Abstract
-
Background
- Ventilator-associated pneumonia (VAP) is a significant nosocomial infection in intensive care units (ICUs). Ventilator bundle (VB) implementation has been shown to decrease the incidence of VAP. This study presents a 1-year quality improvement (QI) project conducted in the ICU of a tertiary care hospital with the goal of increasing VB compliance to greater than 90% and evaluating its impact on VAP incidence and ICU length of stay.
-
Methods
- A series of Plan-Do-Study-Act (PDSA) cycles, including educational boot camps, checklist implementation, and simulation-based training, was implemented. Emphasis on standardization and documentation for each VB component further improved compliance. Data were compared using a chi-square test, unpaired t-test, or Mann-Whitney U-Test, as appropriate. A P-value <0.05 was considered statistically significant.
-
Results
- The initial observed compliance was 40.7%, with a significant difference between knowledge and implementation. The compliance increased to 90% after the second PDSA cycle. In the third PDSA cycle, uniformity and standardization of all components of VAP were ensured. After increasing the VB compliance at greater than 90%, there was a significant decline in the incidence of VAP, from 62.4/1,000 ventilatory days to 25.7/1,000 ventilatory days, with a 2.34 times risk reduction in the VAP rate (P= 0.004)
-
Conclusions
- The study highlights the effectiveness of a structured QI approach in enhancing VB compliance and reducing VAP incidence. There is a need for continued education, protocol standardization, and continuous monitoring to ensure the sustainability of this implementation.
-
Keywords: checklist; intensive care unit; nosocomial infection; quality improvement; ventilator-associated pneumonia
INTRODUCTION
Ventilator-associated pneumonia (VAP) is a concerning but avoidable nosocomial infection. Its prevention has the potential to reduce patient morbidity, hospital stays, and healthcare costs. According to data provided by the International Nosocomial Infection Control Consortium (INICC), the incidence of VAP in developing countries is much higher than the international VAP rate. There are VAP incidences of 13.6 and 3.5–41.7 per 1,000 ventilatory days in developed and Asian countries, respectively [1,2]. In India, the reported VAP rate varies from 10 to 41.7 per 1,000 ventilatory days [3,4]. Preventing VAP is not only a demanding task, but also has become a vital quality standard in many intensive care unit (ICU) settings. A simplified bundled approach, tailored to the availability of local resources, has demonstrated its effectiveness in reducing VAP incidence [5].
The Institute of Healthcare Improvement and the INICC advocate for straightforward, evidence-based infection control measures [1,6]. One of the most widely adopted strategies for VAP prevention is the ventilator bundle (VB), which encompasses various preventive components. These components include oral hygiene, daily sedation assessment and readiness to extubate, prophylaxis for peptic ulcers and deep venous thrombosis, and elevating the head of the patient's bed by 30º–45º. The implementation of such a bundle has demonstrated a substantial decrease in VAP incidence [5,7].
However, despite the compelling evidence supporting the effectiveness of the VB in preventing VAP, many hospitals and ICUs in resource-constrained settings struggle to adopt it. This is often due to a lack of awareness and compliance with VB guidelines [8,9]. In response to this pressing concern, a cross-sectional survey was conducted among healthcare workers, specifically resident doctors and staff nurses who directly provide care, to assess their knowledge and identify potential barriers to the implementation of the VB. Observed compliance to VB was 40.7%, with daily sedation vacation the least compliant component [10]. On this ground, we planned a continuous quality improvement project to increase compliance with VB protocols at our tertiary care institution and to evaluate its impact on the VAP rate. The primary objective of our project was to increase compliance to VB by more than 90% from baseline within a 6-month time frame in all patients on ventilator support. Our method to achieve this objective included continued education, simulation-based training, and implementation of a checklist. The secondary objectives were the impact of increasing compliance with VB on the incidence of VAP, the duration of ventilatory days, and the length of ICU stays.
