Intensive and Critical Care Nursing (2013) 29, 261265

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/iccn

Reducing risk for ventilator associated pneumonia through nursing sensitive interventions
Svatka Micik , Nihada Besic, Natalie Johnson, Matilda Han, Stephen Hamlyn, Hayley Ball
Cardiothoracic Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia Accepted 21 April 2013

KEYWORDS
Nursing sensitive interventions; Nursing sensitive patient outcomes; Ventilator associated pneumonia

Summary The purpose of this paper is to describe an improvement initiative designed to implement nurse sensitive interventions known to reduce patients risk for ventilator associated pneumonia (VAP), in cardiothoracic intensive care patients. This initiative is a part of one Australian critical care units efforts to identify and measure compliance with key nursing interventions known to improve cardiac surgical patients outcomes. The premise behind the initiative is that improved nursing process and surveillance systems allow emerging trends to catalyse action and motivate nurses to reduce patients risk for infection acquisition. At ve and nine months following implementation of the initiative a > 70% compliance rate in 11 out of the 15 nurse sensitive interventions known to reduce patients risks for VAP and a drop in VAP incidence from 13.4% to 7.69% from per 1000 ventilator days was accomplished. Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved.

Implications for Clinical Practice Assists nurses to transition from task focused to outcome based care. Promotes implementation of evidence based recommendations. Represents a low cost, yet cost effective infection control measure.

Corresponding author. Tel.: +61 8 8222 2288. E-mail address: svatka.micik@health.sa.gov.au (S. Micik).

0964-3397/$ see front matter. Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.iccn.2013.04.005

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S. Micik et al.
Safety from preventable infections

Introduction
As a result of the economic and clinical burden of ventilator acquired pneumonia (VAP), it is important to reduce patients risk of VAP acquisition. Although there are a myriad of reasons why patients develop VAP and a multidisciplinary approach is needed to reduce its incidence, nursing interventions play a vital role in VAP risk reduction. Establishing nursing sensitive patient outcomes (NSPOs) for patients predisposed to VAP provides measurable metrics that may be used to design and or implement specic nursing interventions.

Care bundles CRBSI SSI MRO VAP Standard of care Series of fundamental, interdependent and scientifically grounded nursing steps grouped into care bundles aimed at controlling microorganisms on the skin and in the oropharynx for which the CICU RN has sole responsibility to implement Nursing sensitive patient outcomes CRBSI SSI MRO VAP acquisition rates Nursing sensitive indicators Specific nursing assessment indicators such as oral cavity assessment score and intervention indicators such as 30 degree HOB elevation. 70% benchmark set to validate nursing compliance and performance Quarterly surveillance/reporting of the indicators of each infection prevention care bundle

Rationale for our QI project

Our unit is an eight bed cardiothoracic intensive care unit (CTICU) in South Australia. Since our units inception we have worked within a culture of nurse-led patient care. In 2008, having read the United States (US) Oncology Nursing Society white paper on nursing sensitive patient outcomes that promoted them as measurable effects of nursing care and provided a guiding framework for developing NSPOs, we considered how we might integrate this into our care (Given and Sherwood, 2005). This has been an ongoing project for the last four years and continues to be a work in progress. The white paper prompted our nurses to ask two questions: what do we know about our performance and what is in the literature about the development, implementation and utilisation of NSPO initiatives? Upon considering these questions we noted that although we had broad performance measures such as quarterly infection control performance indicator reports to help us understand our practice, we did not have specic nursing intervention and patient outcome measures to benchmark and inform and reafrm cardiothoracic intensive care nursing practice.

Diagram 1 Categorisation of care bundles, standard of care, nursing sensitive patient outcomes and nursing sensitive indicators for preventable infections in the CTICU.

