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(Chest. 2004;125:2224-2231.)
© 2004 American College of Chest Physicians

An Educational Intervention to Reduce Ventilator-Associated Pneumonia in an Integrated Health System*

A Comparison of Effects

Hilary M. Babcock, MD; Jeanne E. Zack, BSN; Teresa Garrison, MSN; Ellen Trovillion, BSN; Marilyn Jones, BSN; Victoria J. Fraser, MD and Marin H. Kollef, MD, FCCP

* From the Division of Infectious Diseases (Drs. Babcock and Fraser) and Pulmonary and Critical Care Division (Dr. Kollef), Washington University School of Medicine; and Departments of Hospital Epidemiology and Infection Control (Ms. Trovillion, Ms. Jones, Ms. Zack, and Ms. Garrison), BJC HealthCare, St. Louis, MO.

Correspondence to: Hilary M. Babcock, MD, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8051, St. Louis, MO 63110; e-mail: hbabcock{at}im.wustl.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To determine whether an educational initiative could decrease rates of ventilator-associated pneumonia in a regional health-care system.

Setting: Two teaching hospitals (one adult, one pediatric) and two community hospitals in an integrated health system.

Design: Preintervention and postintervention observational study.

Patients: Patients admitted to the four participating hospitals between January 1, 1999, and June 30, 2002, who acquired ventilator-associated pneumonia.

Intervention: An educational program for respiratory care practitioners and ICU nurses emphasizing correct practices for the prevention of ventilator-associated pneumonia. The program included a self-study module on risk factors for, and strategies to prevent, ventilator-associated pneumonia and education-based in-services. Fact sheets and posters reinforcing the information were posted throughout the ICU and respiratory care departments.

Measurements and results: Completion rates for the module were calculated by job title at each hospital. Rates of ventilator-associated pneumonia per 1,000 ventilator days were calculated for all hospitals combined and for each hospital separately. Overall 635 of 792 ICU nurses (80.1%) and 215 of 239 respiratory therapists (89.9%) completed the study module. There were 874 episodes of ventilator-associated pneumonia at the four hospitals during the 3.5-year study period out of 129,527 ventilator days. Ventilator-associated pneumonia rates for all four hospitals combined dropped by 46%, from 8.75/1,000 ventilator days in the year prior to the intervention to 4.74/1,000 ventilator days in the 18 months following the intervention (p < 0.001). Statistically significant decreased rates were observed at the pediatric hospital and at two of the three adult hospitals. No change in rates was seen at the community hospital with the lowest rate of study module completion among respiratory therapists (56%).

Conclusions: Educational interventions can be associated with decreased rates of ventilator-associated pneumonia in the ICU setting. The involvement of respiratory therapy staff in addition to ICU nurses is important for the success of educational programs aimed at the prevention of ventilator-associated pneumonia.

Key Words: education • infection • mechanical ventilation • pneumonia • prevention respiratory therapy


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Ventilator-associated pneumonia is the most common hospital-acquired infection among patients requiring mechanical ventilation, resulting in excess mortality, prolonged lengths of hospitalization, and increased medical care costs.123456 Colonization of the aerodigestive tract with pathogenic bacteria and subsequent aspiration of contaminated secretions into the lower airways appear to be the most important mechanisms for the development of ventilator-associated pneumonia.7 Therefore, clinical strategies aimed at preventing bacterial colonization of the host and subsequent aspiration have been most extensively investigated for the prevention of this nosocomial infection.8

