2006 OPEN FORUM Abstracts
10 YEAR EXPERIENCE ON REDUCTION OF VENTILATOR ASSOCIATED PNEUMONIA - ONE INSTITUTION'S EXPERIENCE
John Sabo,
MS, RN, RRT and Joy Hargett, BS, RRT, St. Luke's Episcopal Hospital,
Houston, Texas
Background: Advances in critical care
have led to more patients receiving mechanical ventilation. Quality initiatives
should include prevention of disease whenever possible. Our institution faced a
growing trend in ventilator-associated pneumonias in the mid 1990's. Between
1995 and 1996, an increase from 5.68 to 8.19 pneumonias per 1000 patient days
was noted.
Method: A task force was formed, consisting of infection
control practitioners, respiratory therapists, nurses, pulmonary physicians and
infectious disease physicians. That group developed a screening tool to identify
patients at risk for developing pneumonia, which was called the Nosocomial
Pneumonia Protocol. This protocol
evaluated patients who were mechanically ventilated for greater than 24 hours
and did not have an infectious disease or pulmonary consulting physician. The
nosocomial pneumonia protocol included (1) obtain sputum sample (2) obtain
chest x-ray if not done within last 24 hours, (3) order complete blood count if
not done in last 24 hours, (4) institute closed suction catheter, (5) repeat
orders every 48 hours until patient was extubated, trached, positive sputum
culture obtained or pulmonary or infectious disease physician consult occurred.
Attending physicians were notified if the sputum gram stain was positive or if
certain organisms (pseudomonas aeruginosa, klebsiella pneumoniae, enterobacter
specifies, serratia marcescens, staphylococcus aureus) were identified.
Physicians were also given guidelines for empiric therapy.
Results: This
project was piloted in a 41-bed cardiovascular intensive care unit and then
moved to other intensive care units. From October 1996 - September 1997, a 29%
reduction in the pneumonia rate house wide was noted. Other changes in practice
occurred through the next 9 years. These
included use of heated wire circuits, replacement of the inline nebulizer
canister every 24 hours, use of the closed suction catheter on all ventilator
patients and changing the ventilator circuit once per week. In 2004, ventilator
circuits were not longer changed out routinely. In 2005, all Methicillin-Resistant
Staphylococcus Aureas patients were no longer placed in isolation unless they
had a draining wound. Also in 2005, the Fisher Paykel RT 240 circuit was
initiated, which evaporates water molecules into the atmosphere. No changes in
practice caused the VAP rate to increase.
The
following table shows the rate of ventilator-associated pneumonia from FY 95 -
FY 05:
| Fiscal Year (fiscal years run October 1 - September 30, until 2005) | VAP rate | Average number of ventilators per day |
| 1995 | 5.68 | 41 |
| 1996 | 8.19 | 40 |
| 1997 | 8.97 | 45 |
| 1998 | 7.65 | 49 |
| 1999 | 5.4 | 55 |
| 2000 | 3.79 | 60 |
| 2001 | 3.32 | 59 |
| 2002 | 2.66 | 60 |
| 2003 | 2.17 | 56 |
| 2004 | 1.90 | 58 |
| Oct- Dec 2004 (3 months) | 1.4 | 54 |
| 05 | 1.2 | 63 |
Conclusion: We have seen continuing reduction in the VAP
rate with implementation of the protocol and adjuncts to the protocol. Our
current focus is to maintain this level of quality by continually monitoring
our institution's infection rate.