Impact of a program of intensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia and its cost-effectiveness.
ABSTRACT We hypothesized that a program of prospective intensive surveillance for ventilator-associated pneumonia (VAP) and concomitant implementations of multimodal, multidisciplinary preventive and intervention strategies would result in a reduction in the incidence of VAP and would be cost-effective.
Medical and surgical intensive care units (ICUs) in a university teaching hospital.
All ventilated patients in the medical and surgical ICUs were monitored for VAP from January 1997 through December 1998. Interventions including elevation of the head of the bed, use of sterile water and replacement of stopcocks with enteral valves for nasogastric feeding tubes, and prolongation of changing of in-line suction catheters from 24 hours to as needed were implemented.
The rates of VAP decreased by 10.8/1,000 ventilator-days in the medical ICU (CI95, 4.65-16.91) and by 17.2/1,000 ventilator-days in the surgical ICU (CI95, 2.85-31.56) when they were compared for 1997 and 1998. With the use of the estimated cost of a VAP of dollars 4,947 from the literature, the reduction resulted in cost savings of dollars 178,092 and dollars 148,410 in the medical and surgical ICUs, respectively, for a total of dollars 326,482. In addition, dollars 25,497 was saved due to the lengthening of the time for the change of in-line suction catheters, resulting in a cost savings of dollars 351,979. This total cost savings of dollars 351,979 minus the cost of enteral valves of dollars 2,100 resulted in total net savings of dollars 349,899.
Intensive surveillance and interventions targeted at ventilated patients resulted in reduction of VAP and appeared to be cost-effective.
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ABSTRACT: Ventilator-associated conditions (VACs) and infection related ventilator-associated complications (iVACs) are the Centers for Disease Control and Prevention's new surveillance paradigms for mechanically ventilated patients. Little is known regarding the clinical impact and preventability of VACs and iVACs, and their relationship to ventilator associated pneumonia (VAP). We evaluated these using data from a large, multicenter quality improvement initiative. We retrospectively applied definitions for VAC and iVAC to data from a prospective time series study in which VAP clinical practice guidelines were implemented in 11 North American intensive care units (ICUs). Each ICU enrolled 30 consecutive patients mechanically ventilated >48 hours during each of 4 study periods. Data on clinical outcomes and concordance with prevention recommendations were collected. VAC, iVAC, and VAP rates over time, the agreement (kappa statistic) between definitions, associated morbidity/mortality, and independent risk factors for each were determined. Of 1320 patients, 139 (10.5%) developed a VAC, 65 (4.9%) developed an iVAC and 148 (11.2%) developed VAP. The agreement between VAP and VAC was 0.18 and between VAP and iVAC, it was 0.19. Patients who developed VAC or iVAC had significantly more ventilator days, hospital days, antibiotic days, and higher hospital mortality than patients who had neither of these conditions. Increased concordance with VAP prevention guidelines during the study was associated with decreased VAP and VAC rates but no change in iVAC rates. VACs and iVACs are associated with significant morbidity and mortality. Although the agreement between VAC, iVAC and VAP is poor, a higher adoption of measures to prevent VAP was associated with lower VAP and VAC rates.Chest 09/2013; 144(5). DOI:10.1378/chest.13-0853 · 7.13 Impact Factor
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ABSTRACT: Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections. To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence. We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections. Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information. We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times. The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.Cochrane database of systematic reviews (Online) 01/2013; 3(3):CD006559. DOI:10.1002/14651858.CD006559.pub2 · 5.94 Impact Factor
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ABSTRACT: Citation: Elmenshawy AM, Elbadawy TH, Abu khaber H, Hafez SF, Fayed AM, Ibrahim EH. The impact of VAP staff education on VAP morbidity and mor-tality in Alexandria University. Pulm Res Respir Med Open J. 2014; 1(1): 32-45. ABSTRACT Background: Staff education had several success stories in reducing Ventilator-associated Pneumonia (VAP) rate. However, the stability of supplies and the top management support were not addressed in most of these studies. In addition, both were considered essential in several reviews. Aim: To determine the efficiency (VAP rate) and efficacy (mechanical ventilation morbidity and mortality) of VAP staff education with deficient supplies and lack of top management support. Methods: Quasi-experimental study with before and after prospective cohort in two medical/ surgical ICUs of Alexandria university affiliated hospitals during the period from September 2007 till May 2013. The intervention phase included the provision of supplementary supplies, interactive education for physicians and nurses followed by a VAP campaign. All VAP episodes not only the first one was included. Results: A total of 598 patients were enrolled in the study. The adherence to expanded VAP bundle significantly increased in the post-intervention phase as follows; head of bed elevation (from mean of 40 to 100% with p=0.001), oral care (from mean of 20 to 100% with p=0.001), daily sedation vacation (from mean of 56.5 to 91% with p=0.001), daily assessment of weaning (from mean of 9 to 25% with p=0. 03), peptic ulcer prophylaxis (from mean of 83 to 100% with p=0.001), DVT prophylaxis (from mean of 82 to 100% and p=0.001), cuff pressure measure-ment (from mean of 9 to 60% with p=0.001), and hand hygiene (from mean of 8 to 28.5% with p=0.001).The VAP rate decreased significantly by 35% (from 66.5 to 43 per 1000 MV days) with p= 0.002and CI 9.73-37.15 in spite of significant increase of the ventilator utilization ratio (p <0.001) in the post-intervention phase. The MV, antibiotic and ICU days did not change significantly in the post-intervention phase. The distribution of organisms did not differ signifi-cantly between both groups (p=0. 465). The sensitivity of most of carbapenems and β-lactam/β-lactamase inhibitors to Acinetobacter, Klebsiella andPseudomonas decreased significantly in the post intervention phase whereas the sensitivity of vancomyicin to Staphylococcus aureus remained the same. Conclusions: In spite of the lack of top management support and fluctuating supplies, VAP staff education was still efficient in reducing VAP without affecting mortality or MV days or ICU length of stay.