217 Epidemiological and Economic Impact on the Prevention ...
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Epidemiological and Economic Impact on the Prevention and Control of Ventilator-Associated Pneumonia in Intermediate Care Unit: A Model of Effective Analysis Lillyana Flores, MD 1 , Ricardo Valdés, MD 1 , Oscar Sosa, MD 1 , Patricia Rodríguez, MD 1 , Araceli Contreras 2 , Rafael Figueroa, MD 1 and Rafael Valdez, MD 2 , (1) Hospital Epidemiology, Hospital General “Dr. Manuel Gea González”, México City, México, (2) Infectology, Hospital General “Dr. Manuel Gea González”, México City, México ABSTRACT ABSTRACT METHODS REFERENCES BACKGROUND Objective. To evaluate the impact epidemiologic and economic obtained with the implementation project in reducing the incidence rate of VAP and effective costs in the treatment of care. Materials and Methods. A cross-sectional study was developed in the Interme- diate Care Unit (ICU) for respiratory patients comparing before and after. The study was divided into a prospective analysis (post-intervention from October 2011 to September 2012) and a retrospective pre-intervention, (from January to September 2011). The project was implemented and compared the rate of VAP and the costs in both phases. Consists in 3 components: architectural and structural modifications, staff and education of area y process reengineering. The information was obtained through clinical records from 33 patients, who met the criteria for VAP. To estimate the direct costs of treatment following data were obtained: hospital stay, laboratory test, imaging exams, and used antibiotics (dose and time). Their costs were esti- mated from the values established for the administrative direction of the hospital. Results. 22 cases were identified in the first period; the initial incidence rate was 26.93/1000 ventilator days, the average length of stay before infection was 9.8 days, average length of stay with VAP was 16.72 days; 5 deaths were attributed to infection with a fatality rate of 22.73, the average cost of treating a case of HAI was US$13,998, the total cost of these 22 cases was US$578,598. In the second period identified 11 cases, the incidence rate was 3.18/1000 ventilator days, the average length of stay before infection was 11.45 days, average length of stay with VAP was 11.54; 2 death were attributed to infection with a fatality rate of 18.2, the average cost of treating a case of HAI was US$12,629.1, the total cost of these 11 cases was US$170,040. The total cost of implementation project was US$20,318, the difference in cost between a period and the other was US$388,240, which rep- resents a saving of 70%. Conclusions. The implementation of the project was associated with a signifi- cant decrease in the incidence rate VAP and in the costs of treatment. • We conducted a “before and after” cross-sectional study. • Located in the Intermediate Care Unit for respiratory patients. • The study period was divided into 2 phases: • Pre-intervention: from January to September 2011. • Post- intervention: from October 2011 to September 2012. • We used the medical records at Epidemiological Surveillance Unit (case study formats, invasive device monitoring forms and census) • The project was implemented from October 2011, with the objective for prevention and control of the pneumonia, this Project consists of three components: • The Hospitalary Epidemiological Surveillance Unit was responsible at program implementation and monitoring, besides to identify VAP cases. • The VAP rate was calculated as the number of cases / the number of ventilator days x1000, separately for each study period. • Odds ratios (OR) with 95% confidence intervals (IC 95%) were calculated for comparisons of rates of VAP using Epi Info v. 7. P values <0·05 by two-sided tests were considered significant • In order to calculate direct costs the following data were obtained from the medical records: hospital stay, stay length at ICU, diagnostic tests for VAP (bronchial secretion culture, chest radiograph, CAT), antimicrobian scheme (dose and days). We calculate the cost with the unitary prices from hospital. • We made a list of all the inputs used to remodel the area and the resources used in project development and we obtained the cost established by the administrative direction. • Arabi, Y., Al-Shirawi, N., Memish, Z., & Anzueto, A. Ventilator-associated pneumonia in adults in eveloping countries: a systematic review. International Journal of Infectious Dis- eases, 2008; 12, 506-512. • Crnich, J., Safdar, N., & Maki, D. The Role of the Intensive Care Unit Environment in the Pathogenesis and Prevention of