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A targeted educational intervention to reduce ventilator-associated complications
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
Brief Report
A targeted educational intervention to reduce ventilator-associated complications Eric P. Nolley MD a, Sergio E. Trevino MD b, Hilary M. Babcock MD c, Marin H. Kollef MD d,* a
Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA Infectious Diseases and Critical Care Medicine, Essentia Health, Fargo, ND c Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO d Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO b
Key Words: Education Outcomes
The optimal approach for the prevention of ventilator-associated complications (VACs) is currently unknown. A retrospective pre–post intervention analysis was conducted to assess a multifaceted educational intervention targeting the most common causes for VACs and VAC risk factors. Results indicated that the addition of this intervention to existing infection control and treatment protocols did not demonstrate a decrease in VAC occurrence or duration of mechanical ventilation. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
BACKGROUND
METHODS
Although a necessary therapy for critically ill patients, mechanical ventilation (MV) is associated with significant complications.1 Unfortunately, establishing a reliable and objective quality measure for ventilated patients has proven elusive. Ventilator-associated pneumonia (VAP) surveillance used historically is strongly associated with important clinical outcomes.1,2 However, VAP surveillance was shown to be ineffective due to subjectivity of the National Healthcare Safety Network criteria, poor correlation with clinically diagnosed VAP, and overall prevalence of clinically diagnosed VAP despite decreasing VAP surveillance rates.3,4 Consequently, in 2013 the Centers for Disease Control and Prevention and National Healthcare Safety Network developed a new surveillance algorithm for ventilatorassociated conditions (VACs) focused on objective changes in oxygenation variables.5,6 Targeted educational interventions directed at health care workers are known to reduce VAP rates.7 Although concordance with VAP prevention measures may reduce VACs,8 no study has yet examined the effect of targeted educational interventions on VAC rates. Thus, we prospectively evaluated the effect of a multifaceted educational intervention targeting the most common causes of VACs.
The study was conducted in the medical intensive care unit (29 beds) of Barnes-Jewish Hospital, a 1,250-bed teaching hospital in St Louis, MO. The Washington University Human Research Protection Office approved the protocol. Patients who were mechanically ventilated for ≥ 2 days were included and VACs were identified by retrospective surveillance using an automated algorithm.9 VACs were defined as 2 calendar days of stable or decreasing daily minimum positive end-expiratory pressure or fraction of inspired oxygen followed by at least 2 days of increased daily minimum positive endexpiratory pressure (≥ 3 cm water) or fraction of inspired oxygen (≥ 0.20).5,6 The preintervention and intervention periods were consecutive 12-month periods from April 2013-April 2015. Based on a prior study by Babcock et al,7 the education intervention consisted of a self-study module, publicly posted educational materials, and a daily rounding checklist.7 The self-study module included information on the following topics: definition of VACs, rationale for preventing VACs, risk factors for VACs, etiology of VACs, methods to decrease risk for VACs with specific risk-reduction strategies. The points in the module were summarized in the acronym WHAC VAC, in which W stood for “wean patient from sedation and ventilation,” H for “hydration and fluid management,” A for “avoid aspiration and atelectasis,” and C for “contamination prevention.” The module was assigned to intensive care unit nursing staff, respiratory therapists, residents, fellows, and attending physicians. Before the study module, participants completed a multiple choice pretest to assess baseline knowledge on VAC prevention and an identical
* Address correspondence to Marin H. Kollef, MD, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St Louis, MO 63110. E-mail address: [email protected] (M.H. Kollef). Conflicts of Interest: None to report.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2016.03.052
ARTICLE IN PRESS E.P. Nolley et al. / American Journal of Infection Control ■■ (2016) ■■-■■
2
Table 1 Comparison of preintervention and intervention periods
Patients MV > 2 d Episodes MV/mo MV d/MV episode Mean MV, d/mo VACs VACs/mo VACs/1,000 ventilator days
Preinterventiion
Intervention
P value
695 57.9 ± 7.8 9.0 ± 3.0 413 47 3.9 ± 2.1 9.5 ± 4.4
779 64.5 ± 11.7 8.2 ± 1.3 378 34 2.8 ± 2.6 7.2 ± 7.3
.125 .378 .275 .11 .273 .358
NOTE. Values are presented as n or mean ± standard deviation. MV, mechanical ventilation; VAC, ventilator-associated conditions.
