The Eradication of VAP in Scotland
Martin Hughes
Nov 2010
Plan
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Definition
Diagnosis
Importance
Strategies to reduce VAP
Why don’t they work?
What does work?
Eradication in Scotland
Definition
• Inflammation of lung parenchyma > 48
hours post intubation, due to organisms not
present or incubating at the time mechanical
ventilation was commenced.
• Early onset within first 4 days: usually due
to antibiotic sensitive
• Late onset > 5 days: commonly multi-drug
resistant pathogens.
Pathophysiology
• Aspiration of pathogenic organisms from
the oropharynx.
• Normal flora replaced by pathogenic
organisms (S. aureus, P. aeruginosa, H. influenzae, and Enterobacteriaceae
(e.g. E. coli, Proteus, Enterobacter, Klebsiella, Serratia)
• This change directly related to the severity
of illness
• Mixed infection in 50%
• ‘Endotracheal tube associated pneumonia’
Diagnosis
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•
•
•
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Clinical Pulmonary Infection Score (CPIS)
Temperature
Leucocyte (cells/µL)
PaO2/FiO2 (mmHg)
CXR
Tracheal secretions
Culture
89% sensitive; 47% specific
Rx CPIS > 6, stop if < 6 at day 3.
Diagnosis
• BAL, PSB, PCS
• BAL cultures have a high sensitivity and
specificity, resulting in a high positive predictive
value.
• 104 CFU/mL is usual threshold for BAL cultures.
• More expensive
• Complications
• Less Antibiotics?
Diagnosis
• No gold standard
• A Randomized Trial of Diagnostic
Techniques for Ventilator-Associated
Pneumonia. The Canadian Critical Care Trials Group. N Engl J Med
2006; 355:2619-2630, 2006
• No difference in mortality or antibiotic use
• Excluded known MRSA/pseudomonas
Importance
• Incidence 9 – 28%
• Risk per day: 3% day 5, 2% day10, 1% day
15
• Prolonged ventilation and ICU stay
• 50% antibiotics in ICU for respiratory
infections
• Attributable mortality debated
• Common sense?
Strategies to reduce VAP
• Elevation of bed
• One study (1+), 90 pts, 1999. NNT of 4-5 to prevent
one VAP
• Daily sedation break
• One study (1+), 150 pts, 2000. 2.4 vent days, 3.5
ICU days saved
• More recently – sedation break + weaning
assessment.
http://www.sicsebm.org.uk
Evidence
• Sub-glottic ETT:
• One review, 4 studies, Grade A recommendation,
NNT 12 to prevent one VAP
• Chlorhexidine oral care:
• One meta- analysis. NNT 14 to prevent one VAP.
Evidence
• Weaning trial:
– In combination with sedation holiday
– One study (1+) 336 patients. Daily sedation
holiday and weaning trial.
• NNT Death (1 yr) 7
• Reduced ICU & hospital stay
Others
• NIV – avoiding intubation
• Kinetic beds – no evidence
• HME vs Heated Water Humidification –
equally effective
• SDD?
Bundles
• Structured way of improving the processes
of care and patient outcomes
• Small, straightforward set of evidencebased practices
• Three to five in set - when performed
collectively and reliably, have been proven
to improve patient outcomes
Bundles
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Every patient, every time.
‘All necessary and all sufficient’
Level 1 evidence
All-or-nothing measurement of elements
At a specific place and time
Success means the whole bundle
Safe:
Timely:
reduce waits
and delays for
those who
receive and give
care
safety is a
system property
Efficient:
avoid waste
Quality
In
Effective:
evidence
based and
applied to all
who could
benefit
ICU
Equitable:
care does not
vary in quality
Patient
Centered: care
that is
respectful and
responsive to
individual
patient
preferences and
needs
SRI Experience – Nov 2005
• VAP Prevention Bundle
• 30 - 45o positioning
• daily sedation holiday
• daily weaning assessment
• chlorhexidine mouthwash
• subglottic aspiration tube
• tubing management
– appropriate humidification
– avoidance of contamination
Additionally
• S/C enoxaparin pre-printed
• Ranitidine pre-printed
• Enteral feeding encouraged – if tolerated
ranitidine cessation considered.
SRI experience
• At launch
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–
–
–
–
Consultant buy in
Laminated charts by every bed space
Unit posters
Surveillance programme (Helics)
Ahead of the game nationally
Job done?
• What is the VAP rate?
• What is the bundle compliance?
• Hawe, Ellis, Cairns, Longmate
ICM, 2009
G chart
350
250
200
Upper control limit (3SDs)
150
Upper warning line
100
50
Centreline (mean)
67
64
61
58
55
52
49
46
43
40
37
34
31
28
25
22
19
16
13
10
7
4
0
1
Number of at risk ventilation days between.
