Strategies

 

Strategies to prevent ventilator-associated pneumonia in acute care hospitals were just recently published in a supplement from Infection Control and Hospital Epidemiology, October 2008, Vol. 29, Supplement 1 S31-S40. Authors are: Coffin SE, Klompas M, Classen D, Arias KM, et al.

 

The article's purpose was not to serve as an in depth discussion of recommendations for detecting and preventing healthcare-associated pneumonia but rather offer a concise and practical listing of recommendations to assist acute care hospitals to highlight ventilator-associated pneumonia prevention strategies. The article also gives criteria for grading the strength of recommendation and quality of evidence described.

 

The following briefly summarizes the article's 5 major sections. For complete discussion, tables, references and a Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals visit the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America: http://www.shea-online.org/about/compendium.cfm

 

 

Section 1: Rationale and Statements of Concern

In this section the authors discuss the occurrence, outcomes, pathogenesis and risk factors associated with VAP. The occurrence of VAP in acute care facilities has been identified as the most common infection acquired by adults and children in intensive care units (ICUs) but with quality improvement initiatives it might be preventable.

 

Under the outcomes section it was noted that VAP requires increased utilization of healthcare resources and costs as well as being a significant cause of patient morbidity and mortality. VAP extends hospitalization and increases the use of antimicrobial medications; with an overall increase in medical costs.

 

The pathogenesis of VAP shows that it is multifactorial and occurs when bacteria invade and colonize the respiratory tract of a patient receiving mechanical ventilation. It can also be caused by aspiration of secretions, colonization of the aero digestive tract, use of contaminated equipment and use of contaminated medications.

 

Risk factors contributing to the developing VAP are prolonged intubation, enteral feeding, witnessed aspiration, paralytic agents, underlying illness and extremes of age.

 

Section 2: Strategies to Detect VAP

Under strategies to detect VAP the definition and methods of surveillance are discussed. The authors note that there appears to be a lack of a consistent definition of VAP and that the definition is subjective. Most hospital epidemiologists and infection prevention and control professionals use the National Healthcare Safety Network VAP definition.

 

Methods for surveillance of VAP need to be ongoing to accurately identify VAP. Surveillance requires not only review of 2 or more chest radiographs but also appropriate laboratory culturing of endotracheal secretions or specimens from bronchoalveolar lavage. Methodology for specimen collection remains controversial; while, electronic surveillance tools which are not yet widely available but can be used in the identifying patients with possible VAP.

 

Section 3: Strategies to Prevent VAP

In this section the authors refer to existing guidelines as a way to improve patient outcomes and cost effectiveness; they also recommend different strategies that decrease the risk of developing VAP which include prevention of aspiration, reduce colonization (aerodigestive tract) and minimization of equipment contamination used to care for patients receiving mechanical ventilation.

 

A majority of the current recommendations are from adult patient studies since there are few studies which have evaluated prevention of VAP in children. Aspiration of secretions, colonization of the aero digestive tract and use of contaminated equipment are the 3 most common causes of VAP.

 

General strategies that decrease the risk developing of VAP are active surveillance, adherence to hand-hygiene guidelines, use of noninvasive ventilation (when feasible), minimizing ventilator time, daily assessment for readiness to wean, the use weaning protocols and lastly VAP education to all healthcare personnel.

 

Specific strategies to prevent aspiration include maintaining patients in a semi-recumbent position, unless contraindicated; avoiding gastric over distention, unplanned extubation and reintubation, and using a cuffed endotracheal tube with in-line or subglottic suctioning.

 

Strategies to reduce colonization of the aerodigestive tract include orotracheal intubation and avoidance of nasotracheal intubation. Avoid histamine receptor 2 (H2)–blocking agents and proton pump inhibitors unless the patient is at high risk for developing a stress ulcer or stress gastritis. The use of sucralfate or H2-blocking agents is still unresolved and the frequency of performing oral care with an antiseptic solution remains in question.

 

Strategies to minimize contamination of equipment used to care for patients receiving mechanical ventilation include use rinsing reusable respiratory equipment with sterile water, keeping ventilatory circuits free of condensation, maintaining a closed ventilator circuit during condensate removal, changing the ventilator circuit only when necessary eg. visible soil or malfunctioning and lastly store and disinfect respiratory therapy equipment properly.