MATERIALS AND METHODS
This project was conducted within the ICU of a tertiary care hospital from September 2022 to August 2023 according to the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines [11]. Before commencing the project, approvals were obtained from the institute's Research and Ethics Committee (No. SNMC/IRB/HP/2022/061). The utmost care was taken to ensure the anonymity and confidentiality of both patients and participants throughout the study. All information collected was stored securely and confidentially under the responsibility of the principal investigator and co-principal investigator.
Study Setting
The ICU at our facility consists of 15 beds and provides services to adult patients with a mixed range of medical and surgical diagnoses. It is a closed ICU with a full time intensivist. The staffing ratio is maintained at 1 nurse for every 1.5 patients, and the resident-to-patient ratio is structured at one resident for every four patients.
In this study, the implementation of the VB and the assessment of VAP incidence were focused on adult patients aged over 18 years and under 65 years who were placed on mechanical ventilation for a duration exceeding 48 hours. The exclusion criteria were onset of pneumonia <48 hours after intubation, NIV use, chest trauma, severe immune-compromise, known history of chronic obstructive pulmonary disease/lung disease, Acute Physiology and Chronic Health Evaluation (APACHE) II score >35 at ICU admission, high dose of vasopressor support, and suspected C-spine injury. Patients who were intubated prior to admission to our ICU were also excluded. These exclusions were performed to achieve a more homogeneous sample population, ensuring that the observed effects of the VB on VAP incidence are not confounded by unrelated risk factors or conditions. Regardless, the excluded patients received appropriate preventive measures. As the study is an internal audit conducted before and after a quality improvement (QI) project and focuses on internal processes and systems rather than direct patient interactions, the need for informed consent from patients was waived.
Design
The study was conducted as a prospective observational study, following the Plan-Do-Study-Act (PDSA) model of a QI project [12]. A QI team was established, comprising the intensivist, the anesthesiology faculty, a microbiologist, the senior staff, and a representative from the resident doctors. VAP was defined according to the criteria established by the Centers for Disease Control and Prevention (CDC), which included clinical, microbiological, and radiological assessments [13]. The VAP rate was calculated as the total number of VAP cases per 1,000 ventilator days (total number of patients who developed VAP/ventilator days ×1,000). The observed compliance with the VB was calculated as the total number of ICU patients on ventilator support in whom all five components of the VB were documented divided by the total number of ICU patients on ventilator support.
Needs Assessment and Root Cause Analysis
At the project's outset, a cross-sectional survey was conducted among healthcare workers (specifically resident doctors and staff nurses who directly provide care) to assess their knowledge and identify potential barriers to implementation of the VB. Baseline data, which included observed compliance with the VB, rate of VAP, ventilator days, and average length of stay in the ICU, were also determined.
In a cross-sectional survey, we identified potential barriers for poor compliance to the VB. The major problem identified in the needs assessment was poor observed compliance (40.75%) with the VB in the ICU. A significant gap was observed between knowledge and the actual implementation of the VB among healthcare workers in the ICU. Although healthcare workers were aware of the importance of various components of the VB, barriers to implementation included fear of adverse events, lack of awareness, insufficient training in VB procedures, and inadequate adherence to proper documentation practices. Subsequently, a fishbone diagram was created that concentrates on the causes and sub-causes related to human factors, the environment, and the processes involved (Figure 1). To achieve a compliance rate exceeding 90%, a series of PDSA cycles was repeated. Compliance with the VB was monitored by two independent observers who reported compliance at least three times a week during random shifts (morning, evening, and night), totaling 24 observations in a month.
Interventions
Our strategy to improve compliance with VB protocols in the ICU involved a comprehensive, iterative approach. Each PDSA cycle focused on addressing barriers identified during the previous cycle. We targeted key drivers for improving VB compliance, which included nursing care, resident care, and involvement of faculty members or consultants (Figure 2). Monthly reports were presented by the nursing lead and the most senior resident doctor, focusing on patient admissions, VAP occurrences, and compliance with the VB. The audit report emphasized overall compliance with VB by all healthcare workers rather than individual performance. The audit reports also highlighted major barriers to ongoing attention in the next PDSA cycle. To further motivate and engage the staff and doctors, we displayed the results and audit reports related to VAP rates and VB compliance in the ICU, promoting transparency and accountability.
