VAP bundle compliance in ICU - Clinical Audit

VAP bundle compliance in ICU

Authors A. Al-Harthy , A. F. Mady , H. Al-Hanafy , W. Al-Etreby , M. Asim Rana Department of Intensive Care Medicine,

King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Corresponding Author Waleed Tharwat Hashim Al-Etreby Kingdom of Saudi Arabia, Riyadh, P.O. Box 331140 ZIP code 11373 Al-Shemaisi

[email protected]

Lead Consultant Abdul Rahman Mishal Al-Harthy

King Saud Medical City, Critical Care Department

Riyadh, Kingdom of Saudi Arabia The Online Journal of Clinical Audits. 2014; Vol 6(2).

Published June 2014. To subscribe to The Online Journal of Clinical Audits go to: http://www.clinicalaudits.com/index.php/ojca/user/register Article submission and authors instructions: http://www.clinicalaudits.com/index.php/ojca/about/submissions

ISSN 2042-4779 ClinicalAudits.com

Abstract: Healthcare associated infection is a major concern worldwide, and ventilator associated pneumonia (VAP) is the leading cause of mortality among them, VAP is also associated with increased length of stay in ICU, and increased cost of treatment. Authorities all over the world have issued guidelines and recommendations for the prevention of VAP in an effort to decrease its incidence. Aims – To measure the compliance of healthcare providers in ICU with VAP bundle. Methods – Concurrent snapshot review of the medical files of 88 adults ventilated patients took place, during April 2014, for evidence of compliance with components of VAP bundle, namely: Hand hygiene, mouth wash, elevation of head of bed (HOB), sedation vacation, non-routine changing of the ventilator tubing, and the use of Endotracheal tube (ETT) with subglottic suction port. Results – compliance with mouth wash and non-routine tubing change was 100%, while compliance with hand hygiene was 87.5%, compliance with the elevation of HOB was 95.2%, compliance with sedation vacation was 65.5%, no patients were intubated with ETT with subglottic suction port, so the compliance was 0% Conclusions – Awareness and education are required for the VAP bundle, every effort must be made to minimize load of work on physicians and nurses, periodic preventive maintenance needs to be more effective, and administration of the ICU will be addressed to provide ETT with subglottic suction ports. Introduction Healthcare-associated infection (HAI) is a major patient safety concern all over the world 1 . The leading cause of death among (HAI) is ventilator associated pneumonia (VAP), exceeding deaths due to central line infections, severe sepsis, and respiratory tract infections in non-intubated patients 2. With mortality rates ranging from 15% to 70% depending on the patient population 1. And approximately 60% of deaths among patients with hospital-acquired pneumonia 3. Studies have also shown higher hospital mortality rates of ventilated patients who develop VAP (about 46%) compared to mortality rates of 32% of ventilated patients who do not develop VAP 4. VAP is not only associated with high mortality rates, but accounts also to increasing the length of stay in ICU by an average of 4 to 9 days 3. And consequently increasing directly hospitalization costs to up to $40,000 per patient 5. As well as increasing the duration of mechanical ventilation, and making it more difficult to wean the patient from the ventilator 6. Because of the seriousness of VAP and its morbid effect on patients’ outcome, many authorities around the globe, like The Center for Disease Control (CDC), Joint Commission, and the Leapfrog Group, have identified VAP rates as a measure of the quality of care provided by an institution 7,8. Several organizations have recommended approaches, interventions, and evidence-based guidelines to address that issue 9. And many hospitals worldwide implemented a group of patient care practices, to be carried out by the care team to standardize treatment, named the ventilator bundle or the VAP bundle 10. Including King Saud Medical City, Riyadh, KSA. Where this audit was carried out.


Aims To measure the compliance of the care providers with the elements of the VAP bundle. Audit Standards (table 1)

1- Intubated patients should be positioned with their upper body elevated (semi-recumbent or sitting) for as much of the time as possible, unless contraindicated like spine injury.

2- Oral antiseptics (for example, chlorhexidine) should be included as part of an oral hygiene regimen for all patients who are intubated, unless contraindicated due to oro-pharyngeal trauma.

3- Hand hygiene, in accordance with national hand hygiene guidelines, should be part of the routine clinical care of mechanically ventilated patients, without exception.

4- The ventilator circuit should be changed only if soiled or damaged, not on a routine basis.

5- Sedation reviewed, and if appropriate stopped daily, and the patient is assessed for weaning and extubation, unless contraindicated due to difficulty of ventilation, refractory hypoxia, or HFO.

6- Use of subglottic secretion drainage ETT in patients likely to be ventilated for more than 48 hours.

Table 1: Audit standards and criteria. Evidence of quality of care or service

(criterion) Standard

(% compliance) Exception(s) Definitions and

instructions for data collection

1 Elevation of head of bed 30 – 45 degrees 100% Spine injury All ventilated adult patients in ICU

2 Oral hygiene with chlorhexidine 100% Oro-pharyngeal trauma

All ventilated adult patients in ICU

3 Hand Hygiene 100% NONE All ventilated adult patients in ICU

4 Circuit change only when needed 100% NONE All ventilated adult patients in ICU

5 Sedation review and vacation 100% HFO, high ICP, difficult to ventilate

All ventilated adult patients in ICU

6 Subglottic suction ETT 100% Not available All ventilated adult patients in ICU

Methods The study was carried out at King Saud Medical City (KSMC), Riyadh, Saudi Arabia. KSMC has a 120 bed state of the art ICU, making it one of the largest ICUs in the middle east, accepting both medical and surgical cases. During the month of April 2014, 88 mechanically ventilated adult patients were included in the study. Concurrent snap shot data were collected from the patients’ medical records, in a YES/NO tick box form, concerning the six audit standards stated above. Percentage of compliance with each standard was calculated separately, by dividing the number of patients who meet the standard, by the number of patients to whom the standard applies minus exceptions, multiplied by 100.


