Michael Klompas, MD, Professor of Population Medicine at Harvard Medical School and Associate Hospital Epidemiologist at Brigham and Women’s Hospital, Boston, addresses misconceptions about the prevalence of ventilator-associated pneumonia and delves into the reasons why it occurs, the most promising approaches to prevention, and what might be on the horizon to keep patients healthier. Dr. Klompas also served on the Infectious Disease Society of America (IDSA)/ATS Guideline group for Management of Hospital-Acquired and Ventilator-Acquired Pneumonia.
HPN: Why do you think VAP remains so prevalent, despite the availability of evidence-based guidelines?
KLOMPAS: In truth, we don’t know the exact prevalence of VAP and whether rates are changing or not because it’s a very difficult entity to diagnose with any certainty. The lack of clinical certainty carries over into surveillance where the classical VAP surveillance definitions allow lots of room for subjective judgments. This means that two very thoughtful, very knowledgeable people looking at the same patient may well come to very different conclusions about whether or not VAP is present.
What we can say for sure is that clinicians continue to start antibiotics for the possibility of VAP at a relatively high rate. If in fact the rate has not meaningfully changed over time, it might be because our understanding of best practices to prevent VAP is evolving. Many hospitals have implemented ventilator bundles with a common set of prevention measures to try to protect patients from VAP.
Most bundles include elevating the head of the bed, daily spontaneous awakening trials, daily spontaneous breathing trials, stress ulcer prophylaxis, thromboembolism prophylaxis, and oral care with chlorhexidine. The evidence underlying each of these interventions varies widely. Emerging data suggest that in fact some are helpful in improving patient outcomes and others not. The most useful bundle components appear to be spontaneous awakening and breathing trials.
New data suggest that oral care with chlorhexidine and stress ulcer prophylaxis may in fact be harmful. In addition, there are some other prevention strategies that probably are quite helpful but are not necessarily included in all VAP prevention bundles such as early mobility, delirium screening, conservative fluid management, low tidal volume ventilation, and conservative blood transfusion thresholds.
What would you say is the leading cause of VAP?
The leading cause of VAP is invasive mechanical ventilation.
Anything we can do to avoid intubation or speed extubation to minimize the amount of time patients spend on a ventilator will help prevent VAP.
While the CDC’s VAP incident rates showed remarkable progress, a research letter published in JAMA revealed that those numbers — based on hospital self-reporting — were grossly inaccurate and VAP rates haven’t changed at all. What is your reaction to this finding?
As noted above, VAP definitions used for surveillance are very subjective. They require surveyors to assess things like “the quality and quantity of secretions.” There’s lots of room with criteria like these for differences of opinion. In addition, many of these criteria are not at all specific. The worry then is that surveyors intent on demonstrating lower VAP rates may subconsciously err on the side of judging these subjective criteria more strictly and thus think there are fewer VAP cases than there might be.
This is not a fault of the surveyors per se so much as a reflection of the complexity of diagnosing VAP and the subjectivity permitted by the VAP definition. CDC has been very cognizant of these issues and these are amongst the reasons why CDC dropped their classical VAP definitions and replaced them with ventilator-associated event definitions which were specifically designed to be more objective.
Is there anything new — new science — that clinicians should know about? Are there any devices, medications or other products that may be especially helpful for preventing VAP?
On the prevention side, it’s becoming increasingly apparent that the best thing we can do to avoid VAP is to minimize duration of mechanical ventilation. And our best strategy for doing so in my opinion is to minimize sedation using spontaneous awakening trials and to extubate patients as soon as possible by performing spontaneous breathing trials so that we can know as soon as possible when a patient might be ready to breathe without support from a ventilator.
There are many exciting new products under evaluation including novel endotracheal tube designs, tracheal cuff pressure monitoring systems, antiseptic coatings, novel patient positioning methods, and more but none yet has been clearly shown to improve patient outcomes. The infection control and critical care communities remain hopeful that one or more of these approaches might bear fruit.
Advance oral hygiene necessary for preventing pneumonia
Mike Nygren, Director of Marketing Communications, Sage Products LLC, now part of Stryker, discusses the latest research, guidelines and a new oral care product that helps prevent hospital-associated pneumonia among ventilated and non-ventilated patients.
HPN: Have there been any recent changes in VAP prevention guidelines and how does the SAGE product meet those recommendations, specifically?
