The effectiveness of a bundle in the prevention of ventilator-associated pneumonia

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

The

effectiveness

of

a

bundle

in

the

prevention

of

ventilator-associated

pneumonia

Cléria

Rodrigues

Ferreira

_,

_Denis

_Fabiano

_de

_Souza

_,

_Thulio

_Marques

_Cunha

_,

Marcelo

Tavares

_,

_Samir

_Seme

_Arab

_Reis

_,

_Reginaldo

_Santos

_Pedroso

_,

Denise

Von

Dolinger

de

Brito

Röder

a_{FaculdadedeMedicina,UniversidadeFederaldeUberlândia,Uberlândia,MG,Brazil} b_{FaculdadedeMatemática,UniversidadeFederaldeUberlândia,Uberlândia,MG,Brazil} c_{InstitutodoCorac¸ãodoTriânguloMineiro,Uberlândia,MG,Brazil}

d_{EscolaTécnicadeSaúde,UniversidadeFederaldeUberlândia,Uberlândia,MG,Brazil} e_{InstitutodeCiênciasBiomédicas,UniversidadeFederaldeUberlândia,Uberlândia,MG,Brazil}

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Articlehistory: Received25July2015 Accepted4March2016 Availableonline18April2016

Keywords: Ventilator-associatedpneumonia Checklist Cost Mortality

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Objectives: TheaimofthisstudywastoevaluatetheimpactofabundlecalledFASTHUGin ventilator-associatedpneumonia,weighthehealthcarecostsofventilator-associated pneu-moniapatientsintheintensivecareunit,andhospitalmortalityduetoventilator-associated pneumonia.

Materialandmethods:Thestudywasperformedinaprivatehospitalthathasan8-bed inten-sivecareunit.Itwasdividedintotwophases:beforeimplementingFASTHUG,fromAugust 2011toAugust2012andaftertheimplementationofFASTHUG,fromSeptember2012to December2013.Anindividualformforeachpatientinthestudywasfilledoutbyusing informationtakenelectronicallyfromthehospitalmedicalrecords.Thefollowingdatawas obtainedfromeachpatient:age,gender,reasonforhospitalization,useofthreeormore antibiotics,lengthofstay,intubationtime,andoutcome.

Results:AftertheimplementationofFASTHUG,therewasanobservabledecreaseinthe occurrenceofventilator-associatedpneumonia(p<0.01),aswellasareductioninmortality rates(p<0.01).Inaddition,theinterventionresultedinasignificantreductioninintensive careunithospitalcosts(p<0.05).

Conclusion: TheimplementationofFASTHUGreducedthenumberofventilator-associated pneumoniacases.Thus,decreasingcosts,reducingmortalityratesandlengthofstay,which thereforeresultedinanimprovementtotheoverallqualityofcare.

©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Correspondingauthor.}

E-mailaddress:[email protected](D.V.D.d.B.Röder).

http://dx.doi.org/10.1016/j.bjid.2016.03.004

1413-8670/© 2016 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Ventilator-associated pneumonia(VAP) is the second most commonhealthcare-associatedinfections(HAI)intheUnited Statesandisresponsiblefor25–42%ofallinfectionsthatoccur inintensivecareunits(ICUs).Amongthosepatientsrequiring mechanicalventilation, mortalityrates are46% inpatients withVAP.1–3 _{Patients withVAP have significantlyincreases}

thelengthofhospitalstay and thushealthcarecosts. This howevercouldbereducedifstepsaretakentoimprovethe careprovidedfortheventilatedpatient.Therefore,the pre-ventionofVAPmustbeapriorityinthecareofcriticallyill patients.4–6

Healthprofessionalscontinuallystrivetoimprovethecare providedforpatientsadmittedtoICU.3_{Theresultsofrecent}

qualityimprovementinitiatives suggestthatmanycasesof VAP could be prevented by paying careful attention when deliveringcare,whichistheprimaryrole ofthe FASTHUG checklist. FASTHUG is a mnemonicaid to ICU healthcare professionalstoprepareforpatientrounds,helpidentifyand preventmedicationerrors,promotepatientsafety,and maxi-mizetherapeuticinterventions.3,7

Inthisstudy,weevaluatetheimpactofFASTHUGinthe occurrenceofVAP,weighthehealthcarecostsofVAPpatients intheICU,andhospitalmortalityduetoVAP.

