VENTILATOR ASSOCIATED
PNEUMONIA (VAP)
WHAT IS VAP?
“ Ventilator-associated pneumonia (VAP) is pneumonia in
mechanically ventilated patients that develops later ...
RISK FACTORS FOR VAP IN
CHILDREN
o Mechanical ventilation > 48 hours
o Underlying respiratory disease
o Genetic syndromes
...
ISSUES RELATED TO VAP
• VAP is the 2nd most common hospital acquired infection (HAI) in the pediatric and neonatal intensi...
COMPARISON OF SELECTED POLICIES
Issue St Cloud Hospital Minneapolis Children’s Hospital National Guideline
Clearinghouse
D...
RECOMMENDATIONS
o Create an order bundle set for patients on a mechanical ventilator
o Create a checklist/bedside flow she...
RECOMMENDATIONS:
PROPOSED ORDER BUNDLE SET (ORAL CARE)
o Oral care consisting of the following:
 Assess oral cavity and l...
RECOMMENDATIONS:
PROPOSED ORDER BUNDLE SET
 Head of bed elevated approximately, equal to or
greater than 30 degrees unles...
POTENTIAL BENEFITS OF BUNDLE
IMPLEMENTATION
o Elimination of VAP in the PICU
o Decreased mortality
o Decreased length of h...
REFERENCES
Bonsal, V., & Haut, C. (2013). Preventing ventilator-associated pneumonia in children: an evidence-based protoc...
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Scsu dawnjm ventilator associated pneumonia

  1. 1. VENTILATOR ASSOCIATED PNEUMONIA (VAP)
  2. 2. WHAT IS VAP? “ Ventilator-associated pneumonia (VAP) is pneumonia in mechanically ventilated patients that develops later than or at 48 h after the patient has been placed on mechanical Ventilation” (Foglia, 2007)
  3. 3. RISK FACTORS FOR VAP IN CHILDREN o Mechanical ventilation > 48 hours o Underlying respiratory disease o Genetic syndromes o Immunodeficiency o Continuous enteral feedings o Transport out of the pediatric intensive care unit o Previous use of antibiotics o Bloodstream infections o Gastroesophageal reflux o Altered level of consciousness or coma o Use of H2 antagonists, immunosuppressants, neuromuscular blocking agents, narcotics (Bonsal, 2013)
  4. 4. ISSUES RELATED TO VAP • VAP is the 2nd most common hospital acquired infection (HAI) in the pediatric and neonatal intensive care units; 18% to 26% of all HAI’s in a pediatric intensive care unit (PICU) are caused by VAP • VAP results in high morbidity and mortality, increased hospital stay, and high health care costs • Mortality rate is 10% to 20% in the PICU and overall for patients of all ages 33% to 50% • VAP increases length of stay up to 22 days • Costs for patients with VAP are greater than $40,000 per patient per infection • In the PICU, 20% of nosocomial infections are VAP, with an incidence of 4 to 44 per 1000 intubated children • The mean PICU VAP rate is 2.9 per 1000 ventilator days (Bonsal, 2013; Eom, 2014; Foglia, 2007)
  5. 5. COMPARISON OF SELECTED POLICIES Issue St Cloud Hospital Minneapolis Children’s Hospital National Guideline Clearinghouse Deep vein thrombosis prophylaxis None Patients over 13 yrs old In policy – age not specified Drain condensate from ventilator circuit Current policy doesn’t have frequency stated Policy is every 2-4 hrs and with repositioning None Change in-line suction catheter Change 14 French every 72 hrs, other sizes every 24 hrs. Change only when visibly soiled None Bed therapy None None Kinetic bed therapy Daily assessments of readiness to extubate None Yes Yes Cuff pressure Maintain pressure at 25-35 mmHg None Maintain cuff pressure at 20-25 mmHg Oral Care Oral care every 2-4 hrs Oral care at least every 2 hrs Oral care 4 times a day with a 2% Chlorhexidine solution Continuous aspiration None None Continuous aspiration with an ET tube with a dorsal lumen (Children’s Hospital and Clinics of Minnesota, 2011; National Guideline Clearinghouse, 2012; Saint Cloud Hospital, 2012.)
