Education to prevent ventilator-associated pneumonia in intensive care unit

The effectiveness of quality management interventions in reducing hospital-associated infections in adult patients: A systematic literature review

BACKGROUND

This systematic literature review evaluates the effectiveness of Quality Management Tools (QMTs) in reducing Hospital-Associated Infections (HAIs) among adult inpatients in hospital settings.

METHODS

The systematic literature review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, systematically analyzed relevant studies from 2013 to 2023 across three electronic databases: PubMed, CINAHL, and EMBASE, using Covidence. The risk of bias assessment was performed using different validated tools depending on the study design.

RESULTS

The study encompassed 34 studies conducted in diverse healthcare settings worldwide. QMT interventions consisted of a total of 18 bundle interventions, five stewardship programs, four catheter usage interventions, three checklists, two audit and feedback interventions, and two oral care policies. Twenty-five studies showed significant decreases, whereas nine studies showed insignificant decreases in HAI rates after the deployment of QMTs. Although these interventions show promise, caution in interpretation is advised as only 6 of the included 34 studies had low risk of bias. The meta-analysis of seven studies on bundle interventions for ventilator-associated pneumonia (VAP), showed a 40% reduction in VAP incidence (OR: 0.40, 95% CI: 0.24-0.65; I² = 80.8%, P = 0.00).

CONCLUSION

Introduction QMTs has the potential to reduce HAI among adult inpatients. Further research is warranted to optimize the implementation of QMTs to enhance patient care and public health outcomes.

Assessing Critical Care Nurse's Knowledge and Adherence to Evidence-Base Guidelines for Ventilator-Associated Pneumonia Prevention in Palestinian Hospitals

Background: Patients in critical care units who are connected to mechanical ventilators (MV) often face the risk of ventilator-associated pneumonia (VAP). Therefore, the aim of current study is to describe critical care nurses' knowledge and adherence to evidence-base guidelines (EBGs) for preventing the occurrence of VAP. Methodology: A cross-sectional study was applied. Data were collected through a self-administered questionnaire completed by all critical care nurses (n = 213) working at Palestinian hospitals. Descriptive and inferential statistic was utilized to describe ICU nurse's knowledge and adherence to VAP prevention EBGs. Results: The study revealed that the mean knowledge score for critical care nurses was (50.8%). Overall, the findings indicated that nurses' knowledge of VAP guidelines was at an average level. A statistically significant difference (p value = 0.049) in the knowledge level was observed based on nurses' qualifications. On the other hand, the study found that nurses' adherence to EBGs was an acceptable (mean = 8.3, 69.2%). No substantial differences in adherence level were identified based on respondents' characteristics. Conclusion: Critical care nurses possess an average level of knowledge regarding EBGs for preventing VAP, alongside demonstrating an acceptable level of adherence to these guidelines.

Profile of patients in private home care who developed ventilator-associated pneumonia

OBJECTIVES

to analyze the profile and clinical outcomes of patients who developed Ventilator-Associated Pneumonia (VAP) in private home care and to compare the incidence with national data.

METHODS

this was a retrospective study with data collected from July 2021 to June 2022 from patient records at a private clinic. Patients using intermittent ventilation or without ventilatory support were excluded.

RESULTS

the utilization rate of mechanical ventilation was 15.9%. The incidence density of pneumonia in pediatrics was 2.2 cases per 1000 ventilation-days and in adults was 1.7 cases per 1000 ventilation-days, figures lower than those reported by the National Health Surveillance Agency. There were 101 episodes of pneumonia in 73 patients, predominantly male (65.8%), adults (53.4%), and those with neurological diseases (57.5%). The treatment regimen predominantly took place at home (80.2%), and there was one death.

CONCLUSIONS

patients in home care showed a low incidence and mortality rate from ventilator-associated pneumonia.

Contamination of equipment and surfaces in the operating room anesthesia workspace: a cross-sectional study

BACKGROUND

Contamination of the breathing circuit and medication preparation surface of an anesthesia machine can increase the risk of cross-infection.

OBJECTIVE

To evaluate the contamination of the anesthetic medication preparation surface, respiratory circuits, and devices used in general anesthesia with assisted mechanical ventilation.

DESIGN AND SETTING

Cross-sectional, quantitative study conducted at the surgical center of a philanthropic hospital, of medium complexity located in the municipality of Três Lagoas, in the eastern region of the State of Mato Grosso do Sul.

METHODS

Eighty-two microbiological samples were collected from the breathing circuits. After repeating the samples in different culture media, 328 analyses were performed.

RESULTS

A higher occurrence of E. coli, Enterobacter spp., Pseudomonas spp., Staphylococcus aureus, and Streptococcus pneumoniae (P < 0.001) were observed. Variations were observed depending on the culture medium and sample collection site.

CONCLUSION

The study findings underscore the inadequate disinfection of the inspiratory and expiratory branches, highlighting the importance of stringent cleaning and disinfection of high-touch surfaces.

