Ventilator associated pneumonia -Prevention
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  • 1. Prevention ofVentilator Associated Pneumonia DEEPTHI.R, M.S.N Deepthi R.MSN 1
  • 2.  Identify ventilator- associated pneumonia and its incidence Preventventilator- associated pneumonia by implementing “Ventilator Deepthi R.MSN 2
  • 3.  A nosocomial pneumonia associated with mechanical ventilation that develops within 48 hours or more of hospital admission and which was not developing at the time of admission. Deepthi R.MSN Crit Care Nurs Q (2004) 3
  • 4. Deepthi R.MSN 4
  • 5. VAP is the most frequent infection occurring in patients after admission to the intensive care unit. In a recent large European observational study, almost 25% of patients developed an ICU-acquired infection, and the respiratory site accounted for 80%ofthese infections. Prevention of VAP is possibly one of the most cost-effective interventions currently attainable in the ICU Deepthi R.MSN 5
  • 6.  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 Deepthi R.MSN 6
  • 7. Horan TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-careassociated infection andDeepthi R.MSNspecific types of infection in the acute care setting criteria for 7
  • 8.  Figure 1 from Park Park DR. The microbiology of ventilator-associated pneumonia. Deepthi R.MSN 8
  • 9.  Risk factors include Prolonged mech.ventilator days Tracheostomy Multiple central line insertions Reintubation Supine position Impaired cough/depressed LOC Oropharyngeal colonization Presence of NG/OG tubes and enteral feeding Cross contamination by staff Deepthi R.MSN 9
  • 10.  Where do the bacteria come from?  Tracheal colonization- via oropharyngeal colonization or GI colonization  Ventilator system How do they get into the lung?  Breakdown of normal host defenses  Two main routes ▪ Through the tube ▪ Around the tube- micro aspiration around ETT cuff Deepthi R.MSN 10
  • 11.  VAP – leading cause of death among hospital –acquired infections High rate of associated mortality: Hospital mortality of ventilated patients 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 hospital stay and medical cost Deepthi R.MSN 11
  • 12.  Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission Deepthi R.MSN 12
  • 13.  Ventilator associated pneumonia: Pneumonia developing >48 hours of initiation of mechanical ventilation or <72 hours after cessation of mechanical ventilator *New progressive infiltrate, with leukocytosis, fever, and purulent sputum *Bronch protected specimen brush with >103 CFU, or BAL > 104 CFU *Ventilator days/mo is the sum of the number of days each patient was on mechanical ventilation (via ETT/trach tube) Deepthi R.MSN 13
  • 14. A care bundle is …...“A systematic method of measuring and improving clinical care processes based on groups of care elements for particular diagnoses and procedures” NHS Modernization Agency Deepthi R.MSN 14
  • 15.  This care bundle is derived from evidence- based guidance and expert advice. The purpose is to act as a way of improving and measuring the implementation of key elements of care. The risk of VAP increases when one or more elements are excluded or not performed Deepthi R.MSN 15
  • 16.  Head Of Bed elevated to 30˚-45˚ Daily sedation vacation &daily assessment of readiness to wean DVT Prophylaxis Stress Ulcer Prophylaxis Subglottic secretion drainage Daily mouth care with chlorhexidine Deepthi R.MSN 16
  • 17.  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 Deepthi R.MSN 17
  • 18. Contraindications  Hypotension MAP <70  Tachycardia >150  CI <2.0  Central line procedure  Posterior circulation strokes  Cervical spine instability use reverse trendelenburg  Some femoral lines ie: IABP no higher than 30 degrees use reverse trendelenburg  Increased ICP, No higher than 30 degrees avoid hip flexion  ProningDeepthi R.MSN 18
  • 19.  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 Deepthi R.MSN 19
  • 20.  Sedative agents should be stopped, but not disconnected from the patient. Allow the patient to wake. If the patient is co-operative and able to understand commands leave the sedation off. Distressed or agitated patients require re- sedating. Administer boluses as appropriate to achieve safety. Review the patient’s analgesic requirements if Deepthi R.MSN 20
  • 21.  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 Deepthi R.MSN 21
  • 22.  It is an appropriate intervention in all sedentary patients Critically ill intubated patients lack the ability to defend their airway Decreasing pH of gastric contents may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents Deepthi R.MSN 22
  • 23.  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 Deepthi R.MSN 23
  • 24.  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 Deepthi R.MSN 24
  • 25.  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 Deepthi R.MSN 25
  • 26.  Should be done using a 14 Fr sterile suction catheter:  Prior to ETT rotation  Prior to lying patient supine  Prior to extubation Deepthi R.MSN 26
  • 27.  In line suction: ▪ Maintain closed system ▪ Use separate suction tubing Normal saline: ▪ Should not be routinely used to suction pts ▪ Causes desaturation ▪ Does not increase removal of secretions ▪ Can potentially dislodge bacteria ▪ Should be used to rinse the suction catheter after suctioning Deepthi R.MSN 27
  • 28. Deepthi R.MSN 28
  • 29.  Fear of Change Communication Breakdown Physician and staff “partial buy-in” “Just another flavor of the week?” Unplanned extubation (most risky aspect) Lack of standardization Deepthi R.MSN 29
  • 30. Data collection - measurement is impossible - does not submit the dataToo many competing demandsPrioritization of work and issuesToo little cooperationTransforming the culture Deepthi R.MSN 30
  • 31.  Daily Multi-disciplinary Rounds including: Head Nurse(Unit in-charge) Reg.Nurse assigned to patient Clinical Pharmacist / Pharmacy Residents Infection Control Specialist Respiratory Therapist Registered Dietician Nurse Case Manager Speech Therapist Nursing student / Instructor Use of Ventilator Bundle Audit Tool addressing the bundle items daily Deepthi R.MSN 31
  • 32.  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 Deepthi R.MSN 32
  • 33.  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 Deepthi R.MSN 33
  • 34.  1. VAP rate=The total number of cases of ventilator-associated pneumonia for a particular time period. VAP Rate =(Total no. of VAP Cases / Ventilator Days) x 1000 Deepthi R.MSN 34
  • 35. 2.Ventilator Bundle Compliance =On a given day, the assessment of all vent patients for compliance with the ventilator bundle Reliability of bundle compliance =No. receiving ALL components of vent bundleNo. on ventilators for the day of the sample Deepthi R.MSN 35
  • 36. VAP bundle can be initiated in ahospital by applying thefollowing steps: Setting Aims Forming the Team Using the Model for Improvement Getting Started Deepthi R.MSN 36
  • 37.  Hospitals will not successfully implement the ventilator bundle overnight. If they do, chances are that they are doing something sub-optimally. A successful program involves careful planning, testing to determine if the process is successful, making modifications as needed, re-testing, and careful implementation. Deepthi R.MSN 37
  • 38.  Select the team and the venue (ICU) Assess where you stand presently Collaborate with other department to begin preparing for changes.(inf.control) Organize an educational program. Teaching the core principles to the ICU staff (doctors, nurses, therapists, and others) Introduce the ventilator bundle to the key stakeholders in the process Deepthi R.MSN 38
  • 39.  Hand washing is the single most important (and easiest!!!) method for reducing the transmission of pathogens. Use of waterless antiseptic preparations is also acceptable and may increase compliance.
  • 40. Deepthi R.MSN 40
  • 41.  The Programme created by Deepthi R. MSN, TravancoreCollege of Nursing, Kollam for Benefit of Nursing Students Deepthi R.MSN 41