Ventilator-Associated Pneumonia: Improved Clinical Outcomes

Keith DD, Garrett KM, Hicko XG, Echols B, Comeau E. Improved Clinical Outcomes. Journal of Nursing Care Quality. 2004;19(4):328-333.

Introduction

St. Joseph Hospital, a 235-bed Catholic hospital in Augusta, GA, created a multidisciplinary Ventilator-Associated Pneumonia Performance Improvement Team to reduce ventilator associated pneumonia (VAP). The institution’s VAP rate at the beginning of the project was 24.1 incidences per thousand ventilator days, significantly higher than the national benchmark rate at the time of 11.6.

Barriers

The initial response from the facility included doubt about the data’s applicability based on patient population and diagnosis methods. The team addressed these concerns by benchmarking against the CDC VAP data by type of ICU and institution, and by evaluating patient mix to ensure it was similar to the benchmark group. The team also established a procedure for multi-disciplinary review of VAP diagnoses to ensure they met the criteria for nosocomial VAP.

Implementation

The task force reviewed the CDC guidelines and published literature. All team members reviewed the literature relating to their field of expertise. The Infection Control Practitioner (ICP) conducted continuous surveillance and tracking on all patients with VAP. The following interventions were initiated:

• A new ventilator flow sheet was developed to ensure adherence to practices of changing ventilator circuits every 7 days, and changing both in-line suction devices and heat and moisture exchange filters every 24 hours.
• Endotracheal cuff pressures were assessed regularly using new devices and protocols.
• Single-use vials of normal saline for endotracheal lavage were used.
• Oral suction tips were changed every 24 hours and kept in their original package between uses.
• A new antibacterial mouth care product was introduced.
• Head of bed elevation was assessed and the practices at the time were found to be adequate.
• A waterless hand wash containing chlorhexidine gluconate was used by all staff prior to manipulation of the ventilator tubing or devices.
• The last intervention was a specialized endotracheal tube for continuous aspiration of subglottic secretions (CASS), which was piloted in the third quarter of 2001 and made available for use in the Emergency Department, ICU, and Operating Room in the second quarter of 2002.

Results

The performance team began its work in 1999 and formally concluded in 2002. The VAP rates during this time period, including the years before and after the project, are as follows:

The largest VAP rate reduction was a 74% reduction between 2001 and 2002, which coincides with the addition of the last intervention, subglottic secretions removal. At the conclusion of 2003, St. Joseph had reduced their incidence rate by 95%. Additionally, it is estimated that over four years, the project reduced 318 ICU days for an approximate savings of $349,164.

Lessons Learned

One critical factor to success was the addition of a pulmonary intensivist to the group, which improved the accuracy of diagnosis and improved aggressive weaning of high-risk patients from the ventilator. The team also learned that this performance improvement project was a long-term rather than short-term project and that it was important to analyze long-term trends in infection rates rather than focusing on monthly data.

Conclusions

The accomplishments of the team were significant, with a 95% reduction in ventilator-associated pneumonia.