Ventilator associated pneumonia (VAP) is a chronic and costly problem in the intensive care setting. VAP increases patient morbidity, mortality, and length of stay. These negative effects add significantly to the financial and emotional burden to the patient and family. VAP is being considered for addition to the Medicare non-reimbursable infection list, therefore healthcare providers need to proactively evaluate and implement procedures to minimize VAP rates.
The focus of this article was identifying the lack of universal diagnostic criteria for VAP and the impact of the lack of diagnostic standardization on interpretation of hospital reported VAP rates. The author’s contention is, despite an abundance of studies on VAP prevention the inconsistencies between institutions in diagnostic criteria can provide false zero and/or falsely elevated reported rates of infection. Additionally, the study that was primarily cited by the author did not include several interventions which he felt represented a major design flaw. In summary, the disparity in diagnostic criteria and variety of VAP prevention bundles make it difficult to clearly interpret currently available data regarding efficacy of specific interventions. I included this article based upon the three criteria I chose for inclusion: publication date within five years, clinical relevance, and statistically significant data produced by the study. This article specifically addresses the quandary surrounding diagnosis and prevention of VAP.
The authors of this study chose to compare the effects of mechanical treatment, pharmacological treatment, and a combination of both on VAP reduction. In preparation for the study the authors reviewed previously identified causes of VAP and chose to focus their study on the effect of reducing oropharyngeal colonization by potential respiratory pathogens. The conclusion of the study indicated that their analysis was confounded, in part by the defining criteria they chose to identify VAP.
There was no significant reduction in VAP from toothbrushing(mechanical), and no sustained reduction beyond day three for the chlorhexedine(pharmacological) group. As has been noted in many studies there were additional, and perhaps more efficacious interventions concurrently in use, particularly elevation of the head of bed to thirty degrees. I included this article based upon the three criteria I chose for inclusion: publication date within five years, clinical relevance, and statistically significant data produced by the study. This article addresses the outcomes of specific nursing interventions targeting the reduction and/or elimination of VAP.
The researchers who designed this study attempted to minimize some of the confounding factors by applying certain aspects of the institution’s ventilator bundle to all of the study participants. This clearly defined standard of care improved the ability to directly attribute the effects of the research interventions. Prior to beginning the study the researchers observed the standard care of intubated patients in the facility and identified practices that were viewed as potentially contributing to oropharyngeal colonization. Based upon their observations, during the study period advanced oral care kits were exclusively used to provide oral care for the study group along with a clearly delineated schedule for performing different components of the oral care protocol.
The result for the study group was a significant reduction in VAP with increased time to VAP. There was also a decrease in ventilator days and length of intensive care unit stay. The study confirmed that VAP prevention is improved with the incorporation of comprehensive oral assessment and care. I included this article based upon the three criteria I chose for inclusion: publication date within five years, clinical relevance, and statistically significant data produced by the study. This article addresses the outcomes of specific nursing interventions targeting the reduction and/or elimination of VAP
This article was published in Clinical Infectious Diseases, which is a peer reviewed journal. The subject is relevant to my topic in that it is a qualitative analysis of multiple studies on the efficacy of VAP reduction bundles. The author is a physician working in the field of infection control, affiliated with two major United States academic medical centers and as such he has professional credibility. No conflict of interest was reported by the author. The format of the article was a comparison of various VAP bundles and their outcomes from studies conducted by other researchers. The comparison group was large, comprised of seventeen different studies, all of which used the before-after design (Klompas, 2010). As a qualitative study the premise was not answerable by a yes or no hypothesis, instead it relied upon review of specific, focused research. This research substantiated the author’s initial question by defining elements that remain unaddressed in the current body of research surrounding the prevention of VAP (Klompas, 2010).
