2019 Winner of the Quality Week Awareness Poster Competition

1. Working Together to Combat Hospital Acquired
VAE/VAP, NV-HAP, and HAIs
St. Joseph’s University Medical Center 2019 Quality Awareness Week
© Omayra Perez BSHA, RRT
Respiratory Department

2. Methicillin-resistant Staphylococcus
Aureus (MRSA)
• CDC threat category: Serious
• Bacteria
• Spread by contaminated
hands, usually those of
healthcare providers
Multi-drug resistant Acinetobacter
• CDC threat category: Serious
• Gram negative
• Can survive on human skin and
medical equipment
Pseudomonas aeruginosa
• CDC threat category:
Serious
• Gram negative
• Affects hospital patients,
especially those on
mechanical ventilation and
with in situ tracheostomy
Healthcare-associated infections (HAIs) are among
the leading threats to the patient safety, affecting
one out of every 31 hospital patients at any one
time. (AHRQ, 2019)
As people who work in healthcare, you may be
hearing about “superbugs.” Superbug is the
colloquial term for a disease-causing bacteria that’s
‘resistant to’—i.e. immune to treatment with—
multiple antibiotics.
While most often some of these infections manifest
as non-pulmonary infections, they can cause
serious lung infections. The infection can spread
through improperly washed hands, surfaces and
medical equipment.
Commit to Combat VAP,
HAP and HAIs
They're dangerous.
They're tough to treat.
They're "superbugs."

3. Key Terms
Introduction
Hospital Acquired Infections (HAIs)
Also known as nosocomial
infections, are infections that
patients develop during their hospital
stay.
Hospital Acquired Pneumonia (HAP)
Or nosocomial pneumonia, is a lower
respiratory infection not incubating at the
time of hospital admission and that
presents clinically 2 or more days after
hospitalization .
Ventilator Associated Pneumonia (VAP)
Nosocomial pneumonia that develops 48
hours or longer after mechanical
ventilation is given by means of an
endotracheal tube or tracheostomy.
VAP results from invasion of the lower
respiratory tract and lungs by
microorganisms.
HAP/VAP Bundle
A grouping of clinical best
practices that, when applied
together, may result in
substantially reducing the rate of
VAP/HAP.

4. 02
1Inanimate
Surfaces• Privacy Curtains
• Patient Bed Linen
• Bed/Siderails/Furniture
• Door Handles
• Computers/MAKs/Telephones
• Omnicell Keyboard/Door Handle
2Non-critical Healthcare Tools
own by Health Professionals
• Stethoscopes
• Face masks
• White Lab Costs & Scrubs
• Pulse Oximeters
• Writing Instruments (e.g. pens, markets,
etc.)
1out of every 25Statistics:
According to a recent multistate survey of 183 acute care
hospitals in the United States revealed that approximate 1 of
every 25 impatient developed at least one healthcare-
associated infection per day. (N Engl J Med. 2018; 379:
1732 – 1744)
3Respiratory Therapy Equipment
• Mechanical Ventilators
• Non-Invasive Equipment (e.g., BIPAP, CPAP, High-
Flow, Face and nasal masks)
• Circuits, Open and Close Suction Systems
• Nebulizers
• Manual Resuscitator Bag (opened pkg)
Fact: Privacy Curtains
High risk for cross-contamination, because they are
high-touch surfaces that are not cleaned or changed
frequently.
• A 2018 study tracked the contamination rate of 10
freshly laundered privacy curtains in a burn unit and
found that curtains in patient rooms became
increasingly contaminated over time. More than
87% of curtains tested positive for MRSA by day
14. In contrast, control curtains that were not placed
in patient rooms stayed clean the entire 21 days.
(AM J Infect Control, 2018)
Protecting Patients and Healthcare Workers
The Invisible Cross-Contamination Cycle

5. Hospital admissions may be at
a higher risk for HAP (Journal
of Nursing Scholarship,
2013)
Within 48 hrs. of admission,
the normal oral flora changes
to include respiratory
pathogens not normally found
in health individuals (AACN
Procedure Manual for High
Acuity, Progressive, and
Critical Care. 7th Edition. Vol
37. 2nd ed. ELSEVIER.
4-6 Hours
Every 4-6 hours 20 billion
bacteria duplicate in oral cavity
(American Nurse Today, 2015)
In a multistate prevalence study, HAP was
found to be one of the most prevalent
healthcare-acquired infections (HAIs),
accounting for 22% of HAIs. Of these HAIs,
61% were non-ventilator HAP (NV-HA)
Hospital-acquired
Pneumonia (HAP)
HAIs
VAP HAP
39%61%
New England Journal of Medicine,
2014
80%
Facts
&
Figures
48 Hrs.
Areas in the hospital where patients are
most likely to acquire non-vent
pneumonia:
1. Medical surgical 4. Oncology
2. Intensive care 5. Step down
3. Telemetry
Patients with NV-HAP:
5X more likely to require
ventilator
16% average mortality rate
( Micek, S. et al. CHEST. 2017)
The cost of NV-HAP:
19.3%
of patients are readmitted for
pneumonia within 30 days
(AM J Infection Control, 2018)
$40,000
Estimated Acute Care cost per
case (American Journal of Infection Control, 2017)

