The Eradication of VAP in ScotlandMartin Hughes

Nov 2010

Plan• Definition

• Diagnosis

• Importance

• Strategies to reduce VAP

• Why don’t they work?

• What does work?

• Eradication in Scotland

Definition

• Inflammation of lung parenchyma > 48 hours post intubation, due to organisms not present or incubating at the time mechanical ventilation was commenced.

• Early onset within first 4 days: usually due to antibiotic sensitive

• Late onset > 5 days: commonly multi-drug resistant pathogens.

Pathophysiology

• Aspiration of pathogenic organisms from the oropharynx.

• Normal flora replaced by pathogenic organisms (S. aureus, P. aeruginosa, H. influenzae, and Enterobacteriaceae (e.g. E. coli, Proteus, Enterobacter, Klebsiella, Serratia)

• This change directly related to the severity of illness

• Mixed infection in 50%• ‘Endotracheal tube associated pneumonia’

Diagnosis

• Clinical Pulmonary Infection Score (CPIS)• Temperature• Leucocyte (cells/µL)• PaO2/FiO2 (mmHg)• CXR• Tracheal secretions• Culture• 89% sensitive; 47% specific• Rx CPIS > 6, stop if < 6 at day 3.

Diagnosis

• BAL, PSB, PCS• BAL cultures have a high sensitivity and

specificity, resulting in a high positive predictive value.

• 104 CFU/mL is usual threshold for BAL cultures.• More expensive• Complications• Less Antibiotics?

Diagnosis

• No gold standard• A Randomized Trial of Diagnostic

Techniques for Ventilator-Associated Pneumonia. The Canadian Critical Care Trials Group. N Engl J Med 2006; 355:2619-2630, 2006

• No difference in mortality or antibiotic use

• Excluded known MRSA/pseudomonas

Importance

• Incidence 9 – 28% • Risk per day: 3% day 5, 2% day10, 1% day

15• Prolonged ventilation and ICU stay• 50% antibiotics in ICU for respiratory

infections• Attributable mortality debated• Common sense?

Strategies to reduce VAP

• Elevation of bed• One study (1+), 90 pts, 1999. NNT of 4-5 to prevent

one VAP

• Daily sedation break• One study (1+), 150 pts, 2000. 2.4 vent days, 3.5

ICU days saved• More recently – sedation break + weaning

assessment.

http://www.sicsebm.org.uk

Evidence

• Sub-glottic ETT:• One review, 4 studies, Grade A recommendation,

NNT 12 to prevent one VAP

• Chlorhexidine oral care:• One meta- analysis. NNT 14 to prevent one VAP.

Evidence

• Weaning trial:– In combination with sedation holiday – One study (1+) 336 patients. Daily sedation

holiday and weaning trial. • NNT Death (1 yr) 7

• Reduced ICU & hospital stay

Others

• NIV – avoiding intubation

• Kinetic beds – no evidence

• HME vs Heated Water Humidification – equally effective

• SDD?

Bundles

• Structured way of improving the processes of care and patient outcomes

• Small, straightforward set of evidence-based practices 

• Three to five in set - when performed collectively and reliably, have been proven to improve patient outcomes

Bundles

• Every patient, every time.

• ‘All necessary and all sufficient’

• Level 1 evidence

• All-or-nothing measurement of elements

• At a specific place and time

• Success means the whole bundle

SRI Experience – Nov 2005

• VAP Prevention Bundle • 30 - 45o positioning• daily sedation holiday• daily weaning assessment

• chlorhexidine mouthwash • subglottic aspiration tube • tubing management

– appropriate humidification– avoidance of contamination

Additionally

• S/C enoxaparin pre-printed

• Ranitidine pre-printed

• Enteral feeding encouraged – if tolerated ranitidine cessation considered.

SRI experience

• At launch– Consultant buy in – Laminated charts by every bed space– Unit posters– Surveillance programme (Helics)– Ahead of the game nationally

Job done?

• What is the VAP rate?

• What is the bundle compliance?