Nygren: The 7th edition of AACN’s Procedure Manual for High Acuity, Progressive and Critical Care just published at the end of 2016. This edition reinforced key procedures from past editions for ventilated patients but also expanded and established best practices for oral care in non-ventilated dependent and independent patients. Sage’s products continue to comply with these best practices, and we will continue to develop new innovations as evidence evolves.1
There has also been a shift in thinking and a push to address non-ventilated patients, because they too are at risk. The new AACN recommendations for this population are based on a groundswell of clinical evidence that exposes the often morbid condition of NV-HAP.1
Please describe what makes the oral care products from SAGE innovative and unique to others on the market?
Our newly released Corinz product both moisturizes and cleans, reducing a step in the current oral care process and making for an easier workflow. We’ve found that continuing to strive to make the oral care process simpler and easier, leads to fewer compliance barriers. All of our oral care products are designed to provide caregivers a comprehensive system that includes sequential packaging.
Additionally, the clinical success experienced by oral care customers when compliant to oral care protocols on ventilated patients has led us to expand our focus to non-vented patients, who are also at risk for pneumonia and may benefit from comprehensive oral care.
How diligent would you say clinicians are in keeping up with the oral care guidelines for ventilated patients? What are their biggest challenges or barriers and what can you suggest?
The AACN Procedure Manual 7th edition is the first recommendation from a guideline institution since 2009.1-2 Now is a great time for practice committees to reexamine their protocols to make sure they have products/tools that match facilities’ protocols, help remove compliance barriers, and align with these new recommendations. We strive to provide products that can easily fit into staff workflow and match protocols recommended by guidelines set forth by associations and the CDC.
A published four-year study using an oral care protocol including Q•Care Oral Care Systems saw a 33 percent reduction in VAP, plus fewer vent days, shorter length of stay and decreased mortality rates.3
That study is a bit old. Have there been any recent research, case studies or hospital success stories that you can share?
Clinicians have made great strides in VAP prevention, so while this study happened a while ago, VAP rates have dropped considerably and research has shifted to applying best practices from this study to underserved non-ventilated patients.
Quinn & Baker published their pioneering study on the prevalence and prevention of NV-HAP, entitled: “Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia” in the Journal of Nursing Scholarship in 2014. This study uncovered a significant prevalence of NV-HAP in three hospitals, including their interventional site at Sutter Medical Center Sacramento. There, utilizing a comprehensive oral care protocol and product, the team showed a 37 percent reduction in NV-HAP over 12 months, resulting in $1.72 million cost avoidance, 500 extra hospital days averted, and eight lives saved. Since then, Quinn & Baker have gone on to champion intervention in this space and have sparked several hospitals to investigate NV-HAP at their own facilities.4
Several outcome posters have been presented in the last 12 months, which will develop into published studies. Additionally, a national incidence study on NV-HAP just published in the October issue of AJIC where 21 hospitals showed a collective 1,300 cases of NV-HAP in 12 months with similar mortality, length of stay, and readmissions found in earlier studies.5
What would you want supply chain and value analysis teams to know about the Corinz product? Why is it a good investment?
A product must be easy to use and therefore utilized in order to be an effective prevention intervention. Products and programs that drive compliance are what make a sound investment. There are many tools that will work, but go unused because they don’t fit into nursing workflow. Education, service, and support programs are another way to judge the value of products offered. If staff is not properly supported and educated, it’s difficult to drive compliance.
- ReferencesVollman K, Sole ML, Quinn B. Procedure 4 – Endotracheal Tube Care and Oral Care Practices for Ventilated and Non-ventilated Patients. In: AACN Procedure Manual for High Acuity, Progressive, and Critical Care. 7th Edition. Vol 37. 2nd ed. ELSEVIER.
- Greene LR, Sposato K. Guide to Elimination of Ventilator-Associated Pneumonia. Washington, DC: APIC; 2009.
- Garcia R, Jendresky L, Colbert L, Bailey A, Zaman M, Majumder M. Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study. American Journal of Critical Care. 2009;18(6). doi:10.4037/ajcc2009311.
- Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia. Journal of Nursing Scholarship. 2013;46(1):1-9. doi:10.1111/jnu.12050.
- Baker D, Quinn B. Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. American Journal of Infection Control. 2017. doi:10.1016/j.ajic.2017.08.036.