Results (table 2, figure 1)

1. Compliance with hand hygiene was observed in 77 cases out of 88 without exceptions, with a percentage of 87.5%

2. Compliance with mouth wash with chlorhexidine was 100%, no patients were excluded.

3. Compliance with elevation of head of bed was 81 out of 85 patients, with a percentage of 95.2%, and 3 patients with unstable spine fracture were excluded.

4. Compliance with sedation vacation was documented in 57 patients out of 87, with a percentage of 65.5%, while one patient on high frequency oscillation was excluded.

5. Compliance with non-routine changing of the ventilator tubing was 100% without exceptions.

6. Compliance with the use of subglottic suction ETT was 0%

Table 2: Summary of results. Criteria Exception Compliance Percentage

Hand Hygiene zero 77/88 87.5 %

Mouthwash zero 88/88 100 %

HOB elevation 3 81/85 95.2 % Sedation vacation 1 57/87 65.5 %

Changing tubing zero 88/88 100 %

Subglottic suction 88 0/88 0 %

Figure 1: Summary of results.

1- Hand hygiene, 2- Mouth wash, 3- HOB, 4- Sedation vacation, 5- change of tubes, 6- subglottic suction tube


Discussion Mouthwash with chlorhexidine for intubated patients is a part of the daily nursing care in our ICU, and all patients audited received that intervention, resulting in a compliance percentage of 100%. It is also the routine practice of respiratory therapists in the ICU to change tubing only if they become soiled with secretions or damaged, resulting in a 100% compliance. Compliance with hand hygiene was 87.5 %, noncompliance was observed in eleven patients. Out of those eleven episodes of non-compliance, five cases were related to emergency situations, like sudden desaturation or accidental extubation. Non-compliance was observed among physicians, either ICU or out of ICU physicians. Sedation vacation and assessment of readiness of extubation had the lowest compliance percentage of about 66%, 87 patients were included and one patient on HFO was excluded.

As for the use of ETT with subglottic suction port, all of the patients were excluded, resulting in a compliance percentage of zero%

Conclusions Compliance with the nursing elements of VAP bundle (mouth wash, hand hygiene, and non-routine changing of the ventilator tubing) is up to standards, while the inconsistencies were observed from the physicians side. In part due to unawareness and lack of education about the elements of the bundle, especially between physicians from outside the ICU, and in part due to the concentration on resuscitation by ICU physicians in emergency situations, on the expense of policies and recommendations. The overload of work (be it paper work, or critically ill patients handled by the same person) make it impossible sometimes for the ICU physician to consider holding sedation for an intubated patient and start a trial of weaning, which requires his/her undivided attention and concentration. Compliance with the standard of elevation of the head of bed, that was breached four times, was the result of a malfunctioning bed once, and forgetting to return the patient to semi-sitting position after care three times, which could also be attributed to the overload of work on the bedside nurse, with many responsibilities and tasks to be performed. The zero compliance with the standard of using ETT with subglottic suction port was simply due to its unavailability in our institution.

Recommendations

• Education, awareness, and enlightening are a must for the successful implementation of any advocated intervention or practice. A campaign of awareness of the VAP bundle is required to educate healthcare providers, about its importance. Different methods can be used like: posters, reminder (pocket) cards, lectures, group discussions, one-on-one talks …etc.


• Decreasing the load of work on the physician as well as the nurse is recommended, so that the best care can be provided. Minimizing paper work is a method, perhaps also recruitment of more personnel.

• Proper maintenance of all ICU equipment, and periodic checking. If a bed is not functioning, it should not be available for patient admission.

• Administration of the ICU will be addressed to provide the ETT with subglottic suction port.

References 1. Klevens RM, Edwards JR, Richards C,. Estimating health care-associated infections and deaths in U.S. Hospitals. Public Health Reports 2007; 122: 160-166. 2. Move Your Dot™: Measuring, Evaluating, and Reducing Hospital Mortality Rates (Part 1). IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. 3. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. . Chest. 2005; 128(6): 3854-3862. 4. Luna CM, Blanzaco D, Niederman MS, Matarucco W, Baredes NC, Desmery P. Resolution of ventilator associated pneumonia: prospective evaluation of the Clinical Pulmonary Infection Score as an early clinical predictor of outcome. Crit Care Med 2003; 31: 676-82. 5. Warren DK, Shukla SJ, Olsen MA. Outcome and attributable cost of ventilatorassociated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003; 31(5): 1312-1317. 6. Rubenfeld GD, Caldwell E, Peabody E. Incidence and outcomes of acute lung injury. N Engl J Med 2005; 353: 1685-93. 7. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. jama 2006; 295(3): 324-327. 8. Jha AK,Orav EJ, Ridgway AB, Zheng J, EpsteinAM. Does the Leapfrog program help identify high-quality hospitals?. Jt Comm J Qual Patient Saf. 2008; 34(6): 318-325. 9. Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Abstract: Nursing Adherence with Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia. Critical Care Medicine 2003; 31: 2693-2696. 10. Tolentino-DelosReyes AF, Ruppert SD, Shiao SY. Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia.. Am J Crit Care. 2007; 16(1): 20-27.

VAP bundle compliance in ICU - Clinical Audit

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