Although The Joint Commission's National Patient Safety Goals force many organizations to focus primarily on MRSA, central line-associated bloodstream infections, and surgical site infections, ventilator-associated pneumonia (VAP) is a high priority for anyone in the hospital setting.
Mortality rates alone force hospitals to take a critical look at prevention processes. VAP is the leading cause of death among hospital-acquired infections, according to the Institute for Healthcare Improvement (IHI). Hospital mortality of patients already ventilated who develop VAP is 46%, compared to 32% for those who are ventilated and do not develop VAP.
Just as most facilities have implemented central line and surgical site bundles, the IHI has published a ventilator bundle with four evidence-based practices:
- Elevation of the head of the bed
- Daily "sedation vacations" and assessment of readiness to extubate
- Peptic ulcer disease prophylaxis
- Deep venous thrombosis prophylaxis
A study published in the October 2009 American Journal of Infection Control focused on prevention of VAP in the intensive care setting. The study implemented interventions in three different phases to reduce the incidence of VAP in the ICU.
In the study's first phase, from March 2001 to December 2002, researchers evaluated the effectiveness of Centers for Disease Control and Prevention (CDC)-recommended evidence-based practices, including no routine changing of humidified ventilator circuits, periodically draining and discarding condensation collecting in the ventilator tubing, and changing the heat and moisture exchangers when they malfunctioned mechanically or became visibly soiled.
From January 2003 to December 2006, researchers intervened in the processes while performance monitoring was occurring at the bedside.
Finally, from January 2007 to September 2008, the researchers continued interventions and implemented the IHI bundle in addition to oral decontamination with chlorhexidine and the use of continuous aspiration of subglottic secretions (CASS) endotracheal tubes, says Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil.
The incidence density of VAP in the ICU per 1,000 days was reduced from 16.4 in phase one to 15.0 in phase two to 10.4 in phase three. The study noted that achieving a rate of zero VAP was possible only in phase three, when all interventions exceeded 95% compliance. In November 2009, the hospital celebrated one year without VAP.
"Our main reason for doing the study was to show that VAP prevention using the majority of evidence-based measures for controlling this hospital-acquired infection in the ICU is a difficult process that involves the accountability of many healthcare workers who care for ventilated patients," Marra says.
The initial results
The first phase of CDC evidence-based practices yielded disappointing results, particularly regarding compliance rates, Marra says.
"It was necessary to have a lot of discussions and changing ideas with the ICU team to make a better performance in our compliance rates," he says. The ICU team was composed of doctors, nurses, and respiratory therapists.
In early 2007, the hospital's CEO declared zero tolerance for VAP. Intervention measures continued, but with more intensity and urgency, Marra says. At that point, phase three was also initiated as an added measure.
Implementing all three phases at once
Although Marra's study gradually implemented each phase over the course of more than seven years, implementation of all three phases yields optimum results.
"Our recommendation is to begin using all the sources at the same time: VAP bundle, oral decontamination with chlorhexidine, and CASS endotracheal tubes," says Marra. "It is important to mention that VAP bundle is not a checklist, but a process that is necessary to intervene for improving compliance with these processes at the same time that performance monitoring is occurring at the bedside."
The intervention portion of the study was particularly beneficial. It's not enough to simply hand staff members a checklist. Working with ICU team members to ensure consistent and correct compliance is the only way to see improvements, Marra says.
"Our experience shows that it is not enough to control [head of the bed] or only to implement the IHI ventilator bundle, as some centers have advocated," says Marra. "We believe that by getting the involvement of all members of the ICU team, we ultimately had success in applying all these process measures over several years. We have an ICU nurse taking care of these processes every day and also a respiratory therapist giving support to us."
Although the ICU team at Hospital Israelita Albert Einstein has been able to sustain zero VAP rates for a full year, Marra recognizes the goal is ensuring continued compliance to achieve that rate.
"We are completely aware that we may not be able to sustain zero VAP rates indefinitely, but our goal is to sustain nearly perfect compliance with the ventilator bundle and maintain ICU team motivation for VAP prevention," Marra says.
Oral care: The most important phase
Evidence is mounting that in addition to the Institute for Healthcare Improvement's ventilator bundle, oral care is an important infection prevention process, according to a study published in the October 2009 American Journal of Infection Control.
Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil, says the last phase was the most important in significantly reducing VAP rates.
"I strongly believe, and I have no doubt, that the last phase was the most important," Marra says. "We got a decrease of more than 70% in our VAP rate in the ICU."
A study published in the September 2009 American Journal of Infection Control focuses on oral care to prevent VAP. Mercy Medical Center in Springfield, MA, initiated the following measures every four hours for mechanically ventilated patients:
- Brushing patients' teeth with cetylpyridinium chloride (changed to chlorhexidine gluconate in 2007) using a suction toothbrush
- Cleaning the oral cavity with suction swabs treated with hydrogen peroxide
- Applying mouth moisturizer
- Performing deep oropharyngeal suctioning
- Controlling secretions with suction catheters
Kathleen Hutchins, RN, MSN, lead author of the latter study, began research in 2004. By 2007, oral care intervention, coupled with the ventilator bundle, led to an 89.7% reduction in the VAP rate at Mercy.
This article was adapted from one that originally appeared in the January 2010 issue of Briefings on Infection Control, an HCPro publication.