Promoting subglottic secretion drainage: a quality improvement project in a UK critical care unit

The aim of the study was to promote the practice of subglottic secretion drainage (SSD) in a UK critical care unit. SSD is a technique employed to reduce microaspiration of oropharyngeal secretions in patients with cuffed endotracheal airways. Aspiration of oropharyngeal secretions is the accepted cause of the majority of ventilator-associated pneumonia (VAP), a complication of invasive ventilation with high associated mortality. The plan–do–study–act methodology was employed. The local critical care patient database was searched for patients requiring mechanical ventilation via a tracheostomy tube with subglottic port in the 3 months prior to intervention. Patient records were interrogated for evidence of the practice of SSD. The intervention involved the introduction of a tracheostomy care bundle to be prescribed on insertion of a tracheostomy on the critical care unit, in combination with departmental teaching. The bundle included prompts for nursing staff to practise regular SSD and to complete a tracheostomy care plan at the end of shift. A total of 24 patients were included. A review of practice was conducted every 3 months for 1 year. This showed an improvement in documented evidence of SSD from 0% of days at baseline to 85.7% of days at 1 year. Implementation of a tracheostomy order set prescribing regular SSD resulted in an improvement in the practice of SSD in patients ventilated via tracheostomy. This has implications for patient outcomes and healthcare costs, given that SSD has been shown to reduce incidence of VAP.

Impact of Each Component of a Ventilator Bundle on Preventing Ventilator-Associated Pneumonia and Lower Respiratory Infection

Background: Ventilator-associated lower respiratory infections (LRIs) and pneumonia (VAP) are important healthcare-associated infections and are among the leading causes of death worldwide. Prevention of these infections are often based on care bundles. We investigated the incidence of VAP+LRI and the preventive efficacy of each component of our ventilator bundle. Methods: Our ventilator bundle includes 6 components that are daily checked by an infection control practitioner. These 6 evidence-based practices were implemented in 3 ICUs from a general tertiary-care private hospital in Belo Horizonte City (Brazil): (1) daily oral care with chlorhexidine; (2) elevate the head of the bed to between 30 and 45; (3) avoid scheduled ventilator circuit change; (4) monitor cuff pressure; (5) use subglottic secretion drainage; and (6) daily sedation interruption and daily assessment of readiness to extubate. VAP and ventilator-LRI definitions were obtained from the CDC NHSN. The impact of adherence rate to items in the ventilator bundle (%) on the incidence rate of VAP+LRI was assessed using linear regression and scatterplot analyses. Results: Between January 2018 and April 2019, 1,888 ventilator days were observed in the 3 ICUs, with 42 VAP and LRI events, an overall incidence rate of 22.2 cases per 1,000 ventilator days. After September 2018, the infection control service started a campaign to increase the ventilator bundle compliance (Fig. 1). Adherence rates to all 6 bundle components increased between January–August 2018 and September 2018–April 2019 from 25% to 55% for daily oral care, from 34% to 79% for elevating the head of the bed, 28% to 86% for avoiding scheduled ventilator circuit change, from 32% to 83% for cuff pressure monitoring, from 32% to 83% for subglottic secretion drainage, and from 33% to 85% for daily sedation interruption. PAV and LRI incidence decreased from 41 to 16 in ICU A, from 22 to 14 in ICU B and from 24 to 18 in ICU C. The impact of each bundle component was identified by linear regression, calculating the percentage of PAV+LRI incidence rate that is explained by bundle item adherence (r2) and correlation coefficient (r): daily sedation interruption (r2 = 48%; r = 0.69; P = .004) (Fig. 2), cuff pressure monitorization (r2 = 0.3721; r = 0.61; P = .016), subglottic secretion drainage (r2 = 36%; r = 0.60; P = .017), avoidance of scheduled ventilator circuit change (r2 = 34%; r = 0.58; P = .023), daily oral care (r2 = 25%; r = 0.50; P = .050), and elevate the head of the bed (r2 = 25%; r = 0.48; P = .067). Conclusions: The impact of each bundle component on preventing PAV+LRI was identified by the study. An educational intervention performed by the infection control service increased the adherence to the ventilator bundle, and the PAV and LRI incidence decreased.Funding: NoneDisclosures: None

Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis

Although several guidelines recommend subglottic secretion drainage as a strategy for prevention of ventilator-associated pneumonia (VAP), its use is not widespread. With the aim to assess the effectiveness of subglottic secretion drainage for preventing VAP and to improve other outcomes such as mortality, duration of mechanical ventilation and length of stay in the intensive care unit (ICU) or hospital, an electronic search of the Cochrane Library, MEDLINE, Web of Science and Embase was undertaken. Nine systematic reviews with meta-analysis (in the overview of reviews) and 20 randomised controlled trials (in the updated meta-analysis) were included.In the overview of reviews, all systematic reviews with meta-analysis included found a positive effect of subglottic secretion drainage in the reduction of incidence of VAP. In the updated meta-analysis, subglottic secretion drainage significantly reduced VAP incidence (risk ratio (RR) 0.56, 95% CI 0.48–0.63; I2=0%, p=0.841) and mortality (RR 0.88, 95% CI 0.80–0.97; I2=0%, p=0.888).This is the first study that has found a decrease of mortality associated with the use of subglottic secretion drainage. In addition, subglottic secretion drainage is an effective measure to reduce VAP incidence, despite not improving the duration of mechanical ventilation and ICU and/or hospital length of stay.