ICU infection prevention: Trust protocols, but verify compliance

A healthy percentage of the morbidity, mortality, and costs associated with infections acquired in intensive care units are preventable by just following the rules, investigators said at the annual congress of the Society of Critical Care Medicine.

Interventions such as strict hand hygiene, meticulous attention to preinsertion disinfection of the patient’s skin, and the use of sterile dressings and drapes can dramatically reduce the incidence of catheter-related bloodstream infections (CRBSIs). Ventilator-associated pneumonia (VAP) can be prevented with precautions to avoid aspiration, reduction of upper airway colonization, and attention to sterilization of ventilatory equipment, said Dr. Alfred F. Connors Jr., senior associate dean of Case Western Reserve University, Cleveland.

Neil Osterweil/IMNG Medical Media

"These are two areas where we are at a really important turning point, where we can really make a difference and change the incidence of these infections in our patients," he said.

The key to making it all work is ensuring that staff adhere to best practices, said investigators from Sutter General Hospital in Sacramento. They reported that a physician-led multidisciplinary team charged with monitoring adherence to VAP prevention guidelines reduced the incidence of ventilator-associated infections from 17 out of 3,173 ventilator-days in 2004, to 2 in 12,694 ventilator-days from 2008 to 2011, a statistically significant reduction.

Protocols yes, compliance maybe

Dr. Connors noted that in a cross-sectional survey of 415 ICUs in 250 hospitals with a mean of 2.7 VAP infections per 1,000 ventilator-days, 68% of hospitals had a VAP bundle policy in place, but only 45% monitored compliance, and only 18% reported high compliance with the policy (Int. J. Qual. Health Care 2011;23:538-44).

"Unless you have a policy, you’re monitoring it, and you’re demonstrating high compliance, you won’t show any effect on your ventilator-associated pneumonia rate. There’s no magic to this. You can’t just say ‘Okay, we’ve got a policy, please follow it,’ and expect ventilator-associated pneumonia rates to drop; we have to intervene actively to get high compliance, and that’s easier said than done," he said.

At MetroHealth system in Cleveland, where Dr. Connors is chief medical officer, instituting and enforcing a stepped-up hand-hygiene program, isolation procedures, enhanced environmental cleaning, antibiotic stewardship, and implementation of evidence-based protocols for prevention of VAP, CRBSIs, and catheter-associated urinary tract infections resulted in an 18% decrease in antibiotic days of therapy from 2009 through the third quarter of 2012, and 32% decreases in both VAP and CRBSIs from 2010 to 2012.

More importantly, Dr. Connors said, such efforts save both lives and costs. He pointed to a 2011 study of national data on hospital-associated infections, which found that with proper infection control procedures, an estimated 44,762 to 164,127 central line–associated bloodstream infection (CLABSI) cases could be prevented, translating into 5,520 to 20,239 lives saved, and an estimated 95,078 to 137,613 preventable VAP cases, equivalent to 13,667 to 19,782 lives saved (Infect. Control Hosp. Epidemiol. 2011;32:101-14).

Team rounding cuts VAP

Dr. Saman Hayatdavoudi and colleagues at Sutter General Hospital made major inroads into reducing VAP rates through the creation of a multidisciplinary rounding team consisting of an intensivist, acute-care nurse practitioner (ACNP), respiratory therapist, clinical pharmacist, and bedside nurses.

The team made daily clinical rounds to verify whether clinicians were complying with hospital protocols and adhering to ventilator bundles, backed by a checklist.

"When deficiencies were noted, the ACNP was authorized to write orders bringing the care plans into best practice compliance," they wrote in a poster presentation.

As noted before, the team intervention reduced the incidence of VAP substantially, to just 2 per 12,694 ventilator-days, well below the benchmark of the 5.1 per 1,000 ventilator-days established by the Centers for Disease Control and Prevention’s National Healthcare Safety Network.

