Research critique in ventilator associated pneumonea free essay sample

Ventilator-associated pneumonia (VAP), defined as pneumonia occurring 48 72 hours after endotracheal intubation, is the most common and fatal nosocomial infection of intensive care. Risk factors include both impaired host immunity and the introduction of an endotracheal tube, which contributes to the development of VAP in the critically ill patient. VAP is associated with increased mortality and morbidity, increased duration of mechanical ventilation, prolonged intensive care unit and hospital stay, and increased cost of hospitalisation. Both the Centers for Disease Control Guidelines and Pugin’s Clinical Pulmonary Infection Score (CPIS) criteria note that diagnosing VAP requires a combination of clinical signs, impaired gas exchange, radiological changes and positive microscopy to differentiate an episode of VAP from mere colonisation. In a resource-strapped environment, semi-quantitative analysis of specimens obtained utilising a non-invasive sampling technique is an acceptable option. Specific guidelines have been developed to both prevent VAP and treat it appropriately as soon as possible. We will write a custom essay sample on Research critique in ventilator associated pneumonea or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page The guidelines provide targeted strategies, while additional management of VAP includes the provision of essential care, psychosocial support, ventilatory support, enteral feeding and relevant medication including deep-vein thrombosis prophylaxis, and the prevention of complications. The Care Bundle approach offers an interventional tool to implement strategies specifically directed to the prevention of VAP and the facilitation of a team approach to improving its clinical management. The evidence available presents a strong argument to consider a team approach to reducing the incidence of VAP in our own critical care units. Ventilator-associated pneumonia (VAP), defined as pneumonia occurring 48 72 hours after endotracheal intubation, remains the most common and fatal nosocomial intensive care unit (ICU) infection among mechanically ventilated patients. 1-3 Each episode of VAP results in extended ICU and hospital stay and increased cost of treatment per patient. VAP is not particularly selective, and any patient mechanically ventilated for 48 hours is at risk of developing an episode. Patients (adults, children and neonates) who are critically ill and cannot maintain their own respiratory function adequately, or have a compromised airway, require an artificial airway to provide ventilatory support and for clearance of secretions. The indications for endotracheal intubation to facilitate mechanical ventilation to provide adequate oxygenation and respiratory support may be either pulmonary or non-pulmonary, and therefore include trauma, surgical (emergency or elective), and medical Prevention. indd 44 patients. The consequences of VAP warrant efforts to implement prevention strategies and manage each episode effectively. Ventilator-associated pneumonia Definition Pneumonia is defined as inflammation of the lung parenchyma caused by infection. 3 VAP is defined as pneumonia occurring 48 72 hours after endotracheal intubation. 3 VAP is therefore also a nosocomial infection, i. e. an infection that develops 48 hours after a patient has been admitted to a hospital or health care facility. 4 The current classification scheme for pneumonia as outlined by the American Thoracic Society Guidelines for the Management of Adults with Pneumonia refers to nosocomial pneumonia as hospitalacquired pneumonia (HAP), which includes both 11/16/09 9:05:29 AM VAP and health care-associated pneumonia (HCAP). 3 Both are clinically and microbiologically distinct from community-acquired pneumonia (CAP). VAP is further defined as early-onset VAP (occurring 38 °C with no other recognised cause) †¢ Leucopenia (240 or ARDS †¢ ? 240 and no evidence of ARDS 0 2 Pulmonary radiograph †¢ No infiltrate †¢ Diffuse (or patchy) infiltrates †¢ Localised infiltrate 0 1 2 Tracheal secretions Score* †¢ 500 band forms November 2009, Vol. 25, No. 2 0 1 2 0 1 2 Culture of tracheal aspirate (semi-quantitative: 0 1 2 or 3+) †¢ Pathogenic bacteria cultured, minimal or no growth †¢ Pathogenic bacteria cultured, moderate or more growth M †¢ oderate or greater growth of pathogenic bacteria consistent with that seen on original Gram stain Total score of 6 points suggests VAP 47 0 1 2 Total *Score calculated by quantifying amount of tracheal secretions on a subjective 0 4 scale multiple times per day, then summing all the patient’s scores for the day. Management and treatment Given the risk, incidence, increased costs and attributable mortality, measures should be employed to prevent VAP where possible. This is particularly relevant in developing countries, where VAP poses the greatest risk to patients, with the incidence measured at 41% and the crude mortality rate at 44. 