Prevenção da pneumonia associada à intubação. Elaboração e validação de norma de orientação clínica

Abstract

Health care associated infections (HCAI) represent one of the main complications of hospitalization. Intubation associated pneumonia (IAP) is the HCAI with the higher incidence rate in intensive care units (ICUs) and is associated with an increase in antimicrobial resistance and days of invasive ventilation, length of stay (LOS), important health systems quality outcomes, as well as an estimated additional cost of $10,000 USD per episode. The high incidence rate of this infection, coupled with the need for studies in this field in Portugal, motivated this study. Our aim is to improve IAP outcomes through guideline adaptation and implementation. Using the ADAPTE methodology, we performed the following sequence of steps: Configuration (definition of the study area, objectives and research questions), Adaptation (search for guidelines and other relevant documents, quality selection and assessment of currency, acceptability and applicability and elaboration of recommendations); Finalization (production of the final document, implementation and statistical data collection in terms of health outcomes and feedback by users about its content, its contributions and final result) and Evaluation (guideline assessment in terms of process and outcomes). We included in the guideline a set of eight recommendations that we implemented in three ICUs of a central hospital in the North of Portugal. Three groups were then compared: the intervention group (occurred between July and December 2016), the pre intervention group (between October 2015 and March 2016) and the post intervention group (from January to March 2017, in which all the strategies to encourage compliance were suspended). The sample consisted of 1970 patients. We identified a significant reduction in the incidence of IAP (p = 0.020 and p = 0.001) and a significant increase in guideline compliance in two of the ICUs and a reduction in invasive ventilation time, ICU LOS and mortality rate, considering the group that acquired and the group who did not acquire IAP in the three ICUs. We found an association between IAP and male gender, lower age, medical or trauma admission, lower SAPSII and an increase in ICU LOS and created an IAP prediction model. Compliance to the recommendations was high, with a positive evolution during the study implementation in almost all recommendations, suggesting that the use of a multimodal methodology for dissemination and implementation of the guideline was effective. We did not find significant changes in compliance in the 3-month follow-up period, however we found an increase in the incidence rate of IAP, duration of invasive ventilation and ICU LOS. We found an association between some recommendations and the implementation of the set of recommendations and ICU LOS, duration of invasive ventilation and mortality. The evidence supporting some of the recommendations included in the guideline is moderate, and there is a shortage of experimental studies that assess the impact of implementing each individual recommendation. By providing data concerning compliance to each recommendation and outcomes, this study contributes to a better understanding of the effectiveness of the interventions. As limitations of this study, we identified the risk of bias associated with the subjectivity in IAP diagnosis and the methodology used to evaluate compliance in some recommendations as well as time constrains to evaluate the impact of guideline implementation in terms of compliance and outcomes. Through the elaboration of this study we studied the impact of a guideline on IAP incidence as well as other important health outcomes, which focus benchmarking on patients and not statistics.

Date of Award	8 Mar 2019
Original language	Portuguese
Awarding Institution	Universidade Católica Portuguesa
Supervisor	Cândida Ferrito (Supervisor) & José Artur Paiva (Supervisor)