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Intensive Care Medicine

Published in:

01-07-2009 | Original

Reduction of ventilator-associated pneumonia: active versus passive guideline implementation

Authors: Caroline S. Hawe, Kirsteen S. Ellis, Chris J. S. Cairns, Andrew Longmate

Published in: Intensive Care Medicine | Issue 7/2009

Abstract

Purpose

Ventilator-associated pneumonia (VAP) is associated with increased morbidity, mortality and costs. We describe an active, multifaceted implementation of a VAP prevention bundle designed to improve staff compliance with evidence-based actions and reduce the incidence of VAP.

Method

A ‘VAP prevention bundle’ was designed then implemented, first passively, then actively, as defined by a multimodal programme incorporating staff education, process measurement and outcome measurement and feedback to staff and organisational change.

Results

Compliance with the VAP prevention bundle increased after active implementation. VAP incidence fell significantly from 19.2 to 7.5 per 1,000 ventilator days. Rate difference (99% CI) = 11.6 (2.3–21.0) per 1,000 ventilator days; rate ratio (99% CI) = 0.39 (0.16, 0.96).

Conclusions

An active implementation programme increased staff compliance with evidence-based interventions and was associated with a significant reduction in VAP acquisition.

Vincent JL, Bihari DJ, Suter PM, Briuing HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M (1995) The prevalence of nosocomial infection in intensive care unit in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. JAMA 278:639–644CrossRef

Heyland DK, Cook DJ, Griffith LE, Keenan SP, Brun–Buisson C for the Canadian Critical Care Trials Group (1999) The attributable mortality and morbidity of ventilator associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 159:1249–1256PubMed

http://wwwihi.org/IHI/Topics/CriticalCare/IntensiveCare. Accessed 28 Jan 2008

http://www.modern.nhs.uk/criticalcare/. Accessed 28 Jan 2008

Eiggimann P, Pittet D (2001) Infection control in the ICU. Chest 120:2059–2093CrossRef

Manawarthe S, Darrien J, Sneddon J, Longmate A (2005) Acquired intensive care unit infection. Scott Med J 50:184

Tablan AC, Anderson LJ, Besser R, Bridges C, Hajjeh R (2004) Guidelines for preventing healthcare-associated-pneumonia, 2003: recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Morbidity and Mortality Weekly Report. 53(no. RR-3):1-36. Available from http://www.cdc.gov/mmwr/PDF/RR/RR5303.pdf. Accessed 28 Jan 2008

Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun–Buisson for the Canadian Critical Care Trials Group (2004) Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 141:305–313PubMed

Swann D, Stuart J, Miles B, Al-Haddad M (2004) Investigating preventing ventilator associated pneumonia. Scottish Intensive Care Evidence-Based Medicine Group. http://www.sicsebm.org.uk/VAP/VAP%20prevention.htm. Accessed 28 Jan 2008

10.

Budnitz D, Neuman WR, Philips KA, Shlipak MG, Coxson P, Goldman L, Heidenreich PA, Weistein MC, Goldman PA (2001) Underuse of beta-blockers following myocardial infarction. JAMA 285:1013PubMedCrossRef

11.

Rubenfeld G, Caldwell E, Hudson L (2001) Publication of study results does not increase use of lung protective ventilation strategies in patients with acute lung injury. Am J Respir Crit Care Med 163:A295

12.

Young MP, Manning HL, Wilson DL, Mette SA, Riker RR, Leiter JC, Liu SK, Bates JT, Parson PE (2004) Ventilation of patients with acute respiratory distress syndrome: has new evidence changed clinical practice? Crit Care Med 32:1260–1265PubMedCrossRef

13.

Cook D, Ricard JD, Reeve B, Randall J, Wigg M, Brochard L, Dreyfuss D (2000) Ventilator circuit secretion management strategies: a Franco-Canadian survey. Crit Care Med 28:3547–3554PubMedCrossRef

14.

Rello J, Lorente C, Bodi M, Diaz E, Ricart M, Kollef MH (2002) Why do physicians not follow evidence based guidelines for preventing ventilator associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 122:656–661PubMedCrossRef

15.

Wensing M, van der Weijen T, Grol R (1998) Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 48:991–997PubMed

16.

Davis DA, Taylor-Vaisey A (1997) Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 157:408–416PubMed

17.

Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don’t physicians follow practice guidelines? A framework for improvement. JAMA 282:1458–1465PubMedCrossRef

18.

Grol R (2001) Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 39:1146–1154CrossRef

19.