 

Section 4: Recommendations for Implementing Prevention and Monitoring Strategies

This section contains a table that categorizes and grades the strength of the recommendations and the quality of evidence that currently exits. It also offers recommendations for implementing basic practices for prevention and monitoring of VAP in acute care hospitals.

 

The topics discussed were education of healthcare personnel (individuals who care for patients undergoing ventilation) and the appropriate surveillance of VAP which includes performing direct observation of compliance with VAP specific process measures (hand hygiene, bed position, daily sedation interruption and assessment of readiness to wean and regular oral care).

 

Practices and policies that need to be in place to ensure appropriate patient care for patients with VAP are listed. The need for accountability by the hospital's chief executive officer and senior management team to ensure that the healthcare system effectively supports a program to prevent VAP is addressed. It further lists the other levels of hospital employees involved and their roles in preventing VAP.

 

A section on approaches discusses both those that should not be considered a routine part of care as well as special approaches that should be considered for its prevention. And lastly, a list of unresolved issues that are still open for discussion and research as to their impact on the prevention VAP.

 

Section 5: Performance Measures

Internal reporting

In this section performance measures and compliance calculations are discussed. These measures and compliance calculations are intended to support hospital quality improvement efforts.

 

The 4 procedural techniques included in the performance measure are:

  • Compliance with hand-hygiene guidelines for all clinicians who deliver care to patients undergoing ventilation
  • Compliance with daily sedation interruption and assessment of readiness to wean unless clinically contraindicated.
  • Compliance with regular antiseptic oral care
  • Compliance with semi recumbent positioning (30° - 45° elevation of the head of the bed; at the time of observation) for all eligible patients

 

Process (performance) measures:

  • Preferred measure of the above assessment of compliance
    • Numerator: Number of observed episodes of hand-hygiene or the number of patients undergoing ventilation with daily documentation of sedation interruption and assessment of readiness to wean or contraindication; regular oral care; semi recumbent position procedure.
    • Denominator: Number of patients undergoing ventilation or the number of observed instances of caregiver activity
    • Multiply by 100 so that the measure is expressed as a percentage.

 

Outcome measures:

Perform ongoing surveillance of the incidence density of VAP for patients undergoing ventilation to permit longitudinal assessment of process of care.

  • Incidence density of VAP, reported as the number of episodes of VAP per 1,000 ventilator-days.
  • Preferred measure of VAP incidence density
    • Numerator: number of patients undergoing mechanical ventilation who have VAP, defined using National Healthcare Safety Network definitions.
    • Denominator: number of ventilator-days.
    • Multiply by 1,000 so that the measure is expressed as cases per 1,000 ventilator-days.

 

External reporting:

The document contains recommendations for public reporting of healthcare-associated infections which have been provided by the Hospital Infection Control Practices Advisory Committee, the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee, and the National Quality Forum.

 

Because of the difficulties in diagnosing VAP, the validity of comparing VAP rates between facilities is poor, and external reporting of rates of VAP is not recommended.

 

 

The appendix section categorizes statements regarding sterilization, disinfection, and maintenance of respiratory equipment based on the healthcare infection control practices advisory committee recommendations and contains The Healthcare Infection Control Practices Advisory Committee system for categorization.

 

  • The Healthcare Infection Control Practices Advisory Committee system for categorization of recommendations is as follows:
    • Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
    • Category IB: Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
    • Category IC: Required for implementation, as mandated by federal or state regulation or standard.
    • Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale.



Related Links:

 

The American Association for Respiratory Care

The Science Journal of Respiratory Care


RESPIRATORY CARE
is the official science journal of the American Association for Respiratory Care (AARC).

 

Clinical Foundations

A Patient-Focused Education Program for Respiratory Care Professionals

 

 

 

 

Institute of Healthcare Improvement
5 million lives campaign

The 5 Million Lives Campaign is a voluntary initiative to protect patients from five million incidents of medical harm over the next two years (December 2006 – December 2008).

 


Center for Disease Control and Prevention (CDC)
Morbidity and Mortality Weekly Report

 

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

 

 

Other Resources: