Most strategies to prevent HAI’s (healthcare-associated infections) require multifaceted interventions or “bundles” of individual interventions. Use of such bundles has been demonstrated to reduce the risk of various HAI’s, though there is often controversy over which of the individual components of the bundle is most important. One of the problems in implementing bundles, however, is that compliance with all the individual components tends to be highly variable. Having a good auditing tool, such as the one used with IHI’s VAP Bundle, is very important.
Last month, a group from France (Bouadma 2010) demonstrated how they significantly reduced their VAP rates by focusing on improving compliance with 8 targeted measures for VAP prevention. The criteria for the measures they chose were that were (1) based on well-recognized published guidelines, (2) easily and precisely defined acts, and (3) directly concerned healthcare workers’ bedside behavior. Compliance with hand hygiene and glove-and-gown use was high at the start and remained high throughout. But compliance with all other measures was low at the start and showed continuous and sustained improvement throughout. These included backrest elevation, tracheal cuff pressure maintenance, orogastric tube use, avoidance of gastric overdistention, good oral hygiene, and elimination of non-essential tracheal suctioning. Their multidisciplinary team focused on an educational program for staff with written materials (including a mandatory 3-hour slide presentation with interactive discussion) and reminders displayed on screensavers and prominently placed posters and feedback. Compliance improved progressively and produced a sustained improvement with 51% reduction in VAP prevalence.
There were a couple other lessons learned. To help improve compliance with the backrest elevation, they equipped all ICU beds with a simple color-coded visual reminder at the head of the bed to help the healthcare workers determine the optimal position. Maintaining that proper position is one of the most difficult interventions in our experience so this “pearl” is one many organizations can take home. A second intervention they did was to monitor tracheal cuff pressure continuously and use an alarm to warn healthcare workers when the pressure was too low.
The concept here is remarkably simple and similar to Peter Pronovost’s approach when the central line “checklist” was developed: (1) determine what the literature says works (2) look to see whether we comply with those recommendations (3) provide tools to help improve compliance and (4) audit or measure compliance with those interventions. And both are examples of incredibly effective interventions.
Bouadma L, Mourvillier B, Deiler V, et al. A multifaceted program to prevent ventilator-associated pneumonia: Impact on compliance with preventive measures. Critical Care Medicine 2010; 38(3): 789-796