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Abstract
Device related infections are a major cause of patient illness and death in all countries. Device associated infections particularly ventilator associated pneumonia, central venous catheter associated blood stream infections and catheter associated UTIs, pose the greatest threat to patient safety in the ICU.
Ventilator associated pneumonia is the most common hospital infection among patients requiring mechanical ventilation resulting in excess mortality and prolonged lengths of hospital stay. Despite the availability of evidence-based guidelines to prevent VAP, they remain poorly implemented.
Although the evidence supported the use of elements of care bundles, yet each institute has to perform its own bundle from its point of view aiming in declining the incidence of ventilator-associated pneumonia.
Because of a high VAP rate in our respiratory intensive care unit, we implemented a ventilatory bundle aiming to study its effect on reduction of VAP rates.
The study was conducted during the period between December 2008 and December 2009 in the respiratory intensive care unit at Ain Shams University Hospital in three phases.
1- Pre-intervention phase:
Baseline surveillance for device associated infection (VAP, catheter associated urinary tract infection (CAUTI) and central venous catheter blood stream infection (CVC-BSI) was done to detect the size of VAP as a problem and its relation to other device associated infection. Baseline assessment for infection control practices was performed.
2- Intervention phase:
It was started by education and on job training for health care workers (HCWs) for application infection control measures together with ventilatory bundle. The bundle included: hand hygiene, stress ulcer prophylaxis, daily assessment of readiness to extubate, continuous open suction from endotracheal tube, elevation of head of bed between 30-45 degrees, deep venous thrombosis (DVT) prophylaxis, and exchange of ventilatory circuit, chest physiotherapy and oral decontamination by chlorhexidine.
Post-intervention phase:
Re-evaluation of intervention phase through surveillance of VAP, CVC-BSI and CA- UTI was performed. The compliance ventilatory bundle was assessed.
Out of 305 patients admitted to RICU, 107 patients were mechanically ventilated,59 patients developed VAP.Among them,41 died and 18 were discharged alive .VAP represented 70.3 per 1000 ventilator days, in comparison to CAUTI 24.5 per 1000 catheter days and CVC-BSI 18.6 per 1000 catheter days. The VAP rates decline from 75.9 per 1000 ventilator days to 67.2 per 1000 ventilator days. There was no statistically significant decline in device utilization ratio (DU) of VAP from 0.42 to 0.43. The mortality from VAP was 60.7% vs 30.4%. The compliance of stress ulcer prophylaxis was (96.8%), the compliance of daily assessment to extubate was (89%) and the compliance of aspiration of secretions was (96.6%) in the pre intervention phase which did not significantly increase in post intervention period (100%, 99.4% and 99.4% respectively). There was statistically significant increase in compliance in post intervention phase for elevation of head of the bed (43.6% vs 90.1%), DVT prophylaxis (76.1% vs 95.2%), exchange of ventilatory circuit (0 vs 88.9%), chest physiotherapy (0 vs 74.4%), oral decontamination by chlorhexidine (0 vs 72.8%) and hand hygiene (32.5% vs 68.5%).
Lastely, device care associated infections clearly are a huge and largely unrecognized threat to patient safety. We hope that the initial successes of ongoing efforts help to more consistently implement simple and inexpensive measures for prevention and will lead to wider acceptance of infection control practices and consistent reducation in device-associated infections not only in the hospital but in their many neighboring hospitals.