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Evidence
The Cochrane database of systematic reviews was used to obtain background information because the main interest was in evidence -based data that would help in deciding on the best course of action to take in an effort to reduce of VAP incidence. To this end, the search term Ventilator Associated Pneumonia was used and a list of reviews was found. It was revealed by the review on antibiotics prophylaxis in ICU that the incidence of VAP is between 7%-40% and that the crude mortality rate may exceed 50% (Liberati et. al, n.d). Information from the Centers for Disease Control showed that in 2002 approximately 250,000 patients developed Health Care Associated Pneumonia of whom 36,000 passed away. According to this source 5,400 VAP cases were reported in the National Healthcare Safety Network (NHSN) facilities between 2006 and 2007. This research also revealed that the incidence of VAP was 2.1-11.0 per 1000 ventilator days (Centers for Disease control, 2003). This evidence data was sent to the hospitals C.E.O, the senior management, direct health care providers (physicians, nurses, aides, and therapists), the ancillary personnel and unit leaders. The senior management was tasked with ensuring that the health care personnel who were hired were competent, while the unit leaders would hold the personnel accountable in the implementation of the adopted strategies. The basic adoption process of this strategy involved getting the senior hospital management to study the facts that were laid out before them and for them to recommend changes. This information would then be communicated to all hospital staff via the appropriate channels. A method of constantly re-evaluating the success of the strategy would then be developed and once approved by the senior management, the message would once again be trickled down to other staff. Every individuals role in the implementation process would be clearly stipulated in a memo to the hospital staff.
Intervention
One strategy that was aimed towards the prevention of VAP was ensuring that the Head of Bed (HOB) elevation was at least 30 degrees. This semi-recumbent position was necessary in order to help reduce the aspiration of contaminated oropharyngeal secretions. The HOB elevation would also by extension come in handy in reducing the intracranial pressure and maintaining the cerebral perfusion pressure in patients with closed cranial injuries. This instruction was circulated among all attending nurses.
Another intervention approach was deep vein thrombosis (DVT) prophylaxis. This was arrived at on the realization that DVT was a common but easily preventable perioperative complication. With there being some chance of fatal pulmonary embolism occurring in elective general surgery, this interventional strategy proved necessary and it was to be implemented by use of various regimens comprising of antithrombotic and thrombolytic therapy. Anticoagulants such as heparin, low molecular weight heparin (LMWH), Warfarin and Fondaparinux sodium (Arixtra) were to be used in unique combinations for each particular case. For patients whom anticoagulation prophylaxis had been contraindicated, secondary prevention of DVT was suggested by regular screening of high-risk patients and early treatment of subclinical DVT. This message was communicated to all clinical staff that would be attending to the patients including doctors and nurses. It was also realized that specialized mouth care would go a long way in the prevention of VAP. Since the major cause of VAP is colonization of the oropharynx, it was necessary that oral care be provided since dental plaque tends to harbor a lot of pathogens. This was to be implemented by use of Chlorhexidine Gluconate in combination with mechanical biofilm debridement and frequent oral moisture replacement. This routine was found to be more effective than just using foam swabs. This message was communicated to physicians and nurses attending to ICU patients as well as to management who would ensure sufficient supply of the required material.
Stress ulcer prophylaxis was also found to substantially reduce the incidence of VAP (Coffin et. al, 2008). Since gastrointestinal bleeding as a result of stress ulcers could contribute to the increase of microbes invading the oropharynx, hence VAP, it became necessary to use regimens for treatment aimed at controlling the ulcers. The best pharmacological solution that was arrived at was the usage of Sucralfate. This medication was preferred over H2-receptor antagonists because it was found that the latter increased the chances of development of nosocomial pneumonia in ICU patients. (Coffin et.al, 2008)It was communicated to all clinical staff attending to these patients to be more vigilant in the detection of stress ulcers so that medical intervention could be initiated on time.
It was also recommended that daily assessment of the need for sedation and mechanical ventilation be carried out. Reduction of the time that patients spent while intubated would to a great extent help in the reduction of VAP incidence. Wherever possible, non-invasive mask ventilation was recommended especially for patients suffering from chronic obstructive pulmonary disease (Prevention of VAP, 2008) Sedation vacations would also be given six to eight hours a day and assessment made for extubation readiness. This procedure was to be a combined effort of physicians, nurses and respiratory therapists and the appropriate communication was made to the concerned parties.
Outcome and re-evaluation
In summary, the primary desired outcome after applying the VAP bundle was the reduction in the incidence of VAP. After implementing the recommended intervention, the incidence of VAP greatly reduced and the time that patients spent in ICU also substantially went down. The implementation of the HOB elevation was easily taken care of since it was a one time procedure. The use of DVT prophylaxis as a regulative measure against VAP incidence was put into practice and the clinical staff were advised to be vigilant in the effort to identify patients whom anticoagulation therapy had been contraindicated. The use of Chlorhexidine Gluconate and mechanical biofilm debridement as an oral care procedure also produced marked results to the extent that some of the patients were taken off invasive intubation and ventilated using the non-invasive mask. However, like with any new procedure, implementation of the evidence based practice was quite slow with the management trying hard to cut down on costs involved in service provision and the clinical staff taking some time to get used to the new procedures.
References
Centers for Disease Control and Prevention. (2003). Guidelines for Preventing Health-Care Associated Pneumonia: recommendations of CDC and Healthcare Infection Control Practices Advisory Committee. MMWR 2004; 53 (No. RR-3)
Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. (2008) Infect Control Hosp Epidemiol. Suppl 1:S31-40. PubMed PMID: 18840087 [PubMed indexed for MEDLINE]
Liberati A, DAmico R, Pifferi S, Torri V, Brazzi L, Parmelli E.(n.d.). Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000022.
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