Dr. Connors reported having no financial disclosures. The study by Dr. Hayatdavoudi and colleagues was internally funded. The authors reported having no financial disclosures

A healthy percentage of the morbidity, mortality, and costs associated with infections acquired in intensive care units are preventable by just following the rules, investigators said at the annual congress of the Society of Critical Care Medicine.

Interventions such as strict hand hygiene, meticulous attention to preinsertion disinfection of the patient’s skin, and the use of sterile dressings and drapes can dramatically reduce the incidence of catheter-related bloodstream infections (CRBSIs). Ventilator-associated pneumonia (VAP) can be prevented with precautions to avoid aspiration, reduction of upper airway colonization, and attention to sterilization of ventilatory equipment, said Dr. Alfred F. Connors Jr., senior associate dean of Case Western Reserve University, Cleveland.

Neil Osterweil/IMNG Medical Media

"These are two areas where we are at a really important turning point, where we can really make a difference and change the incidence of these infections in our patients," he said.

The key to making it all work is ensuring that staff adhere to best practices, said investigators from Sutter General Hospital in Sacramento. They reported that a physician-led multidisciplinary team charged with monitoring adherence to VAP prevention guidelines reduced the incidence of ventilator-associated infections from 17 out of 3,173 ventilator-days in 2004, to 2 in 12,694 ventilator-days from 2008 to 2011, a statistically significant reduction.

Protocols yes, compliance maybe

Dr. Connors noted that in a cross-sectional survey of 415 ICUs in 250 hospitals with a mean of 2.7 VAP infections per 1,000 ventilator-days, 68% of hospitals had a VAP bundle policy in place, but only 45% monitored compliance, and only 18% reported high compliance with the policy (Int. J. Qual. Health Care 2011;23:538-44).

"Unless you have a policy, you’re monitoring it, and you’re demonstrating high compliance, you won’t show any effect on your ventilator-associated pneumonia rate. There’s no magic to this. You can’t just say ‘Okay, we’ve got a policy, please follow it,’ and expect ventilator-associated pneumonia rates to drop; we have to intervene actively to get high compliance, and that’s easier said than done," he said.

At MetroHealth system in Cleveland, where Dr. Connors is chief medical officer, instituting and enforcing a stepped-up hand-hygiene program, isolation procedures, enhanced environmental cleaning, antibiotic stewardship, and implementation of evidence-based protocols for prevention of VAP, CRBSIs, and catheter-associated urinary tract infections resulted in an 18% decrease in antibiotic days of therapy from 2009 through the third quarter of 2012, and 32% decreases in both VAP and CRBSIs from 2010 to 2012.

More importantly, Dr. Connors said, such efforts save both lives and costs. He pointed to a 2011 study of national data on hospital-associated infections, which found that with proper infection control procedures, an estimated 44,762 to 164,127 central line–associated bloodstream infection (CLABSI) cases could be prevented, translating into 5,520 to 20,239 lives saved, and an estimated 95,078 to 137,613 preventable VAP cases, equivalent to 13,667 to 19,782 lives saved (Infect. Control Hosp. Epidemiol. 2011;32:101-14).

Team rounding cuts VAP

Dr. Saman Hayatdavoudi and colleagues at Sutter General Hospital made major inroads into reducing VAP rates through the creation of a multidisciplinary rounding team consisting of an intensivist, acute-care nurse practitioner (ACNP), respiratory therapist, clinical pharmacist, and bedside nurses.

The team made daily clinical rounds to verify whether clinicians were complying with hospital protocols and adhering to ventilator bundles, backed by a checklist.

"When deficiencies were noted, the ACNP was authorized to write orders bringing the care plans into best practice compliance," they wrote in a poster presentation.

As noted before, the team intervention reduced the incidence of VAP substantially, to just 2 per 12,694 ventilator-days, well below the benchmark of the 5.1 per 1,000 ventilator-days established by the Centers for Disease Control and Prevention’s National Healthcare Safety Network.

