Background Ventilator-associated pneumonia is a common healthcare-associated infection with high attributable morbidity and mortality. Prevention strategies, including prevention bundles, have been widely adopted across the USA. However, the nursing resources required to implement these bundles, and their effect on other aspects of intensive care unit patient care, are unknown.
Methods We conducted a survey of all critical care nurses at our institution to determine the time required, and impact of, a prevention bundle at our hospital.
Results Nurses estimated that the standard ventilator bundle requires a median of 115 min (IQR: 74–182) per patient per day. Although the majority of nurses did not perceive that other patient care tasks were delayed by these prevention activities, this was not universal; 29% (95% CI 21% to 39%) of respondents reported that other patient care tasks were sometimes delayed because time was allocated to ventilator bundle activities.
Conclusions Our estimates may serve as potentially important inputs for cost-effectiveness and decision analyses related to intensive care unit prevention activities. Further research should include direct observations about nursing time allocation related to prevention activities.
- Critical care
- Infection control
- Nosocomial infections
- Patient safety
- Quality improvement
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Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection, with high attributable morbidity and mortality,1 as well as medical costs in excess of $15 000 per case.2–4 Early clinical studies reported that approximately 10–20% of mechanically ventilated patients in the USA develop VAP.1 ,5 However, more recent data suggests that current rates of VAP may be much lower.6 ,7 Recent studies report that the attributable mortality due to VAP may be as low as 1–2%,8 although other studies suggest that VAP may significantly increase death rates in the intensive care unit (ICU).9 ,10
In 2007, the Centers for Medicare and Medicaid Services announced that it may stop reimbursing hospitals for costs incurred secondary to VAP11; this announcement prompted many hospitals to institute VAP prevention protocols.12 In 2005, the Institute for Healthcare Improvement (IHI) introduced a ventilator bundle, consisting of elevation of the head of the bed, daily sedation holiday, daily assessment of readiness to wean, stomach ulcer prevention and deep vein thrombosis (DVT) prevention.13 The ventilator bundle was amended in 2010 to include the use of chlorhexidine (CHG) oral washes for VAP prevention.
The IHI ventilator bundle has been widely adopted across the USA.12 However, no studies have evaluated the nursing resources required for the successful implementation of the bundle, and none have assessed how its adoption is perceived to affect other aspects of intensive care. Therefore, we aimed to quantify the perceived nursing resources required for the successful implementation of VAP prevention activities, including the IHI ventilator bundle, and to gauge respondents’ perceptions about potential impact on other care activities.
The Beth Israel Deaconess Medical Center (BIDMC) is a large, urban tertiary care centre. There are 77 ICU beds, including medical, coronary care, cardiac surgery, surgery, trauma and neurosurgical critical care units. ICUs in our centre work 12 h-long shifts. The average nurse–to-patient ratio in the ICUs is slightly less than one to two, with specific indications for use of a one-to-one nurse-to-patient ratio, such as continuous renal replacement therapy. With the exception of the coronary care unit (20% of patients ventilated), the proportion of patients ventilated per ICU varies slightly, from 32–42% (table 1).
In 2006, BIDMC adopted the IHI ventilator bundle, as well as oral care and tooth brushing for VAP prevention; CHG oral washes were added to the regimen in 2007.14–21 At BIDMC, the IHI ventilator bundle elements are completed once per day, with the exception of DVT prevention and stomach ulcer prevention, which are completed twice per day. Oral care is provided at a minimum every 4 h, which translates into six opportunities for oral care during a 24 h period. Two of these oral care opportunities include CHG rinses and four do not.
We conducted an anonymous internet-based survey of all ICU nurses (N=291) at our institution. After initial instrument development, we performed cognitive testing with a clinical nurse specialist. After revisions were incorporated, we then performed additional pilot testing with ICU nursing leaders. Due to the limited population of eligible participants (ICU nurses), we did not perform additional pilot testing. To encourage participation in the study, potential participants were sent three emails: an initial invitation, followed by two reminder emails, each sent 1 week apart. In addition, nursing managers were contacted prior to study initiation and asked to encourage participation in their units. The survey was open for response for a total of 3 weeks. No compensation was offered for study participation.