literature and found our patients were most at risk of developing catheter related blood stream infections (CRBSI), surgical site infections (SSI), multi resistant organisms (MRO) and ventilator associated pneumonia (VAP), all of which are directly impacted by nursing care processes (Gil-Perotin et al., 2012). Our next step was to develop a nursing standard that promoted safety from preventable infections with specic nursing interventions. We dened the nursing standard as: Series of fundamental, interdependent and scientically grounded nursing steps, grouped into care bundles aimed at controlling micro-organisms on the skin and in the oropharynx for which the CTICU registered nurse has sole responsibility to implement. (CTICU NSPO working party) From our nursing standard we delineated catheter related blood stream infections (CRBSI), surgical site infections (SSI), multi resistant organisms (MRO) and ventilator associated pneumonia (VAP) care bundles aimed at reducing preventable infections. Care bundles are sets of evidence based practices, performed in a series of steps towards an intended effect. They are ongoing processes that focus on how to deliver the best care using a clear-cut method to provide the best possible outcome for patients (NHMRC, 2010). Although we had already determined safety from preventable infections as the overall patient outcome, we also needed to determine outcomes for each of the preventable infection bundles. We were already reporting our CRBSI, SSI and MRO to the National Nosocomial Infection Surveillance Report. This data provided us with specic outcome measures for the CRBSI, SSI and MRO care bundles. We were not yet collecting data on VAP rates. To guide, direct and reach the desired infection free outcomes for our patients we searched the literature for nursing assessment and intervention indicators for each of the four care bundles and chose indicators that were clinically meaningful for the CTICU patient. Once we identied these intervention or process measures for each of the care

Development of our nurse sensitive outcomes project

We reviewed the literature and learned for outcome measures to be meaningful, the chosen outcomes must be specic to the setting, clinical context, patient population, type of intervention, relevant to patient experiences and consistent with the expected effects of the intervention and supported by evidence (Doran and Pringle, 2011). When we considered our CTICU patient group, we identied safety (infections), post-operative symptom control (pain, immobility and constipation) and psychological well-being as important outcomes. Once we determined the patient outcomes we believed were relevant to our setting and could be improved by using established evidence, the CTICU leadership group called for expressions of interest from our nurses to join the NSPO working party. Our aim was to create outcome teams led by experienced clinical nurses working collaboratively with less experienced nurses. This approach would engage the whole team in the project. Safety from preventable infections was one of the rst patient outcomes identied by the NSPO working party (Diagram 1). We looked to our own practice and searched the

Ventilator acquired pneumonia bundles we could correlate these with the outcome data which would provide us with a useful means of identifying areas for improvement. We established audit tools that mirrored the chosen indicators and searched the literature for numerical target goals for each indicator. The literature yielded no nursing benchmark targets for our selected interventions and eventually we adopted Hand Hygiene Australias 70% hand hygiene compliance target rate, believed to decrease incidence of nosocomial infections and new MRSA and VRE cases (SA Health, 2011). Therefore it was reasonable to assume the same would apply to other preventable infections. Setting a numerical goal claried our aims to reduce the risk of infection, directed our agreed upon quarterly measurements of each of the indicators for each of the care bundles. Once the aim had been established, the team could work towards raising the threshold targets. This would help change the initial focus from reducing preventable infections as a desirable practice to reducing preventable infections as a mandatory procedure. Although we followed the same process for establishing outcome and process measures for all of the preventable infections, here we report only on the nursing sensitive care bundle for reducing the cardiothoracic patients VAP risk.
Ventilator associated pneumonia

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Care bundles Limit use of mechanical ventilation Prevent aspiration of secretions Prevent nasal and oro pharyngeal colonisation Prevent use of contaminated equipment Early mobilisation Standard of care Series of fundamental, interdependent and scientifically grounded nursing steps grouped into bundles aimed to control microorganisms in the oropharynx for which the CTICU RN has sole responsibility
VAP acquisition rate

Nursing sensitive patient outcome

Nursing sensitive indicators Specific nursing assessment indicators such as daily assessment of readiness to wean and nursing intervention indicators such as the use of cuffed ETT with above cuff aspirate 70% benchmark set to validate nursing compliance and performance Quarterly surveillance/reporting of the indicators of each VAP prevention bundle with consideration of broader infection control dashboard indicators

Diagram 2 Categorisation of care bundles, standard of care, nursing sensitive patient outcomes and nursing sensitive indicators for reducing patients risk of developing ventilator acquired pneumonia in the CTICU.