  6. 6. RECOMMENDATIONS o Create an order bundle set for patients on a mechanical ventilator o Create a checklist/bedside flow sheet for increased compliance o Compliance audits weekly on intubated patients to ensure VAP bundle implementation o Patient evaluations daily for compliance of the following:  Head of bed elevation is checked every 4 hours  Peptic ulcer prophylaxis medication given daily  Deep vein thrombosis prophylaxis provided daily  Oral care provided with chlorhexidine solution every 12 hours o Provide education modules for staff education and awareness
  7. 7. RECOMMENDATIONS: PROPOSED ORDER BUNDLE SET (ORAL CARE) o Oral care consisting of the following:  Assess oral cavity and lips every 6-8 hours as needed for hydration, infection, pressure points, etc.  Every 12 hours brush teeth with small, soft toothbrush and fluoride toothpaste; suction out toothpaste, but do not rinse out mouth  After brushing teeth rinse mouth with chlorhexidine solution; irrigate with syringe or wipe mucosa with swab; suction excess, but do not rinse out mouth with water  Every 2 hours moisten mouth with swabs soaked in clean water or physiological saline  Every 2 hours and as needed, coat lips with lip balm or petroleum jelly
  8. 8. RECOMMENDATIONS: PROPOSED ORDER BUNDLE SET  Head of bed elevated approximately, equal to or greater than 30 degrees unless currently contraindicated  Perform hand hygiene before and after contact with the patient or ventilator  Drain condensation every 2-4 hours and before repositioning patient  Evaluate need for Kinetic bed therapy  Maintain cuff pressure 20-25 mmHg  Circuit changes: no routine changes, only when visibly soiled or malfunctioning  Heated humidifiers: no routine changes, only when visibly soiled or malfunctioning  Assess patient for daily sedation reduction  Assess for eligibility of daily weaning trials  Suction only when clinically indicated  Use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow continuous suction of tracheal secretions in the subglottic area in children > 12  Store oral suction devices in a non sealed plastic bag when not in use  Monitor gastric residuals every 4 hours to prevent aspiration  Change in-line endotracheal suction catheters only when visibly soiled  Deep vein thrombosis prophylaxis  Pharmacological  Mechanical  Stress ulcer prophylaxis  Sucralfate  H2 antagonist  Proton pump inhibitor
  9. 9. POTENTIAL BENEFITS OF BUNDLE IMPLEMENTATION o Elimination of VAP in the PICU o Decreased mortality o Decreased length of hospital stay o Decreased hospital costs o Improved patient outcomes (Bonsal, 2013)
  10. 10. REFERENCES Bonsal, V., & Haut, C. (2013). Preventing ventilator-associated pneumonia in children: an evidence-based protocol. Critical Care Nurse, 33(3), 21-29. http://dx.doi.org/10.4037/ccn2013204 Children’s Hospitals and Clinics of Minnesota. (2011). Mechanical ventilation: general assessment, care and documentation 401.00. Eom, J., Lee, M., Chun, H., Choi, H., Jung, S., Kim, Y.,… Lee, J. (2014). The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. American Journal of Infection Control, 42, 34-37. Foglia, E., Meier, D., & Elward, A. (2007). Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clinical Microbiology Reviews, 20(3), 409-425. doi: 10.11258/CMR.00041-06 How-to-guide pediatric supplement: ventilator associated pneumonia [PDF document]. Retrieved from http://www.nichq.org/pdf/VAP.pdf Institute for Clinical Systems Improvement. (2014). Pneumonia, ventilator-associated, prevention of. Retrieved from http://www.icsi.org/guidelines_more/catalog_guidelines/catalog_respiratory_guidelines/vap/ Saint Cloud Hospital. (2012). Standards of care: mechanical ventilation, PICU, PPCU. (2012). Prevention of ventilator-associated pneumonia. Health care protocol. Retrieved from http://www.guideline.gov/content.aspx?id=36063

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