A cost-effectiveness analysis of reducing ventilator-associated pneumonia at a Danish ICU with ventilator bundle

A systematic scoping review of the cost-impact of ventilator-associated pneumonia (VAP) intervention bundles in intensive care

BACKGROUND

Evidence-based economic decision making is key in health care. Presently, however, studies reporting financial outcomes of ventilator-associated pneumonia (VAP) care bundles have not been systematically evaluated.

METHOD

This scoping review investigated the characteristics and findings of studies of the economic impact of VAP bundle implementation. A systematic search of electronic databases (MEDLINE, CINAHL) for relevant English language studies was undertaken (January 2000-February 2020). Methodological quality was evaluated using a Joanna Briggs Institute quality appraisal checklist. Article screening and quality appraisals were performed by 2 reviewers. Reference lists of included studies were hand-searched for additional articles. Reporting followed PRISMA Extension for Scoping Reviews (PRISMA-ScR) standards.

RESULTS

From 181 citations, 10 articles met inclusion criteria. Eight studies evaluated cost impacts on acute care and there were 2 cost-modeling studies. Results consistently indicated that effective VAP bundle implementation decreased healthcare costs. However, studies were heterogeneous with respect to research methods and objectives and were judged to have a moderate-to-high risk of bias.

DISCUSSION

Effective implementation of VAP care bundles was associated with superior clinical and economic outcomes. However, despite finding a moderate volume of research, study heterogeneity inhibited strong conclusions being drawn regarding the degree of associated cost savings.

CONCLUSION

Additional research involving multisite/multijurisdiction studies using experimental designs are needed to progress the field and overcome gaps in the existing literature.

Risk Management in Executive Levels of Healthcare Organizations: Insights from a Scoping Review (2018)

Background

This study attempted to present a framework and appropriate techniques for implementing risk management (RM) in executive levels of healthcare organizations (HCOs) and grasping new future research opportunities in this field.

Methods

A scoping review was conducted of all English language studies, from January 2000 to October 2018 in the main bibliographic databases. Review selection and characterization were performed by two independent reviewers using pretested forms.

Results

Following a keyword search and an assessment of fit for this review, 37 studies were analyzed. Based on the findings and considering the ISO31000 model, a comprehensive yet simple framework of risk management is developed for the executive levels of HCOs. It includes five main phases: establishing the context, risk assessment, risk treatment, monitoring and review, and communication and consultation. A set of tools and techniques were also suggested for use at each phase. Also, the status of risk management in the executive levels of HCOs was determined based on the proposed framework.

Conclusion

The framework can be used as a training tool to guide in effective risk assessment as well as a tool to assess non-clinical risks of healthcare organizations. Managers of healthcare organizations who seek to ensure high quality should use a range of risk management methods and tools in their organizations, based on their need, and not assume that each tool is comprehensive.

Ventilator-associated pneumonia in neonates and children: a systematic analysis of diagnostic methods and prevention

AIM

While ventilator-associated pneumonia (VAP) remains frequent in Pediatric ICU, there is no gold standard for diagnosis.

METHODOLOGY

We conducted a systematic PUBMED analysis (January 1990-January 2017) searching original, full-length studies addressing only pediatric patients; for VAP diagnosis, only those comparing different diagnostic methods and for VAP prevention those implementing preventive measures.

RESULTS

Among 367 articles, 17 and 16 were analyzed for diagnosis and prevention, respectively. For diagnosis, 13 studies used CDC criteria; whereas, 14 assessed algorithms: clinical pulmonary index score, ventilator-associated events and biomarkers. Among five randomized trials assessing preventive strategies one found a role of probiotics. Ventilator-care bundles reduced VAP rates.

CONCLUSION

Absence of diagnostic gold standard impedes comparison of current approaches and preventive strategies.

