Ventilator associated pneumonia in Middlemore Hospital

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1 Dr. Edda Jessen, Catherine Hocking, Andrew Gilhooly, Christine Sturrock, Joanna Padora, Jonathan Davis, Sunetra Chand, Victoria Moore Ventilator associated pneumonia in Middlemore Hospital Health and Quality commission challenge 2012 final report Project Outline Ventilator Associated Pneumonia (VAP) is a common problem in ventilated patients in the ICU environment. Up to 30% of all patients who are ventilated for more than 72 hours develop a VAP. Mortality rates are as high as 50% depending on applied criteria and cohort. An audit of the VAP rate at Middlemore Hospital revealed a VAP rate in this environment as high as 90% for patients who underwent ventilatory support for more than 3 days. Middlemore Hospital is a secondary care level metropolitan hospital in South Auckland. The Intensive Care Unit has the capacity to ventilate up to 12 patients in total. The department cares for general intensive care patients including burn patients but excluding cardiac and neurosurgical intensive care patients. Initial evaluation In order to improve our VAP rate we established a VAP action group. The group is led by an intensivist, the Health and Quality Co-ordinator Nurse Specialist and a group of 6 enthusiastic nurses of variable experience levels. The initiative started with a plan to establish measures to improve our VAP rate with the ultimate goal to establish a bundle specific to the critical unit at Middlemore Hospital. The initial process involved the development of a VAP assessment tool. In a journal review we established international criteria for the diagnosis of a VAP. We aimed to apply as stringent criteria as possible. The diagnostic criteria were discussed on various levels within the department: the VAP action group, the Consultant group, management group, with our infectious disease colleagues as well as peers in other ICU departments around the world. The resulting VAP assessment tool is attached in the supplement. After an initial attempt to complete the tool during the ward round by the second on call Consultant we quickly recognised that this practice did not lead to the desired documentation. After discussion with involved stakeholders, we decided to delegate the daily assessment to the bedside nurse. As a consequence all collected data had to be complemented with review of microbiological data and x-ray results. The task was completed monthly by the lead consultant. The assessment tool includes a number of other data, such as date of admission and intubation, diagnosis, time and date of extubation and outcome in ICU. We used the additional information to build a VAP database. Once we achieved a generally - within the department- accepted assessment tool we performed a literature review in order to establish a list of factors which would have an impact on the prevention of a VAP.

2 As such we identified following criteria: oral hygiene using a number of different products DVT prophylaxis oral suction prior to position change PPI therapy daily assessment for extubation feeding strategies/ng suctioning head of bed elevation length of stay in ICU duration of ventilation cuff pressures between cm water Consequently we performed an audit to establish our performance with regards to every aspect of above interventions. A nurse each performed a blinded audit on numerous occasions over a period of up to one month. The bedside nurse was unaware of the nature of the audit being performed. Results were pooled and analyzed independently. The audit results were then revealed in the monthly group meeting. Care aspects which achieved a compliance rate of 97% or above were excluded from consideration for the VAP bundle. Whilst we recognised numerous aspects of our care as particularly problematic we considered all aspects with suboptimal compliance for the bundle. The bundle was finally decided to include following aspects: Suction prior to position change Elevation of the head above 30 degrees Cuff pressure between cm water Oral hygiene Nasogastric suctioning every 4 hours Daily assessment for readiness to extubate Subglottic suctioning With an implementation slogan: It only costs seconds to prevent a VAP Prior to introduction of the bundle the management and quality groups as well as Consultant group agreed to introduce the VAP bundle into daily care. The VAP bundle replaced another care bundle on the daily documentation sheet. Practice The implementation the VAP bundle was introduced after a 1 month period of staff education led by our quality nurse coordinator. Multiple posters were placed around strategic points in the department, the tea room and toilets in order to remind staff of the intended change of practice. A VAP assessment sheet was placed into the patients notes to be completed daily by the bed side nurse. The bedside nurse had to perform all aspects of the bundle as outlined. Towards the end of the shift the bedside nurse had to complete a checklist documenting the application of the VAP bundle.