PDSA cycle 1
We initiated a multidisciplinary educational boot camp encompassing didactic lectures on VAP, its causative factors, prevention strategies, and video demonstrations of VB components. Both ICU nurses and resident doctors participated in structured educational sessions, with anesthesiologists and staff nurses as presenters to foster a collaborative approach. Group sessions were conducted biweekly, followed by focused group interactions to address questions and concerns. We established a WhatsApp group for sharing lecture handouts and minutes, creating an ongoing platform for learning and information exchange among participants.
PDSA cycle 2
Following the first cycle, we identified accountability and the lack of supervision as potential barriers to VB implementation. To address this, we introduced a checklist in the ICU progress chart that required signatures from nursing staff and resident doctors and was countersigned by consultants or faculty members. Additionally, we appointed an observer for random visits and inspections of patient care. To underscore the importance of the VB, a placard was placed on the ICU signboard, illustrating the VB components and the correct protocol for Spontaneous Breathing Trials (SBT) (Figure 3).
PDSA cycle 3
Upon review, it became evident that, while all the components of the VB were being followed, many healthcare workers lacked a standardized understanding of the proper techniques involved. In response to this finding, we planned to improve and standardize the practice for each component of the VB during this cycle. We conducted micro-scenarios to practice hand hygiene, oral care, proper head-end elevation, and SBT sedation holiday assessment. To ensure correct head elevation, red and green marks were placed at the head of the bed; the bed was to be adjusted so that only the green mark was visible. High-fidelity simulation scenarios on the care of ventilated patients in the ICU were also carried out, followed by reflective debriefing sessions to emphasize the significance of VB.
Data Collection
All data regarding age, sex, APACHE II score, and Sequential Organ Failure Assessment score at the time of admission and 48 hours after intubation were collected. Compliance with VB was measured at baseline, after each PDSA cycle, and over the subsequent 6 months to ensure greater than 90% performance. The VAP rate, ventilator days, and ICU length of stay were calculated at baseline, which included 6 months of retrospective data and the subsequent 6 months (after ensuring that the VB compliance was >90%).
The data were analyzed statistically using the statistical package for the MedCalc statistical Software version 22.014 for window editions [14]. Qualitative data were presented in terms of numbers and percentages, while quantitative data were expressed as means±standard deviations or medians (range), as appropriate. Pre- and post-intervention data were compared using a chi-square test, unpaired t-test, or Mann-Whitney U-Test. as appropriate. The incidence rate ratio was also calculated to determine the impact of the intervention on the VAP rate. A P-value <0.05 was considered statistically significant.
RESULTS
We calculated the incidence of VAP at baseline and after ensuring that the compliance to VB was >90% for 6 months (Figure 4). A total of 97 patients were initially included in the intervention period, but 5 were subsequently excluded. In the post-intervention period, 104 patients were included after ensuring more than 90% compliance with the ventilator bundle, though 6 were excluded. As a result, 92 patients were included in the pre-intervention period, and 98 patients were included in the post-intervention period of the study (Figure 5). The demographic profile and patient characteristics at the time of admission were similar between the groups (Table 1). The baseline compliance with the VB was 40.7%, with the lowest rates for daily sedation vacation plus SBT trial and thromboprophylaxis. The most common barriers identified were fear of adverse events, lack of awareness, insufficient training in VB procedures, and inadequate adherence to proper documentation practices.
After boot camp (PDSA cycle 1), compliance with VB was >70%, which further increased to >90% after the second PDSA cycle. In the third PDSA cycle, we ensured the quality of the intervention. Total mechanical ventilation days and ventilation utilization ratio at baseline and after intervention were comparable. The data after the high-quality VB compliance >90% showed a significant decrease in the incidence of VAP from baseline, i.e., from 62.4/1,000 ventilatory days (95% CI, 44.4–85.3) to 25.7/1,000 ventilatory days (95% CI, 12.8–42.5; P=0.004). There was a 2.34-fold decrease in the VAP rate after the intervention (incidence rate ratio, 2.34; 95% CI, 1.25–4.67). The total mechanical ventilation days and ICU length of stay also decreased significantly after achieving >90% compliance with the VB (Table 2).