Ventilator-Associated Pneumonia. Respiratory Care; 2005, 50 (6): 813-828 • Kew, L., Baker, S., Fotecchio, S. Impact of a Program of Intensive Surveillance and Inter- ventions Targeting Ventilated Patients in the Reduction of ventilator-Associated Pneumo- nia and its Cost-Effectiveness. Infect Control Hosp Epidemiol; 2003, 24: 859-863 • Morris, A., Hay, A., Swann, D., Everingham, K., McCulloch, C., McNulty, J., et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med. 2010; 39 (10), 2218-2224. • Murray, T., Goodyear-Brush, C. Ventilator-associated Pneumonia Improvement Program. Advanced Critical Care, 2007: 190-199. • Rello, J., Lode, H., Cornaglia, G., & Masterton, R. A European care bundle for prevention of ventilator-associated penumonia. Intensive Care Med. 2010; 36, 773-780. • Tao, L., Bijie, H., Rosenthal, V., Yiwen, Z. Impact of a multidimensional approach on ven- tilator-associated pneumonia rates in a hospital of Shanghai: Findings of the International Nosocomial Infection Control Consortium. Journal of Critical Care; 2012: 15-23. CONCLUSIONS • Through the study period we assumed that patient characteristics did not vary from month to month, so we accepted that the reduction in the rate of infection is a direct re- sult of the project. • Patients who were hospitalized in the area during January to September 2011 had three times as likely to develop VAP, compared with those who were hospitalized from October 2011 to September 2012. • The study had important health outcomes (decreased VAP rate and case fatality rate). • This project represents a significant resource saving for the Hospital • We did not have the necessary resources to collect more data on process surveillance and measure compliance with all of the interventions examined and therefore we were unable to evaluate effects of specific interventions • This study is among the first scarce studies that have reported a substantial reduction in VAP rates in the ICU setting, proving this kind of infection control approach successful • We expect that these preventive strategies, had proven effective by means of the imple- mentation of the multidimensional approach for VAP prevention, results in a wider ac- ceptance of infection control programs in other hospitals, thus leading to significant VAP reductions • Such studies are useful tools for decision making, and improving hospital management. • Ventilator-associated pneumonia (VAP) was reported the primary cause of mor- bidity and mortality for device-associated infections in the adult intensive care unit setting, and has, therefore, been considered the most serious healthcare- associated infection (HAI) for critically ill patients. • The most important clinical consequences attributable to VAP are increased mortality rates, significant morbidity, and increased length of stay in hospital. From an economic perspective, VAP is also responsible for significant increases in healthcare costs. • The mortality rate is greater than 50%, especially if infection is caused by mul- tiresistant microorganisms (A. baumannii, Methicillin-resistant Staphylococcus aureus and P. aeruginosa). • The General Hospital “Dr. Manuel Gea Gonzalez” is a public referral hospital. It has a sensitive epidemiological surveillance system, so it was able to detect an VAP outbreak in 2011 at Intermediate Care Unit (ICU). As result we established a multi- targeted intervention project. RESULTS • The total number of patients admitted to the ICU was 378 (158 in period 1 and 220 in period 2). • 61% of the cases were male and 39 % female . The average age was 50.24 +3.1 years. • Patients admitted to intermediate care came from the surgical area, or emergency room. • The main microorganisms identified in cultures were: Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus, most of them were resistant to multiple antibiotics. • We calculate the value of the odds ratio to compare when the patients were more likely to develope VAP, obtain- ing a value of OR 3-75 (CI 95% 1.7-8; X2 12.78, p= 0.005) • Cost of implementation and development of the program: U.S. $ 190,358.34 • The hospital care savings in the intermediate care unit U.S. $ 388,240.32 • The overall incidence rate of VAP during the study was 13.8 x 1000 ventilator days. • Case fatality rate before intervention was 22.73 and post-intervention was 18.2. Variable Before the program After the program Difference between periods Statistic Average stayin days 33 32.9 0 days Average: 32.5 SE: 0.72 CI 95% (31.3-34.03) VAP cases 22 11 -11 cases (-50%) Average: 1.9 SE: 0.143 CI 95% (1.65-2.22) OR: 3.75 CI 95% (1.7-8.0) X 2 12.79 Total ventilator days 817 1570 +753 ventilator days (+90%) Average: 115 SE: 4.03 CI 95% (106-123) OR: 1.0 CI 95% (0.77-1.2) X 2 0.0 Hospitalized patients rate/100 13.92 5.0 -8.92 (-65%) Average: 9.06 SE: 2.1 CI 95% (6.96-11.16) OR: 0.9 CI 95% (0.31-2.61) X 2 0.03 Mechanic ventilator days rate/100 26.93 3.18 -23.7 (-88%) Average: 15.1 SE: 3.09 CI 95% (12.01-18.1) OR: 0.95 CI 95% (0.41-2.18) X 2 0.01 217 Comparative distribution of VAP rates by 1000 Ventilator –Days. January 2011 to September 2012. VAP Cases 50 40 30 20 10 0 Pre-intervention Post-intervention Rate X 1000 VD Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Sep-12 Tendency of the incidence rate of VAP January 2011 to June 2012 50.0 40.0 45.0 30.0 35.0 20.0 25.0 10.0 15.0 0.0 5.0 Rate X 1000 VD Pre-intervention Post-intervention Number of cultures grown 74 32 Cost of cultures USD $2637.6 USD $1 140.6 Number of radiodiagnostic images taken 72 38 Cost of images USD $1 639.3 USD $859.5 Antimicrobials cost USD $30 589 USD $15 591 Average cost, diagnosis and treatment of VAP USD $13 998.9 USD $12 629.1 Average cost of an episode of VAP care(hospitalization, treatment) USD $26 299.7 USD $15 458.2 Total cost IIH USD $578 598.7 USD $170 040.1 1. Architectural and struc- tural modifications Remodeling of the area, use of HEPA air filters, one bed was reduced, an- tibacterial curtains were installed, automatic sink placed. 2. Training and education Education of all healthcare staff with workshops and sessions about hand hy- giene and bundles for VAP. 3. Processes reengineering New policies were designed and standard- ized procedures such as high-level disinfec- tion of laryngoscopes, restricted access to the area, and decolonization of patients us- ing a system of hygiene towels impregnated with chlorhexidine gluconate 2% and a sys- tem of oral hygiene with chlorhexidine 0.12% to 0.20% through a brush with manual suc- tion regulator every 12 hrs in the aspiration of the secretions via cannula Yankauer, after 4 hours, the process was repeated. BRUSH DEBRIDE MOISTURIZE 24 HRS SYSTEM 2 ANTISEPTICS CONSISTENCY
Transcript of 217 Epidemiological and Economic Impact on the Prevention ...
Epidemiological and Economic Impact on the Prevention and Control of Ventilator-Associated Pneumonia in Intermediate Care Unit: A Model of Effective Analysis
Lillyana Flores, MD1, Ricardo Valdés, MD1, Oscar Sosa, MD1, Patricia Rodríguez, MD1, Araceli Contreras2, Rafael Figueroa, MD1 and Rafael Valdez, MD2, (1) Hospital Epidemiology, Hospital General “Dr. Manuel Gea González”, México City, México, (2) Infectology, Hospital General “Dr. Manuel Gea González”, México City, México
ABSTRACT ABSTRACTMETHODS
REFERENCES
BACKGROUND
Objective. To evaluate the impact epidemiologic and economic obtained with the implementation project in reducing the incidence rate of VAP and effective costs in the treatment of care.
Materials and Methods. A cross-sectional study was developed in the Interme-diate Care Unit (ICU) for respiratory patients comparing before and after. The study was divided into a prospective analysis (post-intervention from October 2011 to September 2012) and a retrospective pre-intervention, (from January to September 2011). The project was implemented and compared the rate of VAP and the costs in both phases. Consists in 3 components: architectural and structural modifications, staff and education of area y process reengineering. The information was obtained through clinical records from 33 patients, who met the criteria for VAP. To estimate the direct costs of treatment following data were obtained: hospital stay, laboratory test, imaging exams, and used antibiotics (dose and time). Their costs were esti-mated from the values established for the administrative direction of the hospital.
Results. 22 cases were identified in the first period; the initial incidence rate was 26.93/1000 ventilator days, the average length of stay before infection was 9.8 days, average length of stay with VAP was 16.72 days; 5 deaths were attributed to infection with a fatality rate of 22.73, the average cost of treating a case of HAI was US$13,998, the total cost of these 22 cases was US$578,598. In the second period identified 11 cases, the incidence rate was 3.18/1000 ventilator days, the average length of stay before infection was 11.45 days, average length of stay with VAP was 11.54; 2 death were attributed to infection with a fatality rate of 18.2, the average cost of treating a case of HAI was US$12,629.1, the total cost of these 11 cases was US$170,040. The total cost of implementation project was US$20,318, the difference in cost between a period and the other was US$388,240, which rep-resents a saving of 70%.
