Patient safety case studies
Tackling Ventilator Associated Pneumonia
Dates
December 2013 to July 2015
Organisations & people
Eastern AHSN, The Queen Elizabeth Hospital NHS Foundation Trust, Kings Lynn, with
implementation in 11 Intensive Care Units across the East of England.
Project leads: Dr Peter Young, Consultant, Anesthetics and Intensive Care and Dr
Mark Blunt, Consultant, Anesthetics and Intensive Care.
Project co-ordinator: Dr Maryanne Mariyaselvam, Clinical Research Fellow, Intensive
Care.
This is a project overseen by the Respiratory workstream of the Eastern Academic
Health Science Network.
Headline quote
“VAP is the biggest acquired nosocomial killer in the ICU, with an incidence of 10-20%
and mortality of between 15-50%. VAP extends a patient’s length of stay in the ICU by
at least 6 days and has a conservative additional cost estimate of £10,000 per
episode.”
Dr Peter Young, Consultant, Anesthetics and Intensive Care, The Queen Elizabeth
Hospital, Kings Lynn.
Key points at a glance
• Even though the use of SSD endotracheal tubes with a proper cuff pressure monitor
can reduce incidence of Ventilator Associated Pneumonia, this is not routine in all
ventilated patients.
• This project seeks directly to tackle the barriers to changes in practice, by providing
the training and resources to try new approaches, embed new practices and
demonstrate local impact.
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The project is currently recording baseline data to determine current practice over a
3-month period. The implementation phase itself will last 6 months.
Background
Ventilator Associated Pneumonia (VAP) is defined as a pneumonia that occurs after
more than 48 hours of intubation and mechanical ventilation. The incidence of VAP is
10–20%, and mortality is 15–50%. VAP has been shown to extend the length and cost
of stay in the ICU by at least 6 days and has an additional conservative cost of £10,000
per episode.
A solution to the problem of VAP has existed for some years now. There is clear
evidence that VAP can be prevented by the use of subglottic secretion drainage (SSD)
endotracheal tubes, which prevent contaminated oral secretions that accumulate above
the tracheal cuff from leaking past it and into the lungs, and allow suctioning of these
secretions through an opening port and channels that sit above the cuff. The use of
SSD endotracheal tubes alongside proper cuff pressure monitors is a Department of
Health best practice guideline (described in the 2011 High Impact Intervention Care
Bundle).
Despite these guidelines and the evidence behind them, the use of SSD endotracheal
tubes is not routine in all ventilated patients. Even where clinicians are keen to change
their practice, systemic and cultural barriers can make improvement hard to initiate in
areas which are not established priorities – with initial costs and the need for training
causing particular problems.
Actions taken
This project seeks directly to tackle the barriers to changes in practice, by providing the
training and resources to try new approaches, embed new practices and demonstrate
local impact. The project covers the costs of SSD tubes, with participants able to
choose any of the commercially available models. On-site training and follow-up
telephone support are also provided by a research nurse who is fully trained in the use
of different tubes and cuff pressure monitors. Trusts deciding to use the PneuX tube,
which was developed at Kings Lynn, also attend a training day at the Queen Elizabeth
Hospital, where they can see the tube in action.
Participating ICUs commit to ensuring that an SSD tube and appropriate cuff pressure
monitor are used for any patient intubated for more than 48 hours, in line with the Care
Bundle.
Outcomes
The project is currently recording baseline data to determine current practice over a 3month period. The implementation phase itself will last 6 months.
Users in participating trusts use to collect data and send it to a central server remotely
held by the project group. The data collection process is supported by a research
assistant, with a research nurse also available to provide on-site support where
required.
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Plans for the future
The team recognise that sustainable change requires changes elsewhere in the
system. In particular, the team is working with CCGs to find ways to encourage the
continued use of SSD tubes through appropriate CQUINs.
Work on the project is also being publicised more widely across the region, and to as
many different stakeholder groups as possible. In this way, they hope to build wider
momentum for change. The work of the Eastern patient safety collaborative will help
raise awareness of the work.
Tips
Having robust evidence that an innovation will deliver improvements plays a critical role
in creating the willingness and desire to change practice. Evidence alone, however, it
may not be enough to make that change happen. Doing this also requires work to
remove systemic barriers, and creating the opportunities and support for people to try
new ways of doing things.
Contact for further information
Media enquiries: media@eahsn.org
Dr Maryanne Mariyaselvam, maryannemariyaselvam@gmail.com
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