The impact of implementing multifaceted interventions on the prevention of ventilator-associated pneumonia

Khan, Raymond; Al‐Dorzi, Hasan M.; Al-Attas, Khalid; Ahmed, Faisal; Marini, Abdellatif M.; Mundekkadan, Shihab; Balkhy, Hanan H.; Tannous, Joseph; Almesnad, Adel; Mannion, D; Tamim, Hani; Arabi, Yaseen M.

doi:10.1016/j.ajic.2015.09.025

Cited by 71 publications

(84 citation statements)

References 22 publications

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“…15,16 Nevertheless, the potential to decrease VAP rates using VAP prevention bundles has been demonstrated by many authors, [17][18][19][20][21][22] and the preventable proportion of VAP was estimated to be 52%-55%. 23,24 Effective implementation is as important as choosing the right bundle components.…”

Section: (Received 8 May 2018; Accepted 22 July 2018)mentioning

confidence: 99%

Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

Wolfensberger

Meier

Clack

et al. 2018

Infect. Control Hosp. Epidemiol.

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OBJECTIVE Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence. DESIGN Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs). SETTING The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.Patients and participantsAdherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians. RESULTS Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component 'reflective motivation' (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to 'physical capability' (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, 'restructuring environment' and 'enabling HCP') emerged as means to overcome these barriers. CONCLUSIONS Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts. Abstract Objective: Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence. Design: Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs). Setting: The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland. Patients and participants: Adherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians. Results: Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then de...

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Section: (Received 8 May 2018; Accepted 22 July 2018)mentioning

confidence: 99%

Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

Wolfensberger

Meier

Clack

et al. 2018

Infect. Control Hosp. Epidemiol.

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“…[42] Our group at King Abdul-Aziz Medical City, Riyadh, found that by employing a seven-element care bundle, the VAP rates declined significantly (8.6–2.0 cases per 1000 ventilator days, P < 0.001); however, there was no change in the duration of MV or ICU lengths of stay. [43]…”

Section: Initiatives For Improving Ventilator Care In the Kingdom Of mentioning

confidence: 99%

“…We found seven articles that dealt with VAP prevention in Saudi Arabia [Table 3]. [42434445464748] All these studies were based on pre- and post-intervention observational designs except for two, which were prospective cohort studies. [4244] The total number of patient ventilator days was 64,414, with the highest number (41,034) reported by Al-Dorzi et al .…”

Section: Initiatives For Improving Ventilator Care In the Kingdom Of mentioning

confidence: 99%

Introducing the Comprehensive Unit-based Safety Program for mechanically ventilated patients in Saudi Arabian Intensive Care Units

et al. 2017

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Over the past decade, there have been major improvements to the care of mechanically ventilated patients (MVPs). Earlier initiatives used the concept of ventilator care bundles (sets of interventions), with a primary focus on reducing ventilator-associated pneumonia. However, recent evidence has led to a more comprehensive approach: The ABCDE bundle (Awakening and Breathing trial Coordination, Delirium management and Early mobilization). The approach of the Comprehensive Unit-based Safety Program (CUSP) was developed by patient safety researchers at the Johns Hopkins Hospital and is supported by the Agency for Healthcare Research and Quality to improve local safety cultures and to learn from defects by utilizing a validated structured framework. In August 2015, 17 Intensive Care Units (ICUs) (a total of 271 beds) in eight hospitals in the Kingdom of Saudi Arabia joined the CUSP for MVPs (CUSP 4 MVP) that was conducted in 235 ICUs in 169 US hospitals and led by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. The CUSP 4 MVP project will set the stage for cooperation between multiple hospitals and thus strives to create a countrywide plan for the management of all MVPs in Saudi Arabia.

