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Prevention of ventilator-associated pneumonia: Use of the care bundle approach
ARTICLE IN PRESS American Journal of Infection Control ■■ (2016) ■■-■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major Article
Prevention of ventilator-associated pneumonia: Use of the care bundle approach Aliye Okgün Alcan PhD a,*, Fatma Demir Korkmaz PhD a, Mehmet Uyar MD b a b
Faculty of Nursing, Ege University, Izmir, Turkey Faculty of Medicine, Ege University, Izmir, Turkey
Key Words: Adherence evidence-based practices mechanical ventilatory therapy critical care nursing
Background: The ventilator-associated pneumonia (VAP) care bundle consists of evidence-based practices to improve the outcomes of patients receiving mechanical ventilatory therapy. This study aimed to investigate the implementation of the care bundle on VAP rates in this quasiexperimental study. Methods: The protocol of this study consisted of 3 phases. In the initial phase, observations were made to determine the VAP care bundle adherence of intensive care unit (ICU) nurses. In the second phase, education was provided to ICU nurses on the subject of the VAP care bundle. For the third phase, the effect of VAP care bundle adherence on the VAP rates after education was investigated. Results: The nurses’ VAP care bundle adherence improved after education from 10.8% (n = 152) to 89.8% (n = 1,324) and showed statistically significant improvement (P = .0001 and P < .05). In this study, the VAP rates were determined as 15.91/103 ventilator-days before education and 8.50/103 ventilator days after education. It was found that the VAP rates after the education period were significantly lower than the VAP rates before education. Conclusion: VAP care bundle implementation with education prepared according to evidence-based guidelines decreased VAP rates. Thus, implementation of the VAP care bundle on mechanically ventilated patients care is recommended. © 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring later than 48 hours following endotracheal intubation. VAP is among the most common nosocomial infections for critical care patients that contributes to mortality and morbidity.1-3 VAP rates vary depending on the type of intensive care unit (ICU), hospital, and country.2 The Centers for Disease Control and Prevention reported that the VAP incidence ranged from 0.0-4.4/103 for various types of hospital units in 2012.4 The Turkish Ministry of Health reported that the VAP rates varied from 0.7/103-14.2/103 ventilatordays in 2014.5 Although there are many evidence-based clinical practice guidelines for preventing VAP, only approximately 50% of patients received evidence-based recommended care.6-8 For this reason, the care bundle approach was introduced by the Institute for Healthcare Improvement (IHI). A care bundle is defined as the implementation of a set of evidence-based practices such that when each
* Address correspondence to Aliye Okgün Alcan, PhD, Faculty of Nursing, Ege University, Bornova, Izmir, Turkey. E-mail address: [email protected] (A. Okgün Alcan). Conflicts of Interest: None to report.
element is executed individually, it improves the patient recovery process and outcomes; when all of the practices are executed together, they provide better outcomes than when implemented individually.8-11 Ventilator and central line bundles were the first 2 bundles developed by IHI. 11 The ventilator care bundle consists of 5 interventions: head of bed elevation, daily sedative interruption and daily assessment of readiness to extubate, peptic ulcer prophylaxis, deep vein thrombosis prophylaxis, and daily oral care with chlorhexidine. However, many researchers have added evidencebased interventions to the IHI VAP bundle and created their own customized VAP bundle for decreasing VAP rates. Recent studies have shown that the implementation of a customized VAP bundle results in better patient and clinic outcomes.12-19 Of the many factors associated with VAP, hand hygiene and endotracheal tube cuff pressure monitoring are the most inexpensive and effective interventions for preventing VAP. Despite these factors, the effect of hand hygiene and endotracheal tube cuff pressure monitoring in addition to the IHI VAP bundle is lacking. Thus, this research study was designed to investigate the effect of using the care bundle with the inclusion of hand hygiene and endotracheal tube cuff pressure monitoring on VAP.
0196-6553/© 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2016.04.237
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MATERIALS AND METHODS This quasiexperimental study was performed to investigate the effect of using the care bundle on VAP rates. We hypothesized that the implementation of the VAP bundle would decrease the VAP rates of our ICU. Sample All patients older than age 18 years receiving invasive mechanical ventilatory therapy at the Ege University Hospital Anesthesiology ICU between April 7 and October 31, 2014, who were allowed by their relatives to participate were included in the study. During the data collection, a total of 222 patients were admitted to the ICU. One hundred twenty-eight of these patients met the research inclusion criteria. Patients who had a contraindication to head of bed elevation, were diagnosed with VAP before the study, were longterm or chronically ventilated, were receiving noninvasive mechanical ventilatory therapy, were younger than age 18 years, and those who refused to participate were excluded from the study. Setting The Ege University Hospital Anesthesiology ICU has a 27-bed capacity and cares for approximately 450 patients annually. During the study period, there were 54 nurses working in the ICU. The VAP rate of our ICU was 16.21/103 ventilator-days in 2012 and 13.56/ 103 ventilator-days in 2013, according to the surveillance data of the infection control committee of Ege University Hospital.
