Importance of ventilator bundles

compliance on the outcome of ventilator

associated pneumonia (VAP)

Irene Arago
Outubro 2008

Prevention of Ventilator Associated Pneumonia

The contribution of bundle in the prevention of
Ventilator Associated Pneumonia (VAP)
What is a bundle?
How to get the organization to change behaviors?
Preliminary results of Sto Antonio Hospital Campaign

What is a bundle?
A grouping of best practices with respect to a disease

process that individually improve care, but when applied

together result in substantially greater improvement.
The science behind the bundle is so well established that it
should be considered standard of care.
Bundle elements are dichotomous and compliance can be
measured: yes/no answers.
Bundles eschew the piecemeal application of proven
therapies in favor of an all or none approach.

Ventilator bundle
.is a package of evidence-based
interventions that, when
implemented together for all patients
on mechanical ventilation, has
resulted in dramatic reductions in the
incidence of ventilator-associated
pneumonia.

Success, measurable, achievable, relevant,

time bound (SMART approaches)

Bundle Considerations

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

Bundle elements are not prescriptive i.e.,

elements should not be forced if clinically
inappropriate or contraindicated

The ventilator bundle key components

(Institute for Healthcare Improvement - IHI)

1. Elevation of the head of the bed to

between 30 and 45 degrees
2. Daily "Sedation Vacations" and
Assessment of Readiness to Extubate
3. DVT prophylaxis (unless contraindicated)
4. Stress bleeding prophylaxis
www.IHI.org

Elevation of the head of the bed to 30 - 45

Why?
 Reduces potential for aspiration
 Potential to improve ventilation
Randomized controlled trial: 86 intubated patients on mechanical
ventilation assigned to semi-recumbent (45o) or supine
position
Semi-recumbent:
Suspected VAP:
8%

Supine:
34%

(p=0.003)

Confirmed VAP:

5%

(p=0.018)
Drakulovic MB. Lancet 1999; 354: 1851-1858

23%

Daily "Sedation Vacation

Why?
 Has been demonstrated to reduce overall patient sedation
 Promotes early weaning
128 adults on mechanical ventilation randomized to daily
interruption of sedation until the patient was awake or
interruption at the clinicians discretion

Duration of ventilation:
4.9 days vs. 7.3 days (p=0.004)

Kress JP. N Engl J Med 2000; 342: 1471-1477

Deep venous thrombosis (DVT) prophylaxis

Why?
 Reduces potential for clot formation
 Reduces potential for pulmonary emboli
Systematic review of risks of venous
thromboembolism and its prevention:
we recommend, on admission to the intensive care unit,
all patients be assessed for their risk of VTE.
Accordingly, most patients should receive
thromboprophylaxis (Grade 1A)
Geerts WH. Chest 2004; 126: 338S-400S

Peptic stress ulcer prophylaxis

Why?
 Reduces acid production in stomach and the
consequent risk of bleeding from gastric erosions and
peptic ulcers
Surviving Sepsis Campaign Guidelines:
Stress ulcer prophylaxis should be given to all
patients with severe sepsis. H2 receptor inhibitors
are more efficacious than sucralfate and are the
preferred agents. Proton pump inhibitors have not
been assessed in a direct comparison with H2
receptor antagonists and, therefore, their relative
efficacy is unknown. They do demonstrate
equivalency in ability to increase gastric pH.
Dellinger RP.

Crit

Care Med 2004; 32: 858-873

High Level of Compliance

Goal

95 percent of all patients on mechanical

ventilation in the ICU receive all four
elements of the Ventilator Bundle.

Level of Reliability
(compliance with all elements):

Reduction in
VAP Rate:

Unchanged

22%

<95% compliance

40%

>95% compliance

61%

Reducing VAP
Santo Antonio Hospital Campaign

Local definition of the problem by

Hospital Commission on Infection
Control(2006)


PQIP

(Portuguese Quality Indicator Project) 2005/2006

data

Medians 21-28 VAP cases per 1000 days of ventilation

in the 3 ICUs
Mechanical Ventilation rate 80%

Reducing VAP
Santo Antonio Hospital Campaign

VAP prevention became an important goal to the

commission and must involve all the ICU staff

Some studies show that a patient suffering from VAP

stays at least + 4,3 days in intensive care, and raises
his chances of dying by 6% (1) Some other refers even
larger numbers (average added delay 5-13 days, increases
absolute chance of dying by 0-50%)
(1) The Canadian Critical Care Trials Group, Am J Respir Crit Care Med
1999;159:1249-56

Reducing VAP
Santo Antonio Hospital Campaign

The project should be faced as one of the

organization's goals:


Improve the patients safety

Reduce health care costs

Improve quality of care

Reducing VAP
Santo Antonio Hospital Campaign

How to implement the campaign?