• Hawe, Ellis, Cairns, Longmate ICM, 2009

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FV VAP Bundle

(*SICS Bundle)

Postinterventions Chi-squared p value(Nov 2006 vs Oct 2007)

Nov 2006 May 2007 Oct 2007

* Patient at 30o-45o 54% 80% 94% <0.001

Subglottic ETDT 72% 92% 92% <0.001

* Oral chlorhex8% 94% 100% <0.001

Tubing/HMEF 98% 98% 100% 0.31

* Daily weaning plan52% 72% 72% 0.039

* Sedation stop72% 86% 82% 0.23

All elements 0% 48% 54% <0.0001

Process

Problem?

• Passive interventions don’t work

• Educational interventions to reduce VAP

• Structure, Process, Outcome

Active Implementation

• Education: workshops: definition, epidemiology, pathogenesis, risk factors, consequences of VAP, evidence-base for the bundle.

• Written material distributed.• Over 90% of the unit’s medical and nursing

staff by April 2007. • Repeat cycles of process and outcome

measurement and feedback.

FV VAP Bundle

(*SICS Bundle)

Baseline Postinterventions Chi-squared p value(Nov 2006 vs Oct 2007)

Nov 2006 May 2007 Oct 2007

* Patient at 30o-45o 54% 80% 94% <0.001

Subglottic ETDT 72% 92% 92% <0.001

* Oral chlorhex8% 94% 100% <0.001

Tubing/HMEF 98% 98% 100% 0.31

* Daily weaning plan52% 72% 72% 0.039

* Sedation stop72% 86% 82% 0.23

All elements 0% 48% 54% <0.0001

Sequential Process Measurements

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Study Period

Passive

Sept 2005 - Feb 2007

Active

March – Dec 2007

patients ventilated for > 48hrs

374 215

Vent days 2556 1327

episodes of VAP

49 10

VAP/1000 vent days

19.17 7.5rd=11.6 99% CI 2.3-21.0rr=0.39 99% CI 0.16,0.96)

Median LOS 4.5 5.0

Mortality (112/374) 30% (49/215) 23% p=0.06

Lessons

• Passive implementation of the VAP prevention bundle failed.

• Compliance improved during an active multimodal implementation.

• This was associated with a significant reduction in the occurrence of VAP.

The Scottish Patient Safety Programme

Since then………………..

VAP Prevention Bundle

Sedation reviewed and stopped

if appropriate Y N Exclusion

Patient assessed for weaning

and extubation Y N Exclusion

Supine position avoided Y N Exclusion

Chlorhexidine 1-2% QID Y N Exclusion

Use of subglottic drainage ETT Y N Exclusion

VAP: % All Bundle Compliance

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Post spsp improvements

Calendar days between VAP acquisition Sep 2005 - J un 2009

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Passive intervention period Active intervention & compliance feedback

Scottish Patient Safety Programme

VAP Incidence: Bundle Compliance

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Patient Safety Programme begins

Tw ice daily w ean screen sticker added to 24hr chart

VAP bundle prompts added to daily goals sheet.

Active period: Bundle implementation,

audit & education

Continuous measurement initiated

VAP - Pt constantly pulling at trachy, poorly compliant with head up & mouthwash

VAP - Long term pt vent for more than 150 days

VAP - poorly compliant pt, refusing to sit up refusing chlohex. Handling trachy and tubing. Not clear cut!

HELICS surveillance

VAP – Key points

• Evidence is the starting point

• Implementation is difficult – efficacy vs effectiveness

• Process measure identifies failings

• SPSP methodology leads to sustained process improvement

VAP – key points

• Education

• Feedback

• Process measurement / management

• You need the correct clinicians

• The result is outcome improvement

• Resources – without the above, bundles are “futile”

VAP - eliminated

• VAP still here

• So rare that we can now discuss the reasons for individual cases

• Huge reduction in the problem

• Scottish ICU clinicians and SPSP/IHI

• Effective healthcare does not need to cost more