Study data were collected and managed using REDCap electronic data capture tools hosted at BIDMC.22 REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing: (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.22
The survey was comprised of 19 questions. Three multiple choice questions addressed baseline characteristics of the ICU nursing staff (years of ICU experience, primary critical care unit environment, and average percentage of patients who are mechanically ventilated). Eleven questions addressed the amount of time per patient per shift required to complete all aspects of VAP prevention (including receiving the order, printing the order, and completing the task for the IHI bundle, CHG oral care, stomach ulcer prevention, DVT prevention). Questions regarding time required for task completion were presented as a sliding scale, with values ranging from 0 min to 100 min of time per patient per shift per task (see sample survey in appendix). Two questions assessed respondents’ perceptions about the effect of ventilator bundle activities on other patient care tasks (yes/no responses), and two questions qualitatively assessed which other tasks were perceived to be affected, via open-ended short-response questions. A final question assessed ICU nursing attitudes toward VAP prevention, in the form of a free-text, open-ended short-response question. Institutional review board approval from BIDMC was obtained prior to data collection.
All responses were included in the analysis. For the questions regarding time requirements, only entered values were used for calculating results. Time values were collected as minutes per task, and then adjusted to reflect the number of minutes spent per patient per day. Responses left blank were not included in the calculation. For the binary questions, such as for the ‘tasks delayed’ and ‘tasks completed’ yes/no questions, all respondents were included in the denominator, regardless of whether they recorded an answer in their survey response.
Univariate analyses were completed using t test and Fisher's exact test as appropriate, using SAS V.9.3 (SAS Institute, Cary, North Carolina, USA). Medians and IQRs are reported for all time variables. Given the small sample size, multivariate analysis was not attempted. Ninety-five per cent CIs for the mean are reported as appropriate.
Forty-one per cent (n=119) of 291 potential participants responded; 99 of 291 participants completed the survey. Nurses from all ICU environments responded. The majority of respondents (57.1%, 95% CI 48.1% to 65.7%) had ≥10 years of critical care experience, and 85.7% (95% CI 78.7% to 91.2%) had ≥3 years of critical care experience (table 1).
Estimates of nursing time required for ventilator bundle/VAP prevention activities
Overall, we found that nurses estimated that they allocate about 2 h per patient per day (115 min, IQR 74–182 min) to activities named in the 2005 IHI ventilator bundle. A full oral care regimen, including CHG and tooth brushing twice daily and oral rinses every 4 h, was perceived to require a total of more than two additional hours of nursing time (160 min, IQR 104–244 min), a remarkable increase in resource utilization when compared with the 2005 IHI prevention bundle alone. Time required for each component of the oral care regimen is reported in table 2. Several nurses reported in an open-ended question that the time required for IHI ventilator bundle implementation and oral care is highly variable, depending upon patient behaviour, compliance with treatment and suctioning requirements.
Competing patient care priorities
Seventy-one per cent of respondents (95% CI 61% to 79%) reported that ventilator bundle activities did not delay other care activities, and 92% (95% CI 83% to 95%) of respondents did not perceive that other patient care tasks remained uncompleted due to prevention activities. When activities were felt to be delayed due to time spent performing ventilator bundle tasks, respondents (in the free text questions) identified: turning patient (15/26 respondents), passive range of motion (8/26), medication administration (6/26), bathing patient (6/26), ambulating patient (3/26), (≤2/26 each): patient family teaching and support, skin care, central line dressing changes, diagnostic testing, patient care and basic nursing care, intravenous tubing changes, managing orders, mouth care, other aspects of the ventilator bundle and charting. Survey participants reported that some elements of the ventilator bundle take longer to complete, and sometimes interfere with completion of other bundle elements.