9%. 14 Antibiotic therapy remains the mainstay of treating VAP and should be initiated as soon as possible once the patient has been admitted, the clinical diagnosis suspected and the required specimens collected. The choice of antibiotic/s is determined by individual patient risk factors, the institutional pathogens and specific antibiograms. 3 The process should be according to protocol and usually involves initiating empiric broad-spectrum cover in the critically ill patient, which is adjusted and preferably de-escalated once the causative pathogen has been adequately identified and the appropriate sensitivity tests performed. Inadequate or delayed initial antimicrobial Prevention. indd 47 therapy has been associated with increased mortality,15 and should therefore be specifically targeted in the institutional protocol. Critically ill patients require intravenous antibiotics. Eight days of antibiotic therapy has been proven to be effective in treating most cases of VAP, with cases caused by a non-fermenting Gram-negative bacillus such as Pseudomonas or Acinetobacter being exceptions and requiring longer duration of therapy. 3,16 A number of evidence-based guidelines have been developed in recent years to direct clinical practice in an attempt to improve patient care, and in particular care of the critically ill. Specific guidelines have been developed to both prevent VAP and treat it appropriately as soon as possible. 17-21 The guidelines provide targeted strategies, while additional management of VAP includes the provision of essential care, psychosocial support, ventilatory support, enteral feeding, relevant medication including deepvein thrombosis prophylaxis, and the prevention of 11/16/09 9:05:30 AM November 2009, Vol. 25, No. 2 SAJCC complications. A website titled VAPAWAY is dedicated to research and the prevention of VAP, and provides access to relevant information at www. vapaway. com. 22 The Institute for Healthcare Improvement (IHI) in the USA has developed the Ventilator Care Bundle to address VAP as part of their Preventing Harm to 5 Million Lives Camapaign. 23 48 Care of the ventilated patient Strategies to prevent VAP: Recommendations3,17 VAP is preventable, and certain practices have been demonstrated to reduce its incidence and its associated burden of illness. 17 Prevention of VAP is possible through the use of evidence-based strategies intended to minimise endotracheal intubation, the duration of mechanical ventilation, and the risk of aspiration of oropharyngeal pathogens. 3 Modifiable risk factors require understanding and practical implementation. The vast amount of research findings are often overwhelming and conflicting. Having the data synthesised into evidence-based clinical practice guidelines (CPGs) by a credible group of multidisciplinary critical care clinicians (such as the Canadian Critical Care Society and Canadian Clinical Trials Group) improves the accessibility of reliable evidence for application in clinical practice. Guidelines can improve the processes, outcomes and costs of critical care. 17 Successful implementation requires a team approach that embraces an active strategy to improve patient care, participation by all team members, periodic review of guidelines and a continuous process to effect change in behaviour where required. Implementing clinical practice guidelines The IHI in the US recognised a need to reduce preventable errors after the release of the Institute of Medicine’s 1999 report on health care-related errors. 29 The 100,000 Lives Campaign launched by the IHI in 2004 generated an unprecedented commitment to change and collaboration across the US health care industry, led to the launch of a similar programme in the UK, viz. the Saving Lives Campaign,30 and led to the expansion of the IHI programme to become the Protecting 5 Million Lives from Harm Campaign in 2006. 23 The campaign is a national effort targeted at reducing preventable deaths in US hospitals, and protecting patients from harmful events that often have lasting effects. Medical harm is defined as ‘unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital. ’24 The initiative has led to new standards of care being developed and the implementation of relevant research findings at the bedside. The Ventilator Care Bundle The Ventilator Care Bundle is one of the six key programmes of the original campaign and consists of ‘a series of (evidence-based) interventions related to ventilator care, that when implemented together, will achieve significantly better outcomes than when implemented individually’. 