Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish "Zero-VAP" bundle
Álvarez Lerma F (1), Sánchez García M (2), Lorente L (3), Gordo F (4), Añón JM (5), Álvarez J (6), Palomar M (7), García R (8), Arias S (9), Vázquez-Calatayud M (10), Jam R (11); Sociedad Española de Medicina Intensiva; Sociedad Española de Enfermería Intensiva.
(1) Servicio de Medicina Intensiva, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.
(2) Servicio de Medicina Intensiva, Hospital Clínico San Carlos, Madrid, Spain.
(3) Servicio de Medicina Intensiva, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain.
(4) Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain.
(5) Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, Spain.
(6) Servicio de Cuidados Intensivos, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
(7) Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lérida, Spain.
(8) Servicio de Anestesia y Reanimación, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain.
(9) Servicio de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, Spain.
(10) Servicio de Medicina Intensiva, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.
(11) Servicio de Medicina Intensiva, Centro Hospitalario Parc Taulí, Sabadell, Barcelona, Spain.
"Zero-VAP" is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units (ICU) consisting of a bundle of ventilator-associated pneumonia (VAP) prevention measures.
An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses, the project is supported by the Spanish Ministry of Health, and participation is voluntary. In addition to guidelines for VAP prevention, the "Zero-VAP" Project incorporates an integral patient safety program and continuous online validation of the application of the bundle. For the latter, VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program "ENVIN-HELICS" database, which provides continuous information about local, regional and national VAP incidence rates. Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation. A total of 35 preventive measures were initially selected. A task force of experts used the Grading of Recommendations, Assessment, Development and Evaluation Working Group methodology to generate a list of 7 basic "mandatory" recommendations (education and training in airway management, strict hand hygiene for airway management, cuff pressure control, oral hygiene with chlorhexidine, semi-recumbent positioning, promoting measures that safely avoid or reduce time on ventilator, and discouraging scheduled changes of ventilator circuits, humidifiers and endotracheal tubes) and 3 additional "highly recommended" measures (selective decontamination of the digestive tract, aspiration of subglottic secretions, and a short course of iv antibiotic).
We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project. Compared to conventional guideline documents, the associated safety assurance program, the online data recording and compliance control systems, as well as the existence of a pre-defined objective are the distinct features of "Zero VAP".
CITATION Med Intensiva. 2014 May;38(4):226-36. doi: 10.1016/j.medin.2013.12.007.