Conclusions. The implementation of the project was associated with a signifi-cant decrease in the incidence rate VAP and in the costs of treatment.
• We conducted a “before and after” cross-sectional study.
• Located in the Intermediate Care Unit for respiratory patients.
• The study period was divided into 2 phases:
• Pre-intervention: from January to September 2011.
• Post- intervention: from October 2011 to September 2012.
• We used the medical records at Epidemiological Surveillance Unit (case study formats, invasive device monitoring forms and census)
• The project was implemented from October 2011, with the objective for prevention and control of the pneumonia, this Project consists of three components:
• The Hospitalary Epidemiological Surveillance Unit was responsible at program implementation and monitoring, besides to identify VAP cases.
• The VAP rate was calculated as the number of cases / the number of ventilator days x1000, separately for each study period.
• Odds ratios (OR) with 95% confidence intervals (IC 95%) were calculated for comparisons of rates of VAP using Epi Info v. 7. P values <0·05 by two-sided tests were considered significant
• In order to calculate direct costs the following data were obtained from the medical records: hospital stay, stay length at ICU, diagnostic tests for VAP (bronchial secretion culture, chest radiograph, CAT), antimicrobian scheme (dose and days). We calculate the cost with the unitary prices from hospital.
• We made a list of all the inputs used to remodel the area and the resources used in project development and we obtained the cost established by the administrative direction.
• Arabi, Y., Al-Shirawi, N., Memish, Z., & Anzueto, A. Ventilator-associated pneumonia in adults in eveloping countries: a systematic review. International Journal of Infectious Dis-eases, 2008; 12, 506-512.
• Crnich, J., Safdar, N., & Maki, D. The Role of the Intensive Care Unit Environment in the Pathogenesis and Prevention of Ventilator-Associated Pneumonia. Respiratory Care; 2005, 50 (6): 813-828
• Kew, L., Baker, S., Fotecchio, S. Impact of a Program of Intensive Surveillance and Inter-ventions Targeting Ventilated Patients in the Reduction of ventilator-Associated Pneumo-nia and its Cost-Effectiveness. Infect Control Hosp Epidemiol; 2003, 24: 859-863
• Morris, A., Hay, A., Swann, D., Everingham, K., McCulloch, C., McNulty, J., et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med. 2010; 39 (10), 2218-2224.
• Murray, T., Goodyear-Brush, C. Ventilator-associated Pneumonia Improvement Program. Advanced Critical Care, 2007: 190-199.
• Rello, J., Lode, H., Cornaglia, G., & Masterton, R. A European care bundle for prevention of ventilator-associated penumonia. Intensive Care Med. 2010; 36, 773-780.
• Tao, L., Bijie, H., Rosenthal, V., Yiwen, Z. Impact of a multidimensional approach on ven-tilator-associated pneumonia rates in a hospital of Shanghai: Findings of the International Nosocomial Infection Control Consortium. Journal of Critical Care; 2012: 15-23.
CONCLUSIONS• Through the study period we assumed that patient characteristics did not vary from
month to month, so we accepted that the reduction in the rate of infection is a direct re-sult of the project.
• Patients who were hospitalized in the area during January to September 2011 had three times as likely to develop VAP, compared with those who were hospitalized from October 2011 to September 2012.
• The study had important health outcomes (decreased VAP rate and case fatality rate).
• This project represents a significant resource saving for the Hospital
• We did not have the necessary resources to collect more data on process surveillance and measure compliance with all of the interventions examined and therefore we were unable to evaluate effects of specific interventions
• This study is among the first scarce studies that have reported a substantial reduction in VAP rates in the ICU setting, proving this kind of infection control approach successful
• We expect that these preventive strategies, had proven effective by means of the imple-mentation of the multidimensional approach for VAP prevention, results in a wider ac-ceptance of infection control programs in other hospitals, thus leading to significant VAP reductions
• Such studies are useful tools for decision making, and improving hospital management.
• Ventilator-associated pneumonia (VAP) was reported the primary cause of mor-bidity and mortality for device-associated infections in the adult intensive care unit setting, and has, therefore, been considered the most serious healthcare-associated infection (HAI) for critically ill patients.
• The most important clinical consequences attributable to VAP are increased mortality rates, significant morbidity, and increased length of stay in hospital. From an economic perspective, VAP is also responsible for significant increases in healthcare costs.
• The mortality rate is greater than 50%, especially if infection is caused by mul-tiresistant microorganisms (A. baumannii, Methicillin-resistant Staphylococcus aureus and P. aeruginosa).
