Rebound in ventilator-associated pneumonia rates during a prevention checklist washout period

Abstract

OBJECTIVE To describe the washout effect after stopping a prevention checklist for ventilator-associated pneumonia (VAP). METHODS VAP rates were prospectively monitored for special cause variation over 42&emsp14;months in a paediatric intensive care unit. A VAP prevention bundle was implemented, consisting of head of bed elevation, oral care, suctioning device management, ventilator tubing care, and standard infection control precautions. Key practices of the bundle were implemented with a checklist and subsequently incorporated into the nursing and respiratory care bedside flow sheets to achieve long-term sustainability. Compliance with the VAP bundle was monitored throughout. The timeline for the project was retrospectively categorised into the benchmark phase, the checklist phase (implementation), the checklist washout phase, and the flowsheet phase (cues in the flowsheet). RESULTS During the checklist phase (12&emsp14;months), VAP bundle compliance rose from <50% to >75% and the VAP rate fell from 4.2 to 0.7 infections per 1000 ventilator days (p<0.059). Unsolicited qualitative feedback from frontline staff described overburdensome documentation requirements, form fatigue, and checklist burnout. During the checklist washout phase (4&emsp14;months), VAP rates rose to 4.8 infections per 1000 ventilator days (p<0.042). In the flowsheet phase, the VAP rate dropped to 0.8 infections per 1000 ventilator days (p<0.047). CONCLUSIONS Salient cues to drive provider behaviour towards best practice are helpful to sustain process improvement, and cessation of such cues should be approached warily. Initial education, year-long habit formation, and effective early implementation demonstrated no appreciable effect on the VAP rate during the checklist washout period.

Measurable outcomes of quality improvement using a daily quality rounds checklist

“…Our findings are in contrast with recent reports of a washout phenomenon. Cheema et al 16 described a ''checklist washout phase'' in which a rebound in the VAP incidence was observed after a significant initial decrease. Staff feedback in that study suggested that an excessive documentation burden associated with the checklist may have contributed to a ''checklist burnout'' and resulted in the impact loss observed.…”

Dedicated Multidisciplinary Ventilator Bundle Team and Compliance with Sedation Vacation

“…[6][7][8][9][10] As expected, cessation of sustained efforts to monitor compliance are associated with increased rates of VAP. 11 Further, institutions are encouraged to customize the ventilator bundle to their institutional culture in order to maximize effectiveness. 12 To date, most publications describing compliance with the ventilator bundle have involved assessment of the impact on VAP rates.…”

Recipes for checklists and bundles: one part active ingredient, two parts measurement

“…Many outcomes in the field, not just CVC-BSI, involve fundamentally subjective elements—ventilator-associated pneumonia,30 preventable adverse events, ‘unexpected’ cardiac arrests in the setting of evaluations of rapid response teams, ‘unintended medication discrepancies’ and diagnostic errors, to name but a few. Social and psychological factors at the individual and institutional levels make accurate ascertainment of such outcomes, at the very least, a complex challenge, if not an unachievable goal.…”