Transcript Prevention of Ventilator Associated Pneumonia & Catheter

Prevention of
Ventilator Associated Pneumonia
(VAP)
Cindy Lang, RN, BSN, CIC
Senior Infection Control Specialist
VA Medical Center West Palm Beach
Objectives
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
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List four key components of the Institute for Healthcare
Improvement (IHI) Ventilator Bundle
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Describe three signs and symptoms of pneumonia
• Explain four procedures used to reduce the risk of VAP in patients
• Identify two key points for proper ventilator care to reduce VAP risk
VENTILATOR ASSOCIATED
PNEUMONIA (VAP)
• VAP is the leading cause of nosocomial
infection in the ICU and reflects 60% of all
deaths attributable to nosocomial
infections.
• Pneumonia rates are much higher in
mechanically ventilated patients due to the
artificial airway, which increases the
opportunity for aspiration and colonization.
TIMELINE
• IHI announces Saving 100,000 Lives campaign
in December 2004 including practices to reduce
VAP and CR-BSI
• VA agrees to participate based on interest of
VISNS and individual sites
• VISN Directors agree to implement 3 of the 6
practices 5/2005
• Kick-off call for Reduction of VAP 1/2006 by
IPEC
• Development of web based database
Institute for Healthcare Improvement (IHI)
100,000 Lives Saved Campaign
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Six Clinical Evidence Based Initiatives
Prevention of Ventilator Associated Pneumonia Bundle
Prevention of blood borne infections due to central
lines
Prevention of Surgical Site infections
Implementation of Rapid Response Teams
Prevention of Adverse Drug events through medication
reconciliation
Optimization of care for patients with Acute Myocardial
Infarctions
The Case for Preventing VAP
• VAP – leading cause of death among
hospital –acquired infections
• High rate of associated mortality:
• Hosp mortality of vent pts who develop
VAP is 46% compared to 32% for
ventilated patients who don’t develop VAP
• VAP prolongs time spent on vent, length of
stay in ICU and LOS after DC from ICU
COST OF VAP
• Strikingly, VAP adds an estimated cost of
$40,000 to a typical hospital admission
Definitions: VAP
• Ventilator associated pneumonia: Pneumonia developing
>48 hours of initiation of mechanical ventilation or <72
hours after cessation of mv
*New progressive infiltrate, with leukocytosis, fever, and
purulent sputum
*Bronch protected specimen brush with >103 CFU, or
BAL > 104 CFU
• Counting
*Ventilator days/mo is the sum of the number of days
each patient was on mechanical ventilation (via
ETT/trach tube)
Evidence Based Practice Ventilator
Associated Pneumonia Care
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HOB elevated 30 degrees or higher
Stress Ulcer Prophylaxis
DVT Prophylaxis
Daily sedation vacation
Daily Assessment of readiness to wean
Daily Spontaneous Breathing Trial
VENTILATOR BUNDLE AUDIT
FORM
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Pat ie nt
H O B up 30
S tr e ss U lc e r
D V T Pr o p h ylax is
D aily se d at io n
D aily A ss e ss m e nt o f
D aily S p o nt a ne o u s
SS #
degrees or
Pr o p h ylax is w / in
w /in 2 4 h r s
vac atio n
r e ad in e ss to w e a n
B r e ath in g T r ial
h ig h e r
24 hrs
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HOB UP 30 DEGREES OR HIGHER
• Recommended elevation is 30-45 degrees
• If semi-recumbent or supine 34% incidence VAP
• If semi-recumbent position
8% incidence VAP*
• ↑HOB → ↓risk of aspiration of gastrointestinal contents
↓risk of aspiration of oropharyngeal secretions
↓risk of aspiration of nasopharyngeal secretions
↑HOB improves patients’ ventilation
Supine patients have lower spontaneous tidal volumes on PS
than those seated in upright position
↑HOB may aid ventilatory efforts and minimize atelectasis
Daily “Sedation Vacation” and Daily
Assessment of Readiness to Wean
• Correlated with reduction in rate of VAP
• Sedation vacation results in significant
reduction in time on mechanical ventilation
• Duration of mv decreased from 7.3 days to
4.9 days-study by Kress et al. NEJM 2000
• Weaning is easier when patients are able
to assist themselves at extubation with
coughing and control of secretions
Sedation Vacation Risks
• Increased potential for self-extubation
• Increased potential for pain and anxiety
• Increased tone and poor synchrony with
the ventilator during the maneuver may
risk episodes of desaturation
Peptic Ulcer Disease (PUD)
Prophylaxis
• Appropriate intervention in all sedentary
patients, however,
• ↑ incidence of stress ulceration in
critical illness
• Decreasing pH of gastric contents may
protect against greater pulmonary
inflammatory response to aspiration of
gastrointestinal contents
PUD Prophylaxis
• Aspiration causes either pneumonitis or
pneumonia and can be prevented
• Effects of aspirating acidic contents may
be worse than those with higher pH.
