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Clinical Audit Project:
Prevention of Ventilator
Associated Pneumonia
Audit team: Lead
Dr. Abdul-Rahman Al-Harthy
Chair-man CCD, KSMC
ICU consultant
Audit team: Members
Dr. Ahmed F. Madi
KSMC, ICU consultant
Dr. Hosam Al-Hanafi
KSMC, ICU fellow
Dr. Waleed Al-Etreby
KSMC, ICU Registrar
Why VAP prevention ?
• National target, as indicated by MOH.
• Department and specialty priority.
• Clinical risk issue.
• Patient safety issue.
• Involves a wide sector of our customers.
• Cost and LOS.
Guidelines and Recommendations
Objectives
• Based on those guidelines, we have set six
objectives (criteria):
1. Mechanically ventilated patients who are
intubated should be positioned with their
upper body elevated (semi-recumbent or
sitting) for as much of the time as possible.
2. Oral antiseptics (for example,
chlorhexidine) should be included as
part of oral hygiene regimens for all
patients who are intubated and
receiving mechanical ventilation.
• 3. Hand hygiene, in accordance
with national hand hygiene
guidelines, should be part of the
routine clinical care of
mechanically ventilated patients.
• Hands should be decontaminated
appropriately with soap and water
or alcohol hand rub before and after
every episode of direct patient
contact, after any activity that
potentially results in hands
becoming contaminated and after
removal of gloves.
4. The ventilator circuit should be
changed only if soiled or damaged.
Scheduled changing of the circuit is not
recommended. New circuit tubing
should be provided for each patient.
5. Sedation reviewed, and if appropriate
stopped each day, and the patient is
assessed for weaning and extubation.
6. Use of subglottic secretion drainage in
patients likely to be ventilated for more
than 48 hours.
Criteria and Standards
Evidence of quality of care or
service (criterion)
Standard
(% compliance)
Exception(s)
Definitions and
instructions for
data collection
1 Elevation of head of bed 30 – 45
degrees
100 % Spine injury All ventilated adult
patients in ICU
2 Oral hygiene with chlorhexidine 100% Oro-pharyngeal
trauma
All ventilated adult
patients in ICU
3 Hand Hygiene 100% NONE All ventilated adult
patients in ICU
4 Circuit change only when needed 100% NONE All ventilated adult
patients in ICU
5 Sedation review and vacation 100% HFO, high ICP,
difficult to ventilate
All ventilated adult
patients in ICU
6 Subglottic suction 100% Not available All ventilated adult
patients in ICU
Methodology:
• Time frame: 1/3/2014 - 30/4/2014
• Sample size: 88
• Source of data: Patients’ charts, direct observation.
• Data collection form: Yes/No tick box form.
• Data analysis:
Clinical audit project

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Clinical audit project

  • 1. Clinical Audit Project: Prevention of Ventilator Associated Pneumonia
  • 2. Audit team: Lead Dr. Abdul-Rahman Al-Harthy Chair-man CCD, KSMC ICU consultant
  • 3. Audit team: Members Dr. Ahmed F. Madi KSMC, ICU consultant Dr. Hosam Al-Hanafi KSMC, ICU fellow Dr. Waleed Al-Etreby KSMC, ICU Registrar
  • 4. Why VAP prevention ? • National target, as indicated by MOH. • Department and specialty priority. • Clinical risk issue. • Patient safety issue. • Involves a wide sector of our customers. • Cost and LOS.
  • 6. Objectives • Based on those guidelines, we have set six objectives (criteria):
  • 7. 1. Mechanically ventilated patients who are intubated should be positioned with their upper body elevated (semi-recumbent or sitting) for as much of the time as possible.
  • 8. 2. Oral antiseptics (for example, chlorhexidine) should be included as part of oral hygiene regimens for all patients who are intubated and receiving mechanical ventilation.
  • 9. • 3. Hand hygiene, in accordance with national hand hygiene guidelines, should be part of the routine clinical care of mechanically ventilated patients. • Hands should be decontaminated appropriately with soap and water or alcohol hand rub before and after every episode of direct patient contact, after any activity that potentially results in hands becoming contaminated and after removal of gloves.
  • 10. 4. The ventilator circuit should be changed only if soiled or damaged. Scheduled changing of the circuit is not recommended. New circuit tubing should be provided for each patient.
  • 11. 5. Sedation reviewed, and if appropriate stopped each day, and the patient is assessed for weaning and extubation.
  • 12. 6. Use of subglottic secretion drainage in patients likely to be ventilated for more than 48 hours.
  • 13. Criteria and Standards Evidence of quality of care or service (criterion) Standard (% compliance) Exception(s) Definitions and instructions for data collection 1 Elevation of head of bed 30 – 45 degrees 100 % Spine injury All ventilated adult patients in ICU 2 Oral hygiene with chlorhexidine 100% Oro-pharyngeal trauma All ventilated adult patients in ICU 3 Hand Hygiene 100% NONE All ventilated adult patients in ICU 4 Circuit change only when needed 100% NONE All ventilated adult patients in ICU 5 Sedation review and vacation 100% HFO, high ICP, difficult to ventilate All ventilated adult patients in ICU 6 Subglottic suction 100% Not available All ventilated adult patients in ICU
  • 14. Methodology: • Time frame: 1/3/2014 - 30/4/2014 • Sample size: 88 • Source of data: Patients’ charts, direct observation. • Data collection form: Yes/No tick box form. • Data analysis: