Medicine of the Future in America

Preventing Ventilator-Associated Pneumonia in Adults: Addressing Barriers to Translating Guidelines Into Practice

Preventing Ventilator-Associated Pneumonia in Adults: Addressing Barriers to Translating Guidelines Into PracticeAs with other prevention efforts, interventions aimed at reducing VAP should focus on evidence-based interventions, for which efficacy and cost-effectiveness have been clearly supported by clinical studies and experts in the field (Table 1). Initially, it may be more prudent to focus on a limited number of feasible, cost-effective prevention strategies for VAP prevention. In the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign, hospitals are challenged to adopt as many of the six recommended initiatives to reduce health-care-associated infections. The VAP or “ventilator bundle” initiative includes five simple components: elevation of the head of the bed to between 30° and 45°, a daily “sedation vacation,” daily assessment for readiness to extubate, and prophylaxis for peptic ulcer disease and deep vein thrombosis. Some participating hospitals using this approach are reporting zero episodes of VAP over sustained periods of time (Donald Berwick, MD; IHI National Forum; personal correspondence; December 13, 2005). Confirmation of these dramatic results in peer-reviewed journals is eagerly anticipated.
Staff education, particularly targeting those clinicians and staff who manage patients receiving mechanical ventilation, is a cornerstone for efforts to reduce the incidence of VAP. Kollef and Babcock and coworkers initially reported the success of a VAP educational prevention program carried out in five ICUs. The program, developed by a multidisciplinary team, targeted respiratory care providers and intensive care nurses who completed a self-study module on risk factors for VAP at baseline and after the program interventions. Relevant in-service teaching programs were coordinated with staff meetings, and fact sheets and posters were placed in the ICU and respiratory care departments. Rates of VAP dropped nearly 58%, to 5.7/1,000 ventilator days, and cost savings were estimated to be from $425,606 to $4,000,000. Babcock et al, using an extension of this program in an integrated health-care system involving four hospitals, reported a 46% reduction in VAP over an 18-month period. Perhaps one of the most important and underappreciated prevention strategy is adequate staffing, particularly in critical care units.’ Staffing must be sufficient to allow patient care to be provided while ensuring that staff are able to comply with essential infection control practices and other prevention strategies.
In a study of abdominal aortic surgery patients by Dang et al, decreased nursing staffing was associated with significantly higher rates of respiratory and cardiac complications than in patients who had higher intensity nursing. Currently, this is of critical importance due to severe nursing shortages and staffing reductions due to budget constraints. Nurse-to-patient ratios should be 1:1 for high-risk complicated ICU patients, or 2:1 for patients with lower disease acuity. Currently, efforts to establish legislation that would cap the number of patients per nurse are underway in some states.

Table 1—Selected VAP Prevention Strategies Abstracted From Recent Guidelines

Intervention/Strategy Support/Evidence Comments
Infrastructure
Multidisciplinary team Programs developed by team consensus are more effective. Input by critical care staff and respiratory therapists is crucial.
Champion of the cause Recognized leader/expert increases “buy-in” by staff and hospital administration. Leadership is needed to set benchmarks, maintain efforts, and secure resources.
Targeted staff education Staff education/awareness programs have been shown to reduce VAP. Such programs are adaptable to local needs and are cost-effective.
Infection control Data support importance in reducing spread of MDR organisms. Coordinate with quality improvement efforts; feedback data to staff.
Antibiotic control This reduces inappropriate antibiotic use and associated costs. Designated pharmacist is optimal; computer programs are good alternative.
Adequate staffing Critical for maintaining patient safety and adherence to protocols. This is particularly important in critical care units; current nursing shortages exist.
Benchmarking/quality Current recommendations from IHI and local multidisciplinary teams. Benchmarks should be evaluated routinely and data communicated.
Patient care
Sedation vacation This is supported by clinical data, and is accessible and feasible. Implement standard protocols.
Semi-upright position Supported by early data; recent data suggest lower elevation target indicated. Few outcome data; poor compliance with strategy. Further studies needed.
NPPV Supported by several clinical trials in recent review by Cochrane. Experience with technique is suggested for patients with COPD and congestive heart failure.
Oral care Evidence is limited, but risk and cost are low. Further studies are needed.
Stress bleeding prophylaxis Data support use of PPIs and H2-blockers; limit to high-risk patients. PPIs and H2-blockers are more effective than sucralfate in preventing bleeding.
Deep vein thrombosis prophylaxis Evidence supportive. Recommended in the VAP 100,000 Lives Campaign VAP “bundle.”
Standardized protocols for weaning and enteral feedings Rates of VAP are lowered by reduced duration of intubation and enteral feeding. Protocols help standardize implementation and provide standards for monitoring.
Chlorhexidine with or without colistin Randomized controlled trials demonstrate efficacy. More data are needed.
SDD VAP and mortality decreased with IV plus topical antibiotics. Concerns about antibiotic resistance limit “routine” use.
Tracheal intubation and use of orogastric tubes Several small clinical trials report decreased sinusitis. Recommended but has limited impact on VAP.
Continuous aspiration of subglottal secretions Decreased VAP shown in at least four RCTs. Optional; cost and impact on staffing are of concern.
HMEs Trend toward decreased VAP. Recommended; eliminates condensate, but decreases humidity.
No change of ventilator circuits Several RCTs support this intervention. Recommended; positive cost and staffing impact
Early tracheostomy Reports from three RCTs; methodologic concerns. Optional; further data from rigorous studies are needed.
Closed endotracheal suctioning Three RCTs showed no effect on VAP but probably reduces environmental contamination. Optional, may reduce environmental spread of MDR pathogens.
Discharge issues
Vaccination Pneumococcal and influenza vaccination reduce hospitalizations. Recommended; poor routine vaccination rates of high-risk populations.
Smoking cessation Smoking cessation has been demonstrated to reduce morbidity and mortality. Recommended; instructions and referrals should be documented.
Nutritional counseling Obesity is a known risk factor for comorbidities associated with pneumonia. Recommended; instructions and referrals should be documented.
Prevention of aspiration Aspiration is a major risk factor for pneumonia. Check sedation, head of the bed; speech and swallow studies, if indicated.
This entry was posted in Pulmonary function and tagged antibiotics, evidence-based data, guidelines, infection control, Institute for Healthcare Improvement, intensive care, prevention of hospital-acquired pneumonia, ventilator-associated pneumonia.
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