Adherence to the items in a bundle for the prevention of ventilator-associated pneumonia

Efficacy of compliance with ventilator-associated pneumonia care bundle: A 24-month longitudinal study at Bach Mai Hospital, Vietnam

Introduction

To decrease the risk of complications from ventilator-associated pneumonia, it is essential to implement preventative measures in all ICU patients. Since 2018, with the help of Japanese experts, we have applied a ventilator-associated pneumonia care bundle with 10 basic standards in patient care and monitoring. Therefore, we conducted a study to evaluate the results of applying 10 solutions to prevent ventilator-associated pneumonia over 24 months.

Methods

A cross-sectional descriptive study with longitudinal follow-up for 24 months on 170 mechanically ventilated patients at the Center for Critical Care Medicine, Bach Mai Hospital. According to the Centers for Disease Control (CDC, 2021), the diagnosis of ventilator-associated pneumonia is when pneumonia appears 48 h after intubation by confirmation by at least two doctors. Evaluate compliance with each solution in the care bundle through camera monitoring, medical records, and directly on patients daily.

Results

The rate of ventilator-associated pneumonia is 12.9%, the frequency of occurrence is 16.54 of 1000 days. The compliance rate for complete compliance with a 10-item ventilator-associated pneumonia was only 1.8%, while the average value was 84.1%. Average values of compliance with each solution for hand hygiene, head elevation 30-45 degrees, oral hygiene, stopping sedation, breathing circuit management, cuff pressure management, hypoplastic suction, Spontaneous breathing trial (SBT) daily and assessed extubation, mobilization and early leaving bed, ulcer and thrombosis prevention were 96.9%, 97.3%, 99.4%, 81.5%, 99.9%, 99.9%, 86.3%, 83.5%, 49.3%, and 46.4%, respectively. The time to appear ventilator-associated pneumonia in the high compliance group was 46.7 ± 5.0 days, higher than in the low compliance group, 10.3 ± 0.7 days, p < 0.001.

Conclusions

A 10-item ventilator-associated pneumonia care bundle has helped reduce the incidence of ventilator-associated pneumonia. To reduce the risk of ventilator-associated pneumonia and shorten ICU and hospital stays, it is essential to fully adhere to subglottic secretion suction, daily SBT, and early mobilization and leaving the bed.

Prevention of ventilator-associated pneumonia through care bundles: A systematic review and meta-analysis

Background

Ventilator-associated pneumonia (VAP) represents a common hospital-acquired infection among mechanically ventilated patients. We summarized evidence concerning ventilator care bundles to prevent VAP.

Methods

A systematic review and meta-analysis were performed. Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation (MV) for at least 48 h were considered for inclusion. Outcomes of interest were the number of VAP episodes, duration of MV, hospital and intensive care unit (ICU) length of stay, and mortality. A systematic search was conducted in the MEDLINE, the Cochrane Library, and the Web of Science between 1985 and 2022. Results are reported as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). The PROSPERO registration number is CRD42022341780.

Results

Thirty-six studies including 116,873 MV participants met the inclusion criteria. A total of 84,031 participants underwent care bundles for VAP prevention. The most reported component of the ventilator bundle was head-of-bed elevation (n=83,146), followed by oral care (n=80,787). A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles, compared with the non-care bundle group (OR=0.42, 95% CI: 0.33, 0.54). Additionally, the implementation of care bundles decreased the duration of MV (MD=-0.59, 95% CI: -1.03, -0.15) and hospital length of stay (MD=-1.24, 95% CI: -2.30, -0.18) in studies where educational activities were part of the bundle. Data regarding mortality were inconclusive.

Conclusions

The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs. Their application in combination with educational activities seemed to improve clinical outcomes.

Critical care nurses' compliance and barriers toward ventilator-associated pneumonia prevention guidelines: cross-sectional survey

OBJECTIVES

This study aims to determine the compliance of critical care nurses with the ventilator-associated pneumonia prevention guidelines and the factors that affect their compliance. We also explored the barriers faced by the nurses in the implementation of these guidelines.