period, researchers also evaluated compliance with the VAP bundle. The researcher interfered in the noncompliance bundle elements and provided prompt feedback to nurses about their performance. Thus, compliance was improved. In addition, posters were provided in the ICU to facilitate remembering the VAP bundle elements and to increase compliance with the VAP bundle. During the postimplementation period, the researchers monitored compliance to the VAP bundle. To avoid any potential effect on compliance with the VAP bundle the researchers only observed and recorded the VAP bundle elements and did not interfere with the process during this period. For all periods of study, compliance with the VAP bundle was evaluated via observations during daily rounds at variable times. One of the researchers who was not hospital staff was elected as observer. The same observer collected the data across the duration of study. The observations were done equally on early and late shifts. The observer stood near the ICU desk, where high-level field of vision to the area of patient care was provided. Every day approximately 2 hours were spent observing nurses. The observer directly watched ICU nurses as they performed their routine care activities every day. Therefore, the observer was allowed to see whether nurses were compliant with the VAP bundle. The researchers performed daily written assessments to determine whether the VAP bundle was being followed. Compliance was recorded for each bundle element daily. If the bundle element was performed, it was recorded as “yes,” whereas if the bundle element was not performed, it was recorded as “no.” Next, the entire bundle was evaluated as compliant for the day if all 7 elements were performed. VAP definitions
The VAP bundle The VAP bundle used in this study was retrofitted from the IHI bundle. Our bundle consisted of head of bed elevation (30°-45°), daily sedative interruption and daily assessment of readiness to extubate, peptic ulcer prophylaxis, deep vein thrombosis prophylaxis, daily oral care with chlorhexidine, hand hygiene, and endotracheal tube cuff pressure monitoring. Although the VAP bundle was not implemented in our ICU at the beginning of the study, daily sedative interruption and daily assessment of readiness to extubate, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis were already in use. The other elements of our VAP bundle had some breakdowns. Intervention This study consisted of 3 phases: the preimplementation period (April 7-June 30, 2014), implementation period (July 1-August 31 2014), and postimplementation period (September 1-October 31, 2014). During the preimplementation period, VAP bundle compliance was evaluated to determine the current status. We did not implement any changes during this period. The VAP bundle elements were observed daily by the researchers to determine compliance rates. During this period, the researchers observed a total of 1,409 ventilator-days. During the implementation period, the researchers implemented the VAP bundle by educating the nursing staff. The education program included an introduction to the VAP and care bundle, importance of the VAP and care bundle, and elements of the VAP bundle. The compliance rates of the preimplementation period were fed back to the nursing staff. Attendance at these education sessions was mandatory for the nursing staff. Written material was delivered to encourage self-study. In total, 54 ICU nurses were educated across 11 education sessions. During the implementation
At Ege University Hospital VAP is defined based on Centers for Disease Control and Prevention definitions during daily surveillance rounds by trained infection control committee members. The infection preventionists (IPs) verified all suspected VAP cases with radiographs and microbiologic analyses confirming VAP diagnosis. The VAP cases were obtained from infection control committee members for the duration of study for minimizing diagnosis bias. The same IPs diagnosed the VAP cases for the duration of the study. None of the researchers was an infection control committee member. In addition, the infection control committee members were not informed about the study. The IPs were blinded to the study to avoid bias. The VAP rates were expressed as cases of VAP per 103 ventilatordays. The VAP rate during the preimplementation period was compared with the VAP rate during the postimplementation period. Ethical issues This study was approved by the Clinical Research Ethics Committee of Ege University Medical Faculty. Written permission to perform the study was obtained from the institution in which the research would be conducted. In addition, the relatives of patients were informed about the details and purpose of the study, and verbal consent from all of the volunteer relatives of patients was obtained. Statistical analyses The study data were analyzed by the Ege University Department of Biostatistics and Medical Informatics using the Statistical Package for the Social Sciences for Windows version 21.0 (IBMSPSS Inc, Armonk, NY). Descriptive data on patients were expressed as numbers, percentages, and mean and median values. For numerical variables, the fit to the normal distribution of the data was assessed using the Shapiro-Wilk test. For the nominal and ordinal variables, Fisher exact test was performed. For variables that did not
ARTICLE IN PRESS A. Okgün Alcan et al. / American Journal of Infection Control ■■ (2016) ■■-■■
3
Table 1 Compliance with the ventilator-associated pneumonia care bundle Preimplementation period April
Head of bed elevation Daily sedative interruption and daily assessment of readiness to extubate Peptic ulcer prophylaxis Deep vein thrombosis prophylaxis Daily oral care with chlorhexidine Endotracheal tube cuff pressure monitoring Hand hygiene Overall compliance
