Successful strategy to reduce ventilator-associated pneumonia

Introduction

VAP rates in Brazil are higher than those related in Europe and USA. The study objective was to examine the effect of the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine (ODC) in the incidence of VAP in an ICU.

Methods

The study was conducted in a 20-bed, medical-surgical ICU. Criteria for nosocomial pneumonia are those from the CDC. Strategy was to implement the IHI's ventilator bundle plus ODC. The goals were the ICU team adhesion of 80% achieved in the ninth month after bundle implementation and 98% after 1 year of follow-up. These measures included five strategies to prevent ventilator-associated pneumonia: 30 to 45° elevation of the head of the bed, adequate sedation level (Ramsay 2 or 3), DVT/PE prevention, peptic ulcer prophylaxis and oral decontamination with chlorhexidine 0.12%.

From February 2009 onwards, the ICU nursing staff and ICT performed a daily checklist in order to observe the five issues accomplishment. If any item was found to be inadequate it was promptly corrected.

Results

In February and September, adhesion to the whole bundle was 9% and 86%, respectively (P < 0.001) (Figure 1). VAP density was proportionally lower to bundle adhesion in the same period, 20 per 1,000 ventilation/day and 4.5, respectively.

Figure 1

Proportion of bundle adhesion and density of incidence of ventilator-associated pneumonia.

Conclusions

Initial VAP rates were extremely high even for Brazilian benchmarks. Although we could not implement expensive technologies like continuous aspiration of subglottic secretions, the ICU team and ICT efforts were crucial for satisfactory results, as well the administrative board support, which turned this issue into an institutional priority. Our goals are to reduce even more, implementing the 'ventilator bundle - getting to zero' program, and maintaining a continued effort to sustain these results.