Nursing sensitive care bundle for reduction of VAP risk

What is VAP? The generally accepted denition of VAP is a sub-type of hospital-acquired pneumonia (HAP) which occurs in people who are mechanically ventilated via an endotracheal or tracheostomy tube at the time the pneumonia is diagnosed or within 48 hours of having been mechanically ventilated (Hess, 2012). The internationally stated rate is between 10 and 41.7% per 1000 ventilator days (Arabi et al., 2008). VAP is identied by using a combination of radiologic, clinical and laboratory criteria. VAP carries an increased pain and suffering burden, prolongs length of stay and carries with it a greater risk of mortality. For hospitals and health care administrators it greatly increases the cost of hospitalisation. VAP, a common intensive care unit complication has a reported incidence in Australia of 25% and a crude mortality of up to 65% (NHMRC, 2010). Understanding VAP pathogenesis is essential in order to develop a standard of care and an associated care bundle to reduce the risk of acquisition. Although optimal patient outcomes are generally associated with interdisciplinary collaboration, reducing risk of VAP is responsive to targeted nursing interventions, surveillance and infection control performance feedback. The literature identies four VAP pathogeneses in the critically ill as: (a) colonisation of the oropharynx by dental plague with subsequent migration of the bacteria to the lower airway (Milstone et al., 2008); (b) exogenous acquisition from the hands of health care workers and through contaminated respiratory equipment (INICC, 2012);

(c) aspiration of microbe laden oropharyngeal and gastric secretions around the cuffed airway management tube into the lower respiratory tract (Fields, 2008); (d) patient positioning with the head of the bed not elevated to 3045 , prolonged ventilation, advanced age and malnutrition (NHMRC, 2010). We reviewed all of the above sources and delineated care bundles, standard of care, patient outcome and nurse sensitive indicators for VAP (Diagram 2). The standard for VAP prevention was dened as; A series of fundamental, interdependent and scientically grounded nursing steps grouped into a care bundle aimed to control micro-organisms in the oropharynx for which the CTICU RN has sole responsibility. (CTICU NSPO working party) From the same literature (INICC, 2012; Milstone et al., 2008; NHMRC, 2010), we identied ve care bundles for reducing cardiothoracic patients risk of VAP: (1) (2) (3) (4) limiting the use of mechanical ventilation; preventing aspiration of secretions; preventing nasal and or pharyngeal colonisation; preventing use of contaminated respiratory equipment; and, (5) early mobilisation.

Finally we delineated several risk reducing nursing assessment and intervention indicators for each of the 5 care bundles (Diagram 3) from which we created a VAP risk reduction audit tool. Our compliance was to be measured by quarterly surveillance of outcome and process measures. The primary outcome measure was the relationship between VAP bundle compliance and VAP incidence. In the absence of data on the actual incidence of VAP in our unit we reached a consensus with the Intensive care consultant to identify patients with suspected VAP by the specic antibiotic regime

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Nursing sensitive indicators for VAP prevention bundle
Limit use of mechanical ventilation Daily sedation vacation followed by a readiness to wean assessment and spontaneous breathing trial Use NIV Wean ASAP Nursing vigilance to avoid accidental extubation as re intubation carries increased risk of VAP Education of health personnel who care for patients undergoing mechanical ventilation about VAP Prevent aspiration of secretions Maintain 30 degrees semi-recumbent position Avoid gastric over distension Use Cuffed ETT with above cuff aspirate Minimal leak ETT technique Maintain ETT cuff pressure at least 20cm H2O Prevent nasal and oro pharyngeal colonisation Mupirocin nasal ointment 5days Reduce oral plague and bacterial count by comprehensive oral hygiene with tooth brushing and oral swabs impregnated with chlorhexidine 0.12% Simple activities such as oral cavity assessment performed during oral care allow for early identification and score based interventions Prevention of use of contaminated equipment Greater than 75% hand hygiene and PPE compliance with performance feedback of infection control practices Closed system suction Adherence to recommended frequency of equipment change (HME filter 48hrs, breathing circuit only if solid, single use yankuer sucker, closed suction system 72hrs) Criteria for humidification (only with tenacious secretion) Early mobilisation Adherence to recommended mobilisation regime (INICC, 201 2 )

S. Micik et al.

Diagram 3 CTICU.

