Implementation of a Ventilator Acquired Pneumonia Prevention Program in a Hospital - Term Paper Example

Introduction Ventilator Acquired Pneumonia (VAP) is a growing problem in many hospitals around the world. As Pittet and Bonton (2000) note, “Ventilator-associated pneumonia (VAP) is the commonest infection acquired in intensive-care units (ICU) and the leading cause of antibiotic use there. It increases mortality and health-care costs.” Some hospitals are in the habit of giving excessive amounts of antibiotics to patients with VAP, only to strengthen the microorganisms. Fortunately, it is not the kind of problem that is without solutions but it requires a good plan and follow-through in implementation to get a handle on the problem. This report focuses on how to develop and implement a VAP prevention program in a hospital. Understanding the problem It is not enough to appreciate that a hospital has a high incidence of VAP. It is important to understand what the risk factors are so that one can attack it with the best possible means. In this regard, it is impossible to comb the literature for the latest findings surrounding VAP. Research is dynamic and new insights are emerging almost daily from the vast pool of research being done around the world. To go ahead and implement a program without proper understanding of the latest information and techniques is to possibly waste money and resources without necessarily achieving one’s aims. So studying the latest findings and boiling them down to easily comprehensible form is essentials especially since much of the literature is voluminous and sometimes not readily comprehensible by readers. Simply telling staff members to go out and read the literature is not good enough. First of all, in many hospitals practically everyone has a full plate. To show that one is serious about preventing and controlling VAP it is necessary to appoint a champion to get the ball rolling and to see the implementation through. Select a champion When something is important to us we devote time and attention to it. This should be no different for VAP prevention. Getting someone to be in charge of the program and giving such an individual time to study the literature and to talk to others who have implemented similar programs can help the hospital to begin its implementation strategy with the best information possible, which may include pitfalls to watch out for. Also, armed with the latest and the best information it is possible to tailor the design of the plan and its implementation to the particular needs of the hospital in question. As Craven (2006) notes, “Prevention and implementation of cost-effective strategies to reduce risk and improve patient outcomes should be prioritized. Clearly, prevention programs should be population specific and may vary among hospitals, but a multidisciplinary prevention team led by a "champion" is recommended to help set priorities, benchmarking goals, analyze data, and sow the seeds of change for risk reduction.” (CHEST 2006; 130:251-260; cited in Craven 2006). Appointing a low-level nurse to head such a program will send the wrong signal to the staff members. Ideally, an administrator or doctor or high standing in the hospital should be tasked to head the program. This should be a person who commands respect and can get the cooperation and trust of others. The appointment of the Champion should be made a hospital-wide affair. A small ceremony might be held at the appointment and the beginning of the Champion’s research efforts. This will give all those in the hospital a cue that something big is in the works and allow them to prime themselves for the implementation of the program. At the same time while the Champion is engaged in research people can themselves ready mentally and also take comfort from the reality that they are being given some time before the big day comes. Nobody likes having a surprise sprang upon him or her. Just announcing one day that there is going to be a VAP implementation can upset some people because they might not have psychologically attuned themselves to the changes coming to the hospital. In addition, staff need to feel confident about what they are doing. Merely, being told to be careful about this or that is not enough. Experts or knowledgeable people about VAP prevention should be brought in prior to the implementation date to help, in particular, those who are involved in managing patients receiving mechanical ventilation to be thoroughly familiar with what they need to do to bring down the incidence of VAP. Meetings about the implementation could be interspersed with in-service teaching programs where fact sheets or posters could be made available to staff. Some programs have opted to use self-study modules. The particular conditions in a hospital and the preferences of staff can guide which methods might be the most useful in a particular case. Seek cooperation from others While the champion is engaged in research he or she can begin to tap other leaders from different departments as co-champions in the prevention and implementation program. Once again, those who are tapped to participate should be made to feel important and to understand that they are being selected because of their demonstrated qualities of integrity, follow-through, and other positive qualities. This will remind them that they have some standards and responsibilities to live up to. Also, the advice of these co-champions should be sought in terms of any experience they might have had. These are also the first people to benefit from the information gleaned by the champion. In fact, the Champion and the champions might hold weekly meetings so that the Champion can apprise them of his or her findings. This will ease the burden on the co-champions of having to be given a thick folder of information that they should read after all the research is done. If they have been involved in discussions for several weeks they would already have a lot of information upon which to draw so that when they are given the final copy of the findings and the implementation plan it will not be completely new to them. Such an approach will let the co-champions feel that their new role is less of a headache. As Craven (2006) suggests, co-champions can be drawn from a wide variety of functional areas. (Craven 2006) Prepare for implementation The co-champions in the different areas should begin as early as possible to begin priming those in their respective units for the coming implementation program. Co-champions should be sharing information about what they are learning from their meetings with the Champion/Researcher so that, once again, people on the front lines can feel some kind of ownership for the upcoming program. It would also lessen the information load on these people if they have already been given snippets of information by the co-champion in their department and participated in meetings that help make them feel that they are valuable members of the department and the hospital. Current knowledge Current knowledge of VAP suggests that “bacterial colonization of the aerodigestive tract and entry of contaminated secretions into the lower respiratory tract” are important targets for the prevention of VAP since this is a big part of the pathogenesis of VAP. The endotracheal tube, because of the possibility of leakage of oropharyngeal