May
Postimplementation period
June
Total
September
October
Total
n
%
n
%
n
%
n
%
n
%
n
%
n
%
P value
158 367
43.1 100.0
287 541
53.0 100.0
401 501
80.0 100.0
846 1409
60.0 100.0
676 710
95.2 100.0
720 765
94.1 100.0
1396 1475
94.6 100.0
.0001 **
367 249 169 255 282 36
100.0 67.8 46.0 69.5 76.8 9.8
541 349 185 288 425 37
100.0 64.5 34.2 53.2 78.6 6.8
500 388 157 323 444 79
99.8 77.4 31.3 64.5 88.6 15.8
1408 986 511 866 1151 152
99.9 70.0 36.3 61.5 81.7 10.8
710 553 697 679 685 619
100.0 77.9 98.2 95.6 96.5 87.2
765 560 754 758 755 705
100.0 73.2 98.6 99.1 98.7 92.2
1475 1113 1451 1437 1440 1324
100.0 75.5 98.4 97.4 97.6 89.8
.489 .001 .0001 .0001 .0001 .0001
**It could not be calculated as statistically.
exhibit a normal distribution, the Mann-Whitney U test was performed. For these results, a P value < .05 was considered statistically significant. RESULTS Of the 128 patients, 57.0% (n = 73) were men and 43.0% (n = 55) were women. The mean age of patients was 58.27 ± 20.67 years (minimum, 18 years and maximum, 93 years). The length of the ICU stay of the patients was a median of 21.5 (information retrieval [IR]:30) days, and the length of mechanical ventilation therapy was a median of 20.0 (IR:33.5) days. It was found that the potential confounder variables such as comorbidities, nutritional status (enteral/ parenteral nutrition or malnutrition), advanced age (> 60 years), reintubation, transportation out of ICU, and cardiopulmonary resuscitation did not affect the VAP rates. Length of ICU stay (P = 0.003) and duration of ventilation (P = 0.0001) increased the VAP rates. Table 1 shows the compliance percentages of individual elements and the overall VAP bundle. Overall compliance with the VAP bundle improved significantly from 10.8%-89.8% after implementation (P = 0.0001). Individual bundle elements also showed improvement during the study. Initially daily oral care with chlorexidine was the most deficient, but was most improved by the postimplementation period. Compliance with peptic ulcer and daily sedative interruption and daily assessment of readiness to extubate were initially excellent and remained higher than 99% throughout the study. There were 23 VAP events with a rate of 15.91/103 ventilatordays during the preimplementation period compared with 10 VAP events with 8.50/103 ventilator-days during the postimplementation period. The VAP rate showed a significant decrease after VAP bundle implementation (U = 0.00; P = 0.0001). DISCUSSION Our data indicated a significant reduction in VAP rates after implementing the VAP bundle. Our VAP rates were reduced to 8.50/ 103 ventilator-days from 15.91/103 ventilator-days by improving VAP bundle compliance to 89.8% from 10.8% during the study period. As demonstrated by the significant difference in VAP rates, implementation of the VAP bundle appears to be effective. IHI on the care bundle concept facilitated implementation of evidence-based practices. Reduction of VAP with the bundle concept has recently been reported. Nearly all authors who studied the ventilator bundle worldwide reported important reductions in VAP rates. In addition, some researchers reported that introduction of the VAP bundle was an effective method and was cost-saving, decreased antibiotic use, decreased the length of ICU stays, and decreased the need for mechanical ventilation therapy.14,15,20-22
Resar et al12 indicated an average 44.5% reduction in VAP rates by implementing the care bundle. Similarly, Berriel-Cass et al21 reported that implementation of the care bundle by staff education reduced the VAP rate by 50%, reduced the number of ventilator days by 50%, reduced the average number of ventilator days by 50%, and reduced the length of ICU stay. Another study reported that the VAP incidence was decreased from 9.47-1.9 ventilator days, and this reduction yielded $1.5 million in cost savings.20 Unahalekhaka et al22 indicated that implementation of the VAP bundle decreased the VAP rate from 13.3/.103-8.3/103 ventilator-days. This report also stated that the costs of antibiotic treatment for VAP decreased by more than half within 12 months. Hawe et al23 demonstrated that increased compliance with the VAP bundle significantly decreased the incidence of VAP from 19.2/103-7.5/103 ventilator-days. Bird et al15 reported that implementation of a VAP bundle significantly reduced VAP rates and health care costs. Al-Tawfiq and Abed14 implemented a VAP bundle to achieve a reduction in VAP rate, and shortened the length of hospital stay and resulting in cost saving annually of $780,000. Data obtained by Morris et al3 suggested that achieving high rates of bundle compliance can decrease both infection incidence and antibiotic use. Al-Dorzi et al24 demonstrated that VAP incidence was significantly reduced from 19.1-6.3 ventilatordays by increasing bundle compliance to 99% from 49%. In a current 7-year study,25 a significant reduction in VAP using VAP bundle was reported. Eom et al26 reported that implementation of the VAP bundle significantly reduced the VAP rates from 4.08/103-1.16/103 ventilator-days. In addition, several authors have reported that they eliminated VAP using care bundles.13,18,19 Youngquist et al13 demonstrated that they decreased the VAP rates from 2.66-0 per 103 ventilator-days in the ICU by achieving 100% compliance with the VAP bundle. Blamoun et al18 reported a statistically significant decrease in VAP rates from 14.1/103-0/103 ventilator-days. Sulis et al19 reported that his facility eliminated VAP using the bundle approach. Furthermore, Ding et al27 reported that implementation of the VAP bundle did not affect the incidence of VAP, but it decreased hospital mortality. Current studies have confirmed that implementation of a VAP bundle was associated with a significant reduction in VAP rates.16,17,23,25,26 Our findings demonstrated a similarity to those studies. Limitation This study has some limitations that have to be mentioned. During the postimplementation period, there may be improvements in compliance with the VAP bundle because ICU nurses become aware that they are being observed. Clearly over time the compliance rates may have increased simply because nurses knew