DISCUSSION
Our findings demonstrate the effectiveness of a structured QI project, which improved compliance with VAP prevention measures from an initial compliance rate of 40.7% to 70% after the first PDSA and 90% after the second PDSA cycle. In the third PDSA cycle, uniformity and standardization of all components of VAP were verified. After increasing the VB compliance to >90%, there was a significant decrease in the incidence of VAP, from 62.4/1,000 ventilatory days to 25.7/1,000 ventilatory days, with 2.34 times risk reduction in VAP rate.
The study focused on the crucial issue of preventing VAP in the ICU of a tertiary care hospital, particularly in resource-constrained settings. Preventing VAP is not only essential for patient outcomes, but also has become a quality standard in many ICU settings. The key aspect of this project was the involvement of a multidisciplinary team, including ICU staff, anesthesiologists, microbiologists, and resident doctors, working together to identify barriers to compliance. The multidisciplinary educational boot camp (with didactic lectures, video demonstrations, and ongoing learning platforms) helped bridge the gap between knowledge and practice among healthcare workers. The literature shows that healthcare works have a lack of sufficient knowledge regarding VB; implementation of continuous education and training, as per the recent evidence-based guidelines, is an important strategy to improve compliance with the protocols [15-18].
Despite the educational intervention, we were only able to improve compliance to >70%. A notable concern that emerged was the inconsistency in documenting the various components of the VB in the ICU chart; specifically, components like peptic ulcer prophylaxis and thromboprophylaxis exhibited higher levels of compliance (almost 100%) because they were documented in the chart. After recognizing the importance of documenting each component of the VB, we introduced a systematic practice of recording all elements of the VB in the daily chart for patients in the ICU to provide clear and organized instructions. Also, the introduction of a checklist in the ICU progress chart, which required documentation from all healthcare workers, and random visits and inspections further enforced accountability and supervision. This strategy ensured that healthcare workers were consistently performing VB components and adhering to proper documentation practices. The checklist also served as a reminder for healthcare workers to comply with VAP prevention measures. The implementation of a checklist aids in the completeness and consistency of work to be accomplished; checklists have been shown to reduce adverse events, including procedural complications, and also enhance communication within teams [19-22].
Another critical facet of our project was the strong emphasis on standardization and the assurance of correct techniques for each component of the VB. Ensuring precise elevation of the head of the patient's bed to the recommended angle and the correct procedures for oral care and hand hygiene were notable challenges. Standardized protocols, micro-scenarios, simulation training, and reflective debriefing sessions helped ensure that healthcare workers were proficient in carrying out VAP prevention measures. A review conducted by Kang et al. [23] highlighted the importance of simulation-based training in the prevention of healthcare-associated infections. The use of visual cues, such as colored marks on the bed for proper head elevation, contributed to standardization and simplification. Appropriately designed visual aids help to simplify communication and aid in accurate interpretation of orders [24].
The major strength of this study is that it is a single-center study with comparable population groups to avoid any biases associated with different populations. The diagnosis of VAP was confirmed by the standardized criteria proposed by the CDC with minimal inter-rater variability; the diagnosis was made by a team of principal investigator, co-investigator, and microbiologist. The future target of this project is to increase stakeholder engagement to achieve VB implementation and increase compliance at other ICUs at our institution. We also aim to sustain VB compliance and to achieve a zero VAP rate at our ICU and to conduct cost-benefit and cost-effective analyses by reducing the VAP rate.
In conclusion, this study underscores the paramount importance of structured QI initiatives in VAP within the ICU by implementing a multi-faceted approach that addresses barriers to compliance with the VB. Crucially, the involvement of a multidisciplinary team, including the ICU charge nurse, anesthesiologists, microbiologists, and resident doctors, played a pivotal role in identifying, addressing, and overcoming the barriers to compliance. Through educational boot camps, checklists, and standardization of practices, healthcare workers were empowered to consistently execute VAP prevention measures, resulting in a significant decrease in VAP incidence.
