1. The Eradication of VAP in Scotland Martin Hughes Nov 2010

2. Plan Definition Diagnosis Importance Strategies to reduce VAP Why dont 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. 10 4 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

15. Quality In ICU Safe: safety is a system property Efficient: avoid waste Patient Centered: care that is respectful and responsive to individual patient preferences and needs Equitable: care does not vary in quality Effective: evidence based and applied to all who could benefit Timely: reduce waits and delays for those who receive and give care

16. SRI Experience – Nov 2005 VAP Prevention Bundle 30 - 45 o 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. Upper control limit (3SDs) Upper warning line Centreline (mean) G chart

21. FV VAP Bundle (* SICS Bundle) Postinterventions Chi-squared p value (Nov 2006 vs Oct 2007) Nov 2006May 2007Oct 2007 * Patient at 30 o -45 o 54%80%94% <0.001 Subglottic ETDT 72%92% <0.001 * Oral chlorhex 8%94%100% <0.001 Tubing/HMEF 98% 100% 0.31 * Daily weaning plan 52%72% 0.039 * Sedation stop 72%86%82% 0.23 All elements 0%48%54% <0.0001 Process

22. Problem? Passive interventions dont 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 units medical and nursing staff by April 2007. Repeat cycles of process and outcome measurement and feedback.

24. FV VAP Bundle (* SICS Bundle) BaselinePostinterventions Chi-squared p value (Nov 2006 vs Oct 2007) Nov 2006May 2007Oct 2007 * Patient at 30 o -45 o 54%80%94% <0.001 Subglottic ETDT 72%92% <0.001 * Oral chlorhex 8%94%100% <0.001 Tubing/HMEF 98% 100% 0.31 * Daily weaning plan 52%72% 0.039 * Sedation stop 72%86%82% 0.23 All elements 0%48%54% <0.0001 Sequential Process Measurements

25. Study Period

26. Passive Sept 2005 - Feb 2007 Active March – Dec 2007 patients ventilated for > 48hrs 374215 Vent days25561327 episodes of VAP 4910 VAP/1000 vent days 19.177.5 rd=11.6 99% CI 2.3-21.0 rr=0.39 99% CI 0.16,0.96) Median LOS4.55.0 Mortality(112/374) 30%(49/215) 23% p=0.06

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 appropriateYNExclusion Patient assessed for weaning and extubationYNExclusion Supine position avoidedYNExclusion Chlorhexidine 1-2% QIDYNExclusion Use of subglottic drainage ETTYNExclusion

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