31 The key components of the Ventilator Care Bundle are: The following recommendations (Tables III and IV) are a summary of the recommendations of some of the more recent literature, including the updated (2008) CPGs of the Canadian Group17 and the recommendations of Pieracci and Barie. 3 †¢ Elevation of the head of the bed (30 45o)32 Note: The use of nebulised endotracheal tobramycin and the intratracheal instillation of tobramycin are not recommended for the prevention of VAP,18 but may be useful in treating tracheobronchitis. †¢ eep-vein thrombosis prophylaxis. 35 D The application of a clinical guideline for the treatment of VAP was found to increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. 19 In addition, routine ventilator-associated pneumonia prevention measures were applied, including semi-recumbent body position, discontinuation of mechanical ventilation using a medical intensive care unit specific weaning protocol, avoidance of gastric distension by monitoring residual volumes following feedings, and routine inspection of ventilator circuits to remove condensate. 19 Prevention. indd 48 †¢ aily ‘sedation vacations’ and assessment of D readiness to extubate33 †¢ eptic ulcer disease prophylaxis34 (for high-risk P patients only) Additional protocols could include: †¢ A structured oral care protocol28 †¢ A patient mobility component †¢ Weaning protocols. Resources are available to facilitate the implementation process. 31 These include: †¢ Daily goal worksheets †¢ Checklists †¢ Audit tools. Impact of a protocol to prevent VAP The Canadian Critical Care Trials Group suggests that ‘Although scientific advances have the potential to improve the outcomes of critically ill patients 11/16/09 9:05:30 AM Table III. Strategies to prevent VAP SAJCC November 2009, Vol. 25, No. 2 Physical strategies †¢ trict infection control, including hand hygiene with alcohol-based hand disinfectants, gowning and gloving S minimises person-to-person transmission of pathogens3 †¢ Adequate ICU staffing24 †¢ Minimise endotracheal intubation where possible3 17 †¢ Orotracheal route preferred to nasotracheal route 3 †¢ Maintenance of orotracheal cuff pressure 20cm H2O (but 72 hours) †¢ se of a closed endotracheal suctioning system for safety considerations only (decrease transmission of U infection-resistant organisms) does not prevent VAP21, 26, 27 17 †¢ Closed endotracheal suctioning system changed between patients, or as clinically indicated 3 †¢ Minimise the duration of mechanical ventilation †¢ Daily interruption of sedation †¢ Standardised weaning protocols 17, 21 †¢ Circuit changes only if the circuit becomes soiled or damaged, and between patients †¢ hanging of heat-moisture exchangers (HMEs) every 5 7 days or as clinically indicated (clogged with C secretions) if in use17 21 †¢ Use of water bath humidification or a heated humidifier is acceptable †¢ Bacterial filters are only indicated for use in patients with infectious diseases such as TB †¢ Consider non-invasive ventilation if possible3 †¢ Consider rotating beds, if available (kinetic bed therapy)17 †¢ emi-recumbent positioning (30? 45? head up) is protective, especially during enteral feeding (prevent S gastro-oesophageal reflux and aspiration)3, 17 †¢ egin enteral feeding slowly, especially during the 48 hours after initiating mechanical ventilation, to B minimise gastric reflux and potential aspiration risk3 †¢ The gastric route for feeding is recommended (post-pyloric route not superior)3 †¢ Oral care28 49 Pharmacological strategies †¢ ropharyngeal decontamination with a topical antiseptic such as chlorhexidine has been proven to be O beneficial17 †¢ Oral decontamination with povidone-iodine oral antiseptic only in patients with severe head injuries †¢ imit stress ulcer prophylaxis to high-risk patients (avoid antacids and histamine type 2 antagonists, L sulcralfate and proton pump inhibitors (PPIs) preferable)3 †¢ Limit red blood cell transfusions in trauma and the critically ill3 †¢ Targeted antibiotic administration strategies such as de-escalation and antibiotic rotation or ‘cycling’3 Note: Selective decontamination of the digestive tract (SDD) with topical or systemic antibiotics or antiseptics has not been shown to provide benefit outside of the Netherlands, may increase the incidence of MDR infections, and is therefore not recommended for general use. 3 Strategies that have not proved beneficial include:17 †¢ A systematic search for prevention of sinusitis (unless patient