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

Performance of a multidisciplinary team and the impact of bundles for reducing health care associated infections in adult intensive care unit: 22 years of experience

A retrospective cohort study was conducted to evaluate the bundle of techniques developed by the multidisciplinary team to minimize infections in an adult intensive care unit over a 22-year span. Two periods were analyzed: 1996-2006 and 2007-2017. Bloodstream infections, urinary tract infections, and ventilator-associated pneumonia declined 58.6%, 56.7%, and 82.6%, respectively (P < .05) from 2007 to 2017 compared with these same infections during 1996-2006.

Effectiveness of a Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia at the PICU: A Systematic Review and Meta-Analysis

OBJECTIVES

Ventilator-associated pneumonia is one of the most frequent hospital-acquired infections in mechanically ventilated children. We reviewed the literature on the effectiveness of ventilator care bundles in critically ill children.

DATA SOURCES

Embase, Medline OvidSP, Web-of-Science, Cochrane Library, and PubMed were searched from January 1990 until April 2017.

STUDY SELECTION

Studies were included if they met the following criteria: 1) implementation of a ventilator care bundle in PICU setting; 2) quality improvement or multicomponent approach with the (primary) objective to lower the ventilator-associated pneumonia rate (expressed as ventilator-associated pneumonia episodes/1,000 ventilator days); and 3) made a comparison, for example, with or without ventilator care bundle, using an experimental randomized or nonrandomized study design, or an interrupted-times series. Exclusion criteria were (systematic) reviews, guidelines, descriptive studies, editorials, or poster publications.

DATA EXTRACTION

The following data were collected from each study: design, setting, patient characteristics (if available), number of ventilator-associated pneumonia per 1,000 ventilator days, ventilator-associated pneumonia definitions used, elements of the ventilator care bundle, and implementation strategy. Ambiguities about data extraction were resolved after discussion and consulting a third reviewer (M.N., E.I.) when necessary. We quantitatively pooled the results of individual studies, where suitable. The primary outcome, reduction in ventilator-associated pneumonia per 1,000 ventilator days, was expressed as an incidence risk ratio with a 95% CI. All data for meta-analysis were pooled by using a DerSimonian and Laird random effect model.

DATA SYNTHESIS

Eleven articles were included. The median ventilator-associated pneumonia incidence decreased from 9.8 (interquartile range, 5.8-18.5) per 1,000 ventilator days to 4.6 (interquartile range, 1.2-8.6) per 1,000 ventilator days after implementation of a ventilator care bundle. The meta-analysis showed that the implementation of a ventilator care bundle resulted in significantly reduced ventilator-associated pneumonia incidences (incidence risk ratio = 0.45; 95% CI, 0.33-0.60; p < 0.0001; I = 55%).

CONCLUSIONS

Implementation of a ventilator-associated pneumonia bundle has the potential to reduce the prevalence of ventilator-associated pneumonia in mechanically ventilated children.

"The multimodal approach for ventilator-associated pneumonia prevention"-requirements for nationwide implementation

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.

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review

BACKGROUND

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes.

AIMS

The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.

METHODS

Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.

RESULTS

Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay.

CONCLUSION

Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.

RELEVANCE TO CLINICAL PRACTICE

Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

A Prospective One-Year Microbiologic Survey of Combined Pneumonia and Respiratory Failure

BACKGROUND

Pneumonia and respiratory failure are common problems in the intensive care unit (ICU) setting, often occurring together. The relative prevalence of pneumonia types (community acquired, hospital acquired, ventilator associated) and causative pathogens is not well described in patients with respiratory failure.

METHODS

This was a prospective observational cohort study conducted in the medical ICU (34 beds) of Barnes-Jewish Hospital, an academic referral center of 1,300 beds from January 2016-December 2016. All patients who were prospectively adjudicated to have respiratory failure and pneumonia (RFP) regardless of pneumonia type were classified into one of four microbiologic categories: pathogen negative, antibiotic-susceptible pathogen (according to ceftriaxone susceptibility), antibiotic-resistant pathogen, and viruses. The primary outcomes assessed were the hospital mortality rate and inappropriate initial antibiotic therapy (IIAT) for non-viral pathogens.

RESULTS

Among 364 consecutive patients with RFP, 63 (17.3%) had organisms that were antibiotic susceptible, 104 (28.6%) had antibiotic-resistant organisms, 118 (32.4%) were pathogen negative, and 79 (21.7%) had viral infections. For these categories, IIAT occurred in 3.2%, 21.2%, 0.8%, and 0, respectively (p < 0.001). Vasopressor-requiring shock was present in 61.9%, 72.1%, 68.6%, and 67.1%, respectively (p = 0.585), and the hospital mortality rates were 27.0%, 48.1%, 31.4%, and 36.7%, respectively (p = 0.020). Multivariable logistic regression analysis identified IIAT as an independent predictor of in-hospital death (adjusted odds ratio 5.28; 95% confidence interval 2.72-10.22; p = 0.012). Male gender, increasing Acute Physiology and Chronic Health Evaluation (APACHE) II scores, greater age, and the presence of shock also predicted death.

