1. Ventilator-associated pneumonia (VAP) prevention in Wales:
a survey of practices and beliefs
P299
R Pugh, W Harrison, C Battle, C Hancock, T Szakmany
On behalf on the Welsh Healthcare Improvement Programme and Welsh Intensive Care Society
Introduction:
Systematic efforts to reduce ventilator-associated morbidity have been established in Wales for over a decade. However, since the original ventilator care bundle (head elevation, sedation hold, stress ulcer prophylaxis and thrombo-prophylaxis) was implemented in Wales in 2006, evidence regarding the effectiveness of interventions has advanced and variations in practice between centres assumed likely to have evolved. Our aims were to investigate practices across Welsh ICUs and to sample views from staff regarding interventions which may affect the development of VAP using an online survey.
Methodology:
From August to November 2016, we conducted an online survey of Critical Care staff identified via the Welsh Intensive Care Society (WICS), other professional networks and the WICS facebook page.
We used a combination of binary questions to understand current practice, Likert-like scale questions to gauge beliefs, and free text for additional commentary.
Results (continued):
Table 2: Enteric/ systemic decontamination and pro-biotic use
Table 3. Interventions by site*
*R= Used Routinely, S= Used Selectively, N= Not used
Intervention
Is administered in my unit
Reduces incidence of VAP
Reduces mortality
Oral chlorhexidine (CHX)
65%
42%
14%
Selective Oral Decontamination (SOD)
10%
18%
Selective Digestive Decontamination (SDD) 3%
23%
16%
Probiotics
(ProB) 5% 4% -
Results:
80 healthcare professionals responded from all 14 centres offering level 3 care. The clinical backgrounds of respondents are detailed in Figure 1 below.
Figure 1. Clinical background of respondents
93% respondents felt that episodes of VAP are associated with poorer outcome, and 82% that VAP is to some degree preventable.
Routine measurement of sedation interruption was reported by 82% and bed elevation by 65%. 90% felt that bed elevation (BED EL) and 73% that routine de-sedation (SED BRK) reduces incidence of VAP. Stress ulcer prophylaxis (SUP) is administered unselectively (83%) and increases VAP incidence (according to 34%). Individual responses are summarised in Table 1 and 2 below, and presented according to site in Table 3.
Table 1. Endo-tracheal tube and breathing circuit
Site
SED BRK
BED EL
SUP
CIRC CH
ETT SG
ETT SC
ETT AP
CHX
SOD
SDD
ProB 1 R S N 2 3 ? 4 5 6 7 8 9 10 11 12 13 14
Discussion:
Welsh units have all developed practices since the initial introduction of VAP bundles. However, there has led to substantial variation between centres.
Routine sedation break and bed elevation seem well- embedded, though compliance data may not always be disseminated effectively.
There has been variable uptake of endo-tracheal tubes with sub-glottic suction, and interestingly the majority of centres perform frequent ventilator circuit change believing that this reduces the risk of VAP - though evidence appears to point to the contrary and change in practice could lead to improved clinical outcomes and cost saving.
Oral chlorhexidine and routine stress ulcer prophylaxis are reported by the majority, despite recent suggestions of harm or doubtful benefit. In contrast, SOD and SDD have had little uptake despite evidence of efficacy.
Conclusions:
VAP prevention practices seem to vary considerably between Welsh ICUs. Re-evaluation of VAP bundles with consideration of a more uniform approach is recommended, and discontinuation of oral chlorhexidine use should be a priority.
Intervention
Is performed in my unit
Reduces incidence of VAP
Routine ventilator circuit change
(CIRC CH)
64%
44%
ETTwith sub-glottic suction
(ETT SG)
73%
57%
ETT with automated cuff pressure
(ETT AP)
10%
19%
Silver coated ETT
(ETT SC) 4%
13%
References:
Hellyer, et al. The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. JICS, 2016
O'Grady, et al. Preventing ventilator-associated pneumonia: does the evidence support the practice? JAMA 2012