The Eradication of VAP in Scotland Martin Hughes Nov 2010

1. The Eradication of VAP in ScotlandMartin HughesNov 2010

2. Plan • Definition • Diagnosis • Importance • Strategies to reduce VAP • Why don’t they work? • What does work? • Eradication in Scotland

3. 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.

4. 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’

5. 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.

6. 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?

7. 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

8. 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?

9. 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

10. 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.

11. 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

12. Others NIV – avoiding intubation Kinetic beds – no evidence HME vs Heated Water Humidification – equally effective SDD?

13. 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

14. 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

16. 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

17. Additionally S/C enoxaparin pre-printed Ranitidine pre-printed Enteral feeding encouraged – if tolerated ranitidine cessation considered.

18. SRI experience At launch Consultant buy in Laminated charts by every bed space Unit posters Surveillance programme (Helics) Ahead of the game nationally

19. Job done? What is the VAP rate? What is the bundle compliance? Hawe, Ellis, Cairns, Longmate ICM, 2009

20. G chart Upper control limit (3SDs) Upper warning line Centreline (mean)

21. Process

22. Problem? Passive interventions don’t work Educational interventions to reduce VAP Structure, Process, Outcome

23. 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.

24. Sequential Process Measurements

25. Study Period

27. 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.

28. The Scottish Patient Safety Programme Since then………………..

29. 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

31. Post spsp improvements

39. 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

40. 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”

41. 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