Reducing Ventilator-Associated Pneumonia Rates Through Staff Education
Abstract & Commentary
Synopsis: A focused-education program was associated with a dramatic reduction in the incidence of ventilator-associated pneumonia.
Source: Zack JE, et al. Crit Care Med. 2002;11:2407-2412.
The purpose of this pre- and postintervention observation study was to evaluate the effect of an educational initiative on ventilator-associated pneumonia (VAP) rate. The educational program was directed toward respiratory therapists and critical care nurses. The patient population consisted of those developing VAP during a 2-year period. A multidisciplinary task force developed policies and an educational initiative to reduce VAP rates. The educational program consisted of a self-study module, lectures, and pre- and post-testing. The focus of the self-study module was coverage of general topics related to VAP and specific emphasis on risk reduction strategies. Successful completion of the program was required of all respiratory therapists and made available to critical care nurses on an elective basis. Posters related to VAP were posted throughout the ICU. The pre-intervention period occurred from October 1, 1999, to September 30, 2000, and the postintervention period occurred from October 1, 2000, until September 30, 2001. The diagnostic criteria for VAP were a modification of those established by the American College of Chest Physicians.
A total of 114 respiratory therapists completed the educational program. The average correct score on the exam increased from 80% to 91% (P < 0.001) after completing the educational module, and the average score 6 months after implementing the intervention was 85%. The educational module was also completed by 146 critical care nurses, and their scores on the test increased from 81% to 91% (P < 0.001). During the 12-month period before the intervention, the VAP rate was 12.6 per 1000 ventilator days. Following the intervention, the VAP rate was 5.7 per 1000 ventilator days—a decrease of 57.6% (P < 0.001). The cost saving associated with this intervention was calculated to be at least $424,000. Zack and colleagues concluded that an educational program focused on respiratory therapists and critical care nurses resulted in significant reductions in VAP rate.
Comment by Dean R. Hess, PhD, RRT
Nosocomial infections are an important cause of morbidity and mortality. Pneumonia is the most common nosocomial infection, and 86% of nosocomial pneumonia cases are associated with mechanical ventilation. Respiratory therapists and intensive care nurses are intimately involved in the care of mechanically ventilated patients and are, thus, uniquely positioned to affect VAP rates. Significant opportunities exist to improve VAP prevention practices.1-3 These include decreasing the frequency of ventilator circuit changes, increasing the use of noninvasive ventilation, and elevation of the head of the bed.
Despite considerable evidence that has emerged in recent years, approaches to the prevention of VAP remain archaic in many intensive care units. Although there is considerable evidence of the benefit of the semi-recumbent position for the prevention of VAP, I frequently observe mechanically ventilated patients who are not positioned accordingly. Despite considerable evidence4 that changing ventilator circuits and in-line suction catheters at regular intervals does not decrease VAP rate (and a meta-analysis suggests that this might actually increase VAP rate), the practice of changing circuits at regular intervals continues in many hospitals. I know of instances where infection control departments blocked the plans of respiratory care departments to implement the practice of as-needed ventilator circuit changes because adopting such a practice "does not make sense"! Unfortunately, what makes sense in the minds of some (dare I call this "expert" opinion?) still trumps high-level evidence in many hospitals. Despite evidence that it decreases intubation rate, increases survival, and decreases VAP rate, noninvasive ventilation in appropriately selected patients remains underused in many hospitals.
This study by Zack et al shows that an educational intervention directed primarily at respiratory therapists and critical care nurses can significantly reduce ventilator-associated pneumonia rates and associated costs. However, Zack et al have not reported whether this intervention affects other important outcomes such as antibiotic use, length of hospital stay, or mortality. In spite of these limitations, an education program such as the one described in this study should be considered—particularly for hospitals with a higher than expected ventilator-associated pneumonia rate.
Dr. Hess is Assistant Professor of Anesthesia at Harvard Medical School and Assistant Directory of Respiratory Care at Massachusetts General Hospital.
References
1. Heyland DK, et al. Prevention of ventilator-associated pneumonia: Current practice in Canadian intensive care units. J Crit Care. 2002;17:161-167.
2. Cook D, et al. Influence of airway management on ventilator-associated pneumonia: Evidence from randomized trials. JAMA. 1998;279:781-787.
3. Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med. 1999;340:627-634.
4. Hess DR. Response to Demers RR. Is the gastrointestinal tract the sole source of organisms in ventilator-associated pneumonia? Respir Care. 2002;47:696-699.
Editor’s Note: For the latest CDC recommendations, see CDC Draft Guidelines for Prevention of Healthcare-Associated Pneumonia, 2002. www.cdc.gov.
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