A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting

BMC Infectious Diseases

Karina Tavares Timenetsky³  Michael B Edmond²  Henrique Sutton de Sousa Neves⁴  Oscar Fernando Pavao dos Santos⁵  Cláudia Vallone Silva¹  Marcelino S Durão³  Alexandre R Marra³  Raquel A Caserta³ 

[1]Infection Control Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil

[2]Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA

[3]Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - 5º Andar – Bloco B, São Paulo, CEP 05651-901, Brazil

[4]Hospital Israelita Albert Einstein, São Paulo, Brazil

[5]Medical Practice Department, Hospital Israelita Albert Einstein, São Paulo, Brazil

关键词: VAP bundle;    Intensive care;    Prevention;    Ventilator associated pneumonia;   

Others  :  1159657
DOI  :  10.1186/1471-2334-12-234

 received in 2012-03-18, accepted in 2012-09-24,  发布年份 2012

【 摘 要 】

Background

Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality.

Methods

A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement’s (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation.

Results

We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%.

Conclusion

These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored.

【 授权许可】

   
2012 Caserta et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Richards MJ, Edwards JR, Culver DH, Gaynes RP: Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000, 21:510-515.
• [2]American Thoracic Society, Infectious Diseases Society of America: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J RespirCrit Care Med 2005, 171:388-416.
• [3]Edwards JR, Peterson KD, Andrus ML, Tolson JS, Goulding JC, Dudeck MA, Mincey RB, Pollock DA, Horan TC, NHSN Facilities: National Healthcare SafetyNetwork (NHSN) report, data summary for 2006, issued June. Am J Infect Control 2007, 35:290-301.
• [4]Marra AR, Cal RGR, Silva CV, Caserta RA, Paes AT, Moura DF Jr, dos Santos OF, Edmond MB, Durão MS: Successful prevention of ventilator associated pneumonia in an intensive care unit setting. Am J Infect Control 2009, 37:619-625.
• [5]Assanasen S, Edmond MB, Bearman G: Impact of 2 different levels of performance feedback on compliance with infection control process measures in 2 intensive care units. Am J Infect Control 2008, 36:407-413.
• [6]Bekaert M, Timsit JF, Vansteelandt S, Depuydt P, Vésin A, Garrouste-Orgeas M, Decruyenaere J, Clec'h C, Azoulay E, Benoit D, Outcomerea Study Group: Attributable mortality of ventilator-associated pneumonia: a reappraisal using causal analysis. Am J Respir Crit Care Med 2001, 184:1133-1139.
• [7]Nquile-Makao M, Zahar JR, Français A, Tabah A, Garrouste-Orgeas M, Allaouchiche B, Goldgran-Toledano D, Azoulay E, Adrie C, Jamali S, Clec'h C, Souweine B, Timsit JF: Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models. Intensive Care Med 2010, 36:781-789.
• [8]Tejerina E, Frutos-Vivar F, Restrepo MI, Anzueto A, Abroug F, Palizas F, González M, D'Empaire G, Apezteguía C, Esteban A, Internacional Mechanical Ventilation Study Group: Incidence, risk factors, and outcome of ventilator-associated pneumonia. J Crit Care 2006, 21:56-65.
• [9]Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH: VAP outcomes scientific advisory group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002, 122:2115-2121.
• [10]Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Bruisson C: The attributable morbidity and mortality of ventilator associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 1999, 159:1249-1256.
• [11]Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, Susag A: Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 2007, 33:219-225.
• [12]Horan TC, Andrus M, Dudeck MA: CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infectioins in the acute care setting. Am J Infect Control 2008, 36:309-332.
• [13]Safdar N, Dezfulian C, Collard HR, Saint S: Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005, 33:2184-2193.
• [14]Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T: Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005, 31:243-248.
• [15]Berriel-Cass D, Adkins FW, Jones P, Fakih MG: Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf 2006, 32:612-620.
• [16]Bouadma L, Deslandes E, Lolom I, Le Corre B, Mourvillier B, Regnier B, Porcher R, Wolff M, Lucet JC: Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis 2010, 51:1115-1122.
• [17]Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J: Continuous Aspiration of Subglottic Secretions (CASS) in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest 2008, 134:938-946.
• [18]Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK: Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med 2011, 39:1985-1991.
• [19]Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V: Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol 2008, 29:131-136.
• [20]Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, Stevenson K, Samore M, Platt R, CDC Prevention Epicenters Program: Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation. PLoS One 2011, 6(3):e18062.
• [21]Edmond MB: Getting to zero: is it safe? Infect Control Hosp Epidemiol 2009, 30:74-76.
• [22]Skrupky LP, McConnell K, Dallas J, Kollef MH: A comparison of ventilator-associated pneumonia rates as identified to the National Healthcare Safety Network and American College of Chest Physicians criteria. Crit Care Med 2012, 40:281-284.
• [23]Klompas M: Ventilator-associated pneumonia: is zero possible? Clin Infect Dis 2010, 51:1123-1126.
• [24]Nguile-Makao M, Zahar JR, Français A, Tabah A, Garrouste-Orgeas M, Allaouchiche B, Goldgran-Toledano D, Azoulay E, Adrie C, Jamali S, Clec'h C, Souweine B, Timsit JF: Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models. Intensive Care Med 2010, 36:781-789.