Measuring adherence rates to ventilator-associated pneumonia prevention guidelines in an academic ICU
CCCF ePoster library. Carlone D. Oct 26, 2015; 117323; P38
David Carlone
David Carlone
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Abstract
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P38


Topic: Quality Assurance/Quality Improvement Project


Measuring adherence rates to ventilator-associated pneumonia prevention guidelines in an academic ICU



David Carlone

Medicine, Queen's University, Kingston, Canada

Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial infection that occurs in patients who are mechanically ventilated for over 48 h. It has an incidence of 13-51 cases per 1000 ventilator-days and a mortality of 20-30%. It is associated with increased length of stay and costs of care. For these reasons, VAP rates are a publicly reported Patient Safety Indicator in Ontario. While many interventions have been demonstrated to reduce VAP incidence, studies have also shown that in order for these interventions to be effective, a high compliance rate is required.

Objectives:

The goals were to prospectively measure adherence to VAP prevention policies in an academic ICU. We also examined for differences in adherence amongst the patients who developed VAP and those who did not.



Methods:

We measured the daily implementation of the following prevention measures: oral intubation, oral chlorhexidine, closed endotracheal suctioning system, subglottic secretion drainage and head of bed elevation above 30 degrees. We also gathered demographic and relevant clinical information.



Results:

We recruited 53 consecutive patients over 2 months, with 497 ventilator-days observed. Average hospitalization was 31.3±22.3 days, ICU stay was 16.0±14.1 days, and average ventilation was 10.6±11.0 days. Eleven (20.8%) patients died and, as per attending physicians’ diagnosis, 11 (20.8%) developed VAP (19.93/1000-ventilator-days).The overall daily compliance rates with oral chlorhexidine and use of closed suctioning systems were 100%. Patients were orally intubated during 69.6% ventilator days, intubated via tracheostmy for 25.6% of days and nasally intubated for 0.08%.The head of bed was elevated above 30 degrees for 82.9% (average angle 31.6 ±9.2 degrees). Subglottic secretion drainage was employed for 53.3% of ventilator days overall, and 76.6% of the time for patients who were orally intubated. There were no differences in the compliance rates between the patients who developed VAP and those who did not, except for use of subglottic secretion drainage which was higher in the VAP group (p=0.04). It is unlikely this represents a true difference.



Conclusion:

Compliance with VAP prevention strategies was variable. The full adherence to oral decontamination was likely achieved through automatic chlorhexidine orders applied in our ICU. Also, closed suctioning systems are the only product available at our ICU. Thus these forced, routine measures resulted in maximal compliance. The number of oral endotracheal tubes without subglottic secretion drainage is mainly due to tubes placed in the OR or by outside hospitals. Head of bed elevation compliance was lower than previously achieved at our ICU through audit/feedback cycles. The incidence of VAP was substantial, likely reflecting the suboptimal compliance with the preventive measures. This study will inform our next quality improvement steps.



References:

Charles, M. P., et al. (2014). Ventilator-associated pneumonia. The Australasian Medical Journal, 7(8), 334-344.

Bonten MJ, Kollef MH, Hall JB. Risk factors for ventilator-associated pneumonia: From epidemiology to patient management. Clin Infect Dis. 2004 Apr 15;38(8):1141-9.

Koenig SM, Truwit JD. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev. 2006 Oct;19(4):637-57.

http://www.hqontario.ca/public-reporting/patient-safety

Pogorzelska, M., et al. (2011). Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit. International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care / ISQua, 23(5), 538-544.

Muscedere, J et al. (2008). Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention. Journal of Critical Care, 23(1), 126-137.


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