• The General Hospital “Dr. Manuel Gea Gonzalez” is a public referral hospital. It has a sensitive epidemiological surveillance system, so it was able to detect an VAP outbreak in 2011 at Intermediate Care Unit (ICU). As result we established a multi- targeted intervention project.
RESULTS• The total number of patients admitted to the ICU was 378 (158 in period 1 and 220 in period 2).
• 61% of the cases were male and 39 % female . The average age was 50.24 +3.1 years.
• Patients admitted to intermediate care came from the surgical area, or emergency room.
• The main microorganisms identified in cultures were: Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus, most of them were resistant to multiple antibiotics.
• We calculate the value of the odds ratio to compare when the patients were more likely to develope VAP, obtain-ing a value of OR 3-75 (CI 95% 1.7-8; X2 12.78, p= 0.005)
• Cost of implementation and development of the program: U.S. $ 190,358.34
• The hospital care savings in the intermediate care unit U.S. $ 388,240.32
• The overall incidence rate of VAP during the study was 13.8 x 1000 ventilator days.
• Case fatality rate before intervention was 22.73 and post-intervention was 18.2.
Variable Before the program
After the program
Difference between periods Statistic
Average stayin days 33 32.9 0 days
Average: 32.5SE: 0.72
CI 95% (31.3-34.03)
vap cases 22 11 -11 cases(-50%)
Average: 1.9SE: 0.143
CI 95% (1.65-2.22)
OR: 3.75CI 95% (1.7-8.0)
X2 12.79
Total ventilator days 817 1570
+753 ventilator days
(+90%)
Average: 115SE: 4.03
CI 95% (106-123)
OR: 1.0CI 95% (0.77-1.2)
X2 0.0
Hospitalized patients rate/100 13.92 5.0 -8.92
(-65%)Average: 9.06
SE: 2.1CI 95% (6.96-11.16)
OR: 0.9CI 95% (0.31-2.61)
X2 0.03Mechanic ventilator
days rate/10026.93 3.18 -23.7
(-88%)Average: 15.1
SE: 3.09CI 95% (12.01-18.1)
OR: 0.95CI 95% (0.41-2.18)
X2 0.01
217
Comparative distribution of VAP rates by 1000 Ventilator –Days. January 2011 to September 2012.
VAP Cases
50
40
30
20
10
0
Pre-intervention Post-intervention
Rat
e X
1000
VD
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep
-11
Nov
-11
Jan-
12
Mar
-12
May
-12
Jul-1
2
Feb-
11
Apr
-11
Jun-
11
Aug
-11
Oct
-11
Dec
-11
Feb-
12
Apr
-12
Jun-
12
Aug
-12
Sep
-12
Tendency of the incidence rate of VAPJanuary 2011 to June 2012
50.0
40.0
45.0
30.0
35.0
20.0
25.0
10.0
15.0
0.0
5.0
Rat
e X
1000
VD
Pre-intervention Post-interventionNumber of cultures grown 74 32
Cost of cultures usd $2637.6 usd $1 140.6Number of radiodiagnostic images taken 72 38
Cost of images usd $1 639.3 usd $859.5Antimicrobials cost usd $30 589 usd $15 591
Average cost, diagnosis and treatment of vap usd $13 998.9 usd $12 629.1Average cost of an episode of vap care(hospitalization, treatment) usd $26 299.7 usd $15 458.2
Total cost IIH usd $578 598.7 usd $170 040.1
1. Architectural and struc-tural modificationsRemodeling of the area, use of HEPA air filters, one bed was reduced, an-tibacterial curtains were installed, automatic sink placed.
2. Training and educationEducation of all healthcare staff with workshops and sessions about hand hy-giene and bundles for VAP.
3. Processes reengineeringNew policies were designed and standard-ized procedures such as high-level disinfec-tion of laryngoscopes, restricted access to the area, and decolonization of patients us-ing a system of hygiene towels impregnated with chlorhexidine gluconate 2% and a sys-tem of oral hygiene with chlorhexidine 0.12% to 0.20% through a brush with manual suc-tion regulator every 12 hrs in the aspiration of the secretions via cannula Yankauer, after 4 hours, the process was repeated.
BRUSH
DEBRIDE
MOISTURIZE
24 HRS SYSTEM
2 ANTISEPTICS
CONSISTENCY
