Prevention of Ventilator-Associated Pneumonia - Part 2 (May 2006)

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Prevention of Ventilator-Associated Pneumonia - Part 2 (May 2006)

  1. 1. Rev: January 30, 2015 1
  2. 2. Rev: January 30, 2015 2 Ventilator Associated Pneumonia • Diagnosis of VAP was covered in the previous discussion
  3. 3. Rev: January 30, 2015 3 Adult Ventilator Bundle VAP prevention measures 1. Handwashing 2. Patient positioning 3. Oral care 4. Management of oropharyngeal and tracheal secretions 5. Daily “Sedation Vacation” and daily assessment of readiness to extubate General measures to improve care 1. Peptic ulcer disease prophylaxis 2. Deep vein thrombosis (DVT) prophylaxis
  4. 4. Rev: January 30, 2015 4 Handwashing • Strict handwashing before and after handling patient or patient’s equipment or supplies
  5. 5. Rev: January 30, 2015 5 Patient Positioning • Elevate the Head of the Bed 30-45o by flexing bed or reverse Trendelenberg –Reduces chance of gastric reflux and aspiration of gastric contents • Proper position in bed –keep joints in neutral, semi-flexed position –minimize abdominal compression Drakulovic MB. Lancet.1999;354:1851-1858.
  6. 6. Rev: January 30, 2015 6 Evidence for Elevating Head of Bed •Elevate the Head of the Bed 30-45o by flexing bed or reverse Trendelenberg – Randomized controlled trial: 86 adult intubated patients on mechanical ventilation assigned to semi-recumbent (45o ) or supine position Semi-recumbent: Supine: Suspected VAP: 8% 34% (CI for difference 10-42%: p=0.003) Confirmed VAP: 5% 23% (CI for difference 4-32%: p=0.018)Drakulovic MB. Lancet.1999;354:1851-1858.
  7. 7. Rev: January 30, 2015 7 Patient Positioning • Precautions – Head elevation in patient with hypovolemia - possible significant hypotension – Transporting patients on ventilatory support – Spine precautions • May need to use Reverse Trendelenberg Drakulovic MB. Lancet.1999;354:1851-1858.
  8. 8. Rev: January 30, 2015 8 Do: http://www.tccd.edu/neutral/DivisionDepartmen tPage.asp?pagekey=191&menu=1 http://www.engin.umich.edu/alumni/engineer/03SS/ protective/ http://www.rtmagazine.com/Articles.AS P?articleid=r0202F03 Positioning DO’s and DON’Ts • Leave patient in supine position for prolonged periods • Continue Q 2 hour turning schedule. • Maintain HOB > 30 degrees unless contraindicated. Don’t: • Forget to turn tube feedings off prior to placing patient in supine position
  9. 9. Rev: January 30, 2015 9Picture from Sage
  10. 10. Rev: January 30, 2015 10 Oral care • Colonization of oropharynx - – Normal flora includes both Gram-positive and anaerobic bacteria. – When normal flora compromised, more susceptible to colonization by microorganisms (e.g., Gram-negative bacilli), not normally found in oropharyngeal secretions. – Migration to lower airway can lead to VAP Pfeifer, LT; Orser, L.; Gefer, C.; McGuinness, R.; and Hannon, CV (2001). Preventing ventilator- associated pneumonia. American Journal of Nursing, 101(8), 24AA-24GG.
  11. 11. Rev: January 30, 2015 11 Oral care • Colonization of Oropharynx - Dental Plaque – Colonization of dental plaque is either present on admission or acquired in 40% of ICU patients. – Positive dental plaque culture significantly associated with subsequent nosocomial infections – particularly aerobic pathogens. – ICU patients at risk due to: • Difficulties performing adequate oral hygiene • Changes in properties of saliva • Reduction of anaerobic flora secondary to antibiotics Fourrier, F.; Buvivier, B.; Boutigny, H.; Roussel-Delvallez, M, and Chopin, C. (1998) Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine 26:301-308.