secretions around the cuff, acting thus as “a nidus for the growth of intraluminal biofilm” (Craven 2006). Patient safety and quality improvement should be highlighted as key terms in the program. In other words, even though the hospital is eager to deal with the problem of VAP this should not introduce other more serious problems because of neglect or over-enthusiasm in implementing the program. Responsibility of the Multidisciplinary Team Members of the multidisciplinary team will bring to the table “local knowledge” and advise the champion on what benchmarks are realistic and which ones might perhaps be unrealistic in light of conditions in their particular departments. This opportunity for dialogue, however, should not be allowed to degenerate into opportunities for evading responsibility or participation. The overarching goal of the program should be communicated clearly to the team by the Champion. Overall, “The responsibilities of this group include setting prevention benchmarks, establishing goals and time lines, and providing appropriate education and training, audits, and feedback to the staff, while continually updating themselves on the relevant clinical and prevention strategies” (Craven 2006). Marketing of the Prevention Program Resources are required to implement an effective program so hospital administrators should be brought fully on board and made to understand what the benefits are such as “improved clinical outcomes and significantly reduced costs” (Craven 2006). As noted earlier, the marketing should not be only to those who are in positions of authority, but rather across the whole spectrum. If all members of the hospital team are made to feel that they count and that they could benefit in one way or another from improved conditions the whole program is likely to succeed. Marketing communications should also allow the opportunity for feedback from all in the hospital and not simply be made a top-down matter. It is possible that those on the frontlines of program implementation will uncover important elements that could benefit the hospital as a whole. The champion should have an open door policy so that people across the hospital can freely approach him or her and voice their concerns. This would also allow any information on sabotage of the program to come to the attention of the Champion and have corrective measures taken. As the following flow-chart shows, the multidisciplinary team needs to have institutional support and have access to financial support as well as be fully apprised of the regulatory measures as they go about implementing the program. (Craven 2006) Be selective The research conducted by the Champion should also include an attempt to ascertain if there are any particular risk factors for VAP based on conditions in the hospital. With this information on hand, the Champion and co-champions can focus on the most salient prevention methods. There are numerous prevention opportunities but if hospital staffs are inundated with dozens of elements to focus on it is unlikely that they can grasp all of these well. Far better to focus on the crucial prevention strategies and perhaps add to them over time as staff become attuned to handling and dealing with a few strategies at first. In the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign, hospitals are challenged to adopt as many of the six recommended initiatives to reduce health-care-associated infections.18 The VAP or "ventilator bundle" initiative includes five simple1 components: elevation of the head of the bed to between 30° and 45°, a daily "sedation vacation," daily assessment or readiness to extubate, and prophylaxis for peptic ulcer disease and deep vein thrombosis. Some participating hospitals using this approach are reporting zero episodes of VAP over sustained periods of time (Donald Berwick, MD; IHI National Forum; personal correspondence; December 13, 2005; cited in Craven 2006). During the period of the implementation the Champion and indeed the hospital administration, which must be fully on board by now, need to ensure that there are enough staff members on hand. This is particularly the case for critical care units so that staff members do not have to run around trying to do a million different things. Such a state of affairs is sure to ensure inadequacy in the implementation. Checklists/Monitoring Easy to read checklists and implementation sign-in sheets must be placed at strategic points so that staff can indicate their compliance with expected procedures while also making it easy for supervisors to keep track of them. Staff disinfections can be indicated on a sign sheet while big posters can remind visitors, visiting students, volunteers, and patients to take advantage of disinfectants at their disposal. Also, there should be people designated to provide surveillance of ICU infections on a frequent basis to identify and quantify endemic and new MDR organisms. Such feedback, which is circulated among clinicians, laboratory, pharmacy and infection Control of antibiotics should also be a part of the program. For maximum effectiveness, “In addition, an infections disease pharmacist for the ICU team or computerized surveillance programs to target interventions and aid in determining optimal drug regimens should be considered” (Craven 2006). Position of patients There is a strong suggestion in the literature that patients who are receiving mechanical ventilation during enteral feeding are better off in a 30°to 45° semirecumbent position. Staff members should be continually reminded of this fact which has been document in some recent studies to reduce the incidence of VAP. Conclusion There are other elements that a hospital might focus on its prevention program such as the provision of intensive insulin therapy, a special enteral feeding program as opposed to parenteral feeding, antiseptics, colonization blockers, control of stress bleeding, and oral care, which has received extensive coverage in the literature. Regardless of which of these a particular hospital deems important, the key elements for implementation of a VAP prevention program remains the need to base it on the latest research information, have a champion in place who is well respected, get administrators and those who control access to the hospital’s coffers fully on board, appoint co-champions who act as leaders in their respective units, ensure that all staff involved in the implementation program have been educated about what they need to do and that there are monitoring mechanisms in place. Such monitoring should include keeping track of the incidence of VAP following the implementation of the program so that a proper comparison can be done with the incidence of VAP prior to implementation. Naturally, this will help show the extent to which the program is working or not working and allow for any possible Bibliography Craven, Donald K. “Preventing Ventilator-Associated Pneumonia in Adults: Sowing Seeds of Change.” Vol. 130 Issue 1 (Jul 2006):251. Pittet, Didier & Bonten, Marc J.M. “Towards invasive diagnostic techniques as standard management of ventilator-assisted pneumonia.” The Lancet, Vol. 356 Issue 9233 (Sep 9, 2000):874. Sierra, Rafael et al. “Prevention and Diagnosis of Ventilator-Associated Pneumonia. A Survey on Current Practices in Southern Spanish ICUs.” Vol 128 Issue 3 (Sep 2005):1667. Read More