Skip Navigation
Skip to contents

ACC : Acute and Critical Care

OPEN ACCESS
SEARCH
Search

Articles

Page Path
HOME > Acute Crit Care > Volume 39(4); 2024 > Article
Original Article
Infection
Striving for excellence in ventilator bundle compliance through continuous quality improvement initiative in the intensive care unit of a tertiary care hospital in India
Naveen Paliwal1orcid, Pooja Bihani1orcid, Rishabh Jaju2orcid, Sadik Mohammed3orcid, Prabhu Prakash4orcid, Vidya Tharu5orcid
Acute and Critical Care 2024;39(4):535-544.
DOI: https://doi.org/10.4266/acc.2024.00101
Published online: November 12, 2024

1Department of Anesthesiology, Dr. Sampurnanand Medical College, Jodhpur, India

2Department of Anesthesiology, All India Institute of Medical Sciences, Deoghar, India

3Department of Anesthesiology, All India Institute of Medical Sciences, Jodhpur, India

4Department of Microbiology, Dr. Sampurnanand Medical College, Jodhpur, India

5Seth GS Medical College and KEM Hospital, Parel, India

Corresponding contributor: Pooja Bihani Department of Anesthesiology, Dr. Sampurnanand Medical College, Jodhpur 342001, India Tel: +91-96-9449-0440, E-mail: drpooja.bihani@gmail.com
• Received: January 29, 2024   • Revised: July 10, 2024   • Accepted: August 12, 2024

© 2024 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 348 Views
  • 31 Download
prev next
  • 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.
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.
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.
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).
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.
▪ 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.

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.
acc-2024-00101f1.jpg
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.
acc-2024-00101f2.jpg
Figure 3.
Placard of ventilator bundle.
acc-2024-00101f3.jpg
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.
acc-2024-00101f4.jpg
Figure 5.
Flowchart depicting inclusion of patients in the study. COPD: chronic obstructive pulmonary disease; ICU: intensive care unit.
acc-2024-00101f5.jpg
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

Values are presented as mean± standard deviation or number (%).

VB: ventilator bundle; APACHE: Acute Physiology and Chronic Health Evaluation; SOFA: Sequential Organ Failure Assessment.

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

VAP: ventilator associated pneumonia; VB: ventilator bundle; ICU: intensive care unit; LOS: length of stay; CONS: coagulase-negative Staphylococcus.

a)Median (interquartile range);

b)Incidence rate ratio (95% CI).

