Transcript Reducing Ventilator Associated Pneumonia In Adults

Reducing Ventilator
Associated Pneumonia in
Adults Intensive Care Units
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Goals


Reduction of nosocomial VAP in the
adult intensive care unit based on the
National Healthcare Safety Network
(NHSN) percentiles and the goal for
the first year is to be below the 50th
percentile which is 2.92.
The stretch goal is to be at the 25th
percentile which is equivalent to 1.02
or below the 25th percentile.
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Interventions Implemented

VAP Task Force consisting of physicians, nurses,
respiratory therapist and pharmacist

Education of healthcare workers in the adult ICU’s
through the VAP computer based learning (CBL)

The VAP Bundle with 5 elements were instituted and
utilized in all adult ICU’s


ICP collected data that supported identification of
VAP (i.e., chest x-ray results, blood culture results,
minimally contaminated respiratory cultures, vital
signs, oxygen saturation, sputum quality & quantity,
WBC)
All identified VAP infections were discussed 1:1 with
the medical director of infection control
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Interventions

continued
VAP infection rates were reported back to
clinicians, nursing staff, IC Committee and
senior leadership

Consistent use of hand hygiene

Implementation of Standard Precautions at all
times

Consistent use of additional isolation practices
as indicated (airborne, etc.)

Maintain closed suction system at all times

Contaminated condensate are carefully emptied
from ventilator circuits and condensate
prevented from entering into the lower airway
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Interventions continued

Continuous removal of subglottic secretions

Breathing circuits are not changed routinely, only when visibly
soiled and mechanically malfunctioning

Appropriate cleaning of ventilator during and in between use

Avoidance of re-intubation

Provided education to patient and families
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Loyola VAP Bundle Elements
VTE/DVT Prophylaxis
Head of Bed Elevation
Peptic Ulcer Disease Prophylaxis
Daily Discussion of Readiness to
Extubate/Wean
Oral Care / Hygiene
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VAP CHECKLIST-BUNDLE
VAP
Bundle
Date:
Patient On Ventilator:
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
VTE/DVT PROPHYLAXIS
Does the patient have orders for heparin or
enoxaparin for VTE prophylaxis?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
NA
NA
NA
NA
NA
NA
NA
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
NA
NA
NA
NA
NA
NA
NA
PUD PROPHYLAXIS
Does the patient have PUD Prophylaxis
orders?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
NA
NA
NA
NA
NA
NA
NA
Discussion of Readiness to Extubate/Wean
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
NA
NA
NA
NA
NA
NA
NA
ACTION ITEMS (if on ventilator)
HEAD ELEVATION
Is the HOB elevated at least 30 degrees?
Yes, when readiness to extubate/weaning &
sedation reduction is discussed (even in
very ill patients)
No, when above is not discussed
ORAL CARE / HYGIENE
Oropharyngeal cleaning/decontamination
every 4 hours and prn
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20
06
(n
2/
2 0 =6
06 45
,V
(n
3/
AP
2 0 =5
=
06 96
, V 3)
(
n
4/
2 0 =5 3 A P
=6
06
1,
VA )
(n
5/
2 0 =6
P
=
06 91
, V 5)
(n
6/
AP
2 0 =5
=
06 64
, V 2)
(n
7/
AP
2 0 =2
=
06 00
, V 4)
(n
8/
AP
2 0 =5
=
06 14
, V 1)
(n
9/
2 0 =6 3 A P
=6
0
1,
10 6(n
VA )
=9
/2
00
13 P=4
,V
)
11 6(n
A
=4
/2
00
4 2 P=
2
,V
)
12 6(n
AP
=
/2
00 53
=5
3
6
,V
)
1/ (n=
AP
20
3
=5
07 01
)
(n , V
2/
AP
2 0 =6
0
=
07
7,
2)
(n
V
3/
2 0 =5 1 A P
=4
07
7,
VA )
(n
4/
2 0 =3
P
=
07 37
, V 2)
(n
5/
AP
2 0 =4
=
07 36
, V 3)
(n
6/
AP
2 0 =6
=
07 38
, V 1)
(n
7/
A
=
20
2
P=
07 88
, V 5)
(n
8/
A
=
20
3
P=
07 73,
2
VA )
(n
9/
2 0 =5
P=
4
0
3,
3
10 7(n
VA )
=
/2
P=
00 38
5,
2
11 7(n
VA )
=
/2
P=
00 42
0,
2
12 7(n
VA )
=6
/2
P
00
62
=
7
, V 1)
1/ (n=
20
39 AP=
08
1
5
(n , VA )
2/
2 0 =2
P=
4
08
2,
1
3/
VA )
20 (n=
P=
08 79
4,
3)
(n
V
=
4/
20 107 AP
=3
08
9,
5/
20 (n= VA )
P=
98
08
1,
1
(n
VA )
6 / =1
20 00
P=
08 8,
VA 1 )
(n
7/
2 0 =9 5 P =
08
2,
0
VA )
(n
8/
2 0 =9
P
=
08 00
, V 6)
(n
9/
AP
2 0 =9
41
=
0
, V 4)
10 8(n
AP
=9
/2
0
71
=4
11 08(
n = , VA )
/2
00
84
P=
3
5
12 8(n
=1 , V A )
/2
00
00
P=
8(
4,
2
n=
VA )
1/
20 10
P=
09 24
, V 4)
(n
2/
AP
2 0 =7
4
=4
09
0,
(n
VA )
=5
78 P=0
,V
)
AP
=1
)
Loyola University Medical Center
Overall Adult Ventilator Associated Pneumonia Infection Rate
Rate Per 1000 Ventilator Days
Mean 6.37 Pre Intervention
20
VAP Bundle Flow Sheet for all ICUs
UCL = 16.77
Mean 2.96 Post Intervention
15
10
UCL = 8.30
Me a n = 6 .3 7
5
Me a n = 4 .7 1
Me a n = 2 .9 6
0
Month
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Next Step

Work in progress for VAP bundle to be
completed electronically

Mandatory annual VAP CBL for all healthcare
workers in all adult ICU’s

To scrutinize VAP cases to identify patterns
and trends

To develop a culture of zero VAP philosophy
among clinicians and doing the minimum is not
enough
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References
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Strategies to Prevent Ventilator Associated Pneumonia in Acute Care Hospitals
byInfection Control Hospital Epidemiology of America 2008
Tablan OC., Anderson, LJ., Besser, R., Bridges, C., Hajjeh, R. CDC Guidelines for
Preventing Health Care Associated Pneumonia 2203 (Internet). MMWR
Recommendations and Reports. 2204 March 26 (53(RR03): 1-36
American Thoracic Society and the Infectious Diseases Society of America.
Guidelines for the management of adults with hospital acquired , Ventilator
Associated and Healthcare-associated Pneumonia. Am J Respir Crit Care Med.
2005 15 Feb; 171 (4): 388-416
IHI 100,000 Lives Campaign. Getting Started Kit. Prevent VAP. How to Guide
(Internet). Cambridge: IHI; 2006 (cited 2008 May 16). 34p. Available from:
http://www.ihi.org/NR/rdonlyres/A448DDB1-E2A4-4D13-8F0216417EC52990/0/VAPHow to GuideFINAL.pdf
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