Dr. Connors reported having no financial disclosures. The study by Dr. Hayatdavoudi and colleagues was internally funded. The authors reported having no financial disclosures

A healthy percentage of the morbidity, mortality, and costs associated with infections acquired in intensive care units are preventable by just following the rules, investigators said at the annual congress of the Society of Critical Care Medicine.

Interventions such as strict hand hygiene, meticulous attention to preinsertion disinfection of the patient’s skin, and the use of sterile dressings and drapes can dramatically reduce the incidence of catheter-related bloodstream infections (CRBSIs). Ventilator-associated pneumonia (VAP) can be prevented with precautions to avoid aspiration, reduction of upper airway colonization, and attention to sterilization of ventilatory equipment, said Dr. Alfred F. Connors Jr., senior associate dean of Case Western Reserve University, Cleveland.

Neil Osterweil/IMNG Medical Media

"These are two areas where we are at a really important turning point, where we can really make a difference and change the incidence of these infections in our patients," he said.

The key to making it all work is ensuring that staff adhere to best practices, said investigators from Sutter General Hospital in Sacramento. They reported that a physician-led multidisciplinary team charged with monitoring adherence to VAP prevention guidelines reduced the incidence of ventilator-associated infections from 17 out of 3,173 ventilator-days in 2004, to 2 in 12,694 ventilator-days from 2008 to 2011, a statistically significant reduction.

Protocols yes, compliance maybe

Dr. Connors noted that in a cross-sectional survey of 415 ICUs in 250 hospitals with a mean of 2.7 VAP infections per 1,000 ventilator-days, 68% of hospitals had a VAP bundle policy in place, but only 45% monitored compliance, and only 18% reported high compliance with the policy (Int. J. Qual. Health Care 2011;23:538-44).

"Unless you have a policy, you’re monitoring it, and you’re demonstrating high compliance, you won’t show any effect on your ventilator-associated pneumonia rate. There’s no magic to this. You can’t just say ‘Okay, we’ve got a policy, please follow it,’ and expect ventilator-associated pneumonia rates to drop; we have to intervene actively to get high compliance, and that’s easier said than done," he said.

At MetroHealth system in Cleveland, where Dr. Connors is chief medical officer, instituting and enforcing a stepped-up hand-hygiene program, isolation procedures, enhanced environmental cleaning, antibiotic stewardship, and implementation of evidence-based protocols for prevention of VAP, CRBSIs, and catheter-associated urinary tract infections resulted in an 18% decrease in antibiotic days of therapy from 2009 through the third quarter of 2012, and 32% decreases in both VAP and CRBSIs from 2010 to 2012.

More importantly, Dr. Connors said, such efforts save both lives and costs. He pointed to a 2011 study of national data on hospital-associated infections, which found that with proper infection control procedures, an estimated 44,762 to 164,127 central line–associated bloodstream infection (CLABSI) cases could be prevented, translating into 5,520 to 20,239 lives saved, and an estimated 95,078 to 137,613 preventable VAP cases, equivalent to 13,667 to 19,782 lives saved (Infect. Control Hosp. Epidemiol. 2011;32:101-14).

Team rounding cuts VAP

Dr. Saman Hayatdavoudi and colleagues at Sutter General Hospital made major inroads into reducing VAP rates through the creation of a multidisciplinary rounding team consisting of an intensivist, acute-care nurse practitioner (ACNP), respiratory therapist, clinical pharmacist, and bedside nurses.

The team made daily clinical rounds to verify whether clinicians were complying with hospital protocols and adhering to ventilator bundles, backed by a checklist.

"When deficiencies were noted, the ACNP was authorized to write orders bringing the care plans into best practice compliance," they wrote in a poster presentation.

As noted before, the team intervention reduced the incidence of VAP substantially, to just 2 per 12,694 ventilator-days, well below the benchmark of the 5.1 per 1,000 ventilator-days established by the Centers for Disease Control and Prevention’s National Healthcare Safety Network.

Dr. Connors reported having no financial disclosures. The study by Dr. Hayatdavoudi and colleagues was internally funded. The authors reported having no financial disclosures