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Abstract
Förbättringsarbete:
VAP- en svår IVA-komplikation som kan förebyggas
(Eva Joelsson-Alm,
Katarina Meijers, Jan Häggqvist)
Background
Patients treated with
mechanical ventilation are at great risk of developing ventilator-associated
pneumonia (VAP), which increases mortality, morbidity and costs. There are
several known evidence-based strategies for prevention of VAP, including
semi-recumbent position, suction of subglottal secretions and non-invasive
ventilation. A few of these strategies had already been implemented at the
unit, but most of them had not. A retrospective chart review of all patients
ventilator treated for more than 48 hours at the unit in 2003 showed an
incidence of VAP of 39 %. A project was started in October 2004 with the aim
of decreasing the incidence of VAP.
Brief description of context
This project took place at a 6-bed
multidisciplinary surgical intensive care unit at a general hospital in
Stockholm. The staff consists of intensive care nurses, physiotherapists,
intensivists and anaesthetists, a total of about 100 people.
Key measures for improvement
The Breakthrough Series
Model for Improvement was used. This model identifies four key elements of
successful process improvement; specific and measurable aims, measures of
improvement that are tracked over time, key changes that will result in the
desired improvement and a series of tests using “Plan-Do-Study-Act” (PDSA)
cycles of learning.
The specific and measurable
aim was to decrease the incidence of VAP by 40 %. Throughout the project,
monthly measurements of the incidence of VAP were made. The measurements
included; number of patients treated with ventilator for more than 48 hours,
number of patients fulfilling the criteria of VAP, length in days of
ventilator treatment for every patient and time to VAP, if any.
Process of gathering information
The
project was led by a team of three people; a clinical nurse specialist, an
intensive care nurse and an intensivist. The team conducted a thorough
literature review using Medline and Cochrane databases searching for
articles about VAP and evidence-based preventing strategies. Thirteen
interventions were chosen to be included in the project. Some of the
interventions concerned introducing new routines (e.g. semi-recumbent
position, weaning protocol), some concerned controlling and increasing the
adherence to already existing routines (e.g. hand-hygiene
routines, sedation protocol). For every intervention a responsible person or
group was chosen, which resulted in a total of 19 people (nurses,
intensivists and physiotherapists) directly involved in the project. The
project team supported the staff with articles and the knowledge of the
improvement model used.
Analysis and interpretation
Every intervention was
tested and evaluated by the team responsible for the specific intervention.
All tests were made using PDSA-cycles, but the methods of evaluation of the
tests differed according to the nature of the intervention.
Strategy for change
Those interventions which
were found to be possible to apply were implemented as standard routines.
The results of every monthly VAP-incidence measurement were fed back to the
staff to help to motivate the implementation of the different interventions
at the unit.
Effects of change
The monthly measurements
have showed a declining incidence of VAP. In July 2005, 10 months after the
start of the project, the aim was accomplished: the incidence of VAP had
been decreased by 40 %. The key success factor of the project was the active
involvement of the staff. The multidisciplinary approach with intensivists,
intensive care nurses and physiotherapists responsible for the
implementation of the different interventions, was also very important. The
use of a specific model for improvement (The Breakthrough Series Model) was
a great help and made the whole project possible.
Postoperativ urinretention och blåsöverfyllnad är
betydelsefulla komplikationer i samband med operation. Syftet med föreliggande
studie var att kartlägga blåsvolymer omedelbart före och efter
operationer för att fastställa lämpliga tidpunkter för blåsmonitorering
samt att identifiera riskfaktorer som kan göra det möjligt att förebygga
perioperativ blåsöverfyllnad. I studien deltog 147 vuxna patienter som
skulle opereras på ortopedisk eller kirurgisk klinik. Blåsvolymer mättes
med hjälp av en portabel ultraljudsapparat vid tre tillfällen i samband
med operation: på vårdavdelning omedelbart efter blåstömning strax innan
transport till operation, på operationsavdelning innan anestesi påbörjades,
och direkt vid ankomsten till uppvakningsavdelningen. Trettiotre patienter
(22 %) hade vid något mättillfälle en övertänjd urinblåsa (blåsvolym
> 500 ml), 8 av dessa redan innan operationen startade och resterande 25
patienter postoperativt. Femton procent av alla patienter hade en blåsvolym
på mer än 300 ml strax innan operationsstart. Ortopedpatienter hade högre
frekvens av blåsöverfyllnad och hade även betydligt större
residualurinvolym. Inga samband kunde påvisas mellan blåsöverfyllnad och
ålder, kön, operationstyp, anestesimetod, anestesilängd eller given mängd
intravenös vätska under operation. Studien visar att noggrann monitorering
av blåsvolymen både före och efter operation är viktigt för att förebygga
blåsöverfyllnad.
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