CONCLUSIONS

Microbiologic categorization of patients with RFP suggests that antibiotic-resistant pathogens and viruses are associated with the highest mortality rates. Vasopressor-requiring shock was common regardless of the microbiologic categorization of RFP. Future development and use of rapid diagnostics and novel therapeutics targeting specific RFP pathogens may allow more timely administration of appropriate antimicrobial therapy and enhance antibiotic stewardship practices.

An educational program for decreasing catheter-related bloodstream infections in intensive care units: a pre- and post-intervention observational study

Background

Central venous catheters (CVCs) are commonly used in the management of critically ill patients. This study aimed to determine whether an educational program could reduce the rate of catheter-related bloodstream infections (CRBSIs) in intensive care units (ICUs).

Findings

All patients admitted to a medical ICU at a college affiliated with the Japan Society of Intensive Care Medicine between January 2008 and December 2014 were surveyed prospectively for the development of CRBSIs. A mandatory educational program (the intervention) targeting an infection control committee consisting of physicians was developed by a multidisciplinary task force to highlight correct practices for preventing CRBSIs. The program included a 30-min video-based introduction, 120-min lectures with a number of hands-on training sessions, a post-test, posters, safety check sheets, and feedback from the infection control committee. Lectures based on the education program were held every 3 months, and participants were free to choose when they attended the lectures. Each participant was required to view the 30-min introduction before attending the 120-min lectures and complete the post-test after each lecture. Safety check sheets were made to ascertain adherence to contents of the educational program. Posters describing the educational program were posted throughout the ICU. A pre- and post-intervention observational study design was employed, with the main outcome measure being yearly CRBSIs. We also calculated cost savings that resulted from improved CRBSI rates.

During the 12-month pre-intervention period, four episodes of CRBSIs occurred in 1171 patient ICU-days (i.e., 3.4 per 1000 patient ICU-days). In the first year after the intervention, the rate of CRBSIs decreased to 0 in 1157 patient ICU-days (P ≤ 0.05). The estimated cost savings secondary to this decreased rate for the 1 year following introduction of the program was between 1850,000 and 27,000,000 yen ($14,800–$216,000).

Conclusions

A program aimed at educating healthcare providers on the prevention of CRBSIs led to a dramatic decrease in the rate of primary bloodstream infections. This suggests that educational programs may substantially decrease medical care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training.

Impact and feasibility of an emergency department-based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department

BACKGROUND

Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates.

METHODS

This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day.

RESULTS

PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ² = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11.

CONCLUSIONS

VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.

A targeted educational intervention to reduce ventilator-associated complications

The optimal approach for the prevention of ventilator-associated complications (VACs) is currently unknown. A retrospective pre-post intervention analysis was conducted to assess a multifaceted educational intervention targeting the most common causes for VACs and VAC risk factors. Results indicated that the addition of this intervention to existing infection control and treatment protocols did not demonstrate a decrease in VAC occurrence or duration of mechanical ventilation.

Staff education aimed at reducing ventilator-associated pneumonia

Mechanical ventilation is a life-saving invasive procedure performed in intensive care units (ICUs) where critical patients are given advanced support. The purpose of this study was to assess the effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study, performed prospectively in the ICU, was planned in two periods. In both periods, patient characteristics were recorded on patient data forms. In the second period, ICU physicians and assistant health personnel were given regular theoretical and practical training. Twenty-two cases of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced development of VAP by 31.7 %. Crude VAP mortality was 69 % in the first period and 26 % in the second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged hospitalization, increased number of days on mechanical ventilation, and enteral nutrition; risk factors determined in the first period were re-intubation, central venous catheter use and heart failure and, in the second period, erythrocyte transfusion >5 units (P<0.05). Prior to training, compliance with hand washing (before and after procedure), appropriate aseptic endotracheal aspiration and adequate oral hygiene in particular were very low. An improvement was observed after training (P<0.001). The training of personnel who will apply infection control procedures for the prevention of healthcare-associated infections is highly important. Hand hygiene and other infection control measures must be emphasized in training programmes, and standard procedures in patient interventions must be revised.

Prevalence of Gram-negative bacteria in ventilator-associated pneumonia in neonatal intensive care units: a systematic review and meta-analysis protocol

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a common and potentially lethal problem among mechanically ventilated neonates in neonatal intensive care units (NICUs). The main pathogenic bacteria of VAP in NICUs are Gram-negative pathogens, which show a general decline in sensitivities to commonly used antibiotics, but their true prevalence is not known.

METHODS AND ANALYSIS

We aim to provide a systematic review of studies measuring the prevalence of Gram-negative bacteria in VAP in NICUs. We will search PubMed, SCOPUS, EMBASE and the ISI Web of Science, as well as the Google Scholar search engine with no restriction on language. Full copies of articles will be identified by a defined search strategy and will be considered for inclusion against predefined criteria. Study selection and data extraction will be performed by 2 independent reviewers. Statistical analysis will include the identification of data sources and documentation of estimates, as well as the application of the random-effects and fixed-effects meta-analysis models. This will allow us to aggregate prevalence estimates and account for between-study variability in calculating the overall pooled estimates and 95% CI for the prevalence of Gram-negative bacteria in VAP in NICUs. Heterogeneity will be evaluated using the I² and χ² statistical tests to determine the extent of variation in effect estimates due to heterogeneity rather than chance. Publication bias and data synthesis will be assessed by funnel plots and Begg's and Egger's tests using STATA software V.13. This systematic review protocol was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P) 2015 Statement.