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they were being watched. Another limitation of our study was about defining VAP. Diagnosis of VAP is difficult due to lack of standardized criteria. CONCLUSIONS Our data indicate that implementation of a VAP bundle through nurse education improved compliance to the VAP bundle and decreased the rate of VAP in patients receiving mechanical ventilation. In the future, similar studies with different groups are warranted. Acknowledgments The authors thank the nurses and patients who contributed to this study. References 1. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):S31-40. 2. Gillespie R. Prevention and management of ventilator associated pneumonia the care bundle approach. South Afr J Crit Care 2009;25:44-51. 3. Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med 2011;39:1-7. 4. Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control 2013;41:1148-66. 5. Şencan İ, Kalaycı MZ, Kabasakal E, Callak Oku F, ÇatinkayaŞardan Y, Aşçıoğlu S. Ulusalhastaneenfeksiyonlarısürveyansağı (uhesa) raporuözetveri. 2013. Available from: http://www.saglik.gov.tr/TR/dosya/1-88693/h/uhesa-analiz-2013.pdf. Accessed October 4, 2014. 6. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PC, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282:1458-65. 7. Pronovost P, Berenholtz S, Needham D. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:963-5. 8. Marwick C, Davey P. Care bundles: the holy grail of ınfectious risk management in hospital? Curr Opin Infect Dis 2009;22:364-9. 9. Jarvis WR. The United States approach to strategies in the battle against healthcare-associated infections 2006: transitioning from benchmarking to zero tolerance and clinician accounatability. J Hosp Infect 2007;65:3-9. 10. Institute for Healthcare Improvement. How to guide: prevent ventilatorassociated pneumonia. Cambridge (MA). Available from: http://www.ihi.org. Accessed January 30, 2013.
11. Resar R, Griffin FA, Haraden C, Nolan TW. Care bundles to improve health care quality. IHI innovation series white paper. Cambridge (MA): Institute for Healthcare Improvement; Available from: http://www.ihi.org. Accessed February 22, 2013. 12. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a Bundle approach to improve ventilator care processes and reduce ventilator associated pneumonia. Jt Comm J Qual Patient Saf 2005;31:243-8. 13. Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 2007;33:219-25. 14. Al-Tawfiq JA, Abed MS. Decreasing ventilator associated pneumonia in adult intensive care units using the institute for healthcare improvement bundle. Am J Infect Control 2010;38:552-6. 15. Bird D, Zambuto A, O’Donnell C, Silva J, Korn C, Burke R, et al. Adherence to ventilator associated pneumonia bundle and incidence of ventilator associated pneumonia in the surgical intensive care unit. Arch Surg 2010;145:465-70. 16. Alsadat R, Al-Bardan H, Mazloum MN, Shamah AA, Eltayeb MFE, Marie A, et al. Use of ventilator associated pneumonia bundle and statistical process control chart to decrease VAP rate in Syria. Avicenna J Med 2012;2:79-83. 17. Viana WN, Bragazzi C, Couto De Castro JE, Alves MB, Rocco JR. Ventilatorassociated pneumonia prevention by education and two combined bedside strategies. Int J Qual Health Care 2013;25:308-13. 18. Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Khan MA, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator associated pneumonia in the medical intensive care unit. Am J Infect Control 2009;37:172-5. 19. Sulis CA, Walkey AJ, Abadi Y, Campbell Reardon C, Joyce-Brady M. Outcomes of a ventilator-associated pneumonia bundle on rates of ventilator-associated pneumonia and other health care-associated infections in a long-term acute care hospital setting. Am J Infect Control 2014;42:536-8. 20. Sedwick MB, Lance Smith M, Reeder SJ, Nardi J. Using evidence based practice to prevent ventilator associated pneumonia. Crit Care Nurse 2012;32:41-51. 21. Berriel-Cass D, Adkins FW, Jones P, Fakih MG. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf 2006;32:612-20. 22. Unahalekhaka A, Jamulitrat S, Chongsuvivatwong V, Ovretveit J. Using a collaborative to reduce ventilator-associated pneumonia in Thailand. Jt Comm J Qual Patient Saf 2007;33:387-94. 23. Hawe CS, Ellis KS, Cairns CJS, Longmate A. Reduction of ventilator associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009;35:1180-6. 24. Al-Dorzi HM, El-Saed A, Rishu AH, Balkhy HH, Memish ZA, Arabi YM. The results of a 6 year epidemiologic surveillance for ventilator associated pneumonia at a tertiary care ıntensive care unit in Saudi Arabia. Am J Infect Control 2012;40:794-9. 25. Righi E, Aggazzotti G, Ferrari E, Giovanardi C, Busani S, Rinaldi L, et al. Trends in ventilator associated pneumonia: impact of a ventilator care bundle in an Italian tertiary care hospital intensive care unit. Am J Infect Control 2014;42:1312-6. 26. Eom JS, Lee M, Chun H, Choi HJ, Jung S, Kim Y, et al. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. Am J Infect Control 2014;42:34-7. 27. Ding S, Kilickaya O, Senkal S, Gajic O, Hubmayr RD, Li G. Temporal trends of ventilator associated pneumonia incidence and the effects of implementing health-care bundles in a suburban community. Chest 2013;144:1461-8.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major Article