examination was administered after module completion. Individuals who scored <80% on the posttest were required to repeat the study module. In addition to the study module, the intervention included posters and fact sheets emphasizing VAC prevention measures and a daily rounding checklist. We compared the monthly occurrence of VACs for the 2 study periods. The number and month-to-month change in VACs was also assessed and compared with the number and month-to-month change in ventilator days and ventilator length of stay per episode of MV. Continuous variables were compared using the MannWhitney U test. The relationship between VACs and ventilator days was described by the Pearson correlation coefficient. Analyses were performed using Excel version 15.0 for Windows (Microsoft, Redmond, WA). RESULTS Overall compliance with the educational module for all intensive care unit staff (eg, nurses, respiratory therapists, resident physicians, fellows, and attending physicians) was >70%. During the study period, 1,474 patients were mechanically ventilated for ≥ 2 calendar days, 695 and 779 during the preintervention and intervention periods, respectively (Table 1). Total VACs in the pre- and intervention periods were 47 and 34, respectively, with similar VACs per month. The mean number of VACs was 9.5 ± 4.4 and 7.2 ± 7.3 per 1,000 ventilator days (P = .358) during the preintervention and intervention periods, respectively. There was no significant difference in average number of ventilator days per month (413 vs 378; P = .275), episodes of MV per month (57.9 ± 7.7 vs 65 ± 11.7; P = .125), or number of days per episode of MV (9.0 ± 3.0 vs 8.2 ± 1.3; P = .378) in the preintervention and intervention periods, respectively. The correlation between the number of VACs and the number of ventilator days is shown in Figure 1. DISCUSSION Our main finding is that the intervention did not significantly decrease the rate of VACs in our medical intensive care unit. Despite total fewer VACs in the intervention period, there was no difference in VACs per 1,000 ventilator days. Consistent with prior studies, total number of ventilator days per month correlated with VAC incidence, but the intervention reduced neither average ventilator days per month nor average duration of ventilation per episode.10 In contrast to VAP prevention, targeted educational interventions may not be effective at reducing VACs.7 Moreover, ideal VAC prevention strategies remain unclear, as does the true preventability of VACs.6 The recent study from the Wake Up and Breathe Collaborative suggests that paired spontaneous awaking and breathing trials may reduce VAC rates.10 In this multicenter trial, an increase in paired spontaneous awaking and spontaneous breathing trials correlated with a significant decrease in VACs. Interestingly, when 1 outlier
Fig 1. Scatter plot of the correlation between the number of ventilator-associated events and the number of ventilator days per month (r = 0.300; P = .155).
month with an extremely high VAC rate was excluded, the decrease in VACs was no longer significant, although there was still a significant reduction in iVACs (infection-related ventilatorassociated condition). There was also no reduction in VAC rate per ventilator days, suggesting that the reduction in VACs per episode of MV was due to decreased ventilator exposure because average duration of MV decreased by 2.4 days. Strengths of this study include prior institutional experience with VAP prevention studies; prior characterization of VAC etiologies in our ICU; good baseline VAP awareness and practices for VAP prevention; education of all levels of care providers (ie, nurses, respiratory therapists, and physicians); overall compliance with the educational module; and baseline sedation, fluid management, and weaning protocols that have been previously well described. These strengths likely contributed to our inability to demonstrate further reduction in VACs with this educational initiative. References 1. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416. 2. Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012;33:250-6. 3. Skrupky LP, McConnell K, Dallas J, Kollef MH. A comparison of ventilatorassociated pneumonia rates as identified according to the National Healthcare Safety Network and American College of Chest Physicians criteria. Crit Care Med 2012;40:281-4. 4. Kollef MH, Chastre J, Fagon JY, François B, Niederman MS, Rello J, et al. Global prospective epidemiologic and surveillance study of ventilator-associated pneumonia due to Pseudomonas aeruginosa. Crit Care Med 2014;42:2178-87. 5. Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, et al. Developing a new, national approach to surveillance for ventilator-associated events. Crit Care Med 2013;41:2467-75. 6. Boyer AF, Shoenber N, Babock H, McMullen KM, Micek ST, Kollef MH. A prospective evaluation of ventilator associated conditions and infection related ventilator associated conditions. Chest 2015;147:68-81. 7. Babcock HM, Zack JE, Garrison T, Trovillion E, Jones M, Fraser VJ, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 2004;125:2224-31. 8. Muscedere J, Sinuff T, Heyland DK, Dodek PM, Keenan SP, Wood G, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest 2013;144:1453-60. 9. McMullen KM, Boyer AF, Schoenberg N, Babcock HM, Micek ST, Kollef MH. Surveillance versus clinical adjudication: differences persistent with new ventilator associated event definition. Am J Infect Control 2015;43:589-91. 10. Kompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, et al. The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015;191:292301.