6. HAP
MissionZero
HAP
1What is Hospital Acquired Pneumonia?
Hospital Acquired Pneumonia (HAP) is an
infection in the lung that occurs more than 48
hours after admission to a hospital. It is an
infection that was not present before the patient
came to the hospital.
3
What are some of the RISK factors for HA
• Weakened cough / preexisting chronic lung
disease
• Tracheostomy tubes
• Suctioning (e.g., nasal, oral, and tracheostomy)
• Weakened immune system from age, disease or
medication
• Aspiration
• Enteral feeding
2
What are some of the SIGNS/SYPTOMS of HAP?
A patient may experience the following:
• Green, yellow, or pus-filled secretions
• Fever, Leukocytosis
• Increase fatigue, tachypnea, pleuritic chest pain
• Shortness of breath
• Course (crackling) breath sound
• Loss of appetite
4 How is HAP DIAGNOSED?
• Clinical examination
• Signs and symptoms
• Microbiologic testing (e.g., sputum, nasotracheal
suctioning, bronchoscopy.)
• Radiographic findings (e.g., CT scan, chest x-ray)
FACT: HAP is the
second most common
hospital acquired
infection.
It is the most common
cause of death among
hospital acquired
infections.
HAP Prevention Bundle
• Clean Hands – all staff will wash hands or use antibacterial
hand sanitizer before and after each patient interaction.
Additionally, gloves are worn by staff during all direct patient
contact.
• Frequent Oral Care – reduces the amount of bacteria in the
mouth, decreasing chances of HAP occurring.
• HOB elevation – Keeping the patient’s head of the bed at or
≥30 degrees, when safe and appropriate, reduces the change of
germs from the oral cavity coming in contact with the lungs.
• Clean Suction Technique and Closed Suction Catheters

7. Hospitalized patients are
mechanically ventilated in the
United States annually and of
these, 5 to 10 percent – between
40,000 and 80,000 – develop
some type of VAE. (J Intensive
Care Med. 2006)
Ventilated patients develop a
VAE. (AM J Respir Care Med.
2014)
Mortality attributed to
ventilator associated
pneumonias (VAP).
(Critical Care Med J.
2001)
Over a quarter million patient in the United
States receives mechanical ventilation annually,
putting them at risk for acute lung injury,
including mortality related to pneumonia and
acute respiratory distress syndrome, among
lung injuries and death(Behrendt, 2000;
Wunsch et al., 2010; Kahn et al., 2006)
Ventilator Associated
Events (VAE)/VAP
15-19 Years
60%
24
Critical Care Medicine J. 2010
Facts
&
Figures
5 -10 %
The Centers for Disease Control and Prevention
(CDC) transitioned from VAP to VAE surveillance in
adult inpatient settings in 2013 (CDC, 2015)
VAE surveillance detects a broader range
of conditions and events are classified
into three hierarchical tiers:
• Ventilator-associated conditions (VAC)
• Infection-related ventilator-associated
complications
• Possible/probable VAP
VAP Diagnosis Costs:
$41,000 It is predicted VAP diagnosis
costs.
14 Days Increase LOS
Days increase in length of stay for acute care
hospital patients.
(Zimlichman et al., 2013)
2011 Hospital Acquired
VAP/HAP:
50,000
Patients developed ventilator-associated
pneumonia during the course of their acute care
hospital stay.
157,000
Patients were diagnosed with HAP. (Magill et al.,
2014)
Approx.
800,000
Patients
9% - 13%
35% Mortality Rate for Ventilated Patients

8. VAE
&
VAP
MissionZero
VAE&VAP
1What is Ventilator-associated Events (VAE)?
Defines a broad range of conditions and
complications occurring in mechanically
ventilated patients.
3
What are some Poor Outcomes of VAE?
• Ventilator-associated condition (VAC)
• Infection related ventilator-associated condition (IVAC)
• VAP
• Acute Respiratory Distress Syndrome (ARDS)
• Sepsis
• Pulmonary embolism
• Pulmonary Edema
• Barotrauma
• And More
2
CDC – New diagnostic criteria for VAP?
• High temperature
• Low temperature
• High white blood cell count (WBC)
• Low WBC
• Increased vent. Settings
• Gram stain neutrophils
• New antibiotic start
Ego A, Preiser JC, Vincent JL. Impact of diagnostic criteria on the incidence of
ventilator-associated pneumonia. Chest. 2015
4Ventilator-associated event Data Collection; tracking progress
reducing VAE, VAC, IVAC, and possible VAP events.
FACT:
Measurement
• Collecting these monthly
data points will guide the
quality improvement
efforts as part of the Plan-
Do-Study-Act (PDSA)
process.
• Broadens Awareness
• Catalyze Prevention
• Reflect and Inform
Progress
Calculation VAE Measures Per 1,000
Ventilator Days
Agency for
Healthcare
Research and
Quality
AHRQ, 2017
Process Measures
• Percentage of patients who underwent the ABCDEF bundle assessment
• Percentage of eligible patients who receive spontaneous awakening trial
• Percentage of eligible patients who receive spontaneous breathing trial

9. Ventilator Acquired Pneumonia (VAP)
Types
Early Onset VAP
• Occurs in the period of 2-5 days
post intubation.
• Pathogens responsible are
susceptible to antibiotics therapy:
• Staphylococcus Aureus
• Streptococcus
pneumoniae
• Hemophilus influenzas
• Proteus species
• Serratia species
• Klebsiella pneumoniae
• Escherichia coli
Late Onset VAP
• > 5 days post intubation.
• Usually caused by antibiotics
resistant organisms:
• Pseudomonas
aeruginosa
• Methicillin-resistant
Staphylococcus
aureus (MRSA)
• Acinetobacter species
• Enterobacter species
enterococcus (VRE)

11. You are an important part of infection
PREVENTION?

12. Infection
Prevention
&
YOU

13. Commit to Preventing HAP, VAP, and HAIs
Thank you for visiting
Respiratory Department