Prevention of ventilator-associated pneumonia: Use of the care bundle approach Aliye Okgün Alcan PhD a,*, Fatma Demir Korkmaz PhD a, Mehmet Uyar MD b a b
Faculty of Nursing, Ege University, Izmir, Turkey Faculty of Medicine, Ege University, Izmir, Turkey
Key Words: Adherence evidence-based practices mechanical ventilatory therapy critical care nursing
Background: The ventilator-associated pneumonia (VAP) care bundle consists of evidence-based practices to improve the outcomes of patients receiving mechanical ventilatory therapy. This study aimed to investigate the implementation of the care bundle on VAP rates in this quasiexperimental study. Methods: The protocol of this study consisted of 3 phases. In the initial phase, observations were made to determine the VAP care bundle adherence of intensive care unit (ICU) nurses. In the second phase, education was provided to ICU nurses on the subject of the VAP care bundle. For the third phase, the effect of VAP care bundle adherence on the VAP rates after education was investigated. Results: The nurses’ VAP care bundle adherence improved after education from 10.8% (n = 152) to 89.8% (n = 1,324) and showed statistically significant improvement (P = .0001 and P < .05). In this study, the VAP rates were determined as 15.91/103 ventilator-days before education and 8.50/103 ventilator days after education. It was found that the VAP rates after the education period were significantly lower than the VAP rates before education. Conclusion: VAP care bundle implementation with education prepared according to evidence-based guidelines decreased VAP rates. Thus, implementation of the VAP care bundle on mechanically ventilated patients care is recommended. © 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring later than 48 hours following endotracheal intubation. VAP is among the most common nosocomial infections for critical care patients that contributes to mortality and morbidity.1-3 VAP rates vary depending on the type of intensive care unit (ICU), hospital, and country.2 The Centers for Disease Control and Prevention reported that the VAP incidence ranged from 0.0-4.4/103 for various types of hospital units in 2012.4 The Turkish Ministry of Health reported that the VAP rates varied from 0.7/103-14.2/103 ventilatordays in 2014.5 Although there are many evidence-based clinical practice guidelines for preventing VAP, only approximately 50% of patients received evidence-based recommended care.6-8 For this reason, the care bundle approach was introduced by the Institute for Healthcare Improvement (IHI). A care bundle is defined as the implementation of a set of evidence-based practices such that when each
* Address correspondence to Aliye Okgün Alcan, PhD, Faculty of Nursing, Ege University, Bornova, Izmir, Turkey. E-mail address: [email protected] (A. Okgün Alcan). Conflicts of Interest: None to report.
element is executed individually, it improves the patient recovery process and outcomes; when all of the practices are executed together, they provide better outcomes than when implemented individually.8-11 Ventilator and central line bundles were the first 2 bundles developed by IHI. 11 The ventilator care bundle consists of 5 interventions: head of bed elevation, daily sedative interruption and daily assessment of readiness to extubate, peptic ulcer prophylaxis, deep vein thrombosis prophylaxis, and daily oral care with chlorhexidine. However, many researchers have added evidencebased interventions to the IHI VAP bundle and created their own customized VAP bundle for decreasing VAP rates. Recent studies have shown that the implementation of a customized VAP bundle results in better patient and clinic outcomes.12-19 Of the many factors associated with VAP, hand hygiene and endotracheal tube cuff pressure monitoring are the most inexpensive and effective interventions for preventing VAP. Despite these factors, the effect of hand hygiene and endotracheal tube cuff pressure monitoring in addition to the IHI VAP bundle is lacking. Thus, this research study was designed to investigate the effect of using the care bundle with the inclusion of hand hygiene and endotracheal tube cuff pressure monitoring on VAP.
0196-6553/© 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2016.04.237
ARTICLE IN PRESS 2
A. Okgün Alcan et al. / American Journal of Infection Control ■■ (2016) ■■-■■
MATERIALS AND METHODS This quasiexperimental study was performed to investigate the effect of using the care bundle on VAP rates. We hypothesized that the implementation of the VAP bundle would decrease the VAP rates of our ICU. Sample All patients older than age 18 years receiving invasive mechanical ventilatory therapy at the Ege University Hospital Anesthesiology ICU between April 7 and October 31, 2014, who were allowed by their relatives to participate were included in the study. During the data collection, a total of 222 patients were admitted to the ICU. One hundred twenty-eight of these patients met the research inclusion criteria. Patients who had a contraindication to head of bed elevation, were diagnosed with VAP before the study, were longterm or chronically ventilated, were receiving noninvasive mechanical ventilatory therapy, were younger than age 18 years, and those who refused to participate were excluded from the study. Setting The Ege University Hospital Anesthesiology ICU has a 27-bed capacity and cares for approximately 450 patients annually. During the study period, there were 54 nurses working in the ICU. The VAP rate of our ICU was 16.21/103 ventilator-days in 2012 and 13.56/ 103 ventilator-days in 2013, according to the surveillance data of the infection control committee of Ege University Hospital.