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“…This includes strict handwashing, head elevation to between 30 -45 degrees unless contraindicated, oral care using chlorhexidine, endotracheal tubes with a subglottic aspiration port, early enteral feeding, stress ulcer prophylaxis if enteral feeding is delayed, deep venous thrombosis (DVT) prophylaxis, minimising sedation, and early trials of spontaneous ventilation with a view to extubation as soon as possible. 12 The diagnostic criteria for VAP as per CDC were the combination of new onset pyrexia > 38.0 degrees Celsius, changes on chest auscultation, new infiltrates on chest radiology, purulent endotracheal aspirate (ETA) and a rise or fall in white cell count coupled with a deterioration in lung function manifested by a reduction in the PaO 2 /FiO 2 ratio and reduced compliance. 1 Patients with no record of ETA's, those who did not fulfil the CDC definitions, and those previously treated for other nosocomial infections were excluded.…”

Section: Methodsmentioning

confidence: 99%

The effect of prior antimicrobial therapy for community acquired infections on the aetiology of early and late onset ventilator-associated pneumonia in a level I trauma intensive care unit

Ramsamy

Muckart

Swe-Han

et al. 2017

Southern African Journal of Infectious Diseases

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To cite this article: Yogandree Ramsamy, David JJ Muckart, Khine Swe Swe Han & Koleka P Mlisana (2017) The effect of prior antimicrobial therapy for community acquired infections on the aetiology of early and late onset ventilator-associated pneumonia in a level I trauma intensive care unit, Southern African Journal of Infectious Diseases, 32:3, 91-95, DOI: 10.1080/23120053.2017 Background: Ventilator-associated pneumonia (VAP) is the most common hospital acquired infection in patients who require mechanical ventilation. Early VAP is associated with community acquired pathogens whereas late VAP involves hospital flora. Based on this premise, a protocol may be formulated for microbiological surveillance and antimicrobial stewardship within a specific intensive care unit (ICU) to ensure appropriate empiric antimicrobial choice. The bacterial flora in VAP may be affected, however, by antimicrobials prescribed during the ICU stay. Aim: The aim of this study was to determine the effect of prior antimicrobial therapy for community acquired infections on aetiology and the susceptibility of bacterial isolates from the first episode of early or late VAP in a trauma intensive care unit. Methods: Endotracheal aspirates (ETAs) were obtained from patients with suspected early and late VAP. All ETAs were processed and interpreted as per the Clinical and Laboratory Standards Institute (CLSI). Patients were divided into two cohorts: those whose injuries had required antimicrobial therapy for community acquired infections and those who were antimicrobial naïve. The effect of prior antimicrobial therapy on bacterial isolates from the first episode of suspected VAP was compared between the two groups. Results: Of 288 patients admitted to the Trauma ICU between January and December 2014, pneumonia was suspected in 91 (31.6%). Of these, 69 (76%) patients were antimicrobial naïve and 22 (24%) had received prior antimicrobial therapy. Early VAP occurred in 31 (45%) patients in the naïve cohort compared to 3 (12.5%) with prior antimicrobial exposure (p = 0.01). Of the early VAP isolates 25 (81%) in the naïve cohort contained community flora, whereas all isolates in those with prior antimicrobial therapy revealed hospital acquired organisms (p = 0.01). In the antimicrobial naïve cohort with late VAP 27 (71%) patients had community acquired organisms, whereas only 3 (16%) isolates in late VAP in those with prior therapy revealed community acquired flora (p < 0.001). Conclusion:Patients who receive prior antimicrobial therapy have a significantly lower incidence of early VAP, but in those who developed either early or late VAP hospital acquired pathogens were more commonly isolated. Knowledge of prior antimicrobial exposure in a patient with early or late VAP will assist in determining the correct empiric antimicrobial choice.

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The impact of implementing multifaceted interventions on the prevention of ventilator-associated pneumonia

Cited by 71 publications

References 22 publications

Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

Introducing the Comprehensive Unit-based Safety Program for mechanically ventilated patients in Saudi Arabian Intensive Care Units

The effect of prior antimicrobial therapy for community acquired infections on the aetiology of early and late onset ventilator-associated pneumonia in a level I trauma intensive care unit

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