Transcript Slide 1

Saint Anthony-Crown Point CICU/NSICU
Margie Wickert, RN, MSN -Critical Care CNS
Lisa R. Kwasigroch RN, BSN
Objectives
Define Ventilator-Associated Pneumonia (VAP)
Discuss the risk factors associated with VAP and
the implications for nursing care of patient’s
receiving ventilator therapy
Identify the patients who are at risk for VAP
Identify contributing factors for development of VAP
Discuss the Evidence-Based Practice guidelines to
help reduce VAP
Problem Identification
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Patients that are receiving continuous
mechanical ventilation have 6 to 21 times
greater risk of developing hospitalassociated pneumonia than patients not on
mechanical ventilation
Tablan OC, “Guidelines for preventing health-care--associated pneumonia, 2003,”
Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee
(HICPAC), 2003.
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According to an AJCC study, VAP occurs in 10 to
65% of ventilated critical care patients
mortality rates between 20 and 70%
Sole ML, Am J Crit Care, 2002
Problem Identification
A recent, 9,080-patient study found that the average VAP
patient spends 9.6 additional days on mechanical
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ventilation, 6.1 extra days in the ICU, and
11.5 more days in the hospital
And VAP costs over $40,000 per case to
treat—all paid for by the facility
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Rello, Chest, 2002
Goals
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Decrease / Prevent Ventilator
Associated Pneumonia (VAP)
Decrease LOS in the ICU
VAP . . .What is it?
Ventilator-Associated Pneumonia
Most common nosocomial bacterial
infection among patients requiring
mechanical ventilation
Rello, Chest, 2002
VAP
Increased mortality in critically ill
patients (20% - 70%)
Increased cost of care:
$40,000 additional cost per patient
CDC guidelines from Preventing Healthcare Pneumonias, 2003
AACN Practice alert
Risk Factors
For Developing VAP
Patients at extreme of age spectrum;
malnutrition; severe underlying conditions
Artificial airway
Colonization of dental plaque with respiratory
pathogens
Bacterial colonization of the oropharyngeal area
Aspiration of subglottic secretions
Head of bed < 30 degrees
Risk Factors
For Developing VAP
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Colonization of Dental Plaque with
respiratory pathogens
Bacterial Colonization of the
oropharyngeal area
Aspiration of subglottic secretions
Quality
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CDC Guidelines re: Prevention of
Healthcare-Associated Pneumonia
“…Develop and implement a comprehensive oral hygiene program
(that might include use of an antiseptic agent) for patients in acutecare settings or residents in long-term--care facilities who are at
risk for health-care--associated pneumonia (II).*
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Healthcare Facilities Accreditation
Program
American Thoracic Society
Infectious Diseases Society of America
American Association of Critical Care
Nurses
Six Sigma Process
* In addition to other interventions
Guidelines for preventing health-care associated pneumonia, 2003, Recommendations of
CDC and HICPAG
Evidenced Based Practice
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EVIDENCE LEVEL
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Level I - High
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Level II - Moderate
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Level III - Low
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Evidence comes from
well conducted,
randomized control
trials
Evidence comes from
well designed,
controlled trials without
randomization
Evidence comes from
case studies and expert
opinion; therapy
recommendations
without clinical data
Create Multi-disciplinary
Team
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Dr. Rebessco - Pulmonologist
Margie Wickert, RN, MSN - Critical Care CNS
Lisa Kwasigroch, RN, BSN - Purdue MSN Student
Unit Director CICU / NSICU
Georgine Paulauski - Respiratory Therapy
Chris Shakula - Infectious Disease
Carolyn Bender - Nursing Quality
Nursing Management
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Carol Schuster
Karin Kolisz
Education Goals
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Increase knowledge and awareness
of VAP
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Change attitudes to value the
importance of the role of oral care
in the etiology of VAP
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Change practice
Recommended
Best Practice
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Water based moisturizers provide
hydration
Non-alcoholic oral rinses
Mouthwash with hydrogen peroxide
actives naturally occurring peroxidase
which resists bacterial colonization in
the oral pharynx
Nursing Mgt., Vol. 34, Supplement 3, May 2003
Recommended
Best Practice
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Soft bristle toothbrush removes plaque
and stimulates the mucosa
Sodium bicarbonate toothpaste
overcomes odor, dissolves mucous,
eliminates breeding ground for
bacteria, and reduces acidity
Mouthwash with an antiseptic agent
has an antimicrobial effect on the oral
cavity
Nursing Mgt., Vol. 34, Supplement 3, May 2003
Impact of Standardized
Oral Care Protocol on VAP
Saint Anthony - Crown Point
CICU / NSICU
Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994
In the absence of medical contraindication(s).
CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003
Drakulovic et al, Lancet, 1999,354:1851
Sage - Q•Care® Oral Cleansing
and Suctioning System q4h
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Content Kit 24 Hours:
1 Suction Handle; Covered Yankauer;
Y-Connector
2 Suction toothbrush with Sodium
Bicarbonate, Antiplaque Solution,
Mouth Moisturizer, Applicator Swab
4 Suction swab with Sodium
Bicarbonate; Perox-A-Mint® Solution,
Mouth Moisturizer and Applicator
Swab
2 Suction Catheter
Oral Cavity
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Suction the oral cavity
Swab the oral cavity every 4 hours and
PRN to cleanse and maintain oral
mucosal integrity
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Moisturize oral cavity every 4 hours
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Brush Teeth
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Brush teeth 2 times per day to remove
dental plaque
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0800
2000
Oropharyngeal Suctioning
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Suction every 12 hours to remove
secretions from the oropharyngeal
area above the vocal cords.
Implement Best Practice
VAP / Oral Care Protocol
Inservice Staff
Initiate Protocol
Implement Q•Care® Tools.
Evaluate Progress - Goal
Name: ____________________
Ventilator Associated Pneumonia (VAP)
Oral Care Protocol
Post-Inservice Review
1. What is the additional average cost of Ventilator Associated Pneumonia to the hospital per case?
a.$10,000
b.$20,000
c.$40,000
d.$75,000
2. What is the mortality rate for a patient who develops VAP?
3.List three major risk factors associated with the development of Ventilator Associated Pneumonia?
1.______________________________
2.______________________________
3.______________________________
4. What is the CDC recommendation for all ventilated patients?
5.Critical care nurses can prevent Ventilator Associated Pneumonia.
a. True
b. False
Name: ____________________
Ventilator Associated Pneumonia (VAP)
Oral Care Protocol
Post-Inservice Review
6. What is the St. Anthony Critical Care Unit Protocol for frequency of Oral Care on patients receiving mechanical ventilation > 24 hours?
a. every hour
b.every 2 hours
c.every 4 hours
d.every 8 hours
7. Using the Oral Care Protocol, how often should the critically ill vented patient's teeth be brushed?
a. every 4 hours
b. every 8 hours
c. every 12 hours
d. once a day
8. The purpose of the Sage mouth moisturizer is to: _______________________________.
9.The Sage oral care kit will be changed @ __________ AM every __________.
10. The goal of providing a comprehensive oral care program to ventilated patients is to ma
intain integrity of the oral mucosa, decrease or prevent ventilator associated pneumonia and decrease the ICU length of stay.
a. True
b. False
Name: ____________________
Ventilator Associated Pneumonia (VAP)
Oral Care Protocol
Post-Inservice Review
ANSWER SHEET
1. What is the additional average cost of Ventilator Associated Pneumonia to the hospital per case?
a.$10,000
b.$20,000
c.$40,000
d.$75,000
2. What is the mortality rate for a patient who develops VAP?
20-70%
3.List three major risk factors associated with the development of Ventilator Associated Pneumonia?
1. Colonization of dental plaque with respiratory pathogens
2. Bacterial colonization of the oropharyngeal area
3. Aspiration of subglottic secretions
4. What is the CDC recommendation for all ventilated patients?
Develop and implement a comprehensive oral hygiene program
5.Critical care nurses can prevent Ventilator Associated Pneumonia.
a. True
b. False
Name: ____________________
Ventilator Associated Pneumonia (VAP)
Oral Care Protocol
Post-Inservice Review
ANSWER SHEET
6. What is the St. Anthony Critical Care Unit Protocol for frequency of Oral Care on patients receiving mechanical ventilation > 24 hours?
a. every hour
b.every 2 hours
c.every 4 hours
d.every 8 hours
7. Using the Oral Care Protocol, how often should the critically ill vented patient's teeth be brushed?
a. every 4 hours
b. every 8 hours
c. every 12 hours
d. once a day
8. The purpose of the Sage mouth moisturizer is to:hydrate the mouth and maintain mucosal integrity.
9.The Sage oral care kit will be changed @ 0600 AM every day.
10. The goal of providing a comprehensive oral care program to ventilated patients is to maintain integrity of
the oral mucosa, decrease or prevent ventilator associated pneumonia and decrease the ICU length of stay.
a. True
b. False
Ventilator Associated Pneumonia
Oral Care Protocol
QI Tracking Sheet
Unit: _____________________
Month/Ye ar: ______________
Date
Patient MR #
Oral Cleansing
Suctioning System
Q Care q4h
Oral Care
Documented
Flow Sheet
All Used
Yes
# Left
Created by: Margie Wickert, RN, MSN - Critical Care Clinical Specialist 6/2005
No
Total Number
Ventilator
Days
Q Care Kits
Used