  12. 12. Rev: January 30, 2015 12 Oral care Protocol • Assess oral cavity at least every shift • Brush teeth each shift with suction oral brush and 1.5% hydrogen peroxide solution • Oral care every 2 hours with suction oral swabs and 1.5% hydrogen peroxide solution • Hypopharyngeal/subglottic suctioning at least q6h and as necessary • Apply mouth moisturizer as needed • Sage oral care kit can make compliance easier
  13. 13. Rev: January 30, 2015 13 Management of Oral and Tracheal Secretions • Proper care of oral and tracheal secretions is essential to minimize risk of aspiration • To prevent aspiration of pooled secretions hypopharyngeal suctioning should be performed before – suctioning the ETT – repositioning the ETT – deflating the cuff – repositioning your patient
  14. 14. Rev: January 30, 2015 14 Management of Oral and Tracheal Secretions (3a) • Care of Equipment: – Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
  15. 15. Rev: January 30, 2015 15 Management of Oral and Tracheal Secretions (3b) • Care of Equipment: – Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O) – Use Ballard system or use 2 people to assist
  16. 16. Rev: January 30, 2015 16 • Care of Equipment: – Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O) – Use Ballard system or use 2 people to assist – Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel. Management of Oral and Tracheal Secretions (3c)
  17. 17. Rev: January 30, 2015 17 • Care of Equipment: – Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O) – Use Ballard system or use 2 people to assist – Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel. – Help keep the vent circuit free from accumulated water. Drain water away from the patient. Management of Oral and Tracheal Secretions (3d)
  18. 18. Rev: January 30, 2015 18 Management of Oral and Tracheal Secretions (3e) • Care of Equipment: – Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O) – Use Ballard system or use 2 people to assist – Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper (from gloves or gauze). – Help keep the vent circuit free from accumulated water. Draining water away from the patient. – Change the suction canister and mouth care kit every 24 hours.
  19. 19. Rev: January 30, 2015 19 Management of Oral and Tracheal Secretions (3f) • Care of Equipment: – Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O) – Use Ballard system or use 2 people to assist – Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper (from gloves or gauze). – Help keep the vent circuit free from accumulated water by draining water away from the patient. – Change the suction canister and mouth care kit every 24 hours.
  20. 20. Rev: January 30, 2015 20 Sedation Vacation • Sedation vacation: discontinuation of sedation until patient is responsive (awake) • 128 adults on mechanical ventilation randomized to sedation vacation group or control sedation group. • Duration of ventilation: • sedation vacation group 4.9 days • control sedation group 7.3 days (p=0.004) Kress JP. N Engl J Med. 2000; 342: 1471-1477.
  21. 21. Rev: January 30, 2015 21 PUD Prophylaxis Why? • Reduces acid production in stomach and the consequent risk of bleeding from gastric erosions and peptic ulcers Identified Issues and Concerns • Some studies have shown increasedincreased rates of ventilator associated pneumonia in patients on prophylactic treatments, e.g. sucralfate Anecdotal Experience • None significant
  22. 22. Rev: January 30, 2015 22 PUD Prophylaxis Surviving Sepsis Campaign Guidelines:Surviving Sepsis Campaign Guidelines: “Stress ulcer prophylaxis should be given to all patients with severe sepsis. H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents. Proton pump inhibitors have not been assessed in a direct comparison with H2 receptor antagonists and, therefore, their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.” Dellinger RP. Crit Care Med. 2004; 32: 858-873.
  23. 23. Rev: January 30, 2015 23 DVT Prophylaxis Systematic review of risks of venousSystematic review of risks of venous thromboembolism and its prevention:thromboembolism and its prevention: “We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).” Geerts WH. Chest. 2004; 126: 338S-400S.