Specic nursing sensitive indicators for reducing patients risk of developing ventilator acquired pneumonia in the

ordered. Our pharmacist searched the dispensing data and identied those patients who were prescribed this specic treatment during the pre-initiative and rst post initiative auditing period. We then did a retrospective chart audit to exclude those patients whose antibiotic treatment was not continued because the microbiology ndings did not conrm the initial diagnosis. In the last auditing period VAP cases were identied by the intensive care specialist and entered onto a Nursing Sensitive Outcome data sheet. VAP rates were dened as the percentage of VAP cases per 1000 ventilator days. Nurses routinely count ventilator days for each patient and this practice continued. Our VAP bundle initiative started as a part of the safety from preventable infection NSPOs on November 1st 2011. Prior to bundle initiation, data was collected through a retrospective review of VAP rates for April 1st to June 30th 2011. We created a nursing sensitive patient outcome board that displayed our selected patient outcomes, standards, bundles and their specic interventions and compliance data. The team responsible for this NSPO held weekly education sessions on the bundle and associated nurse sensitive interventions in October 2011. Compliance data was collected on April 2nd 2012 and August 31st 2012, ve and nine months after the initiative started with VAP rates being collected for the three months leading up to and including the audit months of April 2012 and August 2012.The board was updated with the nursing assessment and intervention indicators audit ndings for each of the ve VAP prevention care bundles as well as the VAP prevalence rates. Recommendations for practice for all nursing sensitive indicators with an audit score of less than 70% were made via the display board and communicated to all nurses via the units on line communication forum and at handover.

Findings of our VAP project

A retrospective pre initiative VAP rate for the period starting 1st April 2011 and ending 30th June 2011 revealed a rate of 13.4% per 1000 ventilated days. A post initiative VAP rate for the period starting February 1st 2012 to April 30th 2012 was 7.69% per 1000 ventilated days and remained steady at 7.69% per 1000 ventilated days for the period June 1st 2012 to August 31st 2012. In the period of February 1st 2012 to April 30th 2012 the 7.69% incidence of VAP corresponded to a 70% or greater score for ten out of the fourteen VAP prevention nursing sensitive indicators. Of the four indicators that did not meet the 70% target score, two were related to documentation. The other two were related to inadequate head of bed elevation and frequency of naso enteric tube placement measures. In the second post initiative audit we added eight hourly endo tracheal cuff checks to the care bundle, bringing the nursing interventions number to fteen. For this period the 7.69% incidence of VAP corresponded to a 70% or greater score for ten out of fteen VAP prevention indicators. Of the ve indicators that did not meet the 70% target score, two were related to documentation. The other three were related to daily change of suction equipment and frequency of nasogastric measures and endo tracheal cuff checks.

Conclusion
The CTICU work with NSPOs builds on the work of international nursing colleagues. Our efforts describe the steps CTICU nurses are taking to help move forward knowledge and action related to nursing sensitive patient outcomes for

Ventilator acquired pneumonia cardiac intensive care patients. Our preliminary data suggests a positive trend in decreasing VAP. Furthermore, our work is helping our CTICU nurses to transition to outcome focused care. The outcomes inspire and drive the required interventions and help CTICU nurses own that which is purely nursing. Setting up NSPOs for specic patient groups requires considerable time, drive, commitment and enthusiasm. Once established it is anticipated the NSPOs will continue to evolve, but the process will be a lot less time consuming. Despite the effort required, this group of nurses believe the framework is a valuable tool for benchmarking against recognised standards and validating local nursing practice.

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J Neurosci Nurs J Am Assoc Neurosci Nurses 2008;40(5):2918 [Epub 2008/10/17]. Gil-Perotin S, Ramiez P, Marti V, Sahuquillo JM, Gonzalez E, Calleja I, et al. Implications of endotracheal tube biolm in ventilatorassociated pneumonia response: a state of concept. Crit Care 2012;16(3):R93. Given BA, Sherwood PR. Nursing sensitive patient outcomes a white paper. Oncol Nurs Forum 2005;32(4):77384 [Epub 2005/07/02]. Hess D. The ventilator circuit and ventilator-associated pneumonia; 2012, Available from: http://www.uptodate.com/ contents/the-ventilator-circuit-and-ventilator-associatedpneumonia?source=search result&search=the+ventilator+circuit +and+ventilator&selectedTitle=1%7E150 (13.08.12). INICC bundle to prevent ventilator-associated pneumonia in intensive care units: an international perspective. Buenos Aires: International Nosocomial Infection Control Consortium; 2012. Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: expanding the armamentarium for infection control and prevention. Clin Infect Dis Off Pub Infect Dis Soc Am 2008;46(2):27481 [Epub 2008/01/04]. NHMRC. Australian guidelines for the prevention and control of infection in healthcare. Canberra, ACT: Commonwealth of Australia; 2010. South Australian patient safety report 20092010. Adelaide, SA: SA Health; 2011.

References
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