CLABSI Supplemental Call Series
Ventilator Associated Pneumonia Prevention
Sean Berenholtz, MD MHS FCCM
September 20, 2011 at 2ET/1 CT/12 MT/11 PT
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Slide 2
Learning Objectives
•To describe the morbidity and mortality associated with
Ventilator Associated Pneumonia
•To understand the framework used to achieve
substantial and sustained reductions in VAP as part of
the Michigan Keystone ICU program
•To outline next steps towards implementing VAP
prevention efforts
Slide 3
Impact of VAP
• 10-20% of ventilated patients
• Common HAI
– Median rate 1-4.3 per 1000 vent day
– 250,000 infections per year
• Most lethal HAI
– Mortality likely exceeds 10%
– Up to 36,000 deaths per year
• Cost per episode: $23,000
Safdar CCM 2005, Kollef Chest 2005,
Perencevich ICHE 2007, Public Health Rep. 2007.
Slide 4
Healthcare Associated Pneumonia
Prevention
• CDC/HICPAC: Guidelines for the Prevention of Healthcare
Associated Pneumonia; 2004.
• Canadian Critical Care Trials Group1: Comprehensive
evidence-based clinical practice guidelines for ventilatorassociated pneumonia: Prevention. Journal of Critical Care;
2008.
• SHEA/IDSA: Strategies to Prevent Ventilator-Associated
Pneumonia in Acute Care Hospitals; 2008.
Slide 5
How Can These Errors Happen?
• People are fallible
• Medicine is still treated as an art, not science
• Need to view the delivery of healthcare as a science
• Need systems that catch mistakes before they reach
the patient
Slide 6
To Improve Reliability
• Standardize what is done, when it is done
– Reduce complexity
• Create independent checks for key processes
– How often do we do what we should
• Learn from defects
– How often do we learn from defects
Health Services Research 2006; Circulation 2009;119:330-337.
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Improving Care for Ventilated Patients
• Semirecumbant positioning
• Peptic ulcer disease and DVT prophylaxis
• Appropriate sedation
• Daily assessment of readiness to extubate
• Oral care with antiseptics
• Minimize contamination of equipment
Slide 8
Translating Evidence into Practice
Pronovost, Berenholtz, Needham. BMJ 2008
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Improving Care for Ventilated Patients
• Engage
– Partner with infection preventionists,
– Post performance,
– Tell stories of harm
• Educate
– Reviewed evidence on conference calls,
– One-page fact sheets,
– Slides for teams
Slide 10
Improving Care for Ventilated Patients
• Decrease complexity / create redundancy
– Standardized order sets and protocols
– Daily goals checklist
• Other independent redundancies
– Nursing and families
– Are patients receiving the prevention they should?
Slide 11
Sample Daily
Goals
J Crit Care 2003;18(2):71-75
Slide 12
Improving Care for Ventilated Patients
Evaluate
• VAP
– Standardized CDC NHSN definitions for VAP
– VAP definition varies; Did not change definition
• Ventilator Bundle Process Measures
–
–
–
–
Collected by the ICU teams; daily cross-sectional sample
Standardized definitions and data collection forms
Limited number of trained data collectors
After first quarter of daily data collection, teams were
allowed to collect process measures one to two days/week
(min of 15 vent pts/mo) to minimize burden.
Slide 13
Results
• 124 of 127 ICUs submitted VAP data
– 12 ICUs started after funding ended
• 112 ICUs, 72 hospitals included in analysis
• 3228 ICU months and 550,800 vent days
• 10% quarters without complete data
– 4% missing data; 6% stopped submitting data
• Sensitivity analysis yielded similar results
• Results reported through 28-30 months postimplementation
Slide 14
Michigan Keystone ICU
% Percent of ventilator days where patients
received all five therapies
Quarterly Composite Ventilator Bundle Adherence Over Time
100
80
60
40
20
0
Time (Months)
Infect Control Hosp Epidemiol. 2011;32(4):305-314.
Slide 15
Michigan Keystone ICU
(n=
Infect Control Hosp Epidemiol. 2011;32(4):305-314.
Slide 16
Limitations
• Lack of concurrent control group
– Temporal changes, other interventions
• Did not evaluate accuracy of VAP diagnosis
– All hospitals reported using CDC definitions
– Used existing hospital infrastructure
• Can not evaluate importance of individual therapies in
ventilator bundle
• Can not evaluate importance of other intervention
• Focus on ventilator care vs VAP prevention
Slide 17
Strengths
•
•
•
•
Largest cohort to date
Significant and sustained VAP reductions
Focus on system of care
Engagement of local interdisciplinary teams to assume
ownership
• Centralized support for technical work
• Local adaptation of intervention
• Culture improvement and social networking among ICUs
Slide 18
Summary
• VAP is most lethal HAI; majority are preventable
• Effective interventions to prevent VAP are known;
patients are not receiving the care they should
• Focus on systems to ensure patients receive the
therapies they ought to
Slide 19
Next Steps
• Keystone ICU VAP project focused on ‘Ventilator
Bundle’
• Developing ‘VAP prevention bundle’
– Funded by NIH/NHLBI
– Delphi process led by RAND researcher
Slide 20
European Care Bundle for
VAP Prevention
Intensive Care Med 2010;36:773-780
Slide 21
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https://www.surveymonkey.com/s/Z6FJ28T
Slide 22