• Some studies have shown ↑ risks of VAP
with certain agents such as sucralfate
while others have not
More on PUD Prophylaxis
• Surviving Sepsis Campaign Guidelines reviewed
literature on PUD prophylaxis:
• “H2 receptor inhibitors are more efficacious that
sucralfate and are the preferred agents. Proton
Pump Inhibitors have not been assessed in
direct comparison with H2 receptor antagonists
and, therefore their relative efficacy is unknown.
They do demonstrate equivalency in ability to
increase gastric pH.”*
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Dellinger, RP et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Criit Care Med. Mar
2004;32(3):858-873.
PUD Prophylaxis
• While it is unclear if there is any
association between PUD prophylaxis and
decreasing rates of VAP, experience
shows that when PUD prophylaxis is
applied as part of a package of
interventions for vent care,
the rate of pneumonia
decreases precipitously.
Deep Vein Thrombosis (DVT)
Prophylaxis
• Higher incidence of DVT in critical illness
• Risk of venous thromboembolism is
reduced if prophylaxis is consistently
applied
• TARGET: patients undergoing surgery,
trauma patients, acutely ill medical
patients, and ICU patients
DVT Prophylaxis
• It is unclear if there is any association
between DVT prophylaxis and decreasing
rates of VAP.
• Experience shows that when DVT
prophylaxis is applied as part of a package
of interventions for ventilator care, the rate
of pneumonia decreases precipitously.
DVT Prophylaxis – Risk of Bleeding
• Important considerations include that the
risk of bleeding may increase if
anticoagulants are used to accomplish the
prophylaxis.
• Often, sequential compression devices
• (ie. SCDs, “venodynes” or “pneumoboots”)
are not applied to patients when they go to
or return from procedures.
MEASUREMENT
• VAP Rate: The total number of cases of
ventilator-associated pneumonia for a
specified time period:
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(Total no. of VAP cases / Ventilator Days) x 1000 = VAP Rate
• Ventilator Bundle Compliance: On a given
day, the assessment of all vent patients for
compliance with the ventilator bundle:
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No. receiving ALL components of vent bundle = reliability of
No. on vents for the day of the sample
bundle
compliance
Barriers That May Be Encountered
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Fear of Change
Communication Breakdown
Physician and staff “partial buy-in”
(“Just another flavor of the week?”)
Unplanned extubations (most risky aspect)
Best Practices to Achieve a High Level
of Compliance at WPB VAMC ICU
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Daily Multi-disciplinary Rounds including:
Intensivist / Providers / Residents / Medical students
Lead Unit Facilitator
RN assigned to patient
Clinical Pharmacist / Pharmacy Residents
Infection Control Specialist
Respiratory Therapist
Registered Dietician
Nurse Case Manager
Quality Management / Utilization Management Specialist
Speech Therapist
Nursing student / Instructor
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Use of Ventilator Bundle Audit Tool addressing the bundle items daily
IPEC Data Management Website
• VISN 08 - Station 548 (West Palm Beach, FL) - FY 2007
- Quarter 4
• Unit: Mixed ICU JUL 2007 AUG 2007 SEP 2007
• Count Rate% Count Rate% Count Rate%
• VAP audits completed
• HOB elevated > 30 degrees
• SUD prophylaxis
• DVT prophylaxis
• Daily sedation vacation
• Daily readiness to wean
• Daily spontaneous breathing trial
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HAND HYGIENE
• The best method to prevent healthcare
acquired infections including VAP is to
practice good Hand Hygiene including use
of :
• Antimicrobial soap and water
• Alcohol Based Hand Rub (Isagel) when
there is no visible soiling on hands
Compliance with Isolation
Precautions
• Stringent adherence to the use of
Personal Protective Equipment (PPE)
such as Gowns, Masks, Gloves will
decrease the transmission of pathogenic
microorganisms to ventilated patients
when patients are identified as requiring
Contact and Droplet Precautions
QUESTIONS???????
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Thank you,
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Cindy Lang, RN, BSN, CIC
Senior Infection Control Specialist
2008 Chairperson Healthcare Emergency Response Coalition of Palm
Beach County (HERC)
2007 President Florida Professionals in Infection Control (FPIC)
2007 Syndromic Surveillance Chairperson (HERC)
Department of Veterans Affairs Medical Center
7305 North Military Trail
West Palm Beach, FL 33410-6400
Office
561-422-7358
Digital Pager 561-604-0208
FAX
561-422-6863
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