The study presented in this article was a well-designed 2 x 2 factorial trial (Munro, Grap, Jones, McClish, & Sessler, 2009). The principal investigator reported receiving a grant from the National Institutes of Health in support of this research, no other disclosures were reported. The investigators are fully credentialed in their respective fields. The study took place at a large academic medical center with a population that allows for broad representation. Participants were recruited from three intensive care units with clearly defined inclusion and exclusionary criteria. The study personnel were all appropriately blinded to the participants VAP status (Munro et al., 2009). The performance of the assigned treatments was completed by study personnel rather than the bedside nurse to increase the consistency of treatment delivery.
The authors noted a few limitations as the study progressed. The first limitation was the definition of VAP. In this case they chose to use clinical pulmonary infection score greater than six to define VAP (Munro et al., 2009). During the course of the study they noted that even though a clinical diagnosis of pneumonia was considered exclusionary, that many of the participants in fact had a CPIS greater than six upon enrollment (Munro et al., 2009). A second limitation was enrollment attrition; by day seven the number of participants was no longer large enough to be considered statistically significant (Munro et al., 2009). Despite the noted limitations the investigators were able to draw conclusions applicable to early onset VAP (Munro et al., 2009).
The study presented in this article was completed by a multi-disciplinary team, none of which reported any conflict of interest or financial disclosure. As one of the end points of the study was demonstration of a sustainable reduction in VAP rates use of cohort study was intentional, incorporating an extended time frame to counter the large number of required enrollees to otherwise demonstrate statistical significance (Garcia, Jendresky, Colbert, Bailey, Zaman, & Majumder, 2009). A potential confounding factor was the facility ventilator protocol, which included many interventions which are known to directly and significantly impact on reduction and prevention of VAP i.e. head of bed maintained at thirty degrees and an active weaning protocol (Garcia et al., 2009).
This study was completed at a large urban academic medical center and the participants were screened for defined eligibility criteria and are representative of the adult population at large. The authors or the study are appropriately credentialed in their fields and included a biostatistician to aid in the data analysis (Garcia et al ., 2009). The primary and secondary outcomes were clearly identified. All variables were tested or analyzed using the method demanded by the results. VAP was defined using the Centers for Disease Control and Prevention published definition (Garcia et al., 2009 ).
There remain many unanswered questions as to the etiology and prevention of VAP. In my research I observed that many of the studies included multiple interventions for VAP prevention in the study protocols. They also continued the institutions current policies for managing ventilated patients. It would seem to cloud the interpretation when there are multiple interventions making up the protocol i.e. Chlorhexedine rinse, and subglottic suctioning, and routinely scheduled oral care. Multi-factorial studies make it more difficult to determine which factor is influencing the outcome. A well designed study needs to eliminate or incorporate a single intervention at a time to determine its effect, or lack thereof.
This would enable the researcher to clearly demonstrate a cause and effect relationship More carefully crafted studies will need to be performed with a universally agreed upon definition of VAP. As is always the case when research is involving people there is a reluctance to leave off anything that might be perceived as healing. In this case I believe that multiple interventions performed simultaneously are a hindrance to clearly understanding what is truly the most efficacious VAP prevention protocol design.
In light of ongoing mandates from CMS to eliminate nosocomial infections there is an added impetus to define and eliminate VAP. Ventilator associated pneumonia is a chronic and costly problem in the intensive care setting. VAP increases patient morbidity, mortality, and length of stay. These negative effects add significantly to the financial and emotional burden to the patient, family, and the institution. Therefore, healthcare providers need to proactively evaluate and implement procedures to minimize VAP rates.
Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care: A 48 month study. American Journal of Critical Care, 18(6), 523-532. Doi:10.4037//ajcc2009311 Klompas, M. (2010). Ventilator-associated pneumonia: Is zero possible? Clinical Infectious Diseases, 51(10), 1123-1126. Doi:10.1086/656738 Munro, C., Grap, M., Jones, D., McClish, D., & Sessler, C. (2009). Chlorhexedine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care, 18(5), 428-438. Doi:10.4037//ajcc2009792
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