  24. 24. Rev: January 30, 2015 24 Deep vein thrombosis (DVT) prophylaxis • Atlas Toolkit: keyword search DVT – Educational Materials – Risk Assessment and Order sets – Utilization Monitoring/Evaluation Strategies – HCA Facility Examples • Healthstream Education Module – 1. Log into Healthstream – 2. Select the Find tab at the top of the screen – 3. Select the category Patient Safety – 4. Select the sub-category Medication Safety – 5. Click the course name: Venous Thromboembolism Risk Screening and Prophylaxis
  25. 25. Rev: January 30, 2015 25 Pediatric Ventilator Bundle Applies to patients of ages 1month- 13 years Same as Adult VAP prevention measures Handwashing Patient positioning Oral Care Management of oral and tracheal secretions Daily assessment of readiness to extubate General measures to improve Critical Care Peptic ulcer disease prophylaxis Different from Adult VAP prevention measures: Sedation Vacation Deep vein thrombosis prophylaxis
  26. 26. Rev: January 30, 2015 26 Neonatal Ventilator Bundle (0-28 days of age) No clear data on proven measures to reduce VAP in neonates. Recommendations based on “common sense” best practice. Same as Adult VAP prevention measures Handwashing Management of oral and tracheal secretions Daily assessment of readiness to extubate Different from Adult VAP prevention measures Patient positioning Oral Care Daily “Sedation Vacation” General measures to improve Critical Care Peptic ulcer disease prophylaxis Deep vein thrombosis (DVT) prophylaxis
  27. 27. Rev: January 30, 2015 27 Summary: Consider these Components for your Interventions and Checklists • Handwashing – Before entering patient room – On exiting patient room • Patient Position – Bed elevated 30-45 degrees – Patient properly positioned in bed • Proper Oral Care every 2 hours
  28. 28. Rev: January 30, 2015 28 Summary: Consider these Components for your Interventions and Checklists • Secretion Management – Check and maintain proper ETT cuff pressure – Use inline (Ballard) ETT suction – Suction hypopharyngeal secretions as needed – Keep end-of-circuit suction catheter clean and off patient bed
  29. 29. Rev: January 30, 2015 29 Summary: Consider these Components for your Interventions and Checklists • Care of Ventilator Equipment – Circuit drained of accumulated condensed water – Change suction canister and oral care kit daily • Sedation Vacation – Discontinue sedation daily
  30. 30. Rev: January 30, 2015 30 For a Successful Strategy to Reduce VAP • Set an Aim: “Improve the health and well-being of ventilated patients by reducing the VAP rate.” • Set goals: for example: “Reduce VAP rate by 50% by April 2006.” “Implement use of ventilator bundle with greater than 95% reliability.” • Plan Well: Adopt a change methodology that • accelerates improvement such as The Model for Improvement. • Benchmark: use national benchmark (e.g., National Healthcare Safety Network - NHSN)
  31. 31. Rev: January 30, 2015 31 Selected references1. Drakulovic MB, Torres A, et al. Supine body position as a risk factor for noscomila pneumonia in mechanically ventilated patients: a randomized trial. Lancet.1999;354:1851-1858 2. Pfeifer LT, Orser L, Gefer C, McGuinness R, Hannon CV. Preventing ventilator- associated pneumonia. American Journal of Nursing. 2001; 101(8), 24AA-24GG 3. Fourrier F, Buvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine. 1998;26:301-308. 4. Kress JP, Pohlman AS, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000; 342: 1471-1477 5. Schweickert WD, Gehlbach BK, et al. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004, 32(6):1272-1276. 6. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53 (RR- 3):1-36. 7. IHI.org: A resource from the Institute for Healthcare Improvement. Getting Started Kit: Prevent Ventilator-Associated Pneumonia, Bibliography. Accessed April 2006. http://www.ihi.org/NR/rdonlyres/FD28C31B-5E93-448D-B5DC-9941ACB6C150/0/VAPBibliog 8. American Thoracic Society Documents. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416. 9. Garcia R. Addressing JCAHO’s Patient Safety Goal #7: Focus on Key HICPAC Strategies for the Prevention of VAP. Brookdale University Medical Center, Brooklyn, NY:APIC Seminar; 2004

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