Impact of Outcome and Process surveillance on ventilator associated pneumonia rates in an ICU from Macedonia: INICC Findings

Background: Ventilator-associated pneumonia (VAP) is one of the most common infections acquired by adults and children in intensive care units (ICUs). Recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but VAP rates are higher in developing countries. The results of recent quality improvement initiatives, however, suggest that many cases of VAP can be prevented with careful attention to the process of care.

Objective: We report the impact on VAP rates of process surveillance of measures to prevent VAP and outcome surveillance of VAP rates, in a Cardio Surgical ICU in Macedonia member of the International Nosocomial Infection Control Consortium (INICC).

 

Methods: Process surveillance includes observation, monitoring and performance feedback of adherence to hand-hygiene, use of noninvasive ventilation, minimization of the duration of ventilation, daily assessments of readiness to wean, semirecumbent position of patients, avoiding gastric overdistention and unplanned extubation, use of a cuffed endotracheal tube with in-line or subglottic suctioning, to maintain an endotracheal cuff pressure of at least 20 cm H2O, use orotracheal intubation instead of nasotracheal intubation, avoid histamine receptor 2 (H2)–blocking agents and proton pump inhibitors, regular oral care with an antiseptic solution, use of sterile water to rinse reusable respiratory equipment, removal of condensate from ventilatory circuits, changing the ventilatory circuit only when visibly soiled or malfunctioning, and to store and disinfect respiratory therapy equipment properly.

Outcome surveillance includes measurement of patients’characteristics, mechanical ventilator days, VAPs, length of stay, costs, mortality, microorganism profile, and bacterial resistance.

VAP rates were registered by applying the definitions of the CDC NHSN. Data of process and outcome surveillance were collected in the participating ICU, and were uploaded and analyzed at the INICC headquarters.

Pooled VAP rates within the ICU during the first 3 months (baseline) of participation in INICC were compared with the rates in the subsequent intervention period during the following 42 months (intervention).

Results: During the baseline period, 150 ICU patients were enrolled, and 1,775 during the intervention period.

Patients’ characteristics were similar over the two periods (patient gender, P: 0.8349; renal insufficiency, P: 0.6193; abdominal surgery, P: 0.4823).

The VAP rate per 1,000 ventilator days in the intervention period was significantly lower than in the baseline period, 21.1 (6/284) vs 3.6 (14/3,930) VAP per 1000 ventilator days (RR, 0.17; 95% CI, 0.06-0.44; P 0.001).

 

Conclusions: Ongoing process surveillance of measures to prevent VAP, and outcome surveillance of VAP rates were associated with an 83% reduction in the incidence of VAP rate.