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
Brief Report
A targeted educational intervention to reduce ventilator-associated complications Eric P. Nolley MD a, Sergio E. Trevino MD b, Hilary M. Babcock MD c, Marin H. Kollef MD d,* a
Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA Infectious Diseases and Critical Care Medicine, Essentia Health, Fargo, ND c Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO d Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO b
Key Words: Education Outcomes
The optimal approach for the prevention of ventilator-associated complications (VACs) is currently unknown. A retrospective pre–post intervention analysis was conducted to assess a multifaceted educational intervention targeting the most common causes for VACs and VAC risk factors. Results indicated that the addition of this intervention to existing infection control and treatment protocols did not demonstrate a decrease in VAC occurrence or duration of mechanical ventilation. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
BACKGROUND
METHODS
Although a necessary therapy for critically ill patients, mechanical ventilation (MV) is associated with significant complications.1 Unfortunately, establishing a reliable and objective quality measure for ventilated patients has proven elusive. Ventilator-associated pneumonia (VAP) surveillance used historically is strongly associated with important clinical outcomes.1,2 However, VAP surveillance was shown to be ineffective due to subjectivity of the National Healthcare Safety Network criteria, poor correlation with clinically diagnosed VAP, and overall prevalence of clinically diagnosed VAP despite decreasing VAP surveillance rates.3,4 Consequently, in 2013 the Centers for Disease Control and Prevention and National Healthcare Safety Network developed a new surveillance algorithm for ventilatorassociated conditions (VACs) focused on objective changes in oxygenation variables.5,6 Targeted educational interventions directed at health care workers are known to reduce VAP rates.7 Although concordance with VAP prevention measures may reduce VACs,8 no study has yet examined the effect of targeted educational interventions on VAC rates. Thus, we prospectively evaluated the effect of a multifaceted educational intervention targeting the most common causes of VACs.
The study was conducted in the medical intensive care unit (29 beds) of Barnes-Jewish Hospital, a 1,250-bed teaching hospital in St Louis, MO. The Washington University Human Research Protection Office approved the protocol. Patients who were mechanically ventilated for ≥ 2 days were included and VACs were identified by retrospective surveillance using an automated algorithm.9 VACs were defined as 2 calendar days of stable or decreasing daily minimum positive end-expiratory pressure or fraction of inspired oxygen followed by at least 2 days of increased daily minimum positive endexpiratory pressure (≥ 3 cm water) or fraction of inspired oxygen (≥ 0.20).5,6 The preintervention and intervention periods were consecutive 12-month periods from April 2013-April 2015. Based on a prior study by Babcock et al,7 the education intervention consisted of a self-study module, publicly posted educational materials, and a daily rounding checklist.7 The self-study module included information on the following topics: definition of VACs, rationale for preventing VACs, risk factors for VACs, etiology of VACs, methods to decrease risk for VACs with specific risk-reduction strategies. The points in the module were summarized in the acronym WHAC VAC, in which W stood for “wean patient from sedation and ventilation,” H for “hydration and fluid management,” A for “avoid aspiration and atelectasis,” and C for “contamination prevention.” The module was assigned to intensive care unit nursing staff, respiratory therapists, residents, fellows, and attending physicians. Before the study module, participants completed a multiple choice pretest to assess baseline knowledge on VAC prevention and an identical
* Address correspondence to Marin H. Kollef, MD, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St Louis, MO 63110. E-mail address: [email protected] (M.H. Kollef). Conflicts of Interest: None to report.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2016.03.052
ARTICLE IN PRESS E.P. Nolley et al. / American Journal of Infection Control ■■ (2016) ■■-■■
2
Table 1 Comparison of preintervention and intervention periods
Patients MV > 2 d Episodes MV/mo MV d/MV episode Mean MV, d/mo VACs VACs/mo VACs/1,000 ventilator days
Preinterventiion
Intervention
P value
695 57.9 ± 7.8 9.0 ± 3.0 413 47 3.9 ± 2.1 9.5 ± 4.4
779 64.5 ± 11.7 8.2 ± 1.3 378 34 2.8 ± 2.6 7.2 ± 7.3
.125 .378 .275 .11 .273 .358
NOTE. Values are presented as n or mean ± standard deviation. MV, mechanical ventilation; VAC, ventilator-associated conditions.