Effects of ventilatory bundles on patient outcomes among ICU patients: A systematic review and meta-analysis

BACKGROUND

Ventilator bundles are suggested to prevent ventilator-associated pneumonia (VAP), but significant variations in the effects of the bundle on patient outcomes have been reported.

OBJECTIVES

To synthesize the evidence and evaluate the effects of the ventilator bundle on patient outcomes among critically ill adult patients.

METHODS

A broad search was performed in seven databases for relevant articles published from January 2002 to November 2022. Randomized controlled trials and quasi-experimental studies investigating the effects of implementing ventilator bundles in adult intensive care units (ICUs) were included. Two independent reviewers performed the study selection, data extraction, and risk of bias assessment. All data for meta-analysis were pooled using the random-effects model.

RESULTS

After screening, 19 studies were included in the meta-analysis. Evidence of low-to-moderate certainty showed that the ventilator bundle reduced the rate of VAP (risk ratio [RR] = 0.64; P = 0.003), length of ICU stay (mean difference [MD] = -2.57; P = 0.03), mechanical ventilation days (MD = -3.38; P < 0.001), and ICU mortality (RR = 0.76; P = 0.02). Ventilator bundle was associated with improved outcomes, except mortality.

CONCLUSIONS

The ventilator bundle, especially the IHI ventilator bundle, was effective in decreasing the incidence of VAP and improving most of the VAP-related outcomes. However, given the low-to-moderate certainty of evidence and high heterogeneity, these results should be interpreted with caution. A future study that adopts hybrid implementation trials with high methodological quality is needed to confirm the effects of the ventilator bundle on patient outcomes.

Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey

INTRODUCTION

Appropriate implementation of a ventilator bundle (VB) is the key step in the prevention of ventilator-associated pneumonia (VAP). However, knowledge and compliance of critical care staff for VB are inconsistent in developing countries. This cross-sectional survey was planned to evaluate critical care practitioners' knowledge of, adherence to, and barriers toward implementation of VB in the ICUs of a tertiary care institute.

METHODOLOGY

All registered nurses and resident doctors who are direct care providers to patients of the ICU were included. Two sets of questionnaires were given to access knowledge and to identify potential barriers in the implementation of VB. To determine compliance with the VB, direct observation was done for three nonconsecutive days, and mean compliance per component of the bundle and overall compliance to VB was determined. Data were analyzed using descriptive and analytic statistics.

RESULTS

Of these 75 participants, 43 (57.33%) were resident doctors and 32 (42.67%) were staff nurses. The median knowledge score of resident doctors and staff nurses for VB was 7 (range 3-10) and 6 (range 2-9), respectively, with an overall score of 7 (range 2-10). Self-reported adherence to individual components of VB ranged from 75% to 95%, among these, adherence to oral care protocol, including use of chlorhexidine oral rinse, was most, and adherence to DVT prophylaxis was least. The most common potential barriers identified were fear of potential adverse effects and unawareness of guidelines.

CONCLUSION

Considerable gap is observed between knowledge and implementation of VB among critical care practitioners. Despite knowledge, fear of adverse events and lack of proper training are key barriers in implementation of VB.

HOW TO CITE THIS ARTICLE

Paliwal N, Bihani P, Mohammed S, Rao S, Jaju R, Janweja S. Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey. Indian J Crit Care Med 2023;27(4):270-276.

Multifaceted interventions are likely to be more effective to increase adherence to the ventilator care bundle: A systematic review of strategies to improve care bundle compliance

BACKGROUND

The implementation of ventilator care bundles has remained suboptimal. However, it is unclear whether improving adherence has a positive relationship with patient outcomes.

OBJECTIVES

To identify the most effective implementation strategies to improve adherence to ventilator bundles and to investigate the relationship between adherence to ventilator bundles and patient outcomes.

METHODS

A systematic review followed the PRISMA guidelines. A systematic literature search from the inception of ventilator care bundles 2001 to January 2021 of relevant databases, screening and data extraction according to Cochrane methodology.

RESULTS

In total, 6035 records were screened, and 24 studies met the eligibility criteria. The implementation strategies were provider-level interventions (n = 15), included educational activities, checklist, and audit/feedback. Organizational-level interventions include (n = 8) included change of medical record system and multidisciplinary team. System-level intervention (n = 1) had motivation and reward. The most common strategies were education, checklists, audit feedback, which are probably effective in improving adherence. We could not perform a meta-analysis due to heterogeneity of the strategies and types of adherence measurement. Most studies (n = 7) had a high risk of bias. There were some conflicting results in determining the associations between adherence and patient outcomes because of the poor quality of the studies.

CONCLUSION

Multifaceted interventions are likely to be effective for consistent improvement in adherence. It remains uncertain whether improvements in adherence have positive outcomes on patients due to limited evidence of low to moderate uncertainty. We recommend the need for robust research methodology to assess the effectiveness of implementation strategies on improving adherence and patient outcomes.

