Impact of a nurse pulmonary care protocol on the incidence of ventilator associated pneumonia: A prospective study

Objective: To determine the change in incidence of ventilator-associated pneumonia (VAP) after the implementation of a package of measures in a nurse pulmonary care protocol. Design: Prospective sequential study. Setting: A 14 bed surgical ICU in a tertiary referral university hospital. Patients: Patients with a stay >3 days were eligible. Forty-six consecutive patients over a 3-month period as controls, and after a two-months instruction period, forty-six consecutive patients after the implementation of the protocol. Interventions: A package of interventions concerning nursing pulmonary care were implemented. These interventions included: (1) Discontinuing standard nebulizing therapy with acetylcysteine and salbutamol; (2) Performing bronchial suction only on indication, these indications being: sputum retention on auscultation, imminent tube obstruction, visible (and audible) sputum in the tube and before turning the patient from supine to prone position; (3) use of a closed catheter suction system in case of PEEP > 10 cm H₂O; (4) use of a filter, which was replaced on a daily basis, on the bedside ambu balloon. Measurements and results: Pneumonia was diagnosed according to the CDC criteria. Mean age of all patients was 62 ± 16 and mean APACHE II score was 16.1 ± 7. The intervention and control group did not differ for age, sex and APACHE II on admission. The intervention group showed a significant reduction in pneumonia compared to the control group: 11/46 versus 21/46 (p < 0.05), with a shorter period on mechanical ventilation (95% Cl 9.4 - 16.0 versus 13.7 - 26.7 days, p < 0.05) and reduction in ICU stay (95% Cl 10.6 - 17.6 versus 14.9 - 27.8 days, p < 0.05). Conclusions: A significant reduction of the incidence of VAP can be achieved by relatively simple changes in the nurse pulmonary care protocol.