A three-step approach to reduce ventilator-associated pneumonia

Introduction

Ventilator-associated pneumonia (VAP) is frequent and has been associated with substantial morbidity, mortality and excess of cost. We hypothesized that the three most important determinants for the rates of VAP are the process of diagnosis, the adoption of standards of care during the time spent on ventilation (adhesion to the ventilator bundle formerly described by the Institute for Health Care Improvement) and the reduction of time spent on ventilation (exposition to risk). Our aim was to reduce rates of VAP by adopting a diagnostic algorithm, measuring adhesion to the bundle and spontaneous breathing trials to all awake patients on mechanical ventilation (MV) sequentially in a 12-bed general ICU.

Methods

Traditionally the diagnosis of VAP was made by the attending physician and there was no determined policy to deal with sedation and adhesion to the ventilator bundle. At the beginning of 2007, we adopted a diagnostic algorithm that included the CPIS and bronchoalveolar lavage cultures. In December 2007, we started auditing adhesion to the items of the bundle and promoting educational discussions about the importance of preventing VAP. These audits were done once a day during the afternoon in the form of a checklist. Daily interruption of sedation was done by the staff nurse every day at 8 o'clock in the morning, unless paralytic drugs were in use. In August 2008, we formalized the spontaneous breathing trial as an approach for ventilated patients who were awoken with the intention to decrease the time spent on MV.

Results

In 2006, the rate of VAP was 32.8/1,000 ventilator days and the average time of MV was 13 days. In 2007, after the diagnostic algorithm, the rate of VAP fell to 21.1/1,000 ventilator days and the average time spent on MV to 10.7 days. In the first 7 months of 2008, after the adoption of the ventilator bundle (with rates of adhesion of: 84% to the head-of-bed; 97% to daily interruption of sedation; 99% to deep vein thrombosis and stress ulcer prophylaxis), the rate of VAP fell to 10.5/1,000 ventilator days and the average time of MV to 8.9 days. Finally, from August 2008 to January 2009, after the adoption of the spontaneous breathing trial, the rate of VAP is 8.66/1,000 ventilator days and the average time spent on MV is 6.6 days.

Conclusion

Adoption of a diagnostic algorithm may decrease the overdiagnosis of VAP, and this approach combined with a more aggressive strategy of discontinuing MV and adhesion to standards of care for ventilated patients can result in a great impact on the rates of VAP.