period, researchers also evaluated compliance with the VAP bundle. The researcher interfered in the noncompliance bundle elements and provided prompt feedback to nurses about their performance. Thus, compliance was improved. In addition, posters were provided in the ICU to facilitate remembering the VAP bundle elements and to increase compliance with the VAP bundle. During the postimplementation period, the researchers monitored compliance to the VAP bundle. To avoid any potential effect on compliance with the VAP bundle the researchers only observed and recorded the VAP bundle elements and did not interfere with the process during this period. For all periods of study, compliance with the VAP bundle was evaluated via observations during daily rounds at variable times. One of the researchers who was not hospital staff was elected as observer. The same observer collected the data across the duration of study. The observations were done equally on early and late shifts. The observer stood near the ICU desk, where high-level field of vision to the area of patient care was provided. Every day approximately 2 hours were spent observing nurses. The observer directly watched ICU nurses as they performed their routine care activities every day. Therefore, the observer was allowed to see whether nurses were compliant with the VAP bundle. The researchers performed daily written assessments to determine whether the VAP bundle was being followed. Compliance was recorded for each bundle element daily. If the bundle element was performed, it was recorded as “yes,” whereas if the bundle element was not performed, it was recorded as “no.” Next, the entire bundle was evaluated as compliant for the day if all 7 elements were performed. VAP definitions
The VAP bundle The VAP bundle used in this study was retrofitted from the IHI bundle. Our bundle consisted of head of bed elevation (30°-45°), daily sedative interruption and daily assessment of readiness to extubate, peptic ulcer prophylaxis, deep vein thrombosis prophylaxis, daily oral care with chlorhexidine, hand hygiene, and endotracheal tube cuff pressure monitoring. Although the VAP bundle was not implemented in our ICU at the beginning of the study, daily sedative interruption and daily assessment of readiness to extubate, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis were already in use. The other elements of our VAP bundle had some breakdowns. Intervention This study consisted of 3 phases: the preimplementation period (April 7-June 30, 2014), implementation period (July 1-August 31 2014), and postimplementation period (September 1-October 31, 2014). During the preimplementation period, VAP bundle compliance was evaluated to determine the current status. We did not implement any changes during this period. The VAP bundle elements were observed daily by the researchers to determine compliance rates. During this period, the researchers observed a total of 1,409 ventilator-days. During the implementation period, the researchers implemented the VAP bundle by educating the nursing staff. The education program included an introduction to the VAP and care bundle, importance of the VAP and care bundle, and elements of the VAP bundle. The compliance rates of the preimplementation period were fed back to the nursing staff. Attendance at these education sessions was mandatory for the nursing staff. Written material was delivered to encourage self-study. In total, 54 ICU nurses were educated across 11 education sessions. During the implementation
At Ege University Hospital VAP is defined based on Centers for Disease Control and Prevention definitions during daily surveillance rounds by trained infection control committee members. The infection preventionists (IPs) verified all suspected VAP cases with radiographs and microbiologic analyses confirming VAP diagnosis. The VAP cases were obtained from infection control committee members for the duration of study for minimizing diagnosis bias. The same IPs diagnosed the VAP cases for the duration of the study. None of the researchers was an infection control committee member. In addition, the infection control committee members were not informed about the study. The IPs were blinded to the study to avoid bias. The VAP rates were expressed as cases of VAP per 103 ventilatordays. The VAP rate during the preimplementation period was compared with the VAP rate during the postimplementation period. Ethical issues This study was approved by the Clinical Research Ethics Committee of Ege University Medical Faculty. Written permission to perform the study was obtained from the institution in which the research would be conducted. In addition, the relatives of patients were informed about the details and purpose of the study, and verbal consent from all of the volunteer relatives of patients was obtained. Statistical analyses The study data were analyzed by the Ege University Department of Biostatistics and Medical Informatics using the Statistical Package for the Social Sciences for Windows version 21.0 (IBMSPSS Inc, Armonk, NY). Descriptive data on patients were expressed as numbers, percentages, and mean and median values. For numerical variables, the fit to the normal distribution of the data was assessed using the Shapiro-Wilk test. For the nominal and ordinal variables, Fisher exact test was performed. For variables that did not
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Table 1 Compliance with the ventilator-associated pneumonia care bundle Preimplementation period April
Head of bed elevation Daily sedative interruption and daily assessment of readiness to extubate Peptic ulcer prophylaxis Deep vein thrombosis prophylaxis Daily oral care with chlorhexidine Endotracheal tube cuff pressure monitoring Hand hygiene Overall compliance