Although the optimal approach to reducing ventilator-associated pneumonia is unclear, studies910111213 indicate that educating health-care workers who care for patients receiving mechanical ventilation can decrease the rate of ventilator-associated pneumonia. In times of limited resources, focusing health-care workers’ efforts on the prevention of ventilator-associated pneumonia is important, especially given the association between inadequate staffing in the ICU setting and the occurrence of nosocomial infections.14151617 Despite the importance of preventing nosocomial infections, available information suggests that such infections are on the rise, resulting in warnings from professional and national agencies to refocus efforts on their prevention.11819 Additionally, there are limited data documenting the influence of infection control education-based interventions targeting regional health-care systems.20 Therefore, we investigated the impact of a targeted educational intervention to prevent ventilator-associated pneumonia at four different hospitals in one large health system. The intervention was previously effective at decreasing rates of ventilator-associated pneumonia at one of these institutions, the adult teaching hospital, as reported by Zack et al.13 In this study, we compared the effect of the intervention in the adult teaching hospital and three other hospitals within the same integrated health system.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Intervention
A multidisciplinary task force consisting of two physicians (M.H.K. and V.J.F.) and members of the Barnes-Jewish Hospital Infection Control Team was formed in February 1999 to develop a policy for the prevention of ventilator-associated pneumonia. This policy was derived in large part from two literature reviews authored by one of the task force members.78 The task force also compared the new policy to the Centers for Disease Control and Prevention recommendations for the prevention of ventilator-associated pneumonia.18 Based on this information, the task force designed an educational module to improve practices related to the prevention of ventilator-associated pneumonia.

The centerpiece of the educational initiative was a 10-page self-study module. The module included information on the following topics related to ventilator-associated pneumonia: (1) epidemiology and scope of the problem, (2) risk factors, (3) etiology, (4) definitions, (5) methods to decrease risk, (6) procedures for collecting suctioned sputum specimens, and (7) clinical and economic outcomes influenced by ventilator-associated pneumonia. Risk factors for ventilator-associated pneumonia that were specifically addressed included those promoting aspiration (supine positioning and gastric overdistention) and those associated with bacterial colonization of the upper airway and stomach (prior antibiotic exposure and the use of stress ulcer prophylaxis). A section from the self-study module outlining specific risk reduction strategies addressed in the infection control policy is shown in Table 1 . The points made in the module were summarized with the acronym WHAP VAP, in which W stood for "Wean the Patient" as soon as possible, H for "Hand Hygiene," A for "Aspiration Precautions," and P for "Prevent Contamination." This acronym was also used on posters and fact sheets posted in the ICUs and respiratory therapy departments of all four hospitals.


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  		Table 1. Section From the Self-Study Module for the Prevention of Ventilator-Associated Pneumonia*

 
Prior to receiving the self-study module, participants were required to undergo a 20-question examination, testing their baseline knowledge about how to prevent ventilator-associated pneumonia. An identical examination was administered after completion of the module. Individuals who scored < 80% on the postintervention test were required to repeat the self-study module. In addition to the self-study module, the intervention included posters and fact sheets and in-services for nursing and respiratory therapy staffs. The in-services were provided by infection control specialists specifically trained on the policy aimed at preventing ventilator-associated pneumonia. In-services were provided at monthly intervals for the first 3 months of the intervention during scheduled training times and staff meetings in order to gain access to the majority of nursing and respiratory therapy staff. At the adult teaching hospital, respiratory care practitioners also received two 1-h lectures on the pathogenesis and prevention of ventilator-associated pneumonia (provided by M.H.K.).

The self-study module was encouraged for all respiratory care practitioners and nursing staff working in the ICU setting. At the pediatric hospital, adult teaching hospital, and Community Hospital 1, it was incorporated into mandatory competency training for the nurses. For staff not participating in the formal self-study module, attendance at the scheduled in-services, review of educational posters describing the "WHAP VAP" intervention (provided in all participating ICUs), and interaction with the local ICU infection control specialist were encouraged to promote acceptance of the guidelines aimed at preventing ventilator-associated pneumonia. Examinations were only administered to staff completing the self-study module.