examination was administered after module completion. Individuals who scored <80% on the posttest were required to repeat the study module. In addition to the study module, the intervention included posters and fact sheets emphasizing VAC prevention measures and a daily rounding checklist. We compared the monthly occurrence of VACs for the 2 study periods. The number and month-to-month change in VACs was also assessed and compared with the number and month-to-month change in ventilator days and ventilator length of stay per episode of MV. Continuous variables were compared using the MannWhitney U test. The relationship between VACs and ventilator days was described by the Pearson correlation coefficient. Analyses were performed using Excel version 15.0 for Windows (Microsoft, Redmond, WA). RESULTS Overall compliance with the educational module for all intensive care unit staff (eg, nurses, respiratory therapists, resident physicians, fellows, and attending physicians) was >70%. During the study period, 1,474 patients were mechanically ventilated for ≥ 2 calendar days, 695 and 779 during the preintervention and intervention periods, respectively (Table 1). Total VACs in the pre- and intervention periods were 47 and 34, respectively, with similar VACs per month. The mean number of VACs was 9.5 ± 4.4 and 7.2 ± 7.3 per 1,000 ventilator days (P = .358) during the preintervention and intervention periods, respectively. There was no significant difference in average number of ventilator days per month (413 vs 378; P = .275), episodes of MV per month (57.9 ± 7.7 vs 65 ± 11.7; P = .125), or number of days per episode of MV (9.0 ± 3.0 vs 8.2 ± 1.3; P = .378) in the preintervention and intervention periods, respectively. The correlation between the number of VACs and the number of ventilator days is shown in Figure 1. DISCUSSION Our main finding is that the intervention did not significantly decrease the rate of VACs in our medical intensive care unit. Despite total fewer VACs in the intervention period, there was no difference in VACs per 1,000 ventilator days. Consistent with prior studies, total number of ventilator days per month correlated with VAC incidence, but the intervention reduced neither average ventilator days per month nor average duration of ventilation per episode.10 In contrast to VAP prevention, targeted educational interventions may not be effective at reducing VACs.7 Moreover, ideal VAC prevention strategies remain unclear, as does the true preventability of VACs.6 The recent study from the Wake Up and Breathe Collaborative suggests that paired spontaneous awaking and breathing trials may reduce VAC rates.10 In this multicenter trial, an increase in paired spontaneous awaking and spontaneous breathing trials correlated with a significant decrease in VACs. Interestingly, when 1 outlier
Fig 1. Scatter plot of the correlation between the number of ventilator-associated events and the number of ventilator days per month (r = 0.300; P = .155).
month with an extremely high VAC rate was excluded, the decrease in VACs was no longer significant, although there was still a significant reduction in iVACs (infection-related ventilatorassociated condition). There was also no reduction in VAC rate per ventilator days, suggesting that the reduction in VACs per episode of MV was due to decreased ventilator exposure because average duration of MV decreased by 2.4 days. Strengths of this study include prior institutional experience with VAP prevention studies; prior characterization of VAC etiologies in our ICU; good baseline VAP awareness and practices for VAP prevention; education of all levels of care providers (ie, nurses, respiratory therapists, and physicians); overall compliance with the educational module; and baseline sedation, fluid management, and weaning protocols that have been previously well described. These strengths likely contributed to our inability to demonstrate further reduction in VACs with this educational initiative. References 1. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416. 2. Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012;33:250-6. 3. Skrupky LP, McConnell K, Dallas J, Kollef MH. A comparison of ventilatorassociated pneumonia rates as identified according to the National Healthcare Safety Network and American College of Chest Physicians criteria. Crit Care Med 2012;40:281-4. 4. Kollef MH, Chastre J, Fagon JY, François B, Niederman MS, Rello J, et al. Global prospective epidemiologic and surveillance study of ventilator-associated pneumonia due to Pseudomonas aeruginosa. Crit Care Med 2014;42:2178-87. 5. Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, et al. Developing a new, national approach to surveillance for ventilator-associated events. Crit Care Med 2013;41:2467-75. 6. Boyer AF, Shoenber N, Babock H, McMullen KM, Micek ST, Kollef MH. A prospective evaluation of ventilator associated conditions and infection related ventilator associated conditions. Chest 2015;147:68-81. 7. Babcock HM, Zack JE, Garrison T, Trovillion E, Jones M, Fraser VJ, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 2004;125:2224-31. 8. Muscedere J, Sinuff T, Heyland DK, Dodek PM, Keenan SP, Wood G, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest 2013;144:1453-60. 9. McMullen KM, Boyer AF, Schoenberg N, Babcock HM, Micek ST, Kollef MH. Surveillance versus clinical adjudication: differences persistent with new ventilator associated event definition. Am J Infect Control 2015;43:589-91. 10. Kompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, et al. The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015;191:292301.