May
Postimplementation period
June
Total
September
October
Total
n
%
n
%
n
%
n
%
n
%
n
%
n
%
P value
158 367
43.1 100.0
287 541
53.0 100.0
401 501
80.0 100.0
846 1409
60.0 100.0
676 710
95.2 100.0
720 765
94.1 100.0
1396 1475
94.6 100.0
.0001 **
367 249 169 255 282 36
100.0 67.8 46.0 69.5 76.8 9.8
541 349 185 288 425 37
100.0 64.5 34.2 53.2 78.6 6.8
500 388 157 323 444 79
99.8 77.4 31.3 64.5 88.6 15.8
1408 986 511 866 1151 152
99.9 70.0 36.3 61.5 81.7 10.8
710 553 697 679 685 619
100.0 77.9 98.2 95.6 96.5 87.2
765 560 754 758 755 705
100.0 73.2 98.6 99.1 98.7 92.2
1475 1113 1451 1437 1440 1324
100.0 75.5 98.4 97.4 97.6 89.8
.489 .001 .0001 .0001 .0001 .0001
**It could not be calculated as statistically.
exhibit a normal distribution, the Mann-Whitney U test was performed. For these results, a P value < .05 was considered statistically significant. RESULTS Of the 128 patients, 57.0% (n = 73) were men and 43.0% (n = 55) were women. The mean age of patients was 58.27 ± 20.67 years (minimum, 18 years and maximum, 93 years). The length of the ICU stay of the patients was a median of 21.5 (information retrieval [IR]:30) days, and the length of mechanical ventilation therapy was a median of 20.0 (IR:33.5) days. It was found that the potential confounder variables such as comorbidities, nutritional status (enteral/ parenteral nutrition or malnutrition), advanced age (> 60 years), reintubation, transportation out of ICU, and cardiopulmonary resuscitation did not affect the VAP rates. Length of ICU stay (P = 0.003) and duration of ventilation (P = 0.0001) increased the VAP rates. Table 1 shows the compliance percentages of individual elements and the overall VAP bundle. Overall compliance with the VAP bundle improved significantly from 10.8%-89.8% after implementation (P = 0.0001). Individual bundle elements also showed improvement during the study. Initially daily oral care with chlorexidine was the most deficient, but was most improved by the postimplementation period. Compliance with peptic ulcer and daily sedative interruption and daily assessment of readiness to extubate were initially excellent and remained higher than 99% throughout the study. There were 23 VAP events with a rate of 15.91/103 ventilatordays during the preimplementation period compared with 10 VAP events with 8.50/103 ventilator-days during the postimplementation period. The VAP rate showed a significant decrease after VAP bundle implementation (U = 0.00; P = 0.0001). DISCUSSION Our data indicated a significant reduction in VAP rates after implementing the VAP bundle. Our VAP rates were reduced to 8.50/ 103 ventilator-days from 15.91/103 ventilator-days by improving VAP bundle compliance to 89.8% from 10.8% during the study period. As demonstrated by the significant difference in VAP rates, implementation of the VAP bundle appears to be effective. IHI on the care bundle concept facilitated implementation of evidence-based practices. Reduction of VAP with the bundle concept has recently been reported. Nearly all authors who studied the ventilator bundle worldwide reported important reductions in VAP rates. In addition, some researchers reported that introduction of the VAP bundle was an effective method and was cost-saving, decreased antibiotic use, decreased the length of ICU stays, and decreased the need for mechanical ventilation therapy.14,15,20-22
Resar et al12 indicated an average 44.5% reduction in VAP rates by implementing the care bundle. Similarly, Berriel-Cass et al21 reported that implementation of the care bundle by staff education reduced the VAP rate by 50%, reduced the number of ventilator days by 50%, reduced the average number of ventilator days by 50%, and reduced the length of ICU stay. Another study reported that the VAP incidence was decreased from 9.47-1.9 ventilator days, and this reduction yielded $1.5 million in cost savings.20 Unahalekhaka et al22 indicated that implementation of the VAP bundle decreased the VAP rate from 13.3/.103-8.3/103 ventilator-days. This report also stated that the costs of antibiotic treatment for VAP decreased by more than half within 12 months. Hawe et al23 demonstrated that increased compliance with the VAP bundle significantly decreased the incidence of VAP from 19.2/103-7.5/103 ventilator-days. Bird et al15 reported that implementation of a VAP bundle significantly reduced VAP rates and health care costs. Al-Tawfiq and Abed14 implemented a VAP bundle to achieve a reduction in VAP rate, and shortened the length of hospital stay and resulting in cost saving annually of $780,000. Data obtained by Morris et al3 suggested that achieving high rates of bundle compliance can decrease both infection incidence and antibiotic use. Al-Dorzi et al24 demonstrated that VAP incidence was significantly reduced from 19.1-6.3 ventilatordays by increasing bundle compliance to 99% from 49%. In a current 7-year study,25 a significant reduction in VAP using VAP bundle was reported. Eom et al26 reported that implementation of the VAP bundle significantly reduced the VAP rates from 4.08/103-1.16/103 ventilator-days. In addition, several authors have reported that they eliminated VAP using care bundles.13,18,19 Youngquist et al13 demonstrated that they decreased the VAP rates from 2.66-0 per 103 ventilator-days in the ICU by achieving 100% compliance with the VAP bundle. Blamoun et al18 reported a statistically significant decrease in VAP rates from 14.1/103-0/103 ventilator-days. Sulis et al19 reported that his facility eliminated VAP using the bundle approach. Furthermore, Ding et al27 reported that implementation of the VAP bundle did not affect the incidence of VAP, but it decreased hospital mortality. Current studies have confirmed that implementation of a VAP bundle was associated with a significant reduction in VAP rates.16,17,23,25,26 Our findings demonstrated a similarity to those studies. Limitation This study has some limitations that have to be mentioned. During the postimplementation period, there may be improvements in compliance with the VAP bundle because ICU nurses become aware that they are being observed. Clearly over time the compliance rates may have increased simply because nurses knew
