Date: 8 Dec 2013; Venue: HKSCCM Annual Scientific Meeting at Intercontinental Grand Stanford, TST, Hong Kong
Speaker: Dr CW Lau, AC, ICU, PYNEH
Abstract: Ventilator-associated pneumonia (VAP) is very common in the ICU. However, according to a local survey of 10 ICUs, the VAP bundle was not a consistent practice in 20%, and only 50% had held compliance audits, and local VAP rates were not routinely reported. The difficulties and reluctance may lie in the fact that the diagnostic criteria involve subjectivity (e.g. CXR interpretation), that most items in the VAP bundle are not of high level of evidence, that outcomes are regarded not being altered, and successful implementation involves multidisciplinary coordination and multidimensional approach. From the literature, a sustained zero rate is not an impossibility...
In our ICU, we had faced a high VAP rate of 20 to 70 per 1000 ventilator days in 2010 using the CDC PNU 1 criteria, the NHSN benchmark being 1 per 1000 ventilator days in 2011. We tackled the problem first by conducting refresher lectures and audit on the VAP bundle. We collaborated with the Polytechnic University for a head-of-bed angle detector. We began to try out novel types of endotracheal tubes, including one with continuous aspiration of subglottic secretions (CASS) and one with cuff made of polyurethrane instead of polyvinyl chloride (PVC). We decided on a research on the comparative benefit of various types of endotracheal tubes (ETT) in preventing microaspiration. The VAP rate dropped to 10 to 20 per 1000 ventilator days in 2011, but remained around 20 throughout 2012. As a result, a Quality Improvement Project for the Prevention of VAP in Critical Care Areas was launched in the HKEC. A logical and pragmatic review of the VAP process as due to microaspiration from the upper airway was done, and we started using antiseptic oral rinse, enforced hand hygiene, reviewed readiness to ventilator weaning, prevented condensate from entering patient’s airway, etc. As the result of our research showed that the Microcuff ETT was superior to both the TaperGuard and Portex in preventing microaspiration, we began using the Microcuff ETT routinely for all patients, and promoted its use to the AED and the operating theatre. As airway disconnection and loss of PEEP were found to be risk factors for microaspiration, we began to use more heated humidifier instead of HMEF which is frequently blocked and airway has to be disconnected for the change. We purchased new ventilators for both regular ventilation and during transport without disconnection, used automated cuff pressure maintenance device, and discouraged routine airway suction. We posted the VAP rates and VAP bundle on notice boards, published in Newsletter, websites and journals to disseminate knowledge. All physician staff now routinely collect VAP rate, and data are analyzed by a nurse consultant. Compliance audits are held regularly. Since early 2013, our VAP rates were successfully controlled to 0 to 10 per 1000 ventilator days and it remained at low level. In conclusion, VAP rates should be monitored and high incidence can be tackled. In future, VAP should be considered as a key performance indicator (KPI) of our local ICUs.
1. Naomi P. O’Grady, MD; Patrick R. Murray, PhD; Nancy Ames, RN, PhD. Preventing Ventilator-Associated Pneumonia - Does the Evidence Support the Practice? JAMA. 2012;307(23):2534-2539.
2. Arthur CW Lau, SM Lam, WW Yan. Benchtop study of leakages across the Portex, TaperGuard and Microcuff Endotracheal tubes under simulated clinical conditions. Hong Kong Med J 2013;19:Epub 2013 Jul 22
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