ETHICS AND DISSEMINATION

No ethical issues are predicted. These findings will be published in a peer-reviewed journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

CRD42016036048.

No Decrease in Early Ventilator-Associated Pneumonia After Early Use of Chlorhexidine

BACKGROUND

Oral chlorhexidine prophylaxis can decrease occurrence of ventilator-associated pneumonia. However, the importance of timing has never been fully explored.

OBJECTIVE

To see if early administration of oral chlorhexidine is associated with lower incidence of early ventilator-associated pneumonia (within 5 days of admission to intensive care unit) in intubated air ambulance patients.

METHODS

A single-center, retrospective cohort study of intubated adults transported by a university-based air ambulance service and admitted to a surgical intensive care unit from July 2011 through April 2013. Primary exposure was time from helicopter retrieval to the first dose of oral chlorhexidine in the intensive care unit. Early chlorhexidine was defined as receipt of the drug within 6 hours of helicopter departure. The primary outcome was clinical diagnosis of early ventilator-associated pneumonia. Patients who were less than 18 years old, died within 72 hours of admission, or had pneumonia at admission were excluded.

RESULTS

Among 134 patients, 49% were treated with chlorhexidine before 6 hours, 84% were treated before 12 hours, and 11% were treated for early pneumonia. Early chlorhexidine (before 6 hours; 15%) was not associated (P = .21) with early pneumonia (8%). Furthermore, median times to chlorhexidine did not differ significantly (P = .23) between patients in whom pneumonia developed (5.2 hours) and patients with no pneumonia (6.1 hours).

CONCLUSIONS

Early administration of oral chlorhexidine in intubated patients was not associated with a reduction in the incidence of ventilator-associated pneumonia in a surgical intensive care unit with high rates of chlorhexidine administration before 12 hours.

Device-associated pneumonia of very low birth weight infants in Polish Neonatal Intensive Care Units

PURPOSE

Late-Onset Pneumonia (LO-PNEU) is still the most important complication associated with the hospitalization of infants with very low birth weight (<1501g). The purpose of this paper is to summarize the results of an ongoing surveillance program defining LO-PNEU as associated or not associated with respiratory support in the NICU and distribution of causative pathogens from the Polish Neonatology Surveillance Network (PNSN).

MATERIALS AND METHODS

Surveillance of infections was conducted in the years 2009-2011 at six Polish NICUs.

RESULTS

The incidence was 3.1/1000 NICU patient days (pds). The mean gestational age and birth weight among infants with LO-PNEU were significantly lower. The VAP incidence was of 18.2/1000 NICU pds for mechanically ventilated (MV) infants, while the rates for those receiving only CPAP were as low as 7.7/1000 NICU pds. MV significantly increased the risk of PNEU, but MV or CPAP for <10 days did not increase the risk of LO-PNEU. Significantly associated with LO-PNEU was the use of central or peripheral venous catheters and total parenteral nutrition for longer periods. Microorganisms isolated in cases of LO-PNEU were Gram-positive cocci (53.5%) and Gram-negative rods, with predominating E. coli. Non fermentative bacilli were significantly more frequent in cases of VAP than in other cases.

CONCLUSIONS

Observed incidence rates associated with VAP and CPAP-PNEU, were higher than in other national surveillance systems and expressing the feasibility of lowering the risk of LO-PNEU and increasing patient safety. The incidence of pneumonia was found to be lower when using CPAP as compared to using MV.

[Prevention of ventilator-associated pneumonia: a comparison of level of knowledge in three critical care units]

OBJECTIVE

To determine the level of knowledge of the prevention of ventilator-associated pneumonia guidelines of nurses working in three intensive care units (ICU) in 3 university hospitals in a Spanish region, and evaluate the relationship between this level of knowledge and years worked in the ICU.

METHOD

A descriptive, prospective, cross-sectional, multicentre study was conducted using a validated and reliable questionnaire, made up by 9 questions with closed answers drawn from the EVIDENCE study. A total of 98 questionnaires were collected from ICU nurses of the three university hospitals (A, B, and C) from January to April 2014. The sample from hospital A responded the most, in contrast with the sample from hospital B, which was the one with the less participation. The Pearson correlation was calculated in order to determine the relationship between nurse years worked in ICU and level of knowledge.

RESULTS

Hospital A obtained in the best mean score in the questionnaire, 6.33 (SD 1.4) points, followed by hospital C with 6.21 (SD 1.4), and finally, the hospital B with 6.06 (SD 1.5) points. A p=.08 was obtained on relating years worked with the level of knowledge.

CONCLUSION

The results showed a high level of knowledge compared other studies. There was a tendency between the years worked in the unit and the level of knowledge in ventilator-associated pneumonia prevention.

Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intubated and mechanically ventilated patients. Endotracheal tubes (ETTs) appear to be an independent risk factor for VAP. Silver-coated ETTs slowly release silver cations. It is these silver ions that appear to have a strong antimicrobial effect. Because of this antimicrobial effect of silver, silver-coated ETTs could be an effective intervention to prevent VAP in people who require mechanical ventilation for 24 hours or longer.

OBJECTIVES

Our primary objective was to investigate whether silver-coated ETTs are effective in reducing the risk of VAP and hospital mortality in comparison with standard non-coated ETTs in people who require mechanical ventilation for 24 hours or longer. Our secondary objective was to ascertain whether silver-coated ETTs are effective in reducing the following clinical outcomes: device-related adverse events, duration of intubation, length of hospital and intensive care unit (ICU) stay, costs, and time to VAP onset.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10, MEDLINE, EMBASE, EBSCO CINAHL, and reference lists of trials. We contacted corresponding authors for additional information and unpublished studies. We did not impose any restrictions on the basis of date of publication or language. The date of the last search was October 2014.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and quasi-randomized trials that evaluated the effects of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs with standard non-coated ETTs or with other antimicrobial-coated ETTs in critically ill people who required mechanical ventilation for 24 hours or longer. We also included studies that evaluated the cost-effectiveness of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs.

DATA COLLECTION AND ANALYSIS

Two review authors (GT, HV) independently extracted the data and summarized study details from all included studies using the specially designed data extraction form. We used standard methodological procedures expected by The Cochrane Collaboration. We performed meta-analysis for outcomes when possible.

MAIN RESULTS

We found three eligible randomized controlled trials, with a total of 2081 participants. One of the three included studies did not mention the amount of participants and presented no outcome data. The 'Risk of bias' assessment indicated that there was a high risk of detection bias owing to lack of blinding of outcomes assessors, but we assessed all other domains to be at low risk of bias. Trial design and conduct were generally adequate, with the most common areas of weakness in blinding. The majority of participants were included in centres across North America. The mean age of participants ranged from 61 to 64 years, and the mean duration of intubation was between 3.2 and 7.7 days. One trial comparing silver-coated ETTs versus non-coated ETTs showed a statistically significant decrease in VAP in favour of the silver-coated ETT (1 RCT, 1509 participants; 4.8% versus 7.5%, risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.96; number needed to treat for an additional beneficial outcome (NNTB) = 37; low-quality evidence). The risk of VAP within 10 days of intubation was significantly lower with the silver-coated ETTs compared with non-coated ETTs (1 RCT, 1509 participants; 3.5% versus 6.7%, RR 0.51, 95% CI 0.31 to 0.82; NNTB = 32; low-quality evidence). Silver-coated ETT was associated with delayed time to VAP occurrence compared with non-coated ETT (1 RCT, 1509 participants; hazard ratio 0.55, 95% CI 0.37 to 0.84). The confidence intervals for the results of the following outcomes did not exclude potentially important differences with either treatment. There were no statistically significant differences between groups in hospital mortality (1 RCT, 1509 participants; 30.4% versus 26.6%, RR 1.09, 95% CI 0.93 to 1.29; low-quality evidence); device-related adverse events (2 RCTs, 2081 participants; RR 0.65, 95% CI 0.37 to 1.16; low-quality evidence); duration of intubation; and length of hospital and ICU stay. We found no clinical studies evaluating the cost-effectiveness of silver-coated ETTs.

AUTHORS' CONCLUSIONS

This review provides limited evidence that silver-coated ETT reduces the risk of VAP, especially during the first 10 days of mechanical ventilation.

A prospective evaluation of ventilator-associated conditions and infection-related ventilator-associated conditions

BACKGROUND

The Centers for Disease Control and Prevention has shifted policy away from using ventilator-associated pneumonia (VAP) and toward using ventilator-associated conditions (VACs) as a marker of ICU quality. To date, limited prospective data regarding the incidence of VAC among medical and surgical ICU patients, the ability of VAC criteria to capture patients with VAP, and the potential clinical preventability of VACs are available.

METHODS

This study was a prospective 12-month cohort study (January 2013 to December 2013).

RESULTS

We prospectively surveyed 1,209 patients ventilated for ≥ 2 calendar days. Sixty-seven VACs were identified (5.5%), of which 34 (50.7%) were classified as an infection-related VAC (IVAC) with corresponding rates of 7.0 and 3.6 per 1,000 ventilator days, respectively. The mortality rate of patients having a VAC was significantly greater than that of patients without a VAC (65.7% vs 14.4%, P < .001). The most common causes of VACs included IVACs (50.7%), ARDS (16.4%), pulmonary edema (14.9%), and atelectasis (9.0%). Among IVACs, 44.1% were probable VAP and 17.6% were possible VAP. Twenty-five VACs (37.3%) were adjudicated to represent potentially preventable events. Eighty-six episodes of VAP occurred in 84 patients (10.0 of 1,000 ventilator days) during the study period. The sensitivity of the VAC criteria for the detection of VAP was 25.9% (95% CI, 16.7%-34.5%).

CONCLUSIONS

Although relatively uncommon, VACs are associated with greater mortality and morbidity when they occur. Most VACs represent nonpreventable events, and the VAC criteria capture a minority of VAP episodes.

Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

Objective.

To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates.

Design.

Collaborative cohort before-after study.

Setting.

Intensive care units (ICUs) predominantly in Michigan.

Interventions.

We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospital's infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first.

Results.

One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16–18 months after implementation (P < .001) and 0 cases (mean, 2.4 cases) at 28-30 months after implementation (P < .001). Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41–0.64) at 16–18 months after implementation and 0.29 (95% confidence interval, 0.24–0.34) at 28–30 months after implementation. Compliance with evidence-based therapies increased from 32% at baseline to 75% at 16–18 months after implementation (P < .001) and 84% at 28–30 months after implementation (P < .001).

Conclusions.

A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

Cost-Effectiveness Analysis of a Silver-Coated Endotracheal Tube to Reduce the Incidence of Ventilator-Associated Pneumonia

Objective.

To conduct a cost-effectiveness analysis of the economic outcomes of ventilator-associated pneumonia (VAP) prevention associated with silver-coated endotracheal tubes versus uncoated endotracheal tubes.

Design.

We used a simple decision model based on a hypothetical 1,000-patient cohort intubated with silver-coated or uncoated endotracheal tubes. The primary end point was marginal hospital savings per case of VAP prevented (savings from using silver-coated endotracheal tubes minus acquisition cost divided by number of VAP cases prevented).

Methods.

We followed each branch of the decision model to VAP or no VAP and conducted Monte Carlo simulations and sensitivity analyses. Inputs for VAP incidence, relative risk reduction, and hospital costs were derived from publicly available sources. Relative risk reduction was derived from the pivotal study of the silver-coated endotracheal tube.

Results.

In the base-case analysis, we reduced the pivotal study relative risk in incidence of microbiologically confirmed VAP in patients intubated ≥24 hours from 35.9% to 24%. Thus, 23 of 97 expected cases of VAP could be prevented with silver-coated endotracheal tubes. The savings per case of VAP prevented was $12,840 in the base case, with assumed marginal VAP cost of $16,620 and costs of $90.00 for coated and $2.00 for uncoated endotracheal tubes. Estimates were most sensitive to assumptions regarding VAP cost and relative risk reduction with silver-coated endotracheal tubes. Nonetheless, in multivariate sensitivity analyses, the silver-coated endotracheal tubes yielded persistent savings (95% confidence interval, $9,630-$16,356) per case of VAP prevented. With other base-case inputs held constant, breakeven cost for silver-coated endotracheal tubes was $388.

Conclusions.

The silver-coated endotracheal tube represents a strategy for preventing VAP that may yield hospital savings.

Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs

Objective.

To estimate the proportion of healthcare-associated infections (HAIs) in US hospitals that are “reasonably preventable,” along with their related mortality and costs.

Methods.

To estimate preventability of catheter-associated bloodstream infections (CABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP), we used a federally sponsored systematic review of interventions to reduce HAIs. Ranges of preventability included the lowest and highest risk reductions reported by US studies of “moderate” to “good” quality published in the last 10 years. We used the most recently published national data to determine the annual incidence of HAIs and associated mortality. To estimate incremental cost of HAIs, we performed a systematic review, which included costs from studies in general US patient populations. To calculate ranges for the annual number of preventable infections and deaths and annual costs, we multiplied our infection, mortality, and cost figures with our ranges of preventability for each HAI.

Results.

AS many as 65%–70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed by VAP. CABSI also has the highest cost impact; costs due to preventable cases of VAP, CAUTI, and SSI are likely less.

Conclusions.

Our findings suggest that 100% prevention of HAIs may not be attainable with current evidence-based prevention strategies; however, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.

Trends in Ventilator-Associated Pneumonia Rates Within the German Nosocomial Infection Surveillance System (KISS)

Objective.

To investigate trends in ventilator-associated pneumonia (VAP) rates during participation in the German nosocomial infection surveillance system (Krankenhaus-Infektions-Surveillance-System [KISS]).

Methods.

A total of 71 ICUs that began participating in KISS in 1999 or later and continued participation for at least 36 months were selected. Beginning with the first month of participation, the pooled mean rate of VAP in the ICUs was calculated for each year of participation. The incidence densities for the 3 years of participation were compared using the Pearson x2 test. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated. VAP rates were calculated for each ICU and year of participation, and rates for years 1 and 3 were compared using the Wilcoxon test for paired samples.

Results.

Twenty-nine medical-surgical, 18 medical, 20 surgical, 2 neurosurgical, and 2 pediatric ICUs met the selection criteria. Surveillance data were available on 181,275 patients, for whom there were 613,098 patient-days and 224,138 ventilator-days. A total of 2,043 cases of VAP were reported. The ICUs had a pooled VAP rate of 10.5 cases per 1,000 ventilator-days during year 1 of KISS surveillance. In year 2, the rate decreased by 19%, to 8.7 cases per 1,000 ventilator-days (RR, 0.81 [95% CI, 0.73-0.90]). In year 3, the rate decreased by 24% from year 1, to 8.0 cases per 1,000 ventilator-days (RR, 0.76; 95% CI, 0.68-0.85). Both results were significant (P < .001 by the Pearson x2 test). Comparison of the VAP rates of the ICUs did not show a significant difference between years 1 and 3 of KISS participation.

