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
0
50
100
150
200
250
300
3501 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67
Nu
mb
er o
f at
ris
k ve
nti
lati
on
day
s b
etw
een
.
Upper control limit (3SDs)
Upper warning line
Centreline (mean)
G chart
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
0
50
100
150
200
250
300
3501 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67
Nu
mb
er o
f at
ris
k ve
nti
lati
on
day
s b
etw
een
.
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
41
62
78
96 100
010
2030
4050
6070
8090
100
March April May June July
Month 08
%
Post spsp improvements
Calendar days between VAP acquisition Sep 2005 - J un 2009
0
20
40
60
80
100
120
140
160
180
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77
Calen
dar d
ays
betw
een
calendar days between UCL CL UWL
Passive intervention period Active intervention & compliance feedback
Scottish Patient Safety Programme
VAP Incidence: Bundle Compliance
0
1
2
3
4
5
6
7
8O
ct-0
6
Nov
-06
Dec
-06
Jan-
07
Feb
-07
Mar
-07
Apr
-07
May
-07
Jun-
07
Jul-0
7
Aug
-07
Sep
-07
Oct
-07
Nov
-07
Dec
-07
Jan-
08
Feb
-08
Mar
-08
Apr
-08
May
-08
Jun-
08
Jul-0
8
Aug
-08
Sep
-08
Oct
-08
Nov
-08
Dec
-08
Jan-
09
Feb
-09
Mar
-09
Apr
-09
May
-09
Jun-
09
Jul-0
9
Aug
-09
Sep
-09
Oct
-09
VA
P I
nci
den
ce
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bu
nd
le C
om
pli
ance
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