CLABSI intervention also whaps VAP
CLABSI intervention also whaps VAP
Study suggests that 'most VAPs are preventable'
A highly successful team approach to preventing blood stream infections shows similar efficacy against ventilator associated pneumonia (VAP), which was sharply reduced in more than 100 participating intensive care units.
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, reports Peter Pronovost, MD, PhD, medical director of the Center for Innovations in Quality Patient Care at Johns Hopkins Hospital in Baltimore.
The VAP intervention was part of a quality improvement effort involving Hopkins and Michigan ICUs participating in the Keystone project, which has been widely hailed for a similar success against central line associated blood stream infections (CLABSIs).
"It's the exact same model," Pronovost tells Hospital Infection Control & Prevention. "We used a checklist, teamwork and feeding back data on performance. We are showing that this method could apply to other types of preventable harm like VAP. We are really on to something for advancing the science to make care safer."
The researchers implemented a VAP prevention bundle that included five key patient care practices:
- Semirecumbent positioning to decrease the risk of VAP.
- Stress ulcer prophylaxis to decrease gastrointestinal bleeding.
- Prophylaxis to decrease deep venous thrombosis.
- Adjustment of sedation until the patient can follow commands.
- Daily assessment of readiness to extubate, to reduce the duration of mechanical ventilation.
Culture change
Just as important as the clinical bundle was the adoption of the kind of unit-based culture change used in the CLABSI model. Before the program began and annually thereafter, a quantitative assessment of the institutional safety culture was performed using a validated survey. A team of frontline staff, which included at least a physician and a nurse, was assembled to implement the program. The process included the following steps:
Step 1: Educate staff on the science of improving patient safety, including systems redesign.
Step 2: Ask teams to identify defects (defined as anything clinically or operationally that should not recur).
Step 3: Involve "senior executive partnerships" to bridge the gap between management and frontline staff, to help prioritize safety hazards and interventions, and to provide resources to improve safety.
Step 4: Ask staff to choose and learn from 1 defect per month.
Step 5: Ask teams to implement tools (e.g., daily goals and morning briefings) to help improve teamwork and communication.
In addition to the bundle practices, the VAP intervention sought to increase use of evidence-based therapies for the prevention of VAP. Those included recommendations to use orotracheal route of intubation, change ventilator circuits for each new patient and for soiled circuits, use closed endotracheal suction systems that are changed for each new patient and as clinically indicated, and use heat and moisture exchangers with weekly changes in the absence of contraindications.
A standardized CDC definition of VAP was used. Baseline data were reported and post-implementation 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. Overall, 112 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 and 0 cases (mean, 2.4 cases) at 28–30 months after implementation. Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 at 16–18 months after implementation and 0.29 at 28–30 months after implementation.
"This study suggests that most VAPs are preventable, which has important public health implications," Pronovost and co-authors concluded. "[T]he Keystone ICU project may be a model for large-scale improvement projects in patient safety and public health."
Reference
- Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011;32:305-314
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