Materials

and

methods

Thestudy was performedin a private hospitalin the city of Uberlandia, Minas Gerais-Brazil that has an 8-bed ICU. Itwas dividedinto two phases: beforeimplementing FAST HUG,fromAugust2011toAugust2012andafterthe imple-mentationofFASTHUG,fromSeptember2012toDecember 2013.Theresearchwasconductedaftertheapprovalofthe EthicsCommitteeonHumanResearchoftheFederal Univer-sityofUberlandia,accordingtotheregistryprotocolCEP/UFU: 442.151/2013.

Anindividualformforeachpatientinthestudywasfilled outbyusinginformationtakenelectronicallyfromthe hos-pitalmedicalrecords.Thefollowingdatawasobtainedfrom eachpatient: age,gender,reasonforhospitalization, useof threeormoreantibiotics,lengthofstay,intubationtime,and clinicaloutcome.Furthermore,theFASTHUGchecklist,which correspondsto10items,wasfollowedandprintedoutdaily bythenursingstaff.

Thestudy inclusion criteria were age over 18 years, be hospitalizedatthe study hospital,and usingamechanical ventilator(MV)forover48h.

Definitions

FASTHUGisachecklistthathighlightskeyaspectsof gen-eralcareforcriticallyillpatients.Themnemonicaidstresses the importance ofthe following clinical practices: feeding, analgesia, sedation, thromboembolic prophylaxis, head of bedelevation,stressulcerprophylaxis,andglycemiccontrol.

FASTHUGcanbeappliedtoallICUpatients.3_Accordingto

scientificliterature,therearealsothreeimportantactionsto betakeninordertoreduceVAP,whichare:oralhygienewith 2%chlorhexidine,monitoringcuffpressurebetween20and 25cmofwater,andsubglotticsuctioneverysixhoursor when-evernecessary.2,3

VAP:mechanicallyventilatedpatientswhoseconditionhas evolvedtothepointwhereaneworprogressivepulmonary infiltrateinachestX-ray.Thedefinitionalsorequiresatleast twoclinicalsigns and/orlaboratoryabnormalities that sug-gestaninfectiousprocesssuchas:fever(>38◦C);leukocytosis (>10,000mm–3_{)orleukopenia(<4000mm}–3_);presenceof

puru-lenttrachealsecretionafter48hofventilation.1,3,8

Statisticalanalysis

TheKolmogorov–SmirnovandShapiro–Wilktestswereused totestthenormalityofallthevariables.TheMann–Whitney test was used for the continuous variables with non-parametricdistributionandtheWilcoxontestforanalyzing the intra-group. Kaplan Meier and Cox regression sur-vival analyses was also used. The chi-square test was applied to compare categorical variables. Furthermore, a binarylogisticregressionanalysiswasperformedamongthe groups.

Results

In total 188 patients were included in the survey, with 56 patientsin2011,79patientsin2012and53patientsin2013, ofwhich37 patientshad VAP,20ofwhom werediagnosed clinicallyand17clinicallyandmicrobiologically.

Table1showsthestatisticalcomparisonofthepatients’ clinical characteristics ofthose withand without VAP.The variables associated with VAP in univariate analysis were use three or more antibiotics prior to infection (p<0.001); enteralnutritionwhileintheICU(p<0.01);andtracheostomy (p<0.01).VAPassociatedmortalityratewas64%(p<0.05)and lastly,thepresenceofinfectionrepresentedanadditional hos-pitalcostofR$7302.70perday(p<0.01).Throughmultivariate analysis(Table2),itwasobservedthatagewasanindependent factorforVAP(p<0.05;OR26.99).

