Critical Care Update
Noninvasive Ventilation Initiative Reduces VAP Rates and Other Patient Outcomes
2012;17(7):15B, 16.

Noninvasive Ventilation Initiative Reduces VAP Rates and Other Patient Outcomes

A hospital was able to reduce its rates of ventilator-associated pneumonia and improve other outcomes through an education program and other measures to encourage the noninvasive ventilation of patients, according to research.

SAN FRANCISCO—A hospital-wide initiative to encourage noninvasive ventilation lowered rates of ventilator-associated pneumonia (VAP) and resulted in many additional benefits, researchers reported at the American Thoracic Society’s 2012 International Conference.

“From a combination of a commitment to patient safety, a multidisciplinary approach to eradicating nosocomial infections, and physician and staff education, positive outcomes have surfaced,” said Tom P. Howard, AAS, RT, and colleagues of the North Shore-Long Island Jewish Health System in Glen Cove, New York. “We have an overall reduction in VAP, a statistically significant reduction in endotracheal intubation, reduced length of stay, a decrease in mortality, and a reduction in ventilator days.”

Using a Proactive Approach
Noting that VAP is the most common infection in ICUs and contributes to poor outcomes, the researchers examined their hospital’s undertaking to eliminate the infection—called the “Journey to Zero” initiative. This initiative included an education program for physicians, intensivists, nurses, and respiratory therapists about the purpose and applications of noninvasive ventilation. “Education focused on modes of operation, settings, inclusion criteria, contraindications, general considerations for identifying and assessing potential candidates, and possible complications,” the researchers explained.

The hospital proactively assessed patients on mechanical ventilation for possible reassignment to noninvasive ventilation. The assessments relied on physiologic and clinical assessments, CDC guidelines, American Thoracic Society criteria, and evidence-based clinical practice guidelines. “Patients meeting criteria were assessed for patient-device interface,” said the investigators. “Settings were determined by the physician, and the [noninvasive ventilation] machine was titrated for patient comfort and synchrony. Arterial blood gasses and patients’ responses to treatment were also monitored.” A trial of noninvasive ventilation was considered successful if a patient’s symptoms ceased and/or their arterial blood gasses improved, making intubation unnecessary.

The hospital also implemented the Institute for Healthcare Improvement Ventilator Bundle, a series of ventilator-care interventions intended to reduce VAP. The interventions include elevation of the head of the bed, breaks from sedation, assessments of patients’ readiness to extubate, prophylaxis for peptic ulcer and deep venous thrombosis, and daily oral care with chlorhexidine.

Furthermore, the hospital developed and implemented a protocol for weaning patients off mechanical ventilation when they do not yet meet criteria for noninvasive ventilation. “Weaning continues when a patient is transferred from critical care to our ventilator unit,” the researchers explained.

Significant Results
The “Journey to Zero” improved patient safety by removing the risk of VAP, the researchers found. Following the quality improvement measures, there was a year-to-date (YTD) reduction in intubations of 86.6%, a YTD reduction in ventilator days of 1%, and a 61% increase in noninvasive ventilation use. No patients needed to be re-intubated within 24 hours of ex-intubation. However, 12.4% of patients eventually required re-intubation due to noninvasive ventilation failure.

The critical care unit’s rate of VAP was 0% from March 9, 2009, to December 2, 2011, as well as from December 2, 2011, to YTD. Although there was one case of VAP since initiation of the program, this case occurred in a chronic ventilator patient who did not meet criteria for noninvasive ventilation or the weaning protocol.

The hospital’s future plans include “continuing data collection, monitoring the use of noninvasive ventilation and the incidence of ventilator-associated pneumonia, and further refining guidelines and protocols for use and implementation,” the researchers concluded.

—Jack Baney

Suggested Reading
Rello J, Ollendorf DA, Oster G; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115-2121.
Shorr AF, Kollef MH. Ventilator-associated pneumonia: insights from recent clinical trials. Chest. 2005;128(5 Suppl 2):583S-591S.

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