is intubated via the nasotracheal route) †¢ Prone positioning †¢ Prophylactic antibiotics (aerolised, nasal or intravenous) †¢ Aerolised antibiotics †¢ Intranasal mupirocin †¢ Topical antibiotics †¢ Post-pyloric feeding Educational strategies †¢ Staff education programmes3 Prevention. indd 49 11/16/09 9:05:31 AM Table IV. Diagnosis and treatment of VAP: Recommendations18 November 2009, Vol. 25, No. 2 SAJCC Diagnosis †¢ on-invasive techniques, viz. endotracheal aspirates with non-quantitative cultures, are recommended for the N diagnosis of VAP in immunocompetent patients as the initial diagnostic strategy2,6,12,18 50 Treatment Initial treatment: E †¢ mpiric antimicrobial therapy v. delayed culture-directed therapy where there is a clinical suspicion of VAP3,15,18 †¢ ppropriate spectrum mono-therapy for empiric therapy of VAP (single agent for each potential A pathogen)3,18 †¢ Choice of antibiotics based on patient factors and local resistance patterns3,18 Duration of treatment †¢ Maximum of 8 days’ antibiotic therapy in patients who received adequate initial antibiotic therapy16,18 †¢ onger duration of antibiotic therapy for cases of VAP caused by a non-fermenting Gram-negative bacillus L such as Pseudomonas or Acinetobacter, viz. 14 -15 days16 †¢ Antibiotic discontinuation strategy based on clinical criteria for the treatment of suspected VAP3,18 †¢ De-escalation of antibiotic therapy to culture-directed sensitive therapy3,18 who are at risk or who have VAP, the translation of research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied in practice in the intensive care unit. Knowledge about VAP may be used more effectively at the bedside by a systematic process of knowledge translation through implementation of clinical practice guidelines. ’36 Clinical practice guidelines aim to improve the quality of care, to decrease costs, and to reduce inappropriate variation in decision making in the critical care setting. 37 While there is some agreement regarding the evidence and the recommended strategies, implementation of guidelines remains a challenge in practice. In a study conducted in 2002 to establish why physicians do not follow guidelines, Rello et al. 37 found that non-adherence to guidelines for preventing VAP was common, and largely uninfluenced by the degree of evidence. The most common reasons identified were disagreement with interpretation of clinical trials, unavailability of resources and costs. 37 Implementation A team approach is essential for the successful implementation of a quality improvement initiative. The support of medical directors, nursing managers, administrators and ancillary services such as the laboratory, together with staff involvement, are key factors to success. The initiative requires a champion that will drive the process, written guidelines, userfriendly tools and regular feedback regarding the process, as well as ongoing review of the programme. Key elements are functional communication systems, accountability and continuous education of all staff. The Canadian Critical Care Trials Group promotes the concept of ‘a systematic process of knowledge translation that incorporates knowledge about clinical preferences and behaviour change theory – this Prevention. indd 50 process is defined as one that uses evidence-based clinical practice guidelines (CPGs) and includes a guideline implementation strategy that addresses understood barriers to clinician’s adherence to guidelines, and capitalizes on the facilitators’. 36 Guideline implementation strategies36 A combination of the following is required: †¢ Educational material, meetings and outreach visits †¢ Reminders †¢ Opinion leaders †¢ Computerised decision support systems †¢ Audit and feedback. The strategies need to be specifically suited to the complex and dynamic ICU environment, the multidisciplinary team, the organisational climate and culture of the ICU. Sinuff et al. found that ‘a coherent ICU team with common patient care goals and agreement with the purpose and goals of a guideline may facilitate guideline adherence’. 36 Behaviour change theory can provide a framework within which to initiate the change process. Critical components include effective leadership, a collaborative team, continued education programme, an effective communication system and an audit-feedback system. Conclusion Significant improvements in quality indicators and patient outcomes have been reported by hospitals that have embraced the bundle approach and implemented the ventilator care bundle in particular. Cruden et al. 38 found that the systematic and methodical implementation of the ventilator care bundle interventions over a 1-year period in a UK hospital