medical Microbiology and Infection Control, Bilthoven, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Bilthoven, The Netherlands.,Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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Barriers to the adoption of ventilator-associated events surveillance and prevention. Clin Microbiol Infect 2019; 25:1180-1185. [DOI: 10.1016/j.cmi.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/28/2019] [Accepted: 03/28/2019] [Indexed: 12/12/2022]
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Chumpia MM, Ganz DA, Chang ET, de Peralta SS. Reducing the rare event: lessons from the implementation of a ventilator bundle. BMJ Open Qual 2019; 8:e000426. [PMID: 31259278 PMCID: PMC6568166 DOI: 10.1136/bmjoq-2018-000426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 04/02/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022] Open
Abstract
The ventilator-associated event (VAE) is a potentially avoidable complication of mechanical ventilation (MV) associated with poor outcomes. Although rare, VAEs and other nosocomial events are frequently targeted for quality improvement efforts consistent with the creed to ‘do no harm’. In October 2016, VA Greater Los Angeles (GLA) was in the lowest-performing decile of VA medical centres on a composite measure of quality, owing to GLA’s relatively high VAE rate. To decrease VAEs, we sought to reduce average MV duration of patients with acute respiratory failure to less than 3 days by 1 July 2017. In our first intervention (period 1), intensive care unit (ICU) attending physicians trained residents to use an existing ventilator bundle order set; in our second intervention (period 2), we updated the order set to streamline order entry and incorporate new nurse-driven and respiratory therapist (RT)-driven spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) protocols. In period 1, the proportion of eligible patients with SAT and SBT orders increased from 29.9% and 51.2% to 67.4% and 72.6%, respectively, with sustained improvements through December 2017. Mean MV duration decreased from 7.2 days at baseline to 5.5 days in period 1 and 4.7 days in period 2; statistical process control charts revealed no significant differences, but the difference between baseline and period 2 MV duration was statistically significant at p=0.049. Bedside audits showed RTs consistently performed indicated SBTs, but there were missed opportunities for SATs due to ICU staff concerns about the SAT protocol. The rarity of VAEs, small population of ventilated patients and infrequent use of sedative infusions at GLA may have decreased the opportunity to achieve staff acceptance and use of the SAT protocol. Quality improvement teams should consider frequency of targeted outcomes when planning interventions; rare events pose challenges in implementation and evaluation of change.
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Affiliation(s)
- Maryanne Matinee Chumpia
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - David A Ganz
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Evelyn T Chang
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Shelly S de Peralta
- Nursing, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Ramirez-Estrada S, Peña-Lopez Y, Kalwaje Eshwara V, Rello J. Ventilator-associated events versus ventilator-associated respiratory infections-moving into a new paradigm or merging both concepts, instead? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:425. [PMID: 30581833 PMCID: PMC6275412 DOI: 10.21037/atm.2018.10.54] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/21/2018] [Indexed: 01/06/2023]
Abstract
Despite ventilator-associated respiratory infections (VARI) are reported as the most common and fatal complications related to mechanical ventilation (MV), they are not the unique occurrences. The new classification of ventilator-associated events (VAE) proposed by the centers for disease control and prevention (CDC) enhance the spectra of complications due to MV including both infection-related and non-infectious events. Both VAEs and VARIs are associated with prolonged duration of MV, longer stay in hospital and in the intensive care unit (ICU) and more antibiotic consumption, nonetheless patients with VAEs have worst outcomes. The VARI and VAE algorithms are focused on different targets and the correlation between both classifications is shown to be poor. The diagnostic criteria of the traditional classification have limited accuracy and the non-infectious complications may be misinterpreted as VARI. While the VAE surveillance enhances the spectra of MV complications but excludes less severe VARIs. Noninfective events explain up to 30% of VAEs, the main causes being atelectasis, acute respiratory distress syndrome, pulmonary edema and pulmonary embolism. The bundles assessing VAE are associated with less incidence of VAP and improved outcomes but they fail to reduce the rates of VAE. Automated VAE surveillance is efficient and useful as a quality indicator in the ICU while the differences in the interpretation of VARI criteria limit its role in the design of global protocols and preventive strategies. We suggest that a more comprehensive strategy should combine both algorithms with emphasis on clinical outcomes.
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Affiliation(s)
- Sergio Ramirez-Estrada
- Critical Care Department, Clínica Corachan, Barcelona, Spain
- Medicine Department, Universitat Autónoma de Barcelona, (UAB), Barcelona, Spain
| | | | - Vandana Kalwaje Eshwara
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Jordi Rello
- Vall d'Hebron Institut of Research, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBERES), Instituto Salud Carlos III, Madrid, Spain
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Álvarez-Lerma F, Sánchez García M. "The multimodal approach for ventilator-associated pneumonia prevention"-requirements for nationwide implementation. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:420. [PMID: 30581828 PMCID: PMC6275409 DOI: 10.21037/atm.2018.08.40] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/17/2018] [Indexed: 01/06/2023]
Abstract
The multimodal approach for ventilator-associated pneumonia (VAP) prevention has been shown to be a successful strategy in reducing VAP rates in many intensive care units (ICU) in some countries. The simultaneous application of several measures or "bundles" to reduce VAP rates has achieved a higher impact than the progressive implementation of the individual interventions. The ultimate objective of recommendation bundles is their integration in the culture of routine healthcare of the staff in charge of ventilated patients for accomplished rates to persist over time. The noteworthy elements of this new strategy include the selection of the individual recommendations of the bundle, education of care workers (HCW) in the culture of patient safety, audit of compliance with the recommendations, commitment of the hospital management to support implementation, nomination and empowerment of local leaders of the projects in ICUs, both physicians and nurses, and the continuous collection of VAP episodes. The implementation of this new strategy is not an easy task, as both its inherent strength and important barriers to its application have become evident, which need to be overcome for maximal reduction of VAP rates.
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Affiliation(s)
- Francisco Álvarez-Lerma
- Service of Intensive Care Medicine, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M. Sánchez García
- Department of Critical Care, Hospital Clínico San Carlos, Madrid, Spain
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Trends of Incidence and Risk Factors of Ventilator-Associated Pneumonia in Elderly Patients Admitted to French ICUs Between 2007 and 2014*. Crit Care Med 2018; 46:869-877. [DOI: 10.1097/ccm.0000000000003019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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“Bundle” Practices and Ventilator-Associated Events: Not Enough – ERRATUM. Infect Control Hosp Epidemiol 2017. [DOI: 10.1017/ice.2017.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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