Reducing Ventilator-Associated Pneumonia in the NICU
Reducing Ventilator-Associated Pneumonia in the NICU
We have shown that implementation of the INICC multidimensional infection control strategy resulted in a significant reduction in the rate of VAP in the participating NICUs, which decreased by 33%. In particular, we found that improvement in hand hygiene compliance, which increased to 81%, was strongly correlated with the decrease in VAP rate. All participating hospitals are from countries with lower-middle-income and upper-middle-income economic levels, and it has been reported in the literature that hospitals associated with these socioeconomic conditions, compared with those from developed economies, are also associated with a higher risk of infection because of their resource limitations. Similarly, the type of hospital is another factor that influences the DA-HAI rates, with the economic level of the country having a stronger impact on public hospitals than on academic and private hospitals. Our high VAP rates have also been influenced by this fact, because developing economies reflect their socioeconomic level in a lack of administrative support and insufficient financial resources within hospitals. The type of hospital at which our NICUs were located, however, did not account for the high VAP rate, because only 11% of enrolled patients were from public hospitals.
Reducing DA-HAIs has been an important issue in developed countries and has become particularly important in many US hospitals after the decision by Medicare to not provide increased payments for VAP or central line–associated bloodstream infection. Unfortunately, several healthcare institutions in developing countries lack basic infection control programs, and most caregivers are unaware of VAP rates at their healthcare facilities. A significant number of VAP preventive strategies have been reported in several studies, which showed the positive impact of basic interventions, such as hand hygiene, early removal of endotracheal tubes, and continuous subglottic suctioning. However, the majority of such studies have not been performed on neonatal patients, but on adult patients, and the majority of such studies are from developed countries.
Our findings lead us to consider that VAP reduction in NICUs from developing countries is feasible. To prevent and control VAP, infection control professionals must implement a strategy that is based on an accurate knowledge of VAP rates at their healthcare facility, so as to approach the interventions with cost-effective preventive measures. It is noteworthy that implementation of only a single measure may not be sufficient to control VAP, and doing so requires a culture change that involves the entire ICU team (doctors, nurses, and respiratory therapists). The benefit of multidimensional infection control programs focused on educational interventions has been shown in many studies. Nevertheless, educational efforts produce benefits that may be short-lived without regular reinforcement.
It is important to note that trained infection control professionals performed our VAP surveillance. With the increasing pressure placed on hospitals to report measures of quality, including VAP rates, there is a risk that hospital staff will interpret the VAP definition in a way that appears to minimize their VAP rates. Interestingly, despite the problems associated with considering VAP to be a good quality indicator, we achieved a successful reduction in VAP rates in the NICU setting.
We are aware that we may not be able to sustain current VAP rates indefinitely, but our goal is to sustain a nearly perfect compliance with the ventilator bundle and maintain ICU team motivation for VAP prevention. The improvement shown in INICC member hospitals, in this setting and elsewhere, provides healthcare personnel with simple but effective and inexpensive preventive strategies. We expect that this will result in a wider acceptance of infection control programs in all hospitals in limited-resource countries.
Argentina: Sandra Guzman, Ariel Boglione, and Oscar Migone (Centro Médico Bernal, Buenos Aires).
Colombia: Nayide Barahona-Guzmán, Alfredo Lagares-Guzmán, and Guillermo Sarmiento-Villa (Universidad Simón Bolívar, Barranquilla).
El Salvador: Ana C. Bran-de-Casares and Lilian de-Jesús-Machuca (Hospital Nacional de Niños Benjamín Bloom, San Salvador).
India: Sweta Shah and Vatsal Kothari (Kokilaben Dhirtubhai Ambani Hospital, Mumbai); Amit Gupta and Narinder Saini (Pushpanjali Crosslay Hospital Ghaziabad).
Mexico: Martha Sobreyra-Oropeza (Hospital de la Mujer, Mexico City).
Morocco: Naima L. Bouazzaoui and Kabiri Meryem (Children Hospital of Rabat, Rabat).
Peru: Favio Sarmiento-López (Hospital Regional de Pucallpa, Pucallpa).
Philippines: Glenn A. S. Genuino, Rafel J. Consunji, and Jacinto B. V. Mantaring III (Philippine General Hospital, Manila); Victoria D. Villanueva and Maria C. V. Tolentino (St. Luke's Medical Center, Quezon City).
Tunisia: Khaldi Ammar and Asma Hamdi (Hospital d'Enfants, Tunis).
Turkey: Mustafa Yildirim and Selvi Erdogan (Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce); Hakan Uzun (Duzce University Medical School Department of Pediatrics); Ali Kaya and Necdet Kuyucu (Mersin University, Faculty of Medicine, Mersin); Sukru Küçüködük (Ondokuz Mayis University Medical School, Samsun).