The Impact of Care Bundles on Ventilator-Associated Pneumonia (VAP) Prevention in Adult ICUs: A Systematic Review

Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We aimed to identify the combined interventions that have been used to by ICUs worldwide from the implementation of "Institute for Healthcare Improvement Ventilator Bundle", i.e., from December 2004. A search was performed on the PubMed, Scopus and Science Direct databases. Finally, 38 studies met our inclusion criteria. The most common interventions monitored in the care bundles were sedation and weaning protocols, semi-recumbent positioning, oral and hand hygiene, peptic ulcer disease and deep venus thrombosis prophylaxis, subglottic suctioning, and cuff pressure control. Head-of-bed elevation was implemented by almost all studies, followed by oral hygiene, which was the second extensively used intervention. Four studies indicated a low VAP reduction, while 22 studies found an over 36% VAP decline, and in ten of them, the decrease was over 65%. Four of these studies indicated zero or nearly zero after intervention VAP rates. The studies with the highest VAP reduction adopted the "IHI Ventilator Bundle" combined with adequate endotracheal tube cuff pressure and subglottic suctioning. Multifaced techniques can lead to VAP reduction at a great extent. Multidisciplinary measures combined with long-lasting education programs and measurement of bundle's compliance should be the gold standard combination.

Performance Assessment of Medical Professionals in Prevention of Ventilator Associated Pneumonia in Intensive Care Units

PURPOSE

Ventilator-associated pneumonia (VAP) is one of the most common infections in intensive care units (ICU) with a 6-52% incidence. The VAP mortality rate is 50% to 70%. Medical professionals (MPs) working in the ICU are expected to follow the guidelines to prevent VAP. The study aimed to assess the performance of MPs in preventing VAP and to associate the performance with the baseline information.

METHODS

An observational cross-sectional study was conducted in the ICUs of selected hospitals in eastern Saudi Arabia. A total of 152 MPs were selected by random sampling. A structured questionnaire including baseline information, knowledge and performance-related questions was used to collect the data. Frequency, mean, and chi-square tests were used for analysis.

RESULTS

Out of 152 MPs, 40.8% had adequate and 7.9% had inadequate knowledge. A high mean score of 12.9 ± 2.2 was obtained by physicians, followed by 11.3 ± 1.6 by nurses, 9.8 ± 2.2 by RTs, and 8.6 ± 2.1 by interns. Overall, 52.6% had satisfactory performance. Approximately 57.9% and 67.8% of MPs cleaned their hands before touching the patient and the ventilator, respectively. Many (79.6%) MPs used personal protective equipment in the ICU. Some (47.4%) of the MPs changed the patient's position regularly. About 77.6% of MPs followed the sterile technique when suctioning the airway. There was a significant association found between the performance of MPs on the prevention of VAP with age (p < 0.001), designation (p < 0.05), professional experience (p < 0.05), managing chronic obstructive pulmonary disease conditions (p < 0.05) and training attended (p < 0.001).

CONCLUSION

Although some of the MPs had satisfactory performance regarding VAP prevention in the ICU, more attention should be paid to training them on clinical guidelines to improve health care quality and reduce the rate of VAP.

Evaluation of the BioFire FilmArray Pneumonia Panel Plus to the Conventional Diagnostic Methods in Determining the Microbiological Etiology of Hospital-Acquired Pneumonia

Hospital-acquired pneumonia (HAP) is a substantial public health issue that is associated with high mortality rates and is complicated by an arsenal of microbial etiologies, expressing multidrug-resistant phenotypes, rendering relatively limited therapeutic options. BioFire FilmArray Pneumonia Panel plus (BFPP) is a simple multiplexed PCR system that integrates sample preparation, nucleic acid extraction, amplification, and analysis of microbial etiology, with a turnaround time of about one hour. In comparison to standard culture methods, BFPP is simpler, easier to perform, and can simultaneously detect the most common pathogens involved in lower respiratory tract infections (34 targets). Accordingly, we evaluated the diagnostic performance of the multiplexed BFPP for the rapid detection of 27 clinically relevant respiratory pathogens and 7 genetic markers among 50 HAP cases admitted to the intensive care unit (ICU), who submitted mini-bronchoalveolar (mBAL) specimens. In comparison to standard culture methods, BFPP showed an overall sensitivity of 100% [95% CI; 90-100] and overall specificity of 90% [95% CI; 87.4-92.5] among all the tested bacterial targets. BFPP identified 11 viral targets (22%) among the tested specimens. The BFPP semi-quantitative analysis showed a concordance rate of 47.4% among positive culture specimens. For the investigation of the antibiotic resistance genes, BFPP showed a positive percent agreement (PPA), a negative percent agreement (NPA), and an overall percent agreement (OPA), reaching 97% [95% CI; 90-100], 95% [95% CI; 91.5-97], and 95% [95% CI; 93-97], respectively, with standard antibiotic sensitivity testing. In conclusion, BFPP has the potential to enhance the rapid microbiological diagnosis of HAP cases, and could aid in tailoring appropriate antibiotic therapies.