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Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

Published online by Cambridge University Press:  02 January 2015

Sean M. Berenholtz*
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
Julius C. Pham
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland
David A. Thompson
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland
Dale M. Needham
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland
Lisa H. Lubomski
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland
Robert C. Hyzy
Affiliation:
University of Michigan, Ann Arbor, Michigan
Robert Welsh
Affiliation:
William Beaumont Hospital, Royal Oak, Michigan
Sara E. Cosgrove
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland
J. Bryan Sexton
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland
Elizabeth Colantuoni
Affiliation:
Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
Sam R. Watson
Affiliation:
Michigan Health and Hospital Association Keystone Center, Lansing, Michigan
Christine A. Goeschel
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland Johns Hopkins University School of Nursing, Baltimore, Maryland Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
Peter J. Pronovost
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland Johns Hopkins University School of Nursing, Baltimore, Maryland Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
*
Johns Hopkins University, Quality and Safety Research Group, 1909 Thames Street, Second floor, Baltimore, MD 21231 (sberenho@jhmi.edu)

Abstract

Objective.

To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates.

Design.

Collaborative cohort before-after study.

Setting.

Intensive care units (ICUs) predominantly in Michigan.

Interventions.

We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospital's infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first.

Results.

One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16–18 months after implementation (P < .001) and 0 cases (mean, 2.4 cases) at 28-30 months after implementation (P < .001). Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41–0.64) at 16–18 months after implementation and 0.29 (95% confidence interval, 0.24–0.34) at 28–30 months after implementation. Compliance with evidence-based therapies increased from 32% at baseline to 75% at 16–18 months after implementation (P < .001) and 84% at 28–30 months after implementation (P < .001).

Conclusions.

A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

Type
Original Article
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2011

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Footnotes

a.

Duke University School of Medicine, Department of Psychiatry, Raleigh, North Carolina

References

1. Safdar, N, Dezfulian, C, Collard, HR, Saint, S. Clinical and economie consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33:21842193.Google Scholar
2. Coffin, SE, Klompas, M, Classen, D, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S31S40.Google Scholar
3. Tablan, OC, Anderson, LJ, Besser, R, Bridges, C, Hajjeh, R, CDC, Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing healthcare-associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep 2004;53:136.Google Scholar
4. Relio, J, Lorente, C, Bodi, M, Diaz, E, Ricart, M, Kollef, MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? a survey based on the opinions of an international panel of intensivists. Chest 2002;122:656661.Google Scholar
5. Craven, DE. Preventing ventilator-associated pneumonia in adults: sowing seeds of change. Chest 2006;130:251260.Google Scholar
6. Pronoyost, PJ, Berenholtz, SM, Goeschel, C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care 2008;23:207221.Google Scholar
7. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:27252732.Google Scholar
8. Pronovost, P, Berenholtz, S, Dorman, T, Lipsett, PA, Simmonds, T, Haraden, C. Improving communication in the ICU using daily goals. J Crit Care 2003;18:7175.Google Scholar
9. Timmel, J, Kent, PS, Holzmueller, CG, Paine, LA, Schulick, RD, Pronovost, PJ. Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36:252260.Google Scholar
10. Sexton, JB, Helmreich, RL, Neilands, TB, et al. The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006;6:44.Google Scholar
11. Pronovost, PJ, Holzmueller, CG, Martinez, E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Saf 2006;32:102108.Google Scholar
12. Berenholtz, SM, Hartsell, TL, Pronovost, PJ. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual 2009;24:192195.Google Scholar
13. Thompson, DA, Holzmueller, CG, Lubomski, L, Pronovost, PJ. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf 2008;34:614618, 561.Google Scholar
14. Thompson, DA, Holzmueller, CG, Cafeo, CL, Sexton, JB, Pronovost, PJ. A morning briefing: setting the stage for a clinically and operationally good day. Jt Comm J Qual Patient Saf 2005;31:476479.Google Scholar
15. Lubomski, LH, Marsteller, JA, Hsu, YJ, Goeschel, CA, Holzmueller, CG, Pronovost, PJ. The team checkup tool: evaluating QI team activities and giving feedback to senior leaders. Jt Comm J Qual Patient Saf 2008;34:619623, 561.Google Scholar
16. Resar, R, Pronovost, P, Haraden, C, Simmonds, T, Rainey, T, Nolan, T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. J Comm J Qual Patient Saf 2005;31:243248.Google Scholar
17. Berriel-Cass, D, Adkins, FW, Jones, P, Fakih, MG. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf 2006;32:612620.Google Scholar
18. Youngquist, P, Carroll, M, Farber, M, et al. Implementing a ventilator bundle in a community hospital. Jt Coram J Qual Patient Saf 2007;33:219225.Google Scholar
19. Joint Commission. Specifications Manual for National Hospital Quality Measures: ICU. Oakbrook Terrace, IL: Joint Commission. http://www.jointcommission.org/PerformanceMeasurement/MeasureReserveLibrary/Spec+Manual-I- -+ICU.htm. Accessed February 18, 2009.Google Scholar
20. Berenholtz, SM, Dorman, T, Ngo, K, Pronovost, PJ. Qualitative review of intensive care unit quality indicators. J Crit Care 2002;17:112.Google Scholar
21. Pronovost, PJ, Berenholtz, SM, Ngo, K, et al. Developing and pilot testing quality indicators in the intensive care unit. J Crit Care 2003;18:145155.Google Scholar
22. Berenholtz, SM, Milanovich, S, Faircloth, A, et al. Improving care for the ventilated patient. Jt Comm J Qual Patient Saf 2004;30:195204.Google Scholar
23. Sinuff, T, Muscedere, J, Cook, D, Dodek, P, Heyland, D, Canadian Critical Care Trials Group. Ventilator-associated pneumonia: improving outcomes through guideline implementation. J Crit Care 2008;23:118125.Google Scholar
24. Pronovost, PJ, Berenholtz, SM, Goeschel, CA, et al. Creating high reliability in healthcare organizations. Health Serv Res 2006;41:15991617.Google Scholar
25. Dodek, P, Keenan, S, Cook, D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141:305313.Google Scholar
26. Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309332.Google Scholar
27. Rabe-Hesketh, S, Skrondal, A. Multilevel and Longitudinal Modeling using Stata. College Station, TX: Stata; 2005.Google Scholar
28. Skrondal, A, Rabe-Hesketh, S. Generalized Latent Variable Modeling: Multilevel, Longitudinal, and Structural Equation Models. Boca Raton, FL: Chapman 8c Hall/CRC; 2004.Google Scholar
29. Pronovost, PJ, Berenholtz, SM, Needham, DM. Translating evidence into practice: a model for large-scale knowledge translation. BMJ 2008;337:963965.Google Scholar
30. Bosk, CL, Dixon-Woods, M, Goeschel, CA, Pronovost, PJ. Reality check for checklists. Lancet 2009;374:444445.Google Scholar
31. Cocanour, CS, Peninger, M, Domonoske, BD, et al. Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 2006;61:122130.Google Scholar
32. Jain, M, Miller, L, Belt, D, King, D, Berwick, DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care 2006;15:235239.Google Scholar
33. DuBose, JJ, Inaba, K, Shiflett, A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J Trauma 2008;64:2229.Google Scholar
34. Bird, D, Zambuto, A, O'Donnell, C, et al. Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg 2010;145:465470.Google Scholar
35. Babcock, HM, Zack, JE, Garrison, T, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 2004;125:22242231.Google Scholar
36. Rosenthal, VD, Guzman, S, Crnich, C. Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals. Am J Infect Control 2006;34:5863.Google Scholar
37. Esmail, R, Duchscherer, G, Giesbrecht, J, King, J, Ritchie, P, Zuege, D. Prevention of ventilator-associated pneumonia in the Calgary health region: a Canadian success story! Healthc Q 2008;11:129136.Google Scholar
38. Unahalekhaka, A, Jamulitrat, S, Chongsuvivatwong, V, Ovretveit, J. Using a collaborative to reduce ventilator-associated pneumonia in Thailand. Jt Comm J Qual Patient Saf 2007;33:387394.Google Scholar
39. Schouten, LM, Hulscher, ME, van Everdingen, JJ, Huijsman, R, Grol, RP. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ 2008;336:14911494.Google Scholar
40. Edwards, JR, Peterson, KD, Andrus, ML, et al. National Healthcare Safety Network (NHSN) report, data summary for 2006, issued June 2007. Am J Infect Control 2007;35:290301.Google Scholar
41. Zilberberg, MD, Shorr, AF, Kollef, MH. Implementing quality improvements in the intensive care unit: ventilator bundle as an example. Crit Care Med 2009;37:305309.Google Scholar
42. Lipitz, AN, Steinwachs, D, Needham, DM, et al. Impact of a statewide ICU quality improvement initiative on hospital mortality and length of stay. BMJ 2011;342:d219.Google Scholar