Mechanically ventilated patients in the intensive care unit (ICU) are vulnerable to multiple complications including ventilator-associated pneumonia, pulmonary edema, ARDS, atelectasis, thromboembolic disease, and other ventilator-associated events (VAEs). In all, about 5% to 10% of patients develop VAEs.
“Four studies used qualitative analysis to identify the most common triggers for VAEs and the findings are consistent across all studies. The four most common conditions that trigger VAEs are pneumonia, pulmonary edema, atelectasis, and ARDS. These four conditions account for 80 percent or more of VAEs,” explained Michael Klompas, MD, MPH, FRCPC, an infectious disease physician and associate hospital epidemiologist at Brigham and Women’s Hospital in Boston.
Armed with this knowledge, hospitals across the country can guide their efforts to prevent these high-burden complications. By reducing the rate of ventilator-associated events, healthcare facilities can get patients out of the ICU faster, reduce readmissions and dramatically lower healthcare costs.
What Steps Can be Taken?
“The main focus needs to be on getting patients off the vent sooner and targeting the top four conditions that cause VAEs,” Klompas shared.
In 2013, the National Healthcare Safety Network (NHSN) released VAE definitions to replace their longstanding surveillance definitions for VAP. The new definitions were based on recommendations from stakeholder societies including critical care physicians, nurses, respiratory therapists, infection preventionists and epidemiologists. They were designed to broaden the focus of prevention to encompass additional complications besides pneumonia and to make surveillance more objective.
When the new definitions were released two years ago, VAE was a brand new concept so people weren’t able to draw on historical reservoirs of information to prevent its occurrence. “Because VAEs were new, it’s taking some time to build the science about what interventions work to prevent VAEs,” Klompas said.
Nonetheless, there are now multiple published studies evaluating risk factors and the impact of different prevention strategies on VAEs. Klompas highlighted recent data that supports the role of coordinated, daily spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) to prevent VAEs by decreasing patients’ sedative and ventilator exposures. “Conservative fluid management is another potentially potent approach,” he said.
Following the new definitions set out by the CDC, Klompas led an investigation to assess the preventability of VAEs. The study tracked consecutive episodes of VAE in 20 intensive care units between November 2011 and May 2013. Twelve ICUs implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs and eight units conducted surveillance only. Members of the collaborative were able to decrease their VAE rates by 37% and their infection-related ventilator-associated complication rates by 65%.
Additional promising interventions include minimizing sedation, avoiding the use of benzodiazepines, and incorporating early mobilization of patients.
What is notable, Klompas told ADVANCE, is that nothing on the prevention list is a surprise. “There is nothing controversial about the proposed prevention strategies,” he said. “These are interventions and processes that are already being widely advocated in the critical care community independent of VAE prevention.”
The changes, therefore, should be prime targets for healthcare facilities to focus upon. “This is not about what we need to do, because we already know what to do,” Klompas shared. “This is about how to put processes into practice to make the performance of these interventions reliable and consistent.”
The most successful groups when it comes to preventing VAEs are those that have broken down silos between different members of the healthcare team. The interventions most likely to prevent VAEs (minimizing sedation, SATs and SBTs, minimizing fluids, early mobility, etc.) by their nature require the efforts and expertise of frontline nurses, doctors, respiratory therapists, physical therapists, pharmacists and unit leadership.
A good starting place is to measure current performance rates for each of these processes. Hospitals need to determine how consistently these interventions are being delivered, identify where the gaps lie, and propose solutions. Klompas noted that, “the solutions will be individual to each ICU depending on the particular ICU’s specific gaps, challenges and protocols.”
Research Focused on Reducing VAEs
Klompas is participating in several ongoing studies to enhance the adoption of best practices in this arena. Spearheaded by The Armstrong Institute for Patient Safety and Quality out of Johns Hopkins, CUSP 4 MVP-VAP is a national collaborative quality improvement project funded by The Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services.
The initiative is designed to decrease the duration of mechanical ventilation, improve outcomes through early mobility, and prevent acute lung injury via low-tidal-volume ventilation. The initiative requires a two-year commitment from hospitals to implement new interventions designed to improve outcomes for this patient population.
Hospitals participating in the initiative work with a national team of clinicians, patient safety professionals, and researchers who specialize in preventing ventilator-associated pneumonia and ventilator-associated events, mechanical ventilation safety, and improving safety culture within units.
Participating teams adopt the Comprehensive Unit-based Safety Program (CUSP), an approach created at Johns Hopkins, for improving safety processes and ensuring that frontline clinicians identify and reduce problems with care delivery. Orientation for hospitals interested in participating in the next two-year cohort, at no cost, will begin in September 2015.
Rebecca Mayer Knutsen is on staff. Contact: [email protected]