Bringing National Healthcare Safety Network Ventilator-associated Pneumonia Definitions to the Bedside

Background:

The National Healthcare Safety Network (NHSN) surveillance definition of Ventilator-associated Pneumonia (VAP) is controversial and the most subjective of all the device-associated infection definitions because it uses radiologic and microbiologic criteria to define VAP as opposed to clinical criteria for VAP treatment. Clinical diagnosis of VAP is made when there is a new or progressive lung infiltrate plus at least two of the following three criteria: fever, purulent sputum, or leukocytosis. Because of these definition variations, agreement between clinicians and infection preventionists on the presence of VAP needed to improve.

Objective:

Helping clinicians understand the differences between clinical and surveillance definitions is an important step in engaging team members team in VAP prevention improvement as stated in “Strategies to Prevent VAP in Acute Care Hospitals” from Infection Control and Hospital Epidemiology (2008).

Methods:

A VAP subcommittee was formed. The group included a senior administrator, a physician, a nursing educator, an infection preventionist, and a respiratory therapist. All subcommittee members gained familiarity with the NHSN VAP definition. Since 2005 Bryn Mawr Hospital has followed the Institute for Healthcare Improvement (IHI) VAP prevention bundle.

Results:

 The NHSN definition notes changes in the patient's Chest X-ray (CXR). To avoid misinterpretation, all CXRs were reviewed in a consistent manner by the same team (the ICU medical director and the infection preventionist).

• Performing hand hygiene was the most important step. Bryn Mawr Hospital (BMH) policy indicates that hand hygiene should occur before and after patient contact. For consistency we asked all physicians and staff to sanitize hands before entering and upon leaving the room. With the medical director's and ICU's patient care manager's agreement, we changed the policy to wash-glove-wash and  placed at each door's entrance to educate staff.
• Daily rounds of  ICU and CCU teams with the medical director considered sedation interruption and assessment of the readiness to wean for each ventilated patient.
• Agreement between nursing and respiratory therapists enabled mouth care every 2 hours.
• ICU/CCU staff became more aware of the head of bed elevation resulting in most ventilated patients being in a semi-recumbent position.

• BMH went 11 months without VAP.

Conclusions:

Although the VAP Subcommittee is working, we plan to expand it to include an anesthesiologist, a radiologist, and an OR nurse. Education and reinforcement on bundle compliance should not be minimized. Drilling down on every case determines if we could have changed some process to prevent VAP. We standardized a VAP worksheet to give to different disciplines for clinical comments. This process improvements assisted our physicians and nurses become more aware of NHSN VAP definitions and decreased the incident of VAP.