Study Location and Patient Population
The intervention was performed at four hospitals in a single health system in the Midwestern United States: one adult teaching hospital, one pediatric teaching hospital, and two community hospitals. The adult teaching hospital is a 1,400-bed primary and tertiary care facility affiliated with a university medical school. An average of 6,400 patients are admitted annually to its five ICUs (medical, 19 beds; surgical/trauma/burns, 18 beds; medical/surgical, 12 beds; surgical cardiothoracic, 17 beds; and neurology/neurosurgical, 20 beds). The pediatric teaching hospital is a 235-bed primary and tertiary care facility associated with the same university medical school. This hospital has two ICUs: a neonatal ICU and a pediatric ICU. The neonatal ICU is a level-three, 52-bed unit with 700 to 750 admissions per year. The pediatric ICU is a combined medical and surgical unit with 26 beds that admits approximately 1,400 patients per year. Community hospital 1 is a 500-bed, private, suburban facility with three ICUs: two 10-bed medical-surgical ICUs and a 10-bed cardiothoracic surgery ICU, which admit approximately 1700 patients, combined, per year. Community hospital 2 is a 700-bed private suburban hospital with two combined medical-surgical ICUs with 25 beds each, with approximately 2,100 admissions to their ICUs.

During this investigation, no other protocols were introduced into these ICUs aimed at influencing the rate of ventilator-associated pneumonia. The ICUs participating in this program are all closed units with multidisciplinary teams providing patient care under the direction of attending physicians who are board certified in adult or pediatric critical care medicine. The leadership of the ICUs, including unit medical directors and clinical nurse specialists, remained constant during this study, and the staffing ratio of one nurse to two patients was also uniform throughout this time period. Overall, there was limited turnover in the respiratory therapy and nursing staffs of the ICUs (approximately ≤ 15% during the study period). Each ICU also had an established protocol or policy for the weaning of mechanical ventilation employed by the nursing staff and respiratory therapists.21

Study Design
At each of the hospitals, ventilator-associated pneumonia is tracked by the infection control specialists of that facility through prospective surveillance. All episodes of ventilator-associated pneumonia are reported to a common database at the Infection Control and Hospital Epidemiology Consortium of the health system. The definitions of ventilator-associated pneumonia used for surveillance are based on the Centers for Disease Control and Prevention National Nosocomial Infection Surveillance definitions,22 and are shown in Table 2 (adults) and Table 3 (children). Rates of ventilator-associated pneumonia per 1,000 ventilator days were followed from January 1, 1999, to June 30, 2002. For the pediatric and adult teaching hospitals and for community hospital 1, data regarding the microbiologic etiologies and timing of pneumonia were also available.


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  		Table 2. Definition of Ventilator-Associated Pneumonia for Adults (Pneumonia Must Meet Only One of the Following Three Criteria Groups But May Meet More)*

 

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  		Table 3. Definition of Ventilator Associated Pneumonia for Children*

 
The educational program was initiated in January 2000. All patients admitted to the participating ICUs were followed up in a similar fashion throughout the study period. The preintervention period was defined as January through December 1999, the year before the intervention was introduced. The postintervention period was defined as January 2001 through June 2002, the 18 months after the intervention was completed at all facilities. An 18-month postintervention period was selected to minimize the influence of early changes associated with the introduction of the education program that eroded with time.

Data were analyzed using a statistical software program (SPSS 10.0 for Windows; SPSS; Chicago, IL). Rates of ventilator-associated pneumonia were compared using {chi}2 analysis. All tests were two tailed; p < 0.05 was considered statistically significant. For the three hospitals with available data, common microbiologic findings and the ratio of early onset (occurring < 96 h after intubation) to late-onset ventilator-associated pneumonia before and after the intervention were analyzed with {chi}2 analysis. The study was approved by the Washington University School of Medicine Human Studies Committee.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Compliance Results
The intervention was introduced in the spring of 2000 at community hospital 1, summer 2000 at community hospital 2, fall 2000 at the adult teaching hospital, and winter 2000 at the pediatric hospital. All hospitals had completed the intervention by the fall of 2000, except the pediatric hospital, which completed the intervention by the end of 2000. The infection control nurse assigned to the individual ICU determined when completion of the intervention had occurred in terms of staff exposure to the available education resources.