Grol R, Grimshaw J (1999) Evidence-based implementation of evidence based medicine. Jt Comm J Qual Improv 25:503–513PubMed

20.

Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O’Brien M (2001) Changing provider behavior: an overview of systematic reviews of interventions. Med Care 39:2–45CrossRef

21.

Babcock HM, Zack JE, Garrison T, Trovillion E, Jones M, Fraser VJ, Kollef MH (2004) An educational intervention to reduce ventilator associated pneumonia in an integrated health system: a comparison of effects. Chest 125:2224–2231PubMedCrossRef

22.

Zack JE, Garrison T, Trovillion E, Clinkscale D, Coopersmith CM, Fraser VJ, Kollef MH (2002) Effect of an educational programme aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 30:2407–2412PubMedCrossRef

23.

Kelleghan SI, Salemi C, Padilla S, McCord M, Mermilliod G, Canola T, Becker L (1993) An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia. Am J Infect Control 21:322–330PubMedCrossRef

24.

Salahuddin N, Zafar A, Sukhyani L, Rahim S, Noor MF, Hussain K, Siddiqui S, Islam M, Husain SJ (2004) Reducing ventilator-associated pneumonia rates through a staff education programme. J Hosp Infect 57:223–227

25.

Danchaivijitr S, Assanasen S, Apisarnthanarak A, Judaeng T, Pumsuwan V (2005) Effect of an education program on the prevention of ventilator-associated pneumonia: a multicenter study. J Med Assoc Thai 88:S36–S41PubMed

26.

Rosenthal VD, Guzman S, Crnich C (2006) Impact of an infection control programme on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals. Am J Infect Control 34:58–63PubMedCrossRef

27.

Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, Hooton TM (1985) The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 121:182–205PubMed

28.

Mant J (2001) Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care 13:475–480PubMedCrossRef

29.

Wall RJ, Ely EW, Elasy TA, Dittus RS, Foss J, Wilkerson KS, Speroff T (2005) Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit. Qual. Saf Healthcare 14:295–302CrossRef

30.

Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T (2005) Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 31:243–248PubMed

31.

Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, Edwards J, Cho TW, Wittlake WA (2007) Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 35(4):1005–1112CrossRef

32.

Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C (2006) An intervention to decrease catheter-related bloodstream infections in ICU. N Engl J Med 355:2725–2732PubMedCrossRef

33.

Hawe C, Ellis K, Cairns C, Longmate A (2008) Quality improvement: reducing ventilator-associated pneumonia. Crit Care 12(S2):P432

34.

Hospital In Europe Link for Infection Control through Surveillance (HELICS). Surveillance of Nosocomial Infections in Intensive Care Units (2004) Protocol version 6.1. Project commissioned by the EC/DG SANCO/F/4. Agreement Reference number: VS/1999/5235 (99CVF4-0125). http://www.helics.univ-lyon1.fr/helicshome.htm. Accessed 28 Jan 2008

35.

Benneyan JC (2001) Number-between g-type statistical quality control charts for monitoring adverse events. Health Care Manag Sci 4:305–318PubMedCrossRef

36.

Benneyan JC, Lloyd RC, Plsek PE (2003) Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care 12:458–464PubMedCrossRef

37.

Benneyan JC (1998) Statistical quality control methods in infection control and hospital epidemiology, part II: chart use, statistical properties, and research issues. Infect Control Hosp Epidemiol 19:4265–4283

38.

Ranji SR, Shetty K, Posley KA, Lewis R, Sundaram V, Galvin CM, Winston LG (2007) Prevention of Health Care Associated Infections. In: Shojania KG, McDonald KM, Wachter RM, Owens DK (eds) Closing the quality gap: a critical analysis of quality improvement strategies, vol 6. Technical review 9 (prepared by Stanford University-UCSF Evidence-based Practice Center under contract No. 290-02-0017). AHRQ Publication No. 04(07)-0051-6. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap6/hainfgap.pdf. Accessed 29 Jan 2008

39.

Adair G (1984) The Hawthorne effect: a reconsideration of the methodological artefact. J Appl Psychol 69:334–345CrossRef

40.

Safdar N, Abad C (2008) Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med 36:933–940PubMedCrossRef

Title: Reduction of ventilator-associated pneumonia: active versus passive guideline implementation
Authors: Caroline S. Hawe
Kirsteen S. Ellis
Chris J. S. Cairns
Andrew Longmate
Publication date: 01-07-2009
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 7/2009
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-009-1461-0

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Reduction of ventilator-associated pneumonia: active versus passive guideline implementation

Abstract

Purpose

Method

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Method

Results

Conclusions

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