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they were being watched. Another limitation of our study was about defining VAP. Diagnosis of VAP is difficult due to lack of standardized criteria. CONCLUSIONS Our data indicate that implementation of a VAP bundle through nurse education improved compliance to the VAP bundle and decreased the rate of VAP in patients receiving mechanical ventilation. In the future, similar studies with different groups are warranted. Acknowledgments The authors thank the nurses and patients who contributed to this study. References 1. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):S31-40. 2. Gillespie R. Prevention and management of ventilator associated pneumonia the care bundle approach. South Afr J Crit Care 2009;25:44-51. 3. Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med 2011;39:1-7. 4. Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control 2013;41:1148-66. 5. Şencan İ, Kalaycı MZ, Kabasakal E, Callak Oku F, ÇatinkayaŞardan Y, Aşçıoğlu S. Ulusalhastaneenfeksiyonlarısürveyansağı (uhesa) raporuözetveri. 2013. Available from: http://www.saglik.gov.tr/TR/dosya/1-88693/h/uhesa-analiz-2013.pdf. Accessed October 4, 2014. 6. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PC, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282:1458-65. 7. Pronovost P, Berenholtz S, Needham D. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:963-5. 8. Marwick C, Davey P. Care bundles: the holy grail of ınfectious risk management in hospital? Curr Opin Infect Dis 2009;22:364-9. 9. Jarvis WR. The United States approach to strategies in the battle against healthcare-associated infections 2006: transitioning from benchmarking to zero tolerance and clinician accounatability. J Hosp Infect 2007;65:3-9. 10. Institute for Healthcare Improvement. How to guide: prevent ventilatorassociated pneumonia. Cambridge (MA). Available from: http://www.ihi.org. Accessed January 30, 2013.
11. Resar R, Griffin FA, Haraden C, Nolan TW. Care bundles to improve health care quality. IHI innovation series white paper. Cambridge (MA): Institute for Healthcare Improvement; Available from: http://www.ihi.org. Accessed February 22, 2013. 12. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a Bundle approach to improve ventilator care processes and reduce ventilator associated pneumonia. Jt Comm J Qual Patient Saf 2005;31:243-8. 13. Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 2007;33:219-25. 14. Al-Tawfiq JA, Abed MS. Decreasing ventilator associated pneumonia in adult intensive care units using the institute for healthcare improvement bundle. Am J Infect Control 2010;38:552-6. 15. Bird D, Zambuto A, O’Donnell C, Silva J, Korn C, Burke R, et al. Adherence to ventilator associated pneumonia bundle and incidence of ventilator associated pneumonia in the surgical intensive care unit. Arch Surg 2010;145:465-70. 16. Alsadat R, Al-Bardan H, Mazloum MN, Shamah AA, Eltayeb MFE, Marie A, et al. Use of ventilator associated pneumonia bundle and statistical process control chart to decrease VAP rate in Syria. Avicenna J Med 2012;2:79-83. 17. Viana WN, Bragazzi C, Couto De Castro JE, Alves MB, Rocco JR. Ventilatorassociated pneumonia prevention by education and two combined bedside strategies. Int J Qual Health Care 2013;25:308-13. 18. Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Khan MA, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator associated pneumonia in the medical intensive care unit. Am J Infect Control 2009;37:172-5. 19. Sulis CA, Walkey AJ, Abadi Y, Campbell Reardon C, Joyce-Brady M. Outcomes of a ventilator-associated pneumonia bundle on rates of ventilator-associated pneumonia and other health care-associated infections in a long-term acute care hospital setting. Am J Infect Control 2014;42:536-8. 20. Sedwick MB, Lance Smith M, Reeder SJ, Nardi J. Using evidence based practice to prevent ventilator associated pneumonia. Crit Care Nurse 2012;32:41-51. 21. Berriel-Cass D, Adkins FW, Jones P, Fakih MG. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf 2006;32:612-20. 22. Unahalekhaka A, Jamulitrat S, Chongsuvivatwong V, Ovretveit J. Using a collaborative to reduce ventilator-associated pneumonia in Thailand. Jt Comm J Qual Patient Saf 2007;33:387-94. 23. Hawe CS, Ellis KS, Cairns CJS, Longmate A. Reduction of ventilator associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009;35:1180-6. 24. Al-Dorzi HM, El-Saed A, Rishu AH, Balkhy HH, Memish ZA, Arabi YM. The results of a 6 year epidemiologic surveillance for ventilator associated pneumonia at a tertiary care ıntensive care unit in Saudi Arabia. Am J Infect Control 2012;40:794-9. 25. Righi E, Aggazzotti G, Ferrari E, Giovanardi C, Busani S, Rinaldi L, et al. Trends in ventilator associated pneumonia: impact of a ventilator care bundle in an Italian tertiary care hospital intensive care unit. Am J Infect Control 2014;42:1312-6. 26. Eom JS, Lee M, Chun H, Choi HJ, Jung S, Kim Y, et al. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. Am J Infect Control 2014;42:34-7. 27. Ding S, Kilickaya O, Senkal S, Gajic O, Hubmayr RD, Li G. Temporal trends of ventilator associated pneumonia incidence and the effects of implementing health-care bundles in a suburban community. Chest 2013;144:1461-8.