Overall, for all four hospitals, 635 of 792 ICU nurses (80.1%) and 215 of 239 respiratory therapists (89.9%) completed the module. The staff completion rates at the individual hospitals for the self-study module are shown in Table 4 . The highest rates of module completion among nurses were at the pediatric hospital (335 of 335 nurses) and at community hospital 1 (93 of 94 nurses). At both of these hospitals, the self-study module was included in mandatory competency training for the nurses. The completion rates among nurses at the adult teaching hospital (146 of 225 nurses) and at community hospital 2 (61 of 138 nurses) were statistically lower than at the other two hospitals (p < 0.001). The highest rates of module completion among respiratory therapists were at the adult teaching hospital (114 of 114 therapists) and community hospital 2 (54 of 54 therapists), and lowest at community hospital 1 (18 of 32 therapists) [p < 0.001 for comparison to both adult hospitals].


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  		Table 4. Staffing Completion Rates for the Self-Study Module

 
Ventilator-Associated Pneumonia Rates
During 1999, the year before the intervention, the overall ventilator-associated pneumonia rate for all four hospitals combined was 8.75/1,000 ventilator days. The intervention was introduced and completely implemented during 2000, and the combined annual rate during that year did not change significantly (7.81/1,000 ventilator days, p = 0.161). In the 18 months after the intervention was completed (January 1, 2001, through June 30, 2002), the overall rate dropped to 4.74/1,000 ventilator days (p < 0.001). There were no statistically significant differences in the ventilator-associated pneumonia rates during the first 6 months or 12 months after the intervention was completed compared to the last 12 months or 6 months after the intervention was completed.

Three of the four hospitals had a statistically significant drop in their ventilator-associated pneumonia rates from the preintervention year to the postintervention period (Fig 1 ). The largest decrease was seen at community hospital 2, where the rate dropped by 61% (5.17 episodes vs 2.03 episodes of ventilator-associated pneumonia per 1,000 ventilator days, p = 0.003). The adult academic center had a decrease of 53% (10.5 episodes vs 4.9 episodes per 1,000 ventilator days, p < 0.001). Rates at the pediatric teaching hospital dropped by 38% (7.9 episodes vs 4.9 episodes per 1,000 ventilator days, p < 0.001). Community hospital 1 did not have a significant change in their rates of ventilator-associated pneumonia (7.9 episodes vs 8.1 episodes per 1,000 ventilator days, p = not significant). While this hospital did have a high module completion rate among nurses (98.9%), the module completion rate among respiratory therapists was the lowest of the four hospitals (56.3% vs 95.2% at the other three hospitals combined, p < 0.001). The changes in ventilator-associated pneumonia rates by quarter are shown in Figure 2 .



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  		Figure 1. Ventilator-associated pneumonia rates preintervention and postintervention by hospital.

 


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  		Figure 2. Ventilator-associated rates by quarter (Q). Solid line indicates when all hospitals had completed their interventions.

 
Microbiologic data from the patients with ventilator-associated pneumonia were available for the two teaching hospitals and for community hospital 1. For these three hospitals, in both the preintervention and postintervention periods, Pseudomonas aeruginosa was the most commonly identified organism associated with ventilator-associated pneumonia (22.3% preintervention vs 23% postintervention). Staphylococcus aureus was the second most commonly identified organism (21.3% preintervention vs 22.5% postintervention). No differences in the proportions of major causative organisms associated with pneumonia were seen when results were reviewed by individual hospital. In these three hospitals, late-onset ventilator-associated pneumonia (after > 96 h intubated) was more common than early onset pneumonia in both the preintervention and postintervention periods (86.6% and 86.9%, respectively). Data were not available for community hospital 2.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This study demonstrated that an educational initiative directed at respiratory care practitioners and ICU nurses was associated with decreases in the incidence of ventilator-associated pneumonia at three of four participating hospitals. Decreases in ventilator-associated pneumonia rates ranged from 38 to 61%. Our results suggest that participation by respiratory therapy staff and incorporation of the self-study module into mandatory competency training for staff are important for reducing ventilator-associated pneumonia rates using education-based interventions.