Conclusion.

Surveillance was associated with a significant reduction in the pooled rate of VAP during years 1-3 of KISS participation.

A survey on oral care practices for ventilator-assisted patients in intensive care units in 3A hospitals of mainland China

Oral hygiene is a critical element of patient care, particularly among patients who need ventilator-assisted equipment. The objective of this study was to explore the current status of oral care practices, attitudes, education and knowledge among intensive care unit (ICU) nurses caring for ventilator-assisted patients in 3A hospitals in mainland China. To achieve this aim, an 18-item self-assessment questionnaire was mailed to head ICU nurses in 189 Grade 3A hospitals. Additional data were collected through in-person interviews at 38 ICUs throughout Sichuan, Shanxi, Jiangsu provinces, as well as Chongqing and Beijing. We found that most ICUs conducted oral examinations at patient admission, and that this care was largely provided by nurses. The most common oral care methods were foam swabs and mouth rinse containing antibiotics or disinfectants. Although the majority of ICUs provided continuing training for oral care, and most training was conducted by head nurses, the content and scope of training were not consistent among the hospitals in the study. The most popular sources of oral care knowledge were academic journals, Internet and professional books. Overall, it is clear that an evidence-based oral care standard manual is urgently needed for oral practice in ICUs in mainland China.

Knowledge translation interventions for critically ill patients: a systematic review*

OBJECTIVE

We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.

DATA SOURCES

We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.

STUDY SELECTION

Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.

DATA EXTRACTION

Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.

DATA SYNTHESIS

From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.

CONCLUSIONS

Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Management and prevention of ventilator-associated pneumonia caused by multidrug-resistant pathogens

Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation. Methicillin-resistant Staphylococcus aureus and several different species of Gram-negative bacteria can cause MDR VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenemase-producing Enterobacteraciae and extended-spectrum β-lactamase producing bacteria. Proper management includes selecting appropriate antibiotics, optimizing dosing and using timely de-escalation based on antiimicrobial sensitivity data. Evidence-based strategies to prevent VAP that incorporate multidisciplinary staff education and collaboration are essential to reduce the burden of this disease and associated healthcare costs.

Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia--a survey study

OBJECTIVES

To explore critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia.

DESIGN

A quantitative cross-sectional survey.

METHODS

Two multiple-choice questionnaires were distributed to critical care nurses (n=101) in a single academic centre in Finland in the autumn of 2010. An independent-samples t-test was used to compare critical care nurses' knowledge and adherence within different groups. The principles of inductive content analysis were used to analyse the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia.

RESULTS

The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p=0.029). The overall, self-reported adherence was 84.0%. The main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance.

CONCLUSION

There is an ongoing need for improvements in education and effective implementation strategies.

CLINICAL IMPLICATIONS

The results could be used to inform local practice and stimulate debate on measures to prevent ventilator-associated pneumonia. Education, guidelines as well as ventilator bundles and instruments should be developed and updated to improve infection control.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study

OBJECTIVE

Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates.

DESIGN

Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009.

SETTING

Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs.

PATIENTS

At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months).

INTERVENTION

Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03).

CONCLUSIONS

A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

A TREM-1 Polymorphism A/T within the Exon 2 Is Associated with Pneumonia in Burn-Injured Patients

Background. The triggering receptor expressed in myeloid cells (TREM-1) is a key mediator in the activation of the local inflammatory response during lung infections. We aimed to evaluate the effect of a functionally relevant TREM-1 single nucleotide polymorphism within the exon 2 (A→T) on the development of pneumonia in burn patients. Objective. To determine whether a single nucleotide polymorphism (SNP) within the exon 2 (A→T) in the TREM-1 gene is associated with ventilator-associated pneumonia (VAP) in burn-injured patients. Methods. 540 patients with ≥10% total body surface area (TBSA) burn injuries or inhalation injury were prospectively enrolled. The influence of a polymorphism (A→T) in exon 2 of the TREM-1 gene was evaluated for association with increased risk of pneumonia by logistic regression analysis. Measurements and Main Results. 209 patients met criteria for VAP. Multivariate regression analysis showed that, after adjustment for potential confounders, we found that carriage of the TREM-1 T allele is associated with more than a 3-fold increased risk of VAP (OR 6.3, 95% CI 4–9). Conclusions. A TREM-1 single nucleotide polymorphism within the exon 2 (A→T) is associated with the development of pneumonia in burn patients.

Oral care education in the prevention of ventilator-associated pneumonia: quality patient outcomes in the intensive care unit

BACKGROUND

Ventilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates in mechanically ventilated patients in the United States. Routine oral care has been shown to have a direct effect on reducing VAP rates.

METHODS

Intensive care unit registered nurses attended educational sessions about oral care and also used online education modules. Nursing care involving 180 intubated patients was observed, and changes were noted in practices related to oral care.

