Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit

Department of Surgery, Boston Medical Center, 88 E Newton St, Boston, MA 02118, USA.
Archives of surgery (Chicago, Ill.: 1960) (Impact Factor: 4.93). 05/2010; 145(5):465-70. DOI: 10.1001/archsurg.2010.69
Source: PubMed


To examine the impact of adherence to a ventilator-associated pneumonia (VAP) bundle on the incidence of VAP in our surgical intensive care units (SICUs).
Prospectively collected data were retrospectively examined from our Infection Control Committee surveillance database of SICU patients over a 38-month period. Cost of VAP was estimated at $30,000 per patient stay.
Two SICUs at a tertiary care academic level I trauma center.
Ventilated patients admitted to a SICU.
The Institute for Healthcare Improvement VAP bundle was instituted at the beginning of the study and included head-of-bed elevation, extubation assessment, sedation break, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis. A daily checklist was considered compliant if all 5 items were performed for each patient.
Patients were assessed for VAP. Staff were assessed for compliance with the VAP bundle.
Prior to initiation of the bundle, VAP was seen at a rate of 10.2 cases/1000 ventilator days. Compliance with the VAP bundle increased over the study period from 53% and 63% to 91% and 81% in each respective SICU. The rate of VAP decreased to 3.4 cases/1000 ventilator days. A cost savings of $1.08 million was estimated.
Initiation of the VAP bundle is associated with a significantly reduced incidence of VAP in patients in the SICU and with cost savings. Initiation of a VAP bundle protocol is an effective method for VAP reduction when compliance is maintained.

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Available from: Suresh Agarwal
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    • "Our results indicate that the availability of written guidance documents (we do not know whether they were really guidelines or internal guidance documents) to prevent VAP in ICU patients is significantly associated with compliance with the prevention measures. A number of interventional studies exist that analyse adherence with all elements of previously defined ventilator bundles [19,25,26,34,35]. In a comparative approach, Bouadma et al. [23] analysed the preventive impact of increased compliance with backrest elevation, tracheal cuff pressure maintenance, orogastric tube use, gastric overdistension avoidance, good oral hygiene and nonessential tracheal suction elimination in a 20-bed medical ICU in a teaching hospital in France [23]. "
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    ABSTRACT: To analyse whether the availability of written standards for management of mechanically ventilated patients and/or the existence of a surveillance system for cases of ventilation-associated pneumonia (VAP) are positively associated with compliance with 6 well-established VAP prevention measures. Ecological study based on responses to an online-questionnaire completed by 1730 critical care physicians. Replies were received from 77 different countries, of which the majority, i.e. 1351, came from 36 European countries. On a cross-country level, compliance with VAP prevention measures is higher in countries with a large number of prevention standards and/or VAP surveillance systems in place at ICU level., Likewise, implementation of standards and VAP surveillance systems has a significant impact on self-reported total compliance with VAP prevention measures (both p < 0.001). Moreover, predictions of overall prevention measure compliance show the effect size of the availability of written standards and existence of surveillance system. For instance, a female physician with 10 years of experience in critical care working in a 15-bed ICU in France has a predicted baseline level of VAP prevention measure compliance of 63 per cent. This baseline level increases by 9.5 percentage points (p < 0.001) if a written clinical VAP prevention standard is available in the ICU, and by another 4 percentage points (p < 0.001) if complemented by a VAP surveillance system. The existence of written standards for management of mechanically ventilated patients in an ICU and the availability of VAP surveillance systems have shown to be positively associated with compliance with VAP prevention measures and should be fostered on a policy level.
    Full-text · Article · Apr 2014 · BMC Infectious Diseases
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    • "self-reported adherences to hand hygiene (Berhe et al., 2005; CDC, 2007; De Wandel et al., 2010; Sahay et al., 2010; Tolentino-DelosReyes et al., 2007; WHO, 2009), oral care (Cutler and Davis, 2005; Furr et al., 2004; Jones et al., 2004) and ETS practices (Day et al., 2002; Kelleher and Andrews, 2008) were generally higher than reported in previous prospective, observational studies. In addition, rigorous hand hygiene with alcohol disinfectants was not common practice when previous studies published prior to 2010 were conducted (Apisarnthanarak et al., 2007; Berrile-Cass et al., 2006; Bird et al., 2010; Bloos et al., 2009; Crunden et al., 2005; Hawe et al., 2009; Hutchins et al., 2009; Marra et al., 2009; Resar et al., 2005; Youngquist et al., 2007; Zaydfudim et al., 2009). Alcohol-based hand disinfection was considered in Blamoun et al.&apos;s (2009) and Bouadma et al.&apos;s studies (2010a,b), whereas earlier studies, such as Cocoanour et al. (2006), merely recommended its use. "
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    ABSTRACT: OBJECTIVES: To explore critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. DESIGN: A quantitative cross-sectional survey. METHODS: Two multiple-choice questionnaires were distributed to critical care nurses (n=101) in a single academic centre in Finland in the autumn of 2010. An independent-samples t-test was used to compare critical care nurses' knowledge and adherence within different groups. The principles of inductive content analysis were used to analyse the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. RESULTS: The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p=0.029). The overall, self-reported adherence was 84.0%. The main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance. CONCLUSION: There is an ongoing need for improvements in education and effective implementation strategies. CLINICAL IMPLICATIONS: The results could be used to inform local practice and stimulate debate on measures to prevent ventilator-associated pneumonia. Education, guidelines as well as ventilator bundles and instruments should be developed and updated to improve infection control.
    Full-text · Article · Apr 2013 · Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses
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    • "The broad distribution of the order set quality score is notable and represents a potential opportunity for quality improvement. Although we were not able to examine whether the order set quality score was associated with patient outcomes, the implementation of sedation, sepsis, ventilator-associated pneumonia and weaning protocols have all been associated with improved patient outcomes and decreased costs [30-39]. As such, we believe our findings are an important first step in improving the structure of the care environment, a step that could lead to improvements in both processes and outcomes. "
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    ABSTRACT: Introduction Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines. Methods Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score. Results Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score. Conclusions Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.
    Full-text · Article · Jun 2012 · Critical care (London, England)
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