Discussion
We have shown that implementation of the INICC multidimensional infection control strategy resulted in a significant reduction in the rate of VAP in the participating NICUs, which decreased by 33%. In particular, we found that improvement in hand hygiene compliance, which increased to 81%, was strongly correlated with the decrease in VAP rate. All participating hospitals are from countries with lower-middle-income and upper-middle-income economic levels, and it has been reported in the literature that hospitals associated with these socioeconomic conditions, compared with those from developed economies, are also associated with a higher risk of infection because of their resource limitations. Similarly, the type of hospital is another factor that influences the DA-HAI rates, with the economic level of the country having a stronger impact on public hospitals than on academic and private hospitals. Our high VAP rates have also been influenced by this fact, because developing economies reflect their socioeconomic level in a lack of administrative support and insufficient financial resources within hospitals. The type of hospital at which our NICUs were located, however, did not account for the high VAP rate, because only 11% of enrolled patients were from public hospitals.
Reducing DA-HAIs has been an important issue in developed countries and has become particularly important in many US hospitals after the decision by Medicare to not provide increased payments for VAP or central line–associated bloodstream infection. Unfortunately, several healthcare institutions in developing countries lack basic infection control programs, and most caregivers are unaware of VAP rates at their healthcare facilities. A significant number of VAP preventive strategies have been reported in several studies, which showed the positive impact of basic interventions, such as hand hygiene, early removal of endotracheal tubes, and continuous subglottic suctioning. However, the majority of such studies have not been performed on neonatal patients, but on adult patients, and the majority of such studies are from developed countries.
Our findings lead us to consider that VAP reduction in NICUs from developing countries is feasible. To prevent and control VAP, infection control professionals must implement a strategy that is based on an accurate knowledge of VAP rates at their healthcare facility, so as to approach the interventions with cost-effective preventive measures. It is noteworthy that implementation of only a single measure may not be sufficient to control VAP, and doing so requires a culture change that involves the entire ICU team (doctors, nurses, and respiratory therapists). The benefit of multidimensional infection control programs focused on educational interventions has been shown in many studies. Nevertheless, educational efforts produce benefits that may be short-lived without regular reinforcement.
Study Limitations
It is important to note that trained infection control professionals performed our VAP surveillance. With the increasing pressure placed on hospitals to report measures of quality, including VAP rates, there is a risk that hospital staff will interpret the VAP definition in a way that appears to minimize their VAP rates. Interestingly, despite the problems associated with considering VAP to be a good quality indicator, we achieved a successful reduction in VAP rates in the NICU setting.
We are aware that we may not be able to sustain current VAP rates indefinitely, but our goal is to sustain a nearly perfect compliance with the ventilator bundle and maintain ICU team motivation for VAP prevention. The improvement shown in INICC member hospitals, in this setting and elsewhere, provides healthcare personnel with simple but effective and inexpensive preventive strategies. We expect that this will result in a wider acceptance of infection control programs in all hospitals in limited-resource countries.
Other INICC Investigators Participating in This Study
Argentina: Sandra Guzman, Ariel Boglione, and Oscar Migone (Centro Médico Bernal, Buenos Aires).
Colombia: Nayide Barahona-Guzmán, Alfredo Lagares-Guzmán, and Guillermo Sarmiento-Villa (Universidad Simón Bolívar, Barranquilla).
El Salvador: Ana C. Bran-de-Casares and Lilian de-Jesús-Machuca (Hospital Nacional de Niños Benjamín Bloom, San Salvador).
India: Sweta Shah and Vatsal Kothari (Kokilaben Dhirtubhai Ambani Hospital, Mumbai); Amit Gupta and Narinder Saini (Pushpanjali Crosslay Hospital Ghaziabad).
Mexico: Martha Sobreyra-Oropeza (Hospital de la Mujer, Mexico City).
Morocco: Naima L. Bouazzaoui and Kabiri Meryem (Children Hospital of Rabat, Rabat).
Peru: Favio Sarmiento-López (Hospital Regional de Pucallpa, Pucallpa).
Philippines: Glenn A. S. Genuino, Rafel J. Consunji, and Jacinto B. V. Mantaring III (Philippine General Hospital, Manila); Victoria D. Villanueva and Maria C. V. Tolentino (St. Luke's Medical Center, Quezon City).
Tunisia: Khaldi Ammar and Asma Hamdi (Hospital d'Enfants, Tunis).
Turkey: Mustafa Yildirim and Selvi Erdogan (Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce); Hakan Uzun (Duzce University Medical School Department of Pediatrics); Ali Kaya and Necdet Kuyucu (Mersin University, Faculty of Medicine, Mersin); Sukru Küçüködük (Ondokuz Mayis University Medical School, Samsun).
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