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Current Practices for Ventilator-Associated Pneumonia Prevention in JapanVentilator-Associated Pneumonia Prevention in Japan: A Survey Study FREE TO VIEW

Nobuaki Shime, MD, PhD; Lee E. Morrow, MD, FCCP
Author and Funding Information

From the Department of Anesthesiology and Intensive Care, Division of Infection Control and Prevention (Dr Shime), University Hospital, Postgraduate School of Medical Science, Kyoto Prefectural University of Medicine; and Division of Pulmonary and Critical Care Medicine (Dr Morrow), Nebraska and Western Iowa Veterans Affairs Medical Center, Creighton University Medical Center.

Correspondence to: Nobuaki Shime, MD, PhD, Department of Anesthesiology and Intensive Care, Postgraduate School of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan; e-mail: shime@koto.kpu-m.ac.jp


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(1):281-283. doi:10.1378/chest.11-2387
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Published online

To the Editor:

Evidence-based guidelines propose bundles of strategies to reduce ventilator-associated pneumonia (VAP) in critically ill patients receiving mechanical ventilation.1,2 Failure to routinely use these preventive measures is an international concern.3-5 In Japan, health care is decentralized, and intensive care is poorly distributed, with only 1% of all hospital beds in dedicated ICUs.6,7 Given the unique organization of the medical system in Japan, we attempted to describe compliance with VAP-prevention measures in Japanese hospitals and to assess the impact of intensivists on compliance.

Health-care providers who attended any of 10 conferences for respiratory care convened in five Japanese cities during 2009 to 2010 were provided a voluntary, written questionnaire. A simple Likert scale (frequently, occasionally, never, unknown) was used to assess adherence with VAP preventive measures in each respondent’s institution: Only a response of frequently was counted as adherence. Factors affecting compliance also were assessed.

The 777 respondents (response rate, 35%) comprised nurses (80%), physicians (7%), bioengineers (5%), and physical therapists (5%); 158 respondents (20%) practiced in intensivist ICUs (n =80 [10%] closed and n =78 [10%] open ICUs), 149 (19%) practiced in nonintensivist ICUs, and the remaining 470 (59%) provided critical care on general wards. Adherence rates for VAP-prevention measures were significantly higher in intensivist ICUs than in nonintensivist ICUs or general wards for head of bed elevation (57%, 32%, and 12%, respectively), daily interruption of sedation (46%, 26%, and 10%), daily assessment of eligibility of extubation (61%, 35%, and 13%), subglottic secretion drainage (40%, 30%, and 29%), oral care (97%, 88%, and 65%), and routine endotracheal tube exchanges (34%, 47%, and 50%) (Table 1). Although lack of knowledge was the most common reason for nonadherence on general wards, a shortage of health-care personnel was frequently cited in all care areas.

Table Graphic Jump Location
Table 1 —Compliance Rates for Preventive Measures for VAP

Data are presented as No. (%). DIS = daily interruption of sedation; ETT = endotracheal tube; HP = health-care personnel; VAP = ventilator-associated pneumonia.

Although adherence rates for VAP-prevention measures in Japan were low overall, greater compliance was consistently observed in intensivist ICUs. This observation is consistent with the international observation that higher concentrations of intensivist staffing in ICUs correlate with increased use of evidence-based practices and reduced incidence of adverse events.8,9 The present data suggest that Japanese intensivists are the most capable candidates to champion locally the further implementation of evidence-based guidelines in the ICU.10 Efforts to increase the availability of intensivists in Japan and to routinely provide mechanical ventilation only in intensivist-led ICUs could be practical solutions to reduce VAP rates and merit further study.

Gastmeier P, Geffers C. Prevention of ventilator-associated pneumonia: analysis of studies published since 2004. J Hosp Infect. 2007;671:1-8 [PubMed] [CrossRef]
 
Rello J, Lode H, Cornaglia G, Masterton R. VAP Care Bundle Contributors A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med. 2010;365:773-780 [PubMed]
 
Rello J, Lorente C, Bodí M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest. 2002;1222:656-661 [PubMed]
 
Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2003;3111:2693-2696 [PubMed]
 
Heyland DK, Cook DJ, Dodek PM. Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. J Crit Care. 2002;173:161-167 [PubMed]
 
Sirio CA, Tajimi K, Taenaka N, Ujike Y, Okamoto K, Katsuya H. A cross-cultural comparison of critical care delivery: Japan and the United States. Chest. 2002;1212:539-548 [PubMed]
 
Uchino S. Are Japanese ICUs properly utilized [in Japanese]? J Japan Soc Intensive Care Med. 2010;172:141-144
 
Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of care in academic medical centres. Qual Saf Health Care. 2007;165:329-333 [PubMed]
 
Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;154:235-239 [PubMed]
 
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;28817:2151-2162 [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Compliance Rates for Preventive Measures for VAP

Data are presented as No. (%). DIS = daily interruption of sedation; ETT = endotracheal tube; HP = health-care personnel; VAP = ventilator-associated pneumonia.

References

Gastmeier P, Geffers C. Prevention of ventilator-associated pneumonia: analysis of studies published since 2004. J Hosp Infect. 2007;671:1-8 [PubMed] [CrossRef]
 
Rello J, Lode H, Cornaglia G, Masterton R. VAP Care Bundle Contributors A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med. 2010;365:773-780 [PubMed]
 
Rello J, Lorente C, Bodí M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest. 2002;1222:656-661 [PubMed]
 
Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2003;3111:2693-2696 [PubMed]
 
Heyland DK, Cook DJ, Dodek PM. Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. J Crit Care. 2002;173:161-167 [PubMed]
 
Sirio CA, Tajimi K, Taenaka N, Ujike Y, Okamoto K, Katsuya H. A cross-cultural comparison of critical care delivery: Japan and the United States. Chest. 2002;1212:539-548 [PubMed]
 
Uchino S. Are Japanese ICUs properly utilized [in Japanese]? J Japan Soc Intensive Care Med. 2010;172:141-144
 
Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of care in academic medical centres. Qual Saf Health Care. 2007;165:329-333 [PubMed]
 
Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;154:235-239 [PubMed]
 
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;28817:2151-2162 [PubMed]
 
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