Prospective observational study to compare oral topical metronidazole versus 0.2% chlorhexidine gluconate to prevent nosocomial pneumonia

BACKGROUND

Nosocomial pneumonia is one of the most common health care-associated infections in intensive care units (ICUs) worldwide, attributing to high morbidity and mortality. Our study aim is to investigate the effectiveness of oral hygiene with 0.2% chlorhexidine gluconate (CHX) and 0.08% metronidazole (MDE) influencing the microbiologic epidemiology and incidence of nonintubation pneumonia (NIP) and ventilator-associated pneumonia (VAP).

METHODS

Patients who stayed >48 hours in the emergency ICU between 2008 and 2012 were enrolled and provided oral hygiene by swabbing with 0.08% MDE twice daily until discharge or death during the first year (period M), whereas CHX was applied during the following 3 years (period C). The incidence and microbiologic epidemiology of NIP and VAP were studied.

RESULTS

There were 873 patients enrolled. There were 44 episodes of NIP and 25 episodes of VAP that occurred among 212 patients in period M, and 84 episodes of NIP and 49 episodes of VAP occurred among 661 patients in period C. Overall, the rate of NIP and VAP decreased year by year. Acinetobacter baumannii was the most frequently identified bacteria for NIP (22.9%) and VAP (25.3%), with an annual ascent. Few changes were observed on bacteria distribution for NIP and VAP.

CONCLUSIONS

Oral hygiene with CHX, having reduced the incidence of nosocomial pneumonia among critical ill patients, suggests a benefit of oral hygiene in decreasing the incidence of nosocomial pneumonia, including VAP in ICUs, but not bacterial epidemiology.

Clinical Assessment of Risk Management: an INtegrated Approach (CARMINA)

Purpose - The European Union recommendations for patient safety calls for shared clinical risk management (CRM) safety standards able to guide organizations in CRM implementation. The purpose of this paper is to develop a self-evaluation tool to measure healthcare organization performance on CRM and guide improvements over time. Design/methodology/approach - A multi-step approach was implemented including: a systematic literature review; consensus meetings with an expert panel from eight Italian leader organizations to get to an agreement on the first version; field testing to test instrument feasibility and flexibility; Delphi strategy with a second expert panel for content validation and balanced scoring system development. Findings - The self-assessment tool - Clinical Assessment of Risk Management: an INtegrated Approach includes seven areas (governance, communication, knowledge and skills, safe environment, care processes, adverse event management, learning from experience) and 52 standards. Each standard is evaluated according to four performance levels: minimum; monitoring; outcomes; and improvement actions, which resulted in a feasible, flexible and valid instrument to be used throughout different organizations. Practical implications - This tool allows practitioners to assess their CRM activities compared to minimum levels, monitor performance, benchmarking with other institutions and spreading results to different stakeholders. Originality/value - The multi-step approach allowed us to identify core minimum CRM levels in a field where no consensus has been reached. Most standards may be easily adopted in other countries.

Targeting bacterial biofilms via surface engineering of gold nanoparticles

Bacterial biofilms are associated with persistent infections that are resistant to conventional antibiotics and substantially complicate patient care. Surface engineered nanoparticles represent a novel, unconventional approach for disruption of biofilms and targeting of bacterial pathogens. Herein, we describe the role of surface charge of gold nanoparticles (AuNPs) on biofilm disruption and bactericidal activity towards Staphylococcus aureus and Pseudomonas aeruginosa which are important ventilator associated pneumonia (VAP) pathogens. In addition, we study the toxicity of charged AuNPs on human bronchial epithelial cells. While 100% positively charged AuNP surface was uniformly toxic to both bacteria and epithelial cells, reducing the extent of positive charge on the AuNP surface at moderate concentrations prevented epithelial cell toxicity. Reducing surface charge was however also less effective in killing bacteria. Conversely, increasing AuNP concentration while maintaining a low level of positivity continued to be bactericidal and disrupt the bacterial biofilm and was less cytotoxic to epithelial cells. These initial in vitro studies suggest that modulation of AuNP surface charge could be used to balance effects on bacteria vs. airway cells in the context of VAP, but the therapeutic window in terms of concentration vs. surface positive charge may be limited. Additional factors such as hydrophobicity may need to be considered in order to design AuNPs with specific, beneficial effects on bacterial pathogens and their biofilms.