METHODS

A cross-sectional descriptive survey was conducted using a self-administered questionnaire containing 17 recommended strategies to prevent ventilator-associated pneumonia and 15 possible barriers. All critical care nurses of varying qualifications, levels of experience, and nationalities working in adult ICUs were invited. Between January and March 2018, the questionnaire was distributed to 283 nurses at eight ICUs in five public hospitals in Almadinah Almunawwarah, KSA.

RESULTS

A total of 229 invitees responded to the questionnaire. The mean compliance score was 85.9%. More than half (54%) of the sample had a high or acceptable compliance level. The lowest compliance rate was reported for the suctioning of subglottic secretions. The main reported barriers were the shortage of nursing staff, forgetfulness, and hospital cost control policies. Working in general ICUs with the capacity of 10-15 beds or prior education related to ventilator-associated pneumonia prevention influenced the nurses' compliance.

CONCLUSION

In our study, the overall compliance of the critical care nurses with the ventilator-associated pneumonia prevention guidelines is acceptable. Shortage of nursing staff, forgetfulness, and cost control policies were the main reported barriers to compliance.

Adhesión al bundle de prevención de neumonía asociada a la ventilación mecánica

Introducción: Evaluar la adhesión y el cumplimiento de las prácticas que conforman el bundle de prevención de la Neumonía Asociada a la Ventilación Mecánica en una Unidad de Terapia Intensiva de adulto. Materiales y Métodos: Se trata de un estudio descriptivo con enfoque prospectivo, en el que se hizo seguimiento a los pacientes internados en la Unidad de Cuidados Intensivos de una Fundación Pública, bajo ventilación mecánica, en los meses de octubre a noviembre de 2017. La muestra fue no probabilística y correspondió a la observación de los cuidados que conforman el Protocolo de Prevención de Neumonía Asociada a la Ventilación Mecánica. Resultados: Se observaron 30 pacientes bajo ventilación mecánica, para un total de 44 días de observación, durante los que se realizaron 2.002 observaciones. Durante el período de estudio, 3 (50%) de las prácticas se mantuvieron por encima del 80% de la adhesión, lo que demuestra la importancia del monitoreo de los cuidados incluidos en el bundle. Discusión y Conclusiones: Se observó que el cumplimiento de algunas prácticas se encuentra por debajo de lo esperado, lo que demuestra la necesidad de estrategias educativas que promuevan la calidad de todos los cuidados. Como citar este artigo: Barros FRB. Adesão ao bundle de prevenção de pneumonia associada à ventilação mecânica. Rev Cuid. 2019; 10(2): e746. http://dx.doi.org/10.15649/cuidarte.v10i2.746  

Boas práticas na prevenção de pneumonia associada à ventilação mecânica

Resumo Objetivo: Avaliar a adesão dos profissionais de saúde a um conjunto de boas práticas de prevenção de Pneumonia Associada à Ventilação Mecânica, índice de conformidade às medidas individuais e associação de características clínicas dos pacientes e adesão ao conjunto de boas práticas com a pneumonia. Métodos: Estudo de coorte prospectivo realizado em uma Unidade de Terapia Intensiva de um hospital universitário no período de maio de 2017 a outubro de 2017. A amostra foi composta por pacientes internados no período do estudo, que preencheram os critérios de inclusão, a coleta de dados foi realizada por meio de consulta a prontuários. Resultados: O item com maior adesão foi a avaliação diária da sedação e redução sempre que possível, 81 (91,0%), seguido da troca do circuito a cada 7 dias, 76 (82,6). A manutenção da pressão do cuff entre 20 e 30 mm H2O foi o item com menor adesão 22 (23,9%). A adesão ao conjunto completo apresentou conformidade em 20 (21,7%) das oportunidades. O estudo mostrou que quanto maior a adesão às medidas de boas práticas, menor é o risco de Pneumonia Associada à Ventilação Mecânica, porém não foi um dado estatisticamente significante. Os pacientes cirúrgicos e em uso de ventilação mecânica apresentaram maior risco de desenvolver PAV (p= 0,05). Conclusão: A Pneumonia Associada à Ventilação Mecânica pode trazer grave repercussão para o paciente, a aplicação de medidas com embasamento científico é fundamental, a fim de se prevenir a ocorrência deste agravo, que é uma das mais frequentes infecções relacionadas à assistência à saúde dentro das Unidades de Terapia Intensiva brasileiras.

Critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle

BACKGROUND

Although evidence-based practices are known to improve the quality of care, making it cost-efficient and improving clinical results, barriers to transferring research into clinical practice have hindered this process.

AIMS

To evaluate critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle.

MATERIAL AND METHODS

In 2015, we conducted an institution-specific, cross-sectional study in a 26-bed adult mixed medical-surgical intensive care unit (ICU) in Finland using quantitative survey of knowledge and self-reported adherence with qualitative gathering of barrier data. A pre-validated multiple-choice Ventilator Bundle Questionnaire was distributed to all registered nurses who were direct care providers (n = 155).

RESULTS

The final response rate was 55.5% (n = 86), and 47.2% (n = 34) of respondents had more than 10 years of ICU experience. The levels of knowledge and self-reported adherence were 71.1% and 65.8% of the total score, respectively. The level of knowledge was higher among respondents who had received in-service education about ventilator bundle compared with respondents who had not received in-service education (27.0 vs 24.0 [P = .012]). Less experienced nurses reported significantly higher adherence than nurses with more ICU experience (29.0 vs 25.0 [P = .034]). The correlation between knowledge and adherence scores was low (ρ 0.48 [P <.001]). The most well-known and adhered-to guidelines described patient positioning, daily chlorhexidine-based oral care, and strict hand hygiene. The least-known guidelines and those least adhered to described respiratory equipment, management of sedation and analgesia, and practices prior to and during endotracheal suctioning. The main barriers were related to the nurse respondents (e.g., lack of education [25.9%]), environment (e.g., role ambiguities [36.4%] and inadequate resources [21.1%]), and patients (e.g., patient discomfort [4.8%] and fear of adverse effects [4.6%]).

CONCLUSIONS

Self-reported adherence did not correlate with knowledge and was not related to work experience. Most of the barriers toward evidence-based guidelines indicated a need for changes that are beyond the control of individual nurses.

Ventilator Bundle Compliance and Risk of Ventilator-Associated Events

OBJECTIVE

Ventilator bundles encompass practices that reduce the risk of ventilator complications, including ventilator-associated pneumonia. The impact of ventilator bundles on the risk of developing ventilator-associated events (VAEs) is unknown. We sought to determine whether decreased compliance to the ventilator bundle increases the risk for VAE development.

DESIGN

Nested case-control study.

SETTING

This study was conducted at 6 adult intensive care units at an academic tertiary-care center in Tennessee.

PATIENTS

In total, 273 patients with VAEs were randomly matched in a 1:4 ratio to controls by mechanical ventilation duration and ICU type.

METHODS

Controls were selected from the primary study population at risk for a VAE after being mechanically ventilated for the same number of days as a specified case. Using conditional logistic regression analysis, overall cumulative compliance, and compliance with individual components of the bundle in the 3 and 7 days prior to VAE development (or the control match day) were examined.

RESULTS

Overall bundle compliance at 3 days (odds ratio [OR], 1.15; P=.34) and 7 days prior to VAE diagnosis (OR, 0.96; P=.83) were not associated with VAE development. This finding did not change when limiting the outcome to infection-related ventilator-associated complications (IVACs) and after adjusting for age and gender. In the examination of compliance with specific bundle components increased compliance with chlorhexidine oral care was associated with increased risk of VAE development in all analyses.

CONCLUSIONS

Ventilator bundle compliance was not associated with a reduced risk for VAEs. Higher compliance with chlorhexidine oral care was associated with a greater risk for VAE development.

Infect Control Hosp Epidemiol 2018;39:637–643