RESULTS

After the education intervention, the frequency of oral care increased significantly (p = .001) to tooth brushing every 4 hours and swabbing every 12 hours with 0.12% chlorhexidine solution. The evidence-based practice education intervention decreased VAP rates by 62.5%.

CONCLUSION

Significant reductions in VAP rates may be achieved through improved education and implementation of oral care protocols with 0.12% chlorhexidine solution.

Ventilator-associated complications, including infection-related complications: the way forward

Acute respiratory failure represents the most common condition requiring admission to an adult intensive care unit. Ventilator-associated pneumonia (VAP) has been used as a marker of quality for patients with respiratory failure. Hospital-based process-improvement initiatives to prevent VAP have been successfully used. The use of ventilator-associated complications (VACs) has been proposed as an objective marker to assess the quality of care for this patient population. The use of evidence-based bundles targeting the reduction of VACs, as well as the conduct of prospective studies showing that VACs are preventable complications, are reasonable first-steps in addressing this important clinical problem.

Mouth care for orally intubated patients: a critical ethnographic review of the nursing literature

OBJECTIVES

The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients.

METHODS

The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time.

RESULTS

A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth care's practical accomplishment.

CONCLUSIONS

Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

Assessment of a training programme for the prevention of ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICUs). Most published studies have analysed nurses' theoretical knowledge about a specific procedure; however, the transfer of this knowledge to the practice has received little attention.

AIM

To assess the impact of training session on nurses' knowledge regarding VAP, compliance with VAP preventive measures, VAP incidence and determining whether nursing workload affects compliance.

METHOD

A prospective, quasiexperimental, pre- and post-study of the nursing team in a 16-bed medical/surgical ICU. Pre-intervention phase: a questionnaire to assess nurses' knowledge of VAP prevention measures, direct observation and review of clinical records to assess compliance. Intervention phase: eight training sessions for nurses. The post-intervention phase mirrored the pre-intervention phase.

FINDINGS

Nurses answered more questions correctly on the post-intervention questionnaire than on the pre-intervention (17·87 ± 2·69 versus 15·91 ± 2·68, p = 0·002). Compliance with the following measures was better during the post-intervention period (p = 0·001): use of the smallest possible nasogastric tube, controlled aspiration of subglottic secretions and endotracheal tube cuff pressure, use of oral chlorhexidine and recording the endotracheal tube fixation number. VAP incidence remained unchanged throughout the study. However, a trend towards lower incidence of late (>4 days after intubation) VAP was observed (4·6 versus 3·1 episodes/1000 ventilation days, p = 0·37).

CONCLUSION

The programme improved both knowledge of and compliance with VAP preventive measures, although improved knowledge did not always result in improved compliance.

Improving trauma care in the ICU: best practices, quality improvement initiatives, and organization

Optimal care of critically ill trauma patients remains a challenge within modern medical systems. During the past decade, emerging technologies and organizational improvements have greatly advanced the care of these patients. The effective implementation of best practice initiatives has led to measurable improvement in outcomes while also reducing health care costs. Continued advances in the implementation of these initiatives and ICU organization are required, however, to insure that optimal care is provided to this unique patient population.

Treatment algorithms in critical care: do they improve outcomes?

Patients admitted to the intensive care unit (ICU) often have significant underlying morbidities that require complex treatment plans. Because of these complexities, numerous guidelines have been developed to facilitate the management of the critically ill patient. Some of these guidelines include sepsis, community-acquired and ventilator-associated pneumonia, sedation, and glycemic control. Once guidelines are written, a treatment protocol must be developed and implemented within the critical care unit. Our medical center has implemented multiple treatment protocols, often with preprinted order sets with various degrees of success. In 2003, we implemented and later evaluated a sedation order form and protocol. Patients whose sedation was initiated with a standardized order form had more frequent sedation score assessment, less time between sedation vacations, reduced ICU length of ICU stay, and a trend in reduction of ventilator days. However, only 37% of eligible patients were treated using the order form and the protocol, despite the potentially beneficial effects. Some recommendations within guidelines are based on sound clinical evidence supported by randomized controlled trials, although others are based on expert opinion only. The most often-cited reason for protocol noncompliance is disagreement with the published clinical trial data. This paper examines both infectious and noninfectious treatment guidelines and the supportive evidence that they improved patient outcomes. In addition, strategies for successful implementation of a treatment guideline are discussed for clinicians to follow in order to maximize clinical outcomes.

ICU 2020: five interventions to revolutionize quality of care in the ICU

Intensive care units (ICUs) are an essential and unique component of modern medicine. The number of critically ill individuals, complexity of illness, and cost of care continue to increase with time. In order to meet future demands, maintain quality, and minimize medical errors, intensivists will need to look beyond traditional medical practice, seeking lessons on quality assurance from industry and aviation. Intensivists will be challenged to keep pace with rapidly advancing information technology and its diverse roles in ICU care delivery. Modern ICU quality improvement initiatives include ensuring evidence-based best practice, participation in multicenter ICU collaborations, employing state-of-the-art information technology, providing point-of-care diagnostic testing, and efficient organization of ICU care delivery. This article demonstrates that each of these initiatives has the potential to revolutionize the quality of future ICU care in the United States.

