Ventilator-associated pneumonia (VAP) is a serious nosocomial infection. In a perspective of quality improvement, we assessed the introduction of a 10-item VAP preventive bundle in a before-after study in an intensive care unit (ICU).
Based on effectiveness, related risk and cost-efficiency, we implemented recommendations on hand hygiene, subglottic secretion drainage (SSD), tracheal tube cuff pressure (22-29 cm H2O), oral care frequency (OCF), semi-recumbent position (SRP) > 30°, ventilator tubing change, awakening trials, weaning from ventilation, early physiotherapy and proton pump inhibitors.
An online survey with 10 multiple-choice questions (MCQ) was sent to ICU physicians and nurses to evaluate baseline knowledge. According to MCQ responses and clinical relevance, we assessed the adherence to 6 selected items before and after implementation of the bundle (period 1, May-June 2017; period 2, March-April 2018). We enrolled all orally intubated patients, except those with end-of-life care or < 6 hours ventilation. Data related to awakening trials, weaning from ventilation, SRP, OCF, SSD and cuff pressure monitoring were collected at 8 and 12 AM by direct observation of patient’s fact sheets and bed inclinometers. The intervention included 12 bundle training sessions, 10 wall posters put up in the ICU, the provision of specific oral care sets and cuff pressure monitoring devices. We compared period 1 and period 2 groups using chi-squared or Fisher exact test as appropriate.
The compliance with the VAP bundle was assessed during 60 and 61 ventilation-days on period 1 and 2, respectively. Achievement of all 6 selected items improved significantly after the intervention (2 / 50 vs 35 / 53, observations, P < 0.001), particularly SRP (8 AM: 31 / 53 vs 48 / 52, P < 0.001; 12 AM: 40 / 50 vs 46 /4 7, P = 0.008), cuff pressure within expected range (37 / 179 vs 390 / 390, P < 0.001) and frequency of cuff controls (≥ 4 per day; 22 / 58 vs 50 / 60, P < 0.001). Adherence to daily awakening (97 - 98 %) and weaning trials (98 - 97 %), SSD (88 - 86 %) and OCF (≥ 4 per day, 78 - 85 %) did not change significantly between the 2 periods.
A good adherence was reported for important aspects of VAP prevention such as daily awakening and weaning trials, subglottic secretion drainage and oral care frequency. Implementation of the VAP bundle with focused teaching and provision of specific tools improved all preventive weaknesses within a year.