  • 1. Rosenthal VD, Maki DG, Jamulitrat S, Medeiros EA, Todi SK, Gomez DY, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009. Am J Infect Control 2010;38:95-104.ArticlePubMed
  • 2. Chawla R. Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries. Am J Infect Control 2008;36(4 Suppl):S93-100.ArticlePubMed
  • 3. Arabi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries: a systematic review. Int J Infect Dis 2008;12:505-12.ArticlePubMed
  • 4. Mathai AS, Phillips A, Isaac R. Ventilator-associated pneumonia: a persistent healthcare problem in Indian Intensive Care Units! Lung India 2016;33:512-6.ArticlePubMedPMC
  • 5. Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A, et al. A care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect 2013;19:363-9.ArticlePubMed
  • 6. Institute for Health Care Improvement. Implement the ventilator bundle [Internet]. Institute for Health Care Improvement; 2008 [cited 2024 Aug 20]. Available from: http://www.ihi.org
  • 7. Speck K, Rawat N, Weiner NC, Tujuba HG, Farley D, Berenholtz S. A systematic approach for developing a ventilator-associated pneumonia prevention bundle. Am J Infect Control 2016;44:652-6.ArticlePubMedPMC
  • 8. Abad CL, Formalejo CP, Mantaring DML. Assessment of knowledge and implementation practices of the ventilator acquired pneumonia (VAP) bundle in the intensive care unit of a private hospital. Antimicrob Resist Infect Control 2021;10:161. ArticlePubMedPMCPDF
  • 9. Mannava Y, Nayak SU, Uppoor A, Naik D, Maddi A. Knowledge, attitude and oral care practices for preventing ventilator-associated pneumonia among critical care nurses: a questionnaire study. Indian J Dent Res 2020;31:426-32.ArticlePubMed
  • 10. Paliwal N, Bihani P, Mohammed S, Rao S, Jaju R, Janweja S. Assessment of knowledge, barrier in implementation, and compliance to ventilator bundle among resident doctors and nurses working in intensive care units of a tertiary care center of Western India: a cross-sectional survey. Indian J Crit Care Med 2023;27:270-6.ArticlePubMedPMC
  • 11. Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016;25:986-92.ArticlePubMed
  • 12. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf 2014;23:290-8.ArticlePubMed
  • 13. Cason CL, Tyner T, Saunders S, Broome L, Centers for Disease Control. Nurses’ implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention. Am J Crit Care 2007;16:28-37.ArticlePubMedPDF
  • 14. MedCalc Software. Medcalc statistical software. Version 22.014 [software]. 2023 [cited 2024 Aug 20]. Available from: www.medcalc.org.
  • 15. Costa DK, Yang JJ, Manojlovich M. The critical care nurse work environment, physician staffing, and risk for ventilator-associated pneumonia. Am J Infect Control 2016;44:1181-3.ArticlePubMed
  • 16. Sahni N, Biswal M, Gandhi K, Kaur K, Saini V, Yaddanapudi LN. Effect of intensive education and training of nurses on ventilator-associated pneumonia and central line-associated bloodstream infection incidence in intensive care unit at a tertiary care center in North India. Indian J Crit Care Med 2017;21:779-82.ArticlePubMedPMC
  • 17. Akın Korhan E, Hakverdioğlu Yönt G, Parlar Kılıç S, Uzelli D. Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia. Nurs Crit Care 2014;19:26-33.ArticlePubMed
  • 18. Jam Gatell MR, Santé Roig M, Hernández Vian Ó, Carrillo Santín E, Turégano Duaso C, Fernández Moreno I, et al. Assessment of a training programme for the prevention of ventilator-associated pneumonia. Nurs Crit Care 2012;17:285-92.ArticlePubMedPMCPDF
  • 19. Thomassen Ø, Espeland A, Søfteland E, Lossius HM, Heltne JK, Brattebø G. Implementation of checklists in health care; learning from high-reliability organisations. Scand J Trauma Resusc Emerg Med 2011;19:53. ArticlePubMedPMCPDF
  • 20. Clay-Williams R, Colligan L. Back to basics: checklists in aviation and healthcare. BMJ Qual Saf 2015;24:428-31.ArticlePubMedPMC
  • 21. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.ArticlePubMed
  • 22. Pageler NM, Longhurst CA, Wood M, Cornfield DN, Suermondt J, Sharek PJ, et al. Use of electronic medical record-enhanced checklist and electronic dashboard to decrease CLABSIs. Pediatrics 2014;133:e738-46.ArticlePubMedPMCPDF
  • 23. Kang M, Nagaraj MB, Campbell KK, Nazareno IA, Scott DJ, Arocha D, et al. The role of simulation-based training in healthcare-associated infection (HAI) prevention. Antimicrob Steward Healthc Epidemiol 2022;2:e20.ArticlePubMedPMC
  • 24. Ancker JS, Senathirajah Y, Kukafka R, Starren JB. Design features of graphs in health risk communication: a systematic review. J Am Med Inform Assoc 2006;13:608-18.ArticlePubMedPMC

Figure & Data

References

    Citations

    Citations to this article as recorded by  

      • PubReader PubReader
      • ePub LinkePub Link
      • Cite
        CITE
        export Copy
        Close
        Download Citation
        Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

        Format:
        • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
        • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
        Include:
        • Citation for the content below
        Striving for excellence in ventilator bundle compliance through continuous quality improvement initiative in the intensive care unit of a tertiary care hospital in India
        Acute Crit Care. 2024;39(4):535-544.   Published online November 12, 2024
        Close
      • XML DownloadXML Download
      Figure
      • 0
      • 1
      • 2
      • 3
      • 4
      Striving for excellence in ventilator bundle compliance through continuous quality improvement initiative in the intensive care unit of a tertiary care hospital in India
      Image Image Image Image Image
      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.
      Striving for excellence in ventilator bundle compliance through continuous quality improvement initiative in the intensive care unit of a tertiary care hospital in India
      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
      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
      Table 1. Patient demographic, characteristics at the time of admission and at 48 hours

      Values are presented as mean± standard deviation or number (%).

      VB: ventilator bundle; APACHE: Acute Physiology and Chronic Health Evaluation; SOFA: Sequential Organ Failure Assessment.

      Table 2. Compliance to ventilator bundle and VAP incidence rate

      VAP: ventilator associated pneumonia; VB: ventilator bundle; ICU: intensive care unit; LOS: length of stay; CONS: coagulase-negative Staphylococcus.

      Median (interquartile range);

      Incidence rate ratio (95% CI).


      ACC : Acute and Critical Care
      TOP