CONTROL OF VAP

Dr Abhijit Chaudhury

SMART APPROACH

Peter F. Drucker in 1954 : Management by Objectives.Advocated the use of: SPECIFIC MEASURABLE ACHIEVABLE RELEVANT TIME BOUND OBJECTIVES

Logic of SMART approach

• A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.

• Compliance can be measured: yes/no answers.

• The piecemeal application of proven therapies in favour of an “all or none” approach.

Kollef M 2008. Chest:134: 447-456.

Need For Such Approach

• At present there are recommendations given by three groups on how to prevent VAP. ( ATS, Joint Planning Group of Canadian Critical Care group, and HICPAC).

• These guidelines are based on VAP pathogenesis and aim to prevent bacterial colonization of aero-digestive tract and aspiration.

Non-adhernce to Guidelines

Physicians• Disagreement with

interpretation of clinical studies (35%)

• Lack of resources (31%)• Costs (17%).

Nurses• Lack of resources (37%),• Miscellaneous [overwork,

lack of time for hand washing] (22%)

• Patient discomfort (8%)• Disagreement with

reported study results (8%)• Fear of potential adverse events (6%).

Features of Existing Guidelines.A. Effective Interventions

• Infection control program (eg, staff education)• Monitor ICU infections• Oral (nonnasal) intubation• Avoidance of unnecessary reintubation• Scheduled drainage of condensate from

ventilator circuits• Enteral (not parenteral) nutrition

A. Effective Interventions

• Continuous subglottic suctioning• Maintenance of adequate pressure in ETT cuff• Hand hygiene between patient contacts• Semi-recumbent positioning (30° to 45°).

B. Effective interventions for selected (not routine) indications

• Antibiotic prophylaxis for patients with head injuries

• Selective digestive decontamination for MDR outbreaks

• Chlorhexidine mouth care(eg, coronary bypass graft)

(ATS Recommendations)

C. Ineffective interventions

• Routine changes of ventilator circuit • Daily changes of heat and moisture

exchangers• Chest physiotherapy• Routine use of antibiotic prophylaxis, Selective

Digestive Decontamination, or chlorhexidine mouth care.

D. Interventions of equivocal or undetermined effectiveness

• Passive humidifier or heat-moisture exchanger • Postural changes• Sucralfate (vs histamine type-2 antagonist) to

prevent stress ulcer.[ ATS Recommendations: Am J Respir Crit Care Med 2005;

171:388–416. Canadian Recommendations: Dodek P et al 2004. Ann Intern

Med ; 141:305–313.HICPAC: Tablan OC et al 2004. MMWR Recomm Rep 2004;

53:1–36].

Bundled Approach

• It is a package of evidence-based best interventions that, when implemented together for all patients on mechanical ventilation, has resulted in dramatic reductions in the incidence of ventilator-associated pneumonia. (www.ihi.org)

• The science behind the bundle is so well established that it should be considered standard of care.

The VAP Bundle

• Not all possible therapies are included in a particular bundle, as the bundle is not intended to be a comprehensive list of all care that should be provided

• Goal is to improve teamwork & communication.

• Education based programmes with multiple interventions.

Effect of Interventions: SMART approach

• Target Group: respiratory care practitioners and ICU nurses. ( Study # 1 and 2)

• Educational interventions :Self-study module, lectures, fact sheets, posters.

• Specific risk-reduction strategies: meticulous hand hygiene, semi-recumbent positioning ( >30°), oral intubation, and regular drainage of condensate from ventilator circuits.

SMART approach

Study # 1: Zack et al 2002. Crit Care Med; 30: 2407-12

No. of Infections /1000 ventilator days: 12.6 : Before Intervention 5.7: After intervention. Significance: p<0.001. Study #2: Babcock et al 2004. Chest; 125: 2224-31.

8.8: Before intervention 4.7: After intervention. Significance: p<0.001.

SMART approach

Study# 3: Lai et al 2003. Infect Control Hosp Epidemiol; 24:859-63.

• Implementation of stepwise strategies: (1) elevating head of bed, (2) using sterile water and enteral valves for nasogastric feeding, (3) prolonging interval for changing in-line suction

catheters. Surgical ICU : 48% Reduction Medical ICU : 38% Reduction

Other interventions.

1. Daily awakening: “sedation vacation”2. Daily assessment of readiness for weaning3. DVT prophylaxis (unless contraindicated)4. Stress bleeding prophylaxis.5. Oral care with Chlorhexidine .Rello J et al . Intensive Care Med. 2010. 36:773-80Miller RS et al . J Trauma. 2010 Jan;68(1):23-31

What YOU Can Do? Start a SMALL Project

1. Is there a system in place now?

2. Know your baseline performance:↳Randomly select 10/20 records of ventilated patient to

apply your measures to them.↳Be sure to check compliance with the total bundle as

well, the “all or none” goal.

3. Educate ICU staff (using your own data).

Small Tests of Change

4. Move on to pilot test in one ICU:↳ Refine the process↳ Test on all shifts↳ Test on all ventilated patients

5. Measure your results to know if a change was an improvement.

“Most discussions of decision making assume that only senior executives make decisions or that only senior executives' decisions matter. This is a dangerous mistake.”

Measure #1

Calculate the Ventilator Associated Pneumonia Rate:Numerator: number of ventilator associated pneumonia cases.Denominator: total ventilator days *Multiply by 1000 to convert to a rate.

Measure # 2

• Identify the intervention measures you are going to adopt in your ICU regarding VAP.

• Identify a modest number of measures: 4/5.

“The things included in the measurement become relevant; the

things omitted are out of sight and out of mind”. Peter F. Drucker

Measure #3Calculate the compliance with the VentilatorBundle:

• Numerator: Number of vented patients receiving ALL components of bundle

↳ please note that this is an ‘all or nothing’ measure: a patient who had 4 out of 5 of the elements would count as a ‘no’.

• Denominator: Total number of patients on ventilators for the day of the prevalence sample.

Concluding Notes

Choose Specific objectives that precisely define and quantify desired outcomes. ( e.g. reducing the VAP rate by 25%). Avoid unrealistic objectives, such as attempting

to completely eliminate VAP.Measure the objective, monitor both staff

adherence to tactics and the infection rate using predefined criteria,

Concluding Notes

Make objectives Achievable and relevant by engaging stakeholders and empowering them to select specific tactics and steps for implementation. Nurses are in the best position to identify the preventive tactics that are achievable.

Objectives should also be Relevant to the institution so that administrators provide adequate staffing and other resources.

Concluding Notes

• Make objectives Time bound; set dates for collecting baseline and periodic data, and a completion date for evaluating the success of the intervention.

“Can we achieve this idea? Or can we only talk about it ?” “Management by objective works - if you know the objectives. Ninety percent of the time you don't”. Peter F. Drucker