Thedemographicandclinicalcharacteristicsofthegroup of patients with and without the FAST HUG checklist are shown in Table 3. In univariate analysis, the number of antibiotic-therapy days was significantly higher for those who usedthreeormoreantibiotics(p<0.001).Furthermore, by using APACHE II, patients undergoing FAST HUG had moresevereclinicalconditionsatadmission(p<0.01),which increased the mortality risk (p<0.05). However, after the implementationofFASTHUG,therewasadecreased occur-rence of VAP among these patients (p<0.01), as well as a mortality reduction(p<0.01). Additionally, the intervention performedinthestudyresultedinasignificantreductionin ICUhospitalcosts(p<0.05).

Throughlogisticregressionanalysis,significantlylessdays ofantibioticuse(p<0.0001)andalowermortalityrate(p<0.05) couldbeseenasaresultofFASTHUG.

Table1–ClinicalcharacteristicsofpatientsadmittedtoaBrazilianhospitalonmechanicalventilationfromJuly2011to

December2013.

Variables VAP(n=37) NoVAP(n=151) pValue OR

Gender(M/F) 26(70.3%) 11(29.7%) 84(55.6%) 67(44.4%) 0.10 0.53(0.24–1.15) Age,y(≥65,<65) 23(62.2%) 14(37.8%) 68(45.1%) 83(54.9%) 0.06 2.0(0.95–4.19) Antibioticsa _{33(89.2%) 46(30.9%) <0.01}c _{18.83(6.30–56.23)} Enteralnutrition 36(97.3%) 77(51%) <0.01c _{34.59(4.62–258.84)} Tracheostomy 30(81.1%) 31(20.5%) <0.01c _{16.59(6.66–41.32)} APACHEII 18.51±10.83 16.0±9.9 0.2 – APACHEIIb _{36.30±27.18 28.23±22.49 0.06 –} Death 24(64%) 68(59%) <0.05c _– Dailycost(R$) 9550.81±6172.21 2248.11±607.20 <0.01c _–

APACHE,AcutePhysiologicalandChronicHealthEvaluation;F,female;M,male;ORoddsratio;VAP,ventilator-associatedpneumonia;R$, Braziliancurrency.

a _{Means≥3antibioticsclass.} b _{Mortalityrisk;}

c _p≤0.05.

Table2–Logisticregressionanalysisoftheclinicalcharacteristicsofpatientsonmechanicalventilationadmittedtoa

BrazilianhospitalfromJuly2011toDecember2013.

Variables VAP(n=37) NoVAP(n=151) pValue OR

Gender(M/F) 26(70.3%) 11(29.7%) 84(55.6%) 67(44.4%) 0.62 0.58(0.68–5.09) Age,y(≥65,<65) 23(62.2%) 14(37.8%) 68(45.1%) 83(54.9%) 0.05c _{26.99(1.16–627.33)} Antibioticsa _{33(89.2%) 46(30.9%) 0.16 10.21(0.54–190.73)} Tracheostomy 30(81.1%) 31(20.5%) 0.16 33.90(1.91–601.5) APACHEII 18.51±10.83 16.0±9.9 0.38 – APACHEIIb _{36.30±27.18 28.23±22.49 0.93 –}

APACHE,AcutePhysiologicalandChronicHealthEvaluation;F,female;M,male;ORoddsratio;VAP,ventilator-associatedpneumonia. a _{Means≥3antibioticsclass.}

b _{Mortalityrisk.} c _p≤0.05.

Thesurvivalanalysisshowedthatlongerlengthofstayin theICUwasassociatedlowersurvival(Fig.1),andthatpatients undergoingFASTHUG survived longer.Cox regression was adjustedtotheriskfactorsidentifiedinthelogisticregression analysis;antibiotics,enteralnutritionandtracheotomycases

showedeventsat38%andcensoring59%,withsimilarityof thetwogroups(p>0.05).