Previous studies have been primarily carried out at single institutions, usually large, urban teaching facilities. Our current study found that educational interventions can also be effective in pediatric settings, where little data exist about the prevention of ventilator-associated pneumonia, and in community hospitals. For the three hospitals with available data, we did not find any change in the time to onset of pneumonia nor any change in the microbiology of the infections. These findings suggest that the intervention improved ventilator management and care, rather than eliminating a particular nosocomial reservoir of infection. Our results also suggest respiratory therapists may be important targets for educational interventions about ventilator-associated pneumonia. The one hospital without any appreciable effect from the intervention had the lowest rate of participation by respiratory therapy staff. High rates of participation from nursing at this hospital did not appear to offset the deficit in participation by respiratory therapists.

Nosocomial infections are common causes of excess morbidity and hospital costs among patients requiring intensive care. A prevalence of 20.6% was reported by Vincent et al23 in the European Prevalence of Infection in Intensive Care study, which included 10,038 patients from 1,417 European ICUs in 1992. Pneumonia was the most common nosocomial infection (46.9%) in that study. In a large study1 of US medical ICUs involving 181,993 patients, urinary tract infections were most frequent (31%), followed by pneumonia (27%). Ventilator-associated pneumonia has been associated with excess attributable mortality in several well-controlled studies,242526 as well as significant attributable cost.27 These studies, as well as several risk factor intervention studies,2829 suggest that prevention of this nosocomial infection could improve patient outcomes.

Prevention of hospital-acquired infections, including ventilator-associated pneumonia, is advocated as an important management objective for all hospitals.30 Several reviews7818 have outlined the available strategies to prevent ventilator-associated pneumonia that have been effective. However, other studies suggest that these interventions are not being widely implemented. Cook et al31 compared Canadian and French ICUs regarding the use of seven strategies to control secretions and care for ventilator circuits to prevent ventilator-associated pneumonia and reduce overall health-care costs. Adherence to specific prevention guidelines for ventilator-associated pneumonia was more common among French ICUs (64% vs 30%, p = 0.002), but rates were low in both countries. These investigators also found that published recommendations did not appear to substantially affect whether prevention interventions were used within individual ICUs. Similarly, a European survey found that 37.0% of ICUs practitioners were not following published recommendations for the prevention of ventilator-associated pneumonia.32 The most common reasons for nonadherence were disagreement with the interpretation of clinical trials (35.0%), lack of resources (31.3%), and costs associated with the implementation of specific interventions (16.9%).

Educational initiatives provide another strategy for preventing nosocomial infections. Joiner et al9 assembled a multidisciplinary team to develop strategies to reduce ventilator-associated lower respiratory tract infections in the ICUs of a 540-bed acute care teaching medical center. The group included medical, nursing, and respiratory therapy staff that developed the intervention and educated the ICU staff on its implementation. This intervention prevented 18 lower respiratory tract infections in 1993, at an estimated cost savings of $126,000. Similarly, Kelleghan et al10 used continuous quality improvement concepts to create a Nosocomial Pneumonia Prevention Team including representatives from nursing, respiratory therapy, pulmonary medicine, internal medicine, anesthesiology, education and training, and infection control. During the intervention year, they observed a 57% reduction in the rate of ventilator-associated pneumonia compared to the baseline years, resulting in a cost savings of $105,000. Similarly, we previously reported the effect of this educational intervention at a large teaching hospital, where it resulted in an estimated cost savings of at least $425,606.13 These experiences suggest that the implementation of educational initiatives to prevent nosocomial infections can result in cost savings, which can justify the initial investment required for the development and implementation of such interventions.