When activities were felt to remain uncompleted due to ventilator bundle activities, respondents identified activities such as: turning patient (3/9; or 3% of all respondents), family education and support (2/9; 2% of all respondents), ambulating the patient (2/9; 2% of all respondents), passive range of motion (1/9 each; 1% of all respondents): paperwork, oral care, medication administration, central line dressing changes and bathing patient.
Several critical care nurses reported in the free-response question that assessed overall attitudes regarding the ventilator bundle that workload could be reduced if other patient care providers, such as respiratory care and nursing assistants, could participate more in ventilator bundle tasks, or with other ICU patient care activities. Some nurses reported that certain aspects of the ventilator prevention bundle, such as oral care, often cause an increased need for suctioning, which may be performed by critical care nursing or respiratory therapy in our ICUs.
Discussion and conclusions
Given potential changes to reimbursement, much attention has been placed on VAP prevention; one of the most widely adopted strategies is the IHI ventilator bundle. Despite its frequent adoption, the costs of bundle use in terms of resource allocation and nursing time have not been carefully studied.
This study found that ICU nurses perceive that the IHI prevention bundle requires upward of 2 h of critical care nursing time per patient per day, or approximately 9% of daily nursing coverage. Previous time studies of nursing workflow have found that administration of all medications in the ICU requires approximately 22% of ICU nursing time.23
Several previous studies have found that increasing time demands on nursing staff are associated with worsening patient-outcomes, including rates of nosocomial pneumonia, hospital length of stay and death.24–28 Two hours per patient per day represents a substantial allocation of resources, and—given ICU nurses’ exquisitely busy existing care activities—raises the possibility of competing demands. Although the majority of nurses in our study did not perceive that other patient care tasks were delayed by ventilator bundle activities, this was not universal; 29% (95% CI 21% to 39%) of respondents reported that other patient care tasks were sometimes delayed because time was allocated to ventilator bundle activities. Frequent turning of patients was the most common task perceived to be affected by competing priorities; this conceptually may lead to unintended consequences, such as an increase in the rate of development of pressure ulcers or other adverse outcomes.
Although our findings raise important questions about allocation of resources to prevention efforts, our study has important limitations. First, the data are based on self-report, which may be subject to recall bias. However, previous studies that compared direct measurement of nursing time to nurse self-reporting required for task completion found that both methods yield similar results.29 Second, the data were collected retrospectively at a single, large, academic hospital. These results may not hold for other types of critical care units. Third, some potential participants did not complete the survey, creating the potential for non-response bias, a challenge for all survey-based studies.
Critical care nursing is a valuable and limited resource, and nursing resources must be applied carefully to ensure optimal patient care. Our study provides important new information, with quantitative estimates of the nursing time required for various components of the IHI ventilator bundle. These estimates are foundational components for careful cost-effectiveness studies evaluating optimal prevention strategies.
Nurses report spending an average of about 2 h per patient per day to administer a standard ventilator prevention bundle. Although most nurses do not perceive this to affect other aspects of patient care, this opinion is not universal: about a quarter of ICU nurses report that some patient care tasks are delayed due to time spent performing ventilator prevention activities. Our estimates may serve as important inputs for cost-effectiveness and decision analyses related to VAP prevention. Further research should include direct observations about nursing time allocation related to prevention activities.
We would like to thank the critical care nursing staff at Beth Israel Deaconess Medical Center for their contribution to this work.
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Contributors All authors contributed significantly to the work presented in the submitted manuscript, and reviewed and edited the manuscript prior to submission.
Competing interests None.
Grant support WBE received support in the form of an educational grant from Harvard Catalyst, The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award 8UL1TR000170-05 and financial contributions from Harvard University and its affiliated academic healthcare centres). The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centres, or the National Institutes of Health. MDH is partially supported by the Physician Faculty Scholars Program of the Robert Wood Johnson Foundation (grant #66350, to MDH).
Ethics approval Beth Israel Deaconess Medical Center Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.