A systematic approach for developing a ventilator-associated pneumonia prevention bundle

Abstract

Background Ventilator-associated pneumonia (VAP) is among the most common health care associated infections in the intensive care unit, and is associated with significant morbidity and mortality. Existing VAP prevention intervention bundles vary widely on the interventions included, as well as in the approaches used to develop these bundles. Objective To develop a new VAP prevention bundle using a systematic approach that elicits clinician perceptions on which interventions are most important and feasible to implement. Methods We identified potential interventions to include through a review of current guidelines and literature. We implemented a two-step modified Delphi method to gain consensus on the final list of interventions. An interdisciplinary group of clinical experts participated in the Delphi process, which was guided by a technical expert panel. Results We identified 65 possible interventions. Through the Delphi method, we narrowed that list to 19 interventions that included 5 process and 14 structural measures. Conclusion We described a structured approach for developing a new VAP prevention bundle. Obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle.

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events

“…Our collaborative builds on prior work to advance the science of bundle development. This entailed a structured approach to distill numerous expert judgments regarding the interventions that were most important and feasible to implement (11). Our intervention bundle targeted VAP prevention because the evidence base for VAE prevention was immature at the time our study began.…”

“…These clinicians did not participate in the collaborative. The structure and results of this process are reported elsewhere (11). We then organized bimonthly followed by monthly training and coaching webinars to educate providers about the six interventions identified by the Delphi process: head-of-bed elevation (HOB), use of subglottic suctioning for endotracheal tubes (Sub-G ETT), oral care (OC) six times per day, chlorhexidine mouth care (CHG) two times per day, performance of spontaneous awakening trials (SAT), and performance of spontaneous breathing trials (SBT).…”

Enteral Access Devices: Types, Function, Care, and Challenges

“…Protocol or algorithm development geared toward minimizing aspiration risk in hospitalized tube‐fed patients should consider the following: HOB elevation 30–45 degrees with documentation at least every 4 hours. If HOB is contraindicated, consider reverse Trendelenburg position Routine oral care with chlorhexidine twice daily Performance of oropharyngeal suctioning when handling of secretions is difficult, before the HOB is lowered, before the endotracheal tube cuff is deflated, and prior to extubation Use continuous tube feedings by pump instead of bolus feedings for patients at high aspiration risk GRV frequency, 4‐hour intervals are suggested in critically ill patients GRV levels at which to: ohold tube feedings and for how long operform a GI review of systems and an abdominal examination oconsider a promotility agent oconvert to a small‐bowel feeding tube Guidelines for volume of GRV to reinstill back to the patient Assess for position of enteral access device: noting that the initial marking on tube is still positioned at the exit site or that the premeasured external tube length is the same, 4‐hour intervals are suggested .…”

“…If HOB is contraindicated, consider reverse Trendelenburg position Routine oral care with chlorhexidine twice daily Performance of oropharyngeal suctioning when handling of secretions is difficult, before the HOB is lowered, before the endotracheal tube cuff is deflated, and prior to extubation Use continuous tube feedings by pump instead of bolus feedings for patients at high aspiration risk GRV frequency, 4‐hour intervals are suggested in critically ill patients GRV levels at which to: ohold tube feedings and for how long operform a GI review of systems and an abdominal examination oconsider a promotility agent oconvert to a small‐bowel feeding tube Guidelines for volume of GRV to reinstill back to the patient Assess for position of enteral access device: noting that the initial marking on tube is still positioned at the exit site or that the premeasured external tube length is the same, 4‐hour intervals are suggested . Tube position should also be checked if the patient has emesis, retching, or a coughing episode, tube has been tugged on, or tube length appears too long or short. Frequency of GI review of systems that includes presence of nausea, emesis, reflux, feelings of fullness, abdominal discomfort, pain, or cramping: 4‐hour intervals are suggested Frequency of abdominal assessments that include evidence of distention and abnormal or absence of bowel sounds, and tracking of bowel movements/ostomy outputs: 4‐hour intervals are suggested Utilization of minimal sedation techniques …”

Adesão às medidas preventivas versus incidência de pneumonia associada à ventilação mecânica

“…[8][9][10][11] Dentre as medidas preventivas da PAV, podem-se destacar as seguintes: a cabeceira elevada em 30 a 45º, o que, apesar de não haver consenso para determinar seu impacto, apresenta risco mínimo e nenhum custo econômico, além de favorecer os pacientes com alimentação enteral, por reduzir riscos de desenvolver PAV, comparados à posição supina, sendo indicada como uma medida básica na prevenção da PAV; cuidados com o circuito do ventilador, realizando a troca apenas quando visivelmente sujo ou com mau funcionamento e removendo periodicamente o condensado do circuito, para evitar que retorne para o paciente; realização de adequada higiene oral, relacionada à diminuição da incidência de PAV, embora a escovação dentária ainda não seja um consenso, pois, apesar de diminuir o tempo de ventilação mecânica (VM), ela pode levar ao deslocamento de biofilme formado na região oral para as vias aéreas inferiores; e a monitorização da pressão do balonete (cuff ) que podem provocar diminuição das taxas de PAV, mantendo-se os valores pressóricos entre 18 a 22 mmHg ou 25 a 30 cmH 2 O, a fim de evitar o comprometimento da microcirculação traqueal devido à pressão excessiva e à passagem de secreção subglótica na pressão insuficiente. 2,8,10,[12][13][14][15][16] Na UTI onde foi realizado o estudo, observou-se que os enfermeiros que realizavam a avaliação do protocolo tinham dificuldade em determinar se as medidas de prevenção de PAV eram realizadas de forma adequada ou não, o que poderia gerar um viés, dependendo do profissional que monitorizava. Diante do problema identificado, realizou-se uma reunião entre os enfermeiros da UTI e a enfermeira do Serviço de Controle de Infecção Hospitalar, resultando na restruturação do protocolo…”