There are a number of limitations to our current study. First, in a preintervention and postintervention observational, nonrandomized study, other possible factors might have occurred coincident with the intervention that resulted in lower pneumonia rates. Similarly, we did not collect baseline data such as demographics or severity of illness that may have influenced the occurrence of ventilator-associated pneumonia. The inclusion of multiple hospitals and of multiple ICUs within each hospital makes this less likely. The use of the module and educational materials may also have resulted in other changes in behavior, in addition to or instead of those directly encouraged by the initiative, among respiratory care practitioners, nurses, or other health-care providers, which could have accounted for these results. Although this is possible, the end result of a reduction in the rate of ventilator-associated pneumonia appears to be temporally associated with implementation of this initiative. Therefore, the goal of decreasing infections was accomplished despite our inability to identify the specific intervention(s) accounting for it. We also did not account for the distribution in staff taking the self-study module vs the in-services and how this may have influenced the overall success of the intervention.

Another important limitation of our study is that we did not evaluate outcomes other than ventilator-associated pneumonia. As a result, we cannot determine whether this intervention influenced antibiotic utilization, length of hospital stay, mortality, or antibiotic resistance patterns. Additionally, staffing in the ICUs setting has been shown to be an important determinant of compliance with infection control policies.14151617 Although we did not collect information on daily staffing, all four participating hospitals had nursing policies on staffing that resulted in unit diversion for new admissions when staffing resources were exceeded. Microbiologic data were not available for one of the community hospitals. Nevertheless, our current and prior experience suggests that the bacteria associated with ventilator-associated pneumonia are similar among the adult community and teaching hospitals in St. Louis, where P aeruginosa and S aureus are the two most common pathogens.2733

A final limitation of our study is that there appeared to be variability in local participation with the education program among the participating hospitals despite encouraging nurses and respiratory therapists to complete the study module and attend the in-services. Our findings demonstrate that even though this education program was incorporated into mandatory competency training for nurses at three of the participating hospitals, completion rates varied from a low of 56% for respiratory therapists at one of the community hospitals to 100% for nurses at the pediatric hospital and respiratory therapists at the adult teaching hospital and one of the community hospitals (Table 4). The high rates of completion for respiratory therapists in the adult teaching hospital and one of the community hospitals may be due, in part, to the physician medical directors of those departments having participated in the initial development and/or review of the education module. Nevertheless, incorporation of the self-study module into formal competency training for staff was associated with the highest completion rates, especially for nurses. Additionally, it appears that support for the education program from the medical directors of respiratory therapy may improve participation in the education program.

Despite these limitations, our results have broad clinical implications. While much emphasis has been placed on guidelines to prevent ventilator-associated pneumonia, a large discrepancy still exists at many institutions between published guidelines and actual practice. This may be accounted for by the lack of motivation for hospitals to invest resources into successful implementation of such guidelines. By instituting a simple, risk-free educational module, infection rates decreased in three hospitals by 38 to 61%. This effect was achieved not only in an adult academic medical center but also in a pediatric teaching hospital and in a large community hospital. The achievement of a similar effect in multiple settings suggests that the intervention may be generalizable to other facilities. Hospital organizations interested in providing similar educational programs to their staffs should consider incorporating them into mandatory competency training. This is currently being planned for the participating hospitals in this study when this educational program is relaunched in 2004.


   Acknowledgements
 
The authors thank the infection control specialists, respiratory care practitioners, and the nursing staffs participating in this quality improvement project.


   Footnotes
 
This work was supported by funding from the Centers for Disease Control and Prevention Cooperative Agreement UR8/CCU715087–01, BJC Hospital Epidemiology and Infection Control Consortium, and the National Institutes of Health (GM00709).

The study module and self-examinations can be obtained as a CD-ROM through the Association for Professionals in Infection Control and Epidemiology.

Received for publication June 24, 2003. Accepted for publication December 9, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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