KEY MESSAGES
▪ Enhancing compliance with ventilator bundle components significantly reduces the incidence of ventilator-associated pneumonia.
▪ Successful improvement in compliance requires a multifaceted strategy, including education, standardization of procedures, ongoing training, systematic monitoring, auditing, and accountability.
▪ Involvement of a multidisciplinary team (comprised of intensive care unit faculty, resident doctors, microbiologists, and nursing staff) is pivotal to identifying barriers and implementing effective solutions.
NOTES
-
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
-
FUNDING
None.
-
ACKNOWLEDGMENTS
We would like to thank Dr. Shiva Patil (Junior Resident, Department of Anesthesia, Dr. Sampurnanand Medical College, Jodhpur) and Dr. Sukhdev Rao (Senior Resident, Department of Anesthesia, Dr. Sampurnanand Medical College, Jodhpur) for their valuable assistance in the data collection process.
-
AUTHOR CONTRIBUTIONS
Conceptualization: NP, PB, SM. Methodology: NP, PB, SM. Software: NP, PB, RJ, SM, PP. Validation: NP, PB, RJ, SM, PP. Formal analysis: NP, PB, VT. Investigation: NP, PB. Data curation: NP, PB. Writing - original draft: RJ, SM, PP. Writing - review & editing: all authors. All authors read and agreed to the published version of the manuscript.
Figure 1.The root causes and associated sub-causes contributing to challenges in the effective implementation of the ventilator bundle protocol. VAP: ventilator associated pneumonia; APACHE: Acute Physiology and Chronic Health Evaluation.
Figure 2.Key driver diagram for increasing ventilator bundle compliance. VAP: ventilator associated pneumonia; ICU: intensive care unit; DVT: deep venous thrombosis; SBT: Spontaneous Breathing Trials.
Figure 3.Placard of ventilator bundle.
Figure 4.Gantt chart for the quality improvement project. VAP: ventilator associated pneumonia; IRB: institutional review board; PDSA: Plan-Do-Study-Act; VB: ventilator bundle.
Figure 5.Flowchart depicting inclusion of patients in the study. COPD: chronic obstructive pulmonary disease; ICU: intensive care unit.
Table 1.Patient demographic, characteristics at the time of admission and at 48 hours
|
Variable |
Pre-intervention (baseline) |
Post-intervention (after VB compliance more than 90%) |
P-value |
|
No. of patients |
92 |
98 |
- |
|
Age (yr) |
51±9 |
55±18 |
0.07 |
|
Male |
56 (60.7) |
56 (57.1) |
- |
|
APACHE II score at admission |
18.6±4.2 |
19.7±5.4 |
0.12 |
|
APACHE II score at 48 hours after intubation |
18.0±5.6 |
18.3±6.2 |
0.74 |
|
SOFA score admission |
8.5±2.0 |
8.9±2.0 |
0.14 |
|
SOFA score at 48 hours after intubation |
8.4±1.9 |
8.8±2.0 |
0.27 |
Table 2.Compliance to ventilator bundle and VAP incidence rate
|
Variable |
Pre-intervention (baseline) |
Post-intervention (after VB compliance more than 90%) |
P-value |
|
Invasive mechanical ventilation days (total) |
625; 5 (3–20)a)
|
526; 4 (3–22)a)
|
0.007 |
|
ICU LOS days |
802; 7 (3–24)a)
|
704; 6 (3–25)a)
|
0.002 |
|
No. of VAPs |
39 |
14 |
- |
|
VAP rate per 1,000 ventilator days |
62.4 (44.4–85.3)b)
|
26.61 (12.8–42.5)b)
|
0.004; 2.334 (1.25–4.67)b)
|
|
Microbiological positive growth on tracheal culture |
|
|
|
|
Klebsiella
|
8 |
3 |
|
|
Acinetobacter
|
5 |
2 |
|
CONS |
5 |
1 |
|
Staphylococcus
|
6 |
1 |
|
Pseudomonas
|
7 |
4 |
|
Enterococcus
|
5 |
2 |
|
Candida
|
3 |
1 |
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