Zero Tolerance: Impact of a Strategy Program to Prevent Ventilator-associated Pneumonia (VAP) in a Neonatal Intensive Care Unit (NICU)

Background: VAP is the 2^nd healthcare-associated infection (HAI) among neonates in NICU. There is an emerging culture in which an HAI is no longer acceptable consequence after a newborn admission. The incidence of VAP per 1000 ventilator-days decreased in our NICU in 2002, but it remained high compared to the data of National Nosocomial Infections Surveillance System (NNISS-2003).

Objective: Evaluate the impact of a strategy program to reduce the incidence of VAP in a NICU, comparing the periods before (period 1) and after interventions (period 2).

Methods: The program was implemented, from 2006, in a 12-bed NICU level 3D of a private hospital in São Paulo, Brazil. The Infection Prevention Link-Group (IPLG) - multidisciplinary teamwork, analyzed the causes and implemented the intervention program using a quality tool - PDCA circle. The VAP reduction established by the CEO of the hospital was 25%. 

Results: In the Plan phase of the PDCA circle, the IPLG identified the possible causes related to the maintenance of VAP in the NICU using brainstorming - the patient care was provided by licensed practical nurses and registered nurses (RN); stable rate of ventilator utilization (0,1-0,19); failure in elevating the head of the bed; high rate of accidental extubation (3,7%); changing of the ventilator circuits every 15 days; lack of routine in removing the condensate from the circuit, inadequate use of protective equipment by the staff and inappropriate environment for the condensate disposal. The action plan has been executed (Do phase)- maintenance and enhancement VAP preventive measures as the use of closed suction system to aspirate the oro-tracheal tube (OTT), an exclusive physiotherapy team in the NICU; care provided only by RN; implementation of a written early extubation policy by medical staff; changes in the fixation of the OTT, measurement of the externalized portion of the OTT once per shift and register the site of fixation of the OTT every two hours; staff training and behavior change in elevation of the head of the bed for all neonates in mechanical ventilation, proper disposal of condensate from the circuit if there is any visible residue; circuits change only if they were apparent dirty. Check phase: The VAP rate per 1000ventilator-days decreased from 5,5 (14 VAP/ 2564ventilator-days) in the 1^st period to 1,5 (2 VAP/ 1370ventilator-days) in the 2^nd indicating a reduction of 73% in the incidence of VAP (Graphic 1). The strategy implemented for the prevention of VAP was effective. Maintaining the positive results achieved depended on multidisciplinary work and monitoring the infections and procedures (Act phase).

Conclusions: Our mean VAP rate is now lower than the data from National Healthcare Safety Network (NHSN) 2007 and this program helped in consolidation of the culture of Zero Tolerance in the Neonatal Intensive Care Unit, aiming patient safety.