3 We continued to perform regular sprint audits to assess the VAP bundle compliance. The audit included the documented compliance but individual elements were cross checked as to having been executed appropriately. We found a significant discrepancy between documented bundle compliance and true performance. Some aspects, in particular elevation of the bed to above 30 degrees, suction prior to position change and cuff pressures, only achieved an overall compliance of 41% for the 6 months period we examined. We escalated the bundle by introduction of a subglottic suctioning tube after 10 weeks. The introduction was preceded by multiple training sessions for nursing and medical staff. We involved our anesthetic colleagues into the use of the subglottic ETT after a brief, 2 weeks, introductory phase in ICU alone. We asked our anesthetic colleagues to consider the use of a subglottic suctioning ETT for any patients anticipated to need ICU transfer or for any planned ETT change for ICU patients who underwent a surgical procedure. The involvement of our colleagues in the local Emergency department is still pending. We recognized that most of our ventilated patients are intubated either in the emergency department or our theatre complex. Therefore our compliance with this component of the bundle remains suboptimal. Pitfalls Any change of practice requires careful and staged introduction. Although we allowed for teaching sessions and education sessions for all nursing and medical staff, we failed to reach all our staff with our educational sessions. As a result the overall bundle compliance is doubtful with only 41% overall documented. We detected problems in 3 aspects of bundle compliance: head-of-bed elevation and suctioning of oral cavity prior to position change, as well as ETT cuff pressures. Two of these aspects are newly introduced into nursing care whereas other aspects of the VAP bundle only represent a modification of care or have been fully established before. The beds used in this department permit the angle of the bed to be measured at all times. Despite that the nurses rely on a visual impression of head elevation. Suctioning of the oral cavity prior to position change is an entirely new concept in our department. Often the nurses seem to memorise this aspect after they performed the position change. The failure to comply with a target cuff pressure is most likely related to the education leading up to our bundle implementation. In the initial audit we frequently found cuff pressure to be in excess of 30cm water. The subsequent education seems to have led to an anxiety to over-inflate the cuffs. As a result we now record cuff pressures below the targeted threshold. The introduction of a different endotracheal tube caused the most discomfort for nursing staff and medical colleagues. The tube per se is perceived as more difficult to insert, partly because an additional suction port seems to be in the way. Additionally the tube feels stiffer than the previously used ETT. Patients who require intubation when after admission to ICU will have a subglottic suction tube inserted unless contraindications apply. We have targeted our anesthetic colleagues in a single education session in an attempt to encourage the use of subglottic suctioning tubes for all patients who will require ICU admission.

4 However, the choice of ETT remains at the discretion of the treating physician. For that reason less than 50% of all intubated patients in ICU currently have a suction ETT in situ. Cost analysis The average cost for a VAP in Middlemore Hospital ICU is NZ$ 91,754. Over the period from 1/1/2012 until 30/6/2012 the cost generated by VAPs in Middlemore Hospital is in excess of $1.1 million. The cost for this period for antibiotics treating patients with confirmed VAP is $47,560. The mortality rate associated for a single episode of VAP in Middlemore Hospital is 31.5%. However, the cost generated by patients sustaining a VAP varies enormously. In order to establish a final cost estimate we collected following data: basic hourly rate per patients in Middlemore Hospital ICU cost for a course of antibiotics cost for imaging (X-rays, CT scans) additional drug cost additional equipment. The overall cost generated by any intervention other than the basic hourly rate for a bed in ICU varied in the range between $765 to $1500 per stay. Compared to the daily cost of $7,920, these monies seemed insignificant and we therefore decided to not factor any of these stipulated cost into the calculation. Middlemore Hospital contributes monthly data to the Melbourne based Australia and New Zealand Intensive Care Society (ANZICS) database. We obtained average length of stay for patients in our ICU for the 100 discrete diagnostic groups as per ANZICS database. We calculated the average cost for the average length of stay for the relevant diagnostic group in relation to our patients who developed a VAP. Following that analysis, we calculated the basic cost for each individual patient who sustained a VAP during their stay in MMH ICU. The average cost for a patient in a specific diagnostic group was then deducted from the overall cost for the stay until the VAP had resolved and subsequent complications had resolved. We then compared the generated cost for the individual with the range of cost as per ANZICS database range for length of stay. The overall averaged cost was taken as the median between all cost per entire range and averaged cost as calculated above. The result forms the stipulated cost for an individual patient with a specific diagnosis as per ANZICS categories in Middlemore Hospital. The average cost leading to an estimated average cost of $91,754 was then calculated for all patients sustaining a VAP during the study period. A cost analysis as described above only estimates a crude figure with large variation. The problems when calculating cost of a specific complication sustained during hospital treatment

5 are multifactorial. Whilst a VAP is likely to prolongue the need for ventilatory support, the impact on each individual patient will depend on a multitude of factors such as: pre-existing lung pathology co-morbidities, in particular heart disease, neurological disease age level of agreed care. The impact of a newly developed VAP in a patient who already struggles to be weaned off the ventilator (such as, patients with chronic lung disease, spinal patients, patients with underlying cardiac failure) has to be considered as much more grave than a VAP sustained in a young and otherwise well patient. Therefore all cost calculation will be flawed by the difference in patients' presentation, co-morbidities, primary pathology and even the care decision. Some patients might have died because the treating team decided not to continue treatment should further complications such as a VAP arise during the course of a stay in Intensive Care. For that reason the authors would like to caution the reader: our cost analysis only represents a small number of VAP patients in a specific setting. The cost for a VAP might vary depending on cost in each individual ICU in New Zealand and worldwide. With our study we hope to contribute to the debate how to improve our patients care and outcome and how to reduce the number of ventilator associated pneumonia in ICU. Dr Edda Jessen, Intensivist Disclaimer: This project was sponsored with funding from the Health Quality & Safety Commission as part of the Quality & Safety Challenge Publishing of project resources on the Commission s website does not necessarily constitute endorsement of the views or approach taken by the project, the Commission s intent in publishing is to showcase the achievements of the Challenge projects and share learnings across the health sector.