Impact of availability of guidelines and active surveillance in reducing the incidence of ventilator-associated pneumonia in Europe and worldwide

BACKGROUND

To analyse whether the availability of written standards for management of mechanically ventilated patients and/or the existence of a surveillance system for cases of ventilation-associated pneumonia (VAP) are positively associated with compliance with 6 well-established VAP prevention measures.

METHODS

Ecological study based on responses to an online-questionnaire completed by 1730 critical care physicians. Replies were received from 77 different countries, of which the majority, i.e. 1351, came from 36 European countries.

RESULTS

On a cross-country level, compliance with VAP prevention measures is higher in countries with a large number of prevention standards and/or VAP surveillance systems in place at ICU level., Likewise, implementation of standards and VAP surveillance systems has a significant impact on self-reported total compliance with VAP prevention measures (both p < 0.001). Moreover, predictions of overall prevention measure compliance show the effect size of the availability of written standards and existence of surveillance system. For instance, a female physician with 10 years of experience in critical care working in a 15-bed ICU in France has a predicted baseline level of VAP prevention measure compliance of 63 per cent. This baseline level increases by 9.5 percentage points (p < 0.001) if a written clinical VAP prevention standard is available in the ICU, and by another 4 percentage points (p < 0.001) if complemented by a VAP surveillance system.

CONCLUSIONS

The existence of written standards for management of mechanically ventilated patients in an ICU and the availability of VAP surveillance systems have shown to be positively associated with compliance with VAP prevention measures and should be fostered on a policy level.

Impact of four sequential measures on the prevention of ventilator-associated pneumonia in cardiac surgery patients

Introduction

Ventilator-associated pneumonia (VAP) is the most frequent infection in patients admitted to intensive care units.

The efficacy of individual measures for the prevention of VAP is well documented, and data on the impact of implementing bundle measures have usually been reported from studies in which several measures are implemented simultaneously in the general intensive care unit (ICU).

The objective of our work was to evaluate the impact of four sequentially implemented measures for preventing VAP in a major heart surgery ICU. The measures were a specific training program, aspiration of subglottic secretions (ASSs), introduction of an inclinometer to improve the semirecumbent position, and reinforcement of oral care with chlorhexidine.

Methods

We compared rates of VAP, days on mechanical ventilation (MV), and cost of antimicrobial agents before and during implementation.

Results

We collected data from 401 patients before the intervention and from 1,534 patients during the intervention. Both groups were comparable. No significant differences in EuroSCORE were observed between the patients of both periods (6.4 versus 6.3; P = 0.7). The rates of VAP (episodes/1,000 days of ventilation) were, respectively, 23.9 versus 13.5 (P = 0.005). Mean number of days of MV/1,000 days of stay was 507 versus 375 (P = 0.001), and the cost of antimicrobial therapy (Euros/1,000 days of stay) was €70,612 versus €52,775 (P = 0.10). The main effect of sequential application of preventive measures in time achieved a relative-rate reduction of VAP of 41% (IRR, 0.41; 95% CI, 0.28 to 0.62). The mortality rate before and during the intervention was 13.0% and 10.2%, respectively.

VAP rate was most significantly reduced by training and the use of the inclinometer.

Conclusions

A sequentially applied bundle of four preventive measures reduces VAP rates, days of MV, and the cost of antimicrobial therapy in patients admitted to the major heart surgery ICU.

Trial registration

Clinical Trials.gov: NCT02060045. Registered 4 February 2014.

Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy

Objective

Nosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line-associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT).

Material and methods

We conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined.

Results

All guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022).

Conclusion

We conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes.