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University of Birmingham
MBChB
Elective Project 2014
Sarawak General Hospital, Malaysia
The use of the ventilator care bundle in a Malaysian Hospital, a service
evaluation
Rachel Victoria Barker
4th year medical student
Thank you to the Association of Anaesthetists of Great Britain and Northern Ireland (AAGBI) for
providing an elective bursary for this elective placement
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INTRODUCTION
Ventilator Associated Pneumonia (VAP) may develop in artificially ventilated patients, as a result of
the micro aspiration of bacteria 1. VAP is defined as a hospital acquired lower respiratory tract
infection that develops 48 hours or more after tracheal intubation and mechanical ventilation 2. A
diagnosis of VAP can be made when three or more of the following features are present in a
ventilated patient: pyrexia (oral body temperature greater than 37 degrees centigrade 3),
leucocytosis, purulent secretions, infiltrate on chest radiography 4. VAP is dissimilar from other types
of pneumonia because the micro-organisms responsible for the development of pneumonia differ
from those which cause other pneumonias 4. Treatment of VAP initially involves broad spectrum
antibiotic treatment; followed by specific antibiotic treatment which targets the causative organism
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.
The development of VAP is thought to be associated with poor outcomes for the patient and the
health care system respectively, however a recent systematic review demonstrated the outcomes
resulting from VAP are not easily quantifiable. Evidence from a large systematic review suggests that
the evidence to support that patients with a diagnosis of VAP have a higher mortality rate than
patients in the intensive care unit (ICU) without VAP is actually equivocal 5. Despite this, some
smaller scale research has concluded the mortality rate for patients’ with VAP is 46%, compared to
32% for a patient residing in the intensive care unit (ICU) without VAP 1; length of time in ICU is
extended, and cost of care is increased 1.
Therefore, it is prudent to prevent the development of VAP in artificially ventilated patients. The
Ventilator Care Bundle (VCB) 6 was developed in 2004 7 with the aim of reducing the incidence of
VAP, through the introduction of a set of interventions. The VCB has been regularly updated, in
accordance with new evidence. The current version used in the UK in 2014 comprises of the
following interventions: patient’s head raised between 35 and 45 degrees; ventilator and sedation
weaning at an appropriate time; provision of daily mouth care, gastric protection, the use of
thromboprophylaxic medication and the use of a subglottic drainage device. The majority of the
interventions included in the bundle have a rigorous evidence base: oral care has been shown to
reduce respiratory tract infection by 69% 8, gastric protection, along with ventilator and sedation
weaning has been shown to reduce the development of VAP 9; and it is well known the use of
thromboprophylaxis is key in preventing morbidity and mortality in ventilated patients 10.
Interestingly ,the optimum usage of subglottic drainage devices is currently debated 11, 12; and there
is no concrete evidence demonstrating that raising the head of the bed for ventilated patients
protects against the development of VAP, however, this intervention was included in the VCB due to
the recommendation by a number of experts 13.
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The VCB has been shown to be successful at reducing the development of VAP 14 and therefore
reducing cost of patient care, due to the prevention of patients’ requiring long ICU stays due to VAP
15, 16, 17
.
The VCB is recognised and implemented throughout the world, including Malaysia 18, however the
precise interventions included in VCBs vary between hospital and country 9. Malaysia is a middle
income country, but despite this has an effective health care system, with resources comparable to
those in a high income country [see figure 1] 19. The Malaysian healthcare system is split in to public
and private components; with the public sector providing approximately 80% of healthcare 18.
Despite the Malaysian healthcare system being an effective service, a major problem that was
observed in public sector hospitals is overcrowding.
Figure 1:
Patient room in ICU, Sarawak General Hospital,
Malaysia.
Photographed with permission of Ward Sister.
Sarawak General Hospital is the largest and most specialised in the state of Sarawak and it is a
referral centre for patients from neighbouring towns with complex problems. The ICU department at
Sarawak General Hospital had 18 beds, however a further 23 ventilators are available to be used in
other areas of the hospital. Caring for ventilated patients outside of the specialist ICU setting is not
advised as such care (outside a specialist setting) is associated with increased patient morbidity and
mortality 20.
VAP is a preventable disease; therefore VAP prophylaxis is an important measurement which
determines the effectiveness of an ICU department. In Europe, on average, the incidence of VAP is
7.0 per 1000 ventilator care days 9. In public (government led) hospitals in Malaysia, the incidence of
VAP was 7.2 per 1000 ventilator days in 2012 21. Research conducted in Sarawak General Hospital
revealed the incidence of VAP in 2012 was 6.3 per 1000 ventilator days 21 and adherence to the VCB
was 97.2% 21.
Data regarding adherence to the VCB and prevalence of VAP is not available after the year 2012. As a
result, this study aims to determine the adherence to the VCB at Sarawak General Hospital, Malaysia.
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AIMS
(1) To explore Sarawak General Hospital’s ICU department’s adherence to VCB
(2) To explore Sarawak General Hospital’s general wards’ adherence to VCB
(3) To provide Sarawak General Hospital with information about their adherence to VCB via a
written report
(4) To highlight areas of weakness relating to the VCB and suggest potential improvements to
improve patient care
METHOD
In order to determine adherence to VCBs, a cross sectional service evaluation 22 was conducted over
a four week period from 5th May until 30th May 2014 in Sarawak General Hospital, a government
run public hospital in Kuching, in Malaysian Borneo. Formal ethical approval was not required to
complete this service evaluation 23. Permission was sought and granted from the hospital director
and head of anaesthetics department.
The researcher (Rachel Barker) would attend the ICU ward round and following this, collect data
about the parameters in table 1 from each patient receiving artificial ventilation in Sarawak General
Hospital. Information detailing the location of all patients in Sarawak General Hospital requiring
artificial ventilation was available in the ICU department.
The researcher collected the information from each patient, travelling in a clockwise direction
around the ICU. Following this, data were collected from each patient in the hospital requiring
ventilator support. No patients were excluded from the audit.
Data regarding the parameters in table 1 were collected. Information was retrieved from the
following sources: observation of the patient; ICU observation chart; the medical notes recorded for
the 24 hours preceding the time of data collection; prescription medication chart; the patient’s
nurse. In the original protocol, it was planned that data regarding the angle of the head of the bed
would be collected using a protractor, however this was not possible due to infection control
reasons, therefore this data was collected by visual observation of the patient.
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The cross sectional study design was chosen as it was not possible to access patient notes
retrospectively 22 on Thursday 8th, Friday 9th, Monday 12th, Friday 16th, Monday 19th, Wednesday
21st May 2014.
Data were recorded in to an anonymised data collection tool. Anonymised data was uploaded to a
password protected computer and the paper copies of the completed data collection tools were
shredded. Data were analysed in July 2014.
Table 1: Parameters included in the ventilator care bundle and how this information was collected
Parameters
Method of collection
Age of patient
Notes
Sex of patient
Notes
Location of patient (ICU vs. general ward)
Observation
Diagnosis of patient
Notes
Form of ventilation
Observation/notes
Position of patient’s head
Observation
Daily discussion about the patient’s suitability for Observation/notes
ventilator weaning
Daily discussion about the patient’s suitability for Observation/notes
decreasing sedation
Provision of daily mouth care
Notes
Provision of gastric protection
Notes
Provision of thromboprophylaxis
Notes
Provision of subglottic drainage device
Notes
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RESULTS
(a)
Patient demographics
In total, data regarding 55 patients requiring artificial ventilation were collected. 44 (80.0%) of the
patients were receiving artificial ventilation on ICU and 11 (20.0%) on general medical wards. 40
(72.7%) patients were artificially ventilated using an endotracheal (ET) tube; 15 (17.3%) patients
were artificially ventilated using a tracheostomy. 35 (63.6%) of the patients requiring artificial
ventilation were male.
The duration the patients’ in the study had received ventilator support varied from 0 days to 34 days,
the median time for patients’ included in the study to receive ventilator support was for 4 days. The
diagnosis of patients’ on the ICU (figure 2 and figure 3), patient’s age (figure 4) varied within and
between locations.
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Figure 4:
Age of patients' included in service
evaluation
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12
10
8
Frequency
6
4
2
0
<14 14-18 19-24 25-34 35-44 45-54 55-64 65-74 75-84
(b)
Results of service evaluation
Patient positioning
In accordance with guidelines 1,2 , 55 (100.0%) patients had the upper part of their bed elevated to
between 30 and 45 degrees. 47 (85.4%) patients had their heads elevated to 45 degrees. 8 (14.6%)
patients had their heads elevated to 30 degrees.
It should be noted data collected regarding patient positioning was collected on a visual
observational basis, rather than measurement of angle using a protractor. This was due to the risk of
spread of infection if a measurement implement was used.
Ventilator weaning
According to documentation in patient notes and observation during the daily ward round, the
medical team taking care of all 55 (100%) patients assessed the patients’ in their care need for
continued ventilation on a daily basis.
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Peptic ulcer disease prophylaxis
Documentation confirmed 51 (92.7%) patients had received peptic ulcer disease prophylaxis. 25
(45.5%) received pantoprazole alone. 2 (3.6%) received pantoprazole and esomeprazole, 1 (1.8%)
received pantoprazole and ranitidine. 14 (25.5%) received esomeprazole alone. 8 (14.5%) received
ranitidine alone. 5 (9.09%) did not receive any peptic ulcer disease prophylaxis medication.
Regarding patients’ whom were not prescribed medication to prevent the development of peptic
ulcer disease; there were 3 (6.8%) such patients on ICU and 2 (18.2%) patients on general medical
wards in these categories.
Venous thromboembolism prophylaxis
According to documentation 18 (32.7%) patients received some form of venous thromboembolism
prophylaxis on the day the audit was conducted; namely subcutaneous enoxaparin (Clexane) (7
patients), intravenous heparin (9 patients), anti-thromboembolism stockings (2 patients).
The numbers of patients’ not receiving venous thromboembolism prophylaxis was high: 31 (70.5%)
patients on ICU and 7 (63.3%) patients on general medical wards.
Sedation review
According to documentation in patient notes and observation during the daily ward round, the
medical team taking care of all 55 (100%) patients assessed the patients’ in their care need for
continued sedation on a daily basis.
Mouth care
It was documented in patient notes that 40 (72.7%) patients received mouth care. 11 (100.0%) of the
patients who did not receive mouth care were located on general medical wards, rather than in the
ICU.
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Provision of mouth care varied as a result of the location of the patient: 11 (100.0%) patients on the
general ward did not receive mouth care, whereas only 5 (11.4%) patients residing on ICU did not
receive mouth care.
Subglottic secretion drainage device
Subglottic secretion drainage devices were not available in Sarawak General Hospital; therefore 0
(0.0%) patients had one in situ. However, manual suction was undertaken every 4 hours.
(c)
Overall results
During the study period, overall adherence to the VCB was 70.6%. Adherence varied depending on
the location in which the patient was being cared for: the patients’ receiving care in the ICU were
cared for with a higher rate of compliance to the VCB (73.1%), whilst patients’ residing on general
wards were cared for with a lower rate of compliance to the VCB (61.0%).
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DISCUSSION
(a) Implications
This service evaluation has evaluated the adherence of staff to the VCB in two areas of Sarawak
General Hospital (the ICU and the general wards). Adherence was evaluated through the collection
of data from patients regarding the interventions stated in table 1. It has shown that adherence to
the VCB is poor (70.6%) and therefore suggests management and staff should work to improve
adherence to 100% adherence to the VCB to provide the best outcomes for patients 24.
Overall, evidence collected illustrated staff fully adhered to some parts of the VCB, namely patient
positioning, ventilator weaning, sedation review. Despite this, care was poor in the VCB domains of
peptic ulcer disease prophylaxis, venous thromboembolism prophylaxis.
There are no obvious reasons for the variations in adherence to the VCB which are related to the
different VCB domains. However, it is interesting the domains which are poorly adhered to are those
which involve the prescription of medication. This may be the result of poor team-working between
nursing and medical staff because doctors are responsible for prescribing medication, whilst nurses
are responsible for administering medication. Poor nurse – doctor team working is a welldocumented cause of poor patient care 25, 26, 27.
The quality of care provided differed according to the locations in which the patient was cared for.
This potentially can be explained by the variations between staff working in the ICU and in general
medical wards. The nurses working in the ICU worked on a one nurse to one patient ratio and have
been trained specifically to manage critically ill patients requiring ventilator support 20. On medical
wards, quality of care for patients on ventilators is poorer as they were not cared for on a one to one
basis and the nurses caring for them are not necessarily highly trained in caring for acutely ill
patients 20.
Subglottic drainage devices were not available in Sarawak General Hospital; therefore 0 patients
were ventilated using such device. Despite a body of evidence demonstrating such devices to be
effective at preventing VAP 11; the use of subglottic secretion devices is debated in clinical practice
due to the optimal patient group and optimum time of implementation of the subglottic drainage
device being yet to be determined 12.
Research published in 2012 stated the adherence to the VCB in Sarawak General Hospital ICU was
97.2%, however data collected in May 2014 illustrates adherence in the ICU to be 73.1%. The
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disparity between the two results may be real, for example due to poor training of staff, poor record
keeping, poor patient care or poor leadership; or it may be as a result of the limitations of the study
which are discussed below. Unfortunately the incidence of VAP in Sarawak General Hospital for 2014
has not yet been calculated; therefore it is not possible to comment upon the incidence of VAP
resulting from the level of adherence to VCB.
(b) Limitations and strengths
This service evaluation study was conducted by a medical student from England, whom was
completely independent from Sarawak General Hospital. Despite collaboration with local staff and
having adequate time to collect data, Rachel Barker, whom was responsible for the collection of data,
may not have accessed the correct information, for example by not looking at the correct place in
the patient’s notes. It is also possible that some medications do not need to be prescribed in the
same manner as they are in the UK, for example subcutaneous enoxaparin. If so, this could account
for a falsely low adherence to the VCB. Furthermore, it is well known that individual hospitals adhere
to individual bundles, therefore interventions included in the bundles may differ 9.
The cross sectional nature of the study only provides a snapshot of the care the patient receives at
that point in time; therefore this may not be a true representation of patient care during the month
or, in fact the year. In an attempt to overcome this, information was collected once a week for four
weeks, on different week days.
Over the years, there have been numerous publications and updates of the VCBs 17 and multiple
versions are available. The disparity between the results from 2012 and 2014 could be the use of a
different VCB, using different interventions to be adhered to. However, the data the service
evaluation would collect was discussed with ICU staff at Sarawak General Hospital, so it would be
surprising if this was the reason for the disparity of results.
(c) Suggestions
The data collected in this service evaluation is specific to Sarawak General Hospital; however the
suggestions for improvements may be useful for other hospitals poorly adhering to VCBs. The team
caring for patients requiring artificial ventilation should aim to improve adherence to VCBs, in order
to reduce the risk of the development of VAP and the implications associated with this condition.
Improving adherence to VCBs can be done in a number of ways: firstly the provision of education
and training about VCB and VAP should be available to all staff (nurses and doctors) caring for
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patients on the ICU. The communication and team working between nurses and doctors should be
improved, in order to reduce barriers to effective communication, such as hierarchical relationships
care 25, 26, 27.
The adherence to VCB should be regularly re-audited in order to measure improvements or decline
in care, as re-auditing can help to improve the quality of care provided to patients by providing staff
with a reminder to adhere with the bundles 7. In addition to regular re-audits, an audit tool could be
included in the notes of all patients receiving artificial ventilation; this would provide a reminder of
the VCB to staff each time they look in patient’s notes and therefore increase adherence to VCB.
The results of this service evaluation will be fed back to the staff at Sarawak General Hospital and
the head of department.
CONCLUSIONS
The VCB is an important tool, with 7 main domains, which when adhered to, can reduce the
incidence of the development of VAP in patients receiving artificial ventilation. Ideally, adherence to
VCB should be 100%, in order to provide the best clinical outcomes for patients. Poor adherence to
care bundles should be prevented by training staff; improving team work between staff; and regular
re-audit of VCB.
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