However,therewasnosurvivaldifferencebetweenthetwo groupsinthefirst20daysofadmission.However,considering thefirst80daysofhospitalization,50%oftheFASTHUGgroup

Table3–AnalysisofdemographicandclinicalcharacteristicsofpatientswithandwithoutFASTHUGadmittedtoa

BrazilianhospitalfromJuly2011toDecember2013.

Variables NoFASTHUG(n=115) FASTHUG(n=73) pValue OR

Gender(M/F) 57/43 35/65 0.86 – Age,y(≥65,<65) 58(50.4%) 33(45%) 0.80 – Hospitalization(days) 16(8.5–35.5) 19(9–47) 0.32 0.99(0.98–1.0) Antibiotics(days) 17(9–140) 8(5–57) <0.001c _– Antibioticsa _{71(62%) 25(34%) <0.001}c _– Surgical 6(5%) 3(4%) 0.72 0.77(0.18–3.21) Clinical 101(88%) 66(90%) 0.58 1.37(0.5–3.4) Trauma 9(8%) 6(8%) 0.92 1.05(0.35–3.09) MVtime 14(6–140) 15(5–139) 0.16 0.99(0.98–1.0) APACHEII 14.75±9.8 20.22±9.87 <0.01c _– APACHEIIb _{26±22 35±26 <0.05}c _– VAP 30(26) 7(9,6) <0.01c _{0.30(0.12–0.32)} Death 70(60) 22(30) <0.01c _{0.27(0.14–0.51)} Dailycost(R$) 6700.20±26,154.29 6339.34±24,529.83 <0.05c _–

APACHE,AcutePhysiologicalandChronicHealthEvaluation;F,female;M,male;MV,mechanicalventilation;ORoddsratio;VAP, ventilator-associatedpneumonia;R$,theBraziliancurrency.

a _{Means≥3antibioticsclass.} b _{Mortalityrisk.}

1.0 No FastHug With FastHug 0.8 0.6 0.4 Probability of sur viv al 0.2 0.0 0 20 40 60 80 Time 100 120 140

Fig.1–SurvivalrateforpatientswithandwithoutFAST HUG.

survivedcomparedto20%forthosewithouttheintervention. Additionally,asthelongerthe lengthofstay, thelowerthe survivalrateforpatientswithouttheintervention.

Discussion

VAPiscommoninpatientsthatareconnectedtomechanical ventilatorsoverlongperiods.Therefore,thecriteriausedfor diagnosingVAPisessential.9_{Althoughtherearevarious}

def-initionsofVAP,inthisstudythecriteriafever,leucocytosis, chest X-ray with presence with new and progressive pul-monaryinfiltrates,andmicrobiologicalcultureareutilized,as thesearerecommendedbytheAmericanThoracicSociety3,8_;

thesecriteriaalsopresentlowcostandarecommonlyused byICUsforthediagnosis ofVAP. Ontheother hand,these criteriahavelimitations:therearepatientswhodespite hav-ingpresentVAPsymptoms, donotfulfillthe morerigorous criteriaandwouldthereforebemissedashavingVAP.9_VAPis

ahealthcarerelatedinfectionandisthesecondleadingcause ofnosocomialinfectionslinkedtomorbidityandmortality.10

Therefore, theimplementation ofcareguidelines protocols hasbecomenecessaryfortheadequatetreatmentandcare ofcriticallyillpatientsinICUs.3,5_{Anexcellentalternativeis}

thecreationofchecklists.Theyaresimpleandeasily imple-mentedbymultidisciplinaryteamsworkinginahospital.7,11

