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Multicenter Study
. 2018 Feb;46(2):181-188.
doi: 10.1097/CCM.0000000000002736.

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU "Pneumonia Zero" Program

Francisco Álvarez-Lerma  1 , Mercedes Palomar-Martínez  2 , Miguel Sánchez-García  3 , Montserrat Martínez-Alonso  4   5 , Joaquín Álvarez-Rodríguez  6 , Leonardo Lorente  7 , Susana Arias-Rivera  8 , Rosa García  9 , Federico Gordo  10 , José M Añón  11 , Rosa Jam-Gatell  12 , Mónica Vázquez-Calatayud  13 , Yolanda Agra  14
Affiliations
Multicenter Study

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU "Pneumonia Zero" Program

Francisco Álvarez-Lerma et al. Crit Care Med. 2018 Feb.

Abstract

Objectives: The "Pneumonia Zero" project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU.

Design: Prospective, interventional, and multicenter study.

Setting: A total of 181 ICUs throughout Spain.

Patients: All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012.

Intervention: Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April-June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status.

Measurements and main results: The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42-11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22-5.84) after 19-21 months of participation.

Conclusions: Implementation of the bundle measures included in the "Pneumonia Zero" project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.

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Conflict of interest statement

Dr. Alvarez-Lerma’s institution received funding from the Spanish Ministry of Health, Social Policy, and Equality through a contract (Number 2012/07/CM016) to Spanish Society of Intensive and Critical Care Medicine and Coroanry Units (SEMICYUC). Dr. Sánchez-García received funding for speaker fees from Pfizer, Merck, Sharp & Dohme, Astra-Zeneca, Orion, and Cepheid; for consulting fees from Bayer, GlaxoSmithKline, Pfizer, and Masimo; and for research grants from the European Union, 7th Framework Programme IMI, H2020. Dr. Vázquez-Calatayud disclosed that the study was supported by the Spanish Ministry of Health, Social Policy and Equality through a minor (Number 2012/07/CMO16) and scientific advised by the SEMICYUC and Sociedad Española de Enfermería Intensiva y Unidades Coronarias. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Changes of rates for ventilator-associated pneumonia for each time period of participation in the “Pneumonia Zero” project according to characteristics of the hospital (individual values of each curve are shown in Table 5-e, Supplemental Digital Content 1, http://links.lww.com/CCM/C886).
See this image and copyright information in PMC

Comment in

References

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