Even though the use of SSD endotracheal tubes with a proper cuff pressure monitor can reduce incidence of Ventilator Associated Pneumonia, this is not routine in all ventilated patients. This project seeks directly to tackle the barriers to changes in practice by providing the training and resources to try new approaches, embed new practices and demonstrate local impact.
Ventilator Associated Pneumonia (VAP) is defined as a pneumonia that occurs after more than 48 hours of intubation and mechanical ventilation. The incidence of VAP is 10 – 20%, and mortality is 15 – 50%. VAP has been shown to extend the length and cost of stay in the ICU by at least 6 days and has an additional conservative cost of £10,000 per episode.
A solution to the problem of VAP has existed for some years now. There is clear evidence that VAP can be prevented by the use of Subglottic Secretion Drainage (SSD) endotracheal tubes, which prevent contaminated oral secretions that accumulate above the tracheal cuff from leaking past it and into the lungs and allow suctioning of these secretions through an opening port and channels that sit above the cuff. The use of SSD endotracheal tubes alongside proper cuff pressure monitors is a department of health best practice guideline (described in the 2011 High Impact Intervention Care Bundle).
Despite these guidelines and the evidence behind them, the use of SSD endotracheal tubes is not routine in all ventilated patients. Even where clinicians are keen to change their practice, systemic and cultural barriers can make improvement hard to initiate in areas which are not established priorities – with initial costs and the need for training causing particular problems.
“VAP is the biggest acquired nosocomial killer in the ICU, with an incidence of 10-20% and mortality of between 15-50%. VAP extends a patient’s length of stay in the ICU by at least 6 days and has a conservative additional cost estimate of £10,000 per episode.”
Dr Peter Young, Consultant, Anesthetics and Intensive Care, The Queen Elizabeth Hospital, Kings Lynn
This project seeks directly to tackle the barriers to changes in practice, by providing the training and resources to try new approaches, embed new practices and demonstrate local impact.
The project covers the costs of SSD tubes, with participants able to choose any of the commercially available models. On-site training and follow-up telephone support are also provided by a research nurse who is fully trained in the use of different tubes and cuff pressure monitors. Trusts deciding to use the PneuX tube, which was developed at Kings Lynn, also attend a training day at the Queen Elizabeth Hospital, where they can see the tube in action.
Participating ICUs commit to ensuring that an SSD tube and appropriate cuff pressure monitor are used for any patient intubated for more than 48 hours, in line with the Care Bundle.
The team recognise that sustainable change requires changes elsewhere in the system. In particular, the team is working with CCGs to find ways to encourage the continued use of SSD tubes through appropriate CQUINs.
Work on the project is also being publicised more widely across the region, and to as many different stakeholder groups as possible. In this way, they hope to build wider momentum for change. The work of the Eastern patient safety collaborative will help raise awareness of the work.