In order to reach the goals of this study, the authors assumedthatachecklistisanindispensabletoolforsafety andcareofcriticallyillpatients.Itissuggestedthat health-careworkerswhomakebedsideroundsadoptamemorization techniqueofonesentence.Thiscanbeassociatedtoaletter torepresenttheproblemsthat mustbeevaluatedand cor-recteddailyincriticallyillpatients.Throughtheexpression oracronymFASTHUG,clinical aspectsofgreatimportance arehighlightedsuchasnutrition,analgesia,headboardheight, andothersthatcharacterizeprophylacticmeasuresforVAP.7

In relation to the research, various risk factors (the use of more than three antibiotics, enteral nutrition, and

tracheotomy)weresignificantlyassociatedwithVAP.Theuse ofantibioticshasbeenshowninscientificliteraturetomake up to 50%of all prescriptionsin the ICUfor patientswith VAP.12,13 _{Regarding enteral nutrition, it iswell known that}

a catheterispresentin almostall patientswitha MVand increasingthePHincreasestheriskofVAP,apredisposition togastriccolonization,whichthusincreasetheriskofreflux and aspirationspneumonitis.14 _{Researchconductedin2003}

showedthatenteralnutritionwasanindependentrisk fac-tor forVAP(p<0.001),as well astracheostomy (p<0.001).15

Anotherstudy showed,throughlogisticregressionanalysis, thattracheostomy(p<0.001)wasanindependentriskfactor thatcanleadtothedevelopmentofVAP.16

Inthisstudy,astatisticallysignificantadditionalmedical cost was seen inpatients with VAP.This hasbeen proven by other studies in the United States, which showed that hospitalexpenses are significantlyhigherforpatientswith VAP ($ 104,983), compared tothose without VAP ($ 63,689) [p=0.001].17 _{In2012, aprojectwas developedwiththeaim}

ofreducingVAPrates,whichresultedinadeclinefrom9.47 to1.9casesper1000ventilatordaysandthus,producingan estimatedsavingsofapproximately$1.5million.18

Inaddition, thesearchforimprovingthe qualityofcare linkedto criticallyillpatients, thus reducing hospital mor-tality,andthe useofhospitalqualityindicators,whichcan leadtobettercareandlowercosts,havebeentargetsofmajor globalagenciesaimedatpreventingdiseasesand iatrogene-sis.Therefore,itisessentialtousewhathascometobeknown aspackagedmeasures.14_{InapplyingFASTHUGtocriticallyill}

patientsdaily,resultedin:adecreaseinantibioticsuse,lower mortalityrates,lowerhospitalcosts,andmostimportantly, it significantlyreduced thenumberofVAP cases.Not tobe forgottenthatpatientsdiagnosedwithasevereillnessat hos-pitaladmittancehavehighermortalityrisk.Patientswhowere partoftheFASTHUGprogramweremorelikelytosurvivethan thosewithouttheintervention.Astudypublishedin2008inan ICUofanAmericanUniversityMedicalCentershoweda sig-nificantreductionofVAPcasesafterimplementingFASTHUG. The rate beforeFAST HUGimplementation was 16.6 cases ofVAPper1000daysofmechanicalventilation,droppedto 1.3casesaftertheimplementation.19_{Amulticenterstudyof}

ICUsintheUnitedStatesandCanadabetween2002and2004 showedsignificantreductioninVAP,andother morerecent studieshaveshownthatimplementingFASTHUGcauseda 41%reductionrateinVAP.20,21

Conclusion

The implementation of FASTHUG reduced the number of VAP cases, the mortality rate and hospital costs, as well asimproved thequality ofcare.FASTHUG isa packageof relatively simpleactionsthat doesnot overloadhealthcare professionals, and does not lead to an increase in hospi-talcosts.Itsimplementationrequiresnothingmorethanan administrativedecisionandpersonnelpreparationand train-ing to bring benefits, particularly to patients. Due to the relativesimplicitylinkedtotheprogram,itcanbeextended todifferentpublicandprivateinstitutionswithoutinterfering withotherplansofaction.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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