Strategies for prevention of ventilator-associated pneumonia: bundles, devices, and medications for improved patient outcomes

Ventilator-associated pneumonia is associated with significant patient morbidity, mortality, and increased health care costs. In the current economic climate, it is crucial to implement cost-effective prevention strategies that have proven efficacy. Multiple prevention measures have been proposed by various expert panels. Global strategies have focused on infection control, and reduction of lower airway colonization with bacterial pathogens, intubation, duration of mechanical ventilation, and length of stay in the intensive care unit. Routine use of the Institute for Healthcare Improvement ventilator care bundle is widespread, and has been clearly demonstrated to be an effective method for reducing the incidence of ventilator-associated pneumonia. In this article, we examine specific aspects of the Institute for Healthcare Improvement bundle, better-designed endotracheal tubes, use of antibiotics and probiotics, and treatment of ventilator-associated tracheobronchitis to prevent ventilator-associated pneumonia.

The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence

AIMS AND OBJECTIVES

The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator-associated pneumonia (VAP) outcomes.

BACKGROUND

The VCB is a group of four evidence-based procedures, which when clustered together and implemented as an 'all or nothing' strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions.

SEARCH STRATEGY

A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded.

CONCLUSIONS

Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four-element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes.

RELEVANCE TO CLINICAL PRACTICE

A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.

Limiting the spread of highly resistant hospital-acquired microorganisms via critical care transfers: a simulation study

PURPOSE

Hospital-acquired infections with highly resistant organisms are an important problem among critically ill patients. Control of these organisms has largely focused within individual hospitals. We examine the extent to which transfers of critically ill patients could be a vector for the wide spread of highly resistant organisms, and compare the efficiency of different approaches to targeting infection control resources.

METHODS

We analyzed the network of interhospital transfers of intensive care unit patients in 2005 US Medicare data and 2004-2006 Pennsylvania all-payer data. We simulated the spread of highly resistant hospital-acquired infections by randomly choosing a single hospital to develop a highly resistant organism and following the spread of infection or colonization throughout the network under varying strategies of infection control and varying levels of infectivity.

RESULTS

Critical care transfers could spread a highly resistant organism between any two US hospitals in a median of 3 years. Hospitals varied substantially in their importance to limiting potential spread. Targeting resources to a small subset of hospitals on the basis of their position in the transfer network was 16 times more efficient than distributing infection control resources uniformly. Within any set of targeted hospitals, the best strategy for infection control heavily concentrated resources at a few particularly important hospitals, regardless of level of infectivity.

CONCLUSIONS

Critical care transfers provide a plausible vector for widespread dissemination of highly resistant hospital-acquired microorganisms. Infection control efforts can be made more efficient by selectively targeting hospitals most important for transmission.

Successful prevention of tracheostomy associated pneumonia in step-down units

BACKGROUND

Prevention of health care-associated infections is well described in critical care. However, surveillance in step-down unit (SDU) patients who need intermediate care with bilevel mechanical ventilation pressure through tracheotomy needs to be better understood. We evaluated the implementation of preventive measures in SDU over 2 different periods on device (bilevel mechanical ventilation)-associated pneumonia.

METHODS

A quasi-experimental, interrupted time series study was conducted in SDUs. Interventions were implemented to optimize the prevention of pneumonia associated with tracheostomy and evaluated in 2 phases. From January to October of 2007 (phase 1), some practices recommended by the Centers for Disease Control and Prevention were implemented, and the epidemiology unit carried out surveillance for pneumonia associated with tracheostomy. From November of 2007 to August of 2008 (phase 2) the same practices recommended by the Centers for Disease Control and Prevention were followed, but, in addition, the assessment of these processes as well as bedside interventions were initiated.

RESULTS

The mean incidence density of tracheostomy associated pneumonia per 1,000 tracheostomy-days in the SDUs was 6.0 in phase 1 and 0.7 in phase 2, P = .002.

CONCLUSION

Reducing pneumonia associated with tracheostomy is a continuous multidisciplinary process that involves the measurement of multiple performance metrics.

Is continuous subglottic suctioning cost-effective for the prevention of ventilator-associated pneumonia?

OBJECTIVE

To establish whether continuous subglottic suctioning (CSS) could be cost-effective.

DESIGN

Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS.

SETTING

A surgical intensive care unit (SICU) of a tertiary care university hospital in France.

PATIENTS

All consecutive patients receiving ventilation in the SICU in 2006.

METHODS

Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient.

RESULTS

At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode.

CONCLUSION

Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising.

AIM

This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings.

METHODS

A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed.

FINDINGS

CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene.

CONCLUSIONS

The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing.

Prevention of VAP: is zero rate possible?

Infection prevention measures, specifically targeting ventilator-associated pneumonia (VAP), have been purposed as quality-of-care indicators for patients in intensive care units. The authors discuss some of the recent evidence of the prevention of nosocomial infections, with a particular emphasis on VAP. Moreover, there are several pitfalls in considering VAP rates as a safety indicator. Because of these limitations, the authors recommend the use of specific process measures, designed to reduce VAP, as the basis for interinstitutional benchmarking.