Revision of the methodology employed in other
places

Campaign promoted by the IHI



100 000 Lives Campaign

Prevent Ventilator-Associated Pneumonia
The ventilator bundle

Reducing VAP
Santo Antonio Hospital Campaign

Modified version of IHI ventilator bundle

1.

Elevation of the head of the bed to 30 - 45

2.

Daily evaluation for the need of sedation

3.

Deep venous thrombosis (DVT) prophylaxis

4.

Peptic stress ulcer prophylaxis

Reducing VAP
Santo Antonio Hospital Campaign

Procedures Review (in progress)



Hands Hygiene (alcohol-based hand hub)

Oral Care (chlorhexidine)

Ventilator circuit time changing

In-line nebulizers vs. MDI inhalers

PROTOCOLO DE PREVENO DA PNEUMONIA ASSOCIADA

VENTILAO

LISTA DE VERIFICAES RELACIONADAS COM O DOENTE VENTILADO (Diria)

DATA

N CAMA INICIAIS
do DOENTE

ELEVAO DA
CABECEIRA
DA CAMA
30/45

INTERRUPO DA
SEDAO
SIM

NO

SEM
SEDA
O

PROFILAXIA DA
LCERA DE
STRESS

PROFILAXIA
TROMBOSE
VENOSA
PROFUNDA

(surveillance unit based)

PROTOCOLO DE PREVENO DA PNEUMONIA

ASSOCIADA VENTILAO
LISTA DE VERIFICAES RELACIONADAS COM O DOENTE VENTILADO (Individual)

(surveillance patient based)

DOENTE: ____________________________

DATA DE ADMISSO: _________________

DIA

10

ELEVAO DA CABECEIRA DA
CAMA A 30/45

INTERRUPO DA SEDAO

PROFILAXIA DA LCERA DE
STRESS

SEM SEDAO

PROFILAXIA TROMBOSE VENOSA

PROFUNDA

Daily "Sedation Vacations" and Assessment of

Readiness to Extubate two components?

Five elements:
1. Elevation of the head of the bed to between 30
and 45 degrees
2.Daily awakening: sedation vacation
3.Daily assessment of readiness for weaning
4. DVT prophylaxis (unless contraindicated)
5. Stress bleeding prophylaxis
IHI 2007

Daily evaluation for the need of sedation

From our results we conclude:

 Difficulties do have a homogeneous criteria
between members of the staff
 Need of a sedation protocol
 Need to develop a weaning protocol

Reducing VAP - Santo Antonio Hospital Campaign

UCIP - 2007
(preliminar data)

Ventilator Bundle Compliance

100,00%
95,00%

97,46%

97,22%

98,94%

100,00%

100,00%
94,00%

90,00%
85,00%
80,00%
75,00%

br
o
m
ez
e
D

ov
e

m
br
o

ub
ro
O
ut

te
m
br
o
Se

to
go
s
A

Ju

lh
o

70,00%

1. Elevation of the head of the bed to 30-45

2. Peptic stress ulcer prophylaxis
3. Deep venous thrombosis prophylaxis

Reducing VAP - Santo Antonio Hospital Campaign

UCIP - 2007
(preliminar data)

55,00

50,00

60,00

55,00

45,00

50,00

50,00

40,00

40,00

34,65

30,00

33,33

19,14

20,00

PAV 2007

31,09

10,00

30,30

21,05

PAV 2006

0,00

PAV 2006

PAV 2007

Ventilator Associated Pneumonia =

n of Ventilator Associated Pneumonia / n ventilador days x 1000

Effects of bundled interventions on VAP

N infeces/1000 dias de ventilao
Antes
Depois
Zack et al

12,6

5,7

p<0.001

8,8

4,7

p<0,001

Surg

45,1

27,9

Med

22,4

11,6

Crit Care Med 2002

Babcock et al
Chest 2004

Lai et al
Infec Control Hosp Epidemiol 2003

CHEST, 134, 2, August, 2008

SMART approaches for reducing Nosocomial

Infections in the ICU
Marin Kollef, CHEST, 134, 2, August, 2008

Choose specific objectives that precisely define and quantify

desired outcomes, such as reducing the nosocomial ICU infection
rate of an institution by 25%. To measure the objective,
monitor the staff adherence to tatics and infection rates, and
provide feedback to ICU staff.
Make objectives time bound; set dates for collecting baseline and
periodic data and a completion date for evaluating the success of
the intervention