300
Process
Postinterventions
FV VAP Bundle
(*SICS Bundle)
* Patient at 30 -45
Chi-squared p value
(Nov 2006 vs Oct 2007)
Nov 2006
May 2007
Oct 2007
54%
80%
94%
<0.001
Subglottic ETDT
72%
92%
92%
<0.001
* Oral chlorhex
8%
94%
100%
<0.001
Tubing/HMEF
98%
98%
100%
0.31
* Daily weaning plan
* Sedation stop
52%
72%
72%
0.039
72%
86%
82%
0.23
All elements
0%
48%
54%
<0.0001
o
o
Problem?
• Passive interventions don’t work
• Educational interventions to reduce VAP
• Structure, Process, Outcome
Active Implementation
• Education: workshops: definition,
epidemiology, pathogenesis, risk factors,
consequences of VAP, evidence-base for the
bundle.
• Written material distributed.
• Over 90% of the unit’s medical and nursing
staff by April 2007.
• Repeat cycles of process and outcome
measurement and feedback.
Sequential Process Measurements
Baseline
FV VAP Bundle
(*SICS Bundle)
* Patient at 30 -45
Postinterventions
Chi-squared p value
(Nov 2006 vs Oct 2007)
Nov 2006
May 2007
Oct 2007
54%
80%
94%
<0.001
Subglottic ETDT
72%
92%
92%
<0.001
* Oral chlorhex
8%
94%
100%
<0.001
Tubing/HMEF
98%
98%
100%
0.31
* Daily weaning plan
* Sedation stop
52%
72%
72%
0.039
72%
86%
82%
0.23
All elements
0%
48%
54%
<0.0001
o
o
67
64
61
58
55
52
49
46
43
40
37
34
31
28
25
22
19
16
13
10
7
4
1
Number of at risk ventilation days between.
350
Study Period
300
250
200
150
100
50
0
Passive
Sept 2005 Feb 2007
patients
ventilated
for > 48hrs
Active
March – Dec
2007
374
215
2556
1327
episodes of
VAP
49
10
VAP/1000
vent days
19.17
7.5
4.5
5.0
(112/374) 30%
(49/215) 23%
Vent days
Median LOS
Mortality
rd=11.6 99% CI 2.3-21.0
rr=0.39 99% CI 0.16,0.96)
p=0.06
Lessons
• Passive implementation of the VAP prevention bundle
failed.
• Compliance improved during an active multimodal
implementation.
• This was associated with a significant reduction in the
occurrence of VAP.
Since then………………..
The Scottish Patient Safety
Programme
VAP Prevention Bundle
Sedation reviewed and stopped
if appropriate
Y
N
Exclusion
Patient assessed for weaning
and extubation
Y
N
Exclusion
Supine position avoided
Y
N
Exclusion
Chlorhexidine 1-2% QID
Y
N
Exclusion
Use of subglottic drainage ETT
Y
N
Exclusion
Post spsp improvements
VAP: % All Bundle Compliance
%
100
90
80
70
60
50
40
30
20
10
0
96
100
78
62
41
March
April
May
Month 08
June
July
Calendar days between VAP acquisition
Sep 2005 - Jun 2009
calendar days between
UCL
CL
UWL
180
Scottish Patient
Safety Programme
Calendar days between
160
140
120
100
Active intervention &
compliance feedback
Passive intervention period
80
60
40
20
0
1
3
5
7
9
11 13
15 17
19 21 23
25 27 29
31 33 35
37 39
41 43 45
47 49 51
53 55 57
59 61 63
65 67
69 71 73
75 77
VAP Incidence: Bundle Compliance
8
HELICS
surveillance
90%
6
70%
VAP bundle prompts
added to daily goals
sheet.
5
60%
Continuous
measurement
initiated
4
50%
VAP - Long term pt
vent for more than
150 days
3
Patient Safety
Programme begins
40%
VAP - poorly compliant pt,
refusing to sit up refusing
chlohex. Handling trachy and
tubing. Not clear cut!
VAP - Pt constantly pulling at
trachy, poorly compliant with
head up & mouthwash
30%
2
20%
1
10%
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
Apr-08
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
0%
Nov-06
0
Oct-06
VAP Incidence
80%
Tw ice daily w ean
screen sticker added
to 24hr chart
Active period: Bundle
implementation,
audit & education
Bundle Compliance
7
100%
VAP – Key points
• Evidence is the starting point
• Implementation is difficult – efficacy vs
effectiveness
• Process measure identifies failings
• SPSP methodology leads to sustained
process improvement
VAP – key points
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Education
Feedback
Process measurement / management
You need the correct clinicians
The result is outcome improvement
Resources – without the above, bundles are
“futile”
VAP - eliminated
• VAP still here
• So rare that we can now discuss the reasons
for individual cases
• Huge reduction in the problem
• Scottish ICU clinicians and SPSP/IHI
• Effective healthcare does not need to cost
more