Impact of implementing of non-pharmacological care in prevention of ventilation-associated pneumonia in adults

Background: Ventilator-associated pneumonia (VAP) represents around 15% of all hospital infections. The lethality of VAP also various and can reach, according to some reports, 70%.

Objective: To evaluate the impact of implementing a non-pharmacological care to prevent VAP in adults  admitted to an intensive care unit.

Methods: Quase experimental with historical controls. The 34 beds ICU of a public teaching hospital in Porto Alegre, Brazil. Adult patients admitted to ICU, between September, 2004 and December, 2007 that required mechanical ventilation for ≥ 48 hours. Implementation of a non-pharmacological care.VAP prevention protocol based on “best clinical practices”. The care protocol for handling VAP was elaborated by a multi-professional team of intensive care doctors and nurses, pneumonologists, microbiologists and professional staff from the Hospital Infections Control Commission (CCIH).The structure of the process was based in: a) system of management information: case mix of the patients; risk classification and quality indicators; b) definition of diagnostic criteria; c) surveillance system  d) education in service.

Results: Our study covered 5,622 patients - 51.9% relating to the pre-intervention period and 48.1% corresponding to the post-intervention period.  The median age of the patients was 58 years (CI95% 57.5 to 58.4), with 55% of them male. The overall mortality rate over the period was 22.5% (CI 95% 21,19 – 23,66), without difference between the periods. The median length of stay in hospital was six days and the intensive care unit occupation rate 87%. The days patients in mechanical ventilation (9,171 pre-intervention and 11,114 pos-intervention), the mean length of ICU stay (5,71 CI95% 5,41 to 6,00 pre and 6,55 CI95% 6,22 to 6,87 pos), and the APACHE II (19,50 CI95% 18,64 to 20,36 pre and 20,79 CI95% 20,00 to 21,59 pos) scores were significantly higher in the group of patients attended during the post-intervention period, which suggests that the cases during this period were more severe. During a total of 20285 days of mechanical ventilation, 367 cases of VAP were diagnosed. The incidence of VAP fell significantly (p<0,001), between the pre-intervention (20,6 cases/1.000 MV days) and the 20 month post-intervention periods (16 cases/1.000 VM days), a reduction of 28,7%. In the analysis of segmented regression there was a significant abrupt reduction in the level of outcome (t =-2,506; p=0,017) but reduction of tendency of the outcome was not significant (t=-1,670; p= 0,104).

Conclusions: The application of a non-pharmacological VAP prevention protocol, based on best clinical practices, possible for the local reality, with participation of the multiprofessional team and with a structured process, significantly reduces the incidence of VAP in adults submitted to mechanical ventilation  and guarantees patient  safety.