This study aimed to measure compliance with ventilator-associated pneumonia (VAP) bundle components in an intensive care unit (ICU) in Saudi Arabia. An audit of 88 mechanically ventilated patients found high compliance (87.5-100%) with hand hygiene, mouth care, and avoiding routine ventilator tubing changes. Compliance was lower for head-of-bed elevation (95.2%) and daily sedation vacations (65.5%). No patients received endotracheal tubes with subglottic suction ports due to unavailability. The authors recommend increasing education, minimizing provider workload, improving equipment maintenance, and ensuring access to recommended ventilation equipment.
A "bundle" is a
group of evidence-based care components
for a given disease that, when executed together, may result in better outcomes than if implemented individually.
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
A "bundle" is a
group of evidence-based care components
for a given disease that, when executed together, may result in better outcomes than if implemented individually.
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
IOSR Journal of Mathematics(IOSR-JM) is an open access international journal that provides rapid publication (within a month) of articles in all areas of mathemetics and its applications. The journal welcomes publications of high quality papers on theoretical developments and practical applications in mathematics. Original research papers, state-of-the-art reviews, and high quality technical notes are invited for publications.
The correct application of the safety check steps in our routine theatre operations and procedures will greatly reduce surgically related mortality and morbidity.
IOSR Journal of Mathematics(IOSR-JM) is an open access international journal that provides rapid publication (within a month) of articles in all areas of mathemetics and its applications. The journal welcomes publications of high quality papers on theoretical developments and practical applications in mathematics. Original research papers, state-of-the-art reviews, and high quality technical notes are invited for publications.
The correct application of the safety check steps in our routine theatre operations and procedures will greatly reduce surgically related mortality and morbidity.
2018 Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiop...Robert Cole
Bag-mask ventilation (BMV) is a less complex technique than endotracheal
intubation (ETI) for airway management during the advanced cardiac life support phase of
cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest.
It has been reported as superior in terms of survival.
Assessment of the Implementation of Ventilator-associated Pneumonia Preventiv...IOSR Journals
Background: Pneumonia associated with mechanical ventilation (VAP) is one of the important
causes of nosocomial infections in pediatric intensive care units (PICU). VAP is the leading cause of morbidity
and mortality in PICUs. Aim: To assess the compliance to ventilator bundle components: elevation of the head
of bed >30, sedation interruption, spontaneous breathing trial, peptic ulcer prophylaxis and its effect on the
prevention of VAP. Subjects and Methods: A case control study at PICU of Abo EL Reish El Moneira Hospital,
including all mechanically ventilated patients admitted over a period of one year. The study tested the effect of
implementation of this bundle as regard the rate of VAP in both group, compliance to bundle and most affecting
component of it. Results: There was decrease incidence of VAP after implementation of the bundle, from (50%)
to (14%). Development of VAP was mostly affected by being in supine position, long duration of mechanical
ventilation and presence of pump failure. (p<0.05) The compliance to bundle components was statistically
significant, p= 0.001. Conclusion: VAP rate decreased after implementation of this bundle. Elevation of the
head of bed was the most compliant component of bundle in the PICU.
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
A simplified description of basal ganglia stroke to help understand the clinical scenarios where patients present with neurological symptoms not clearly pointing towards possibility of stroke.
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
From eye drops to icu, a case report of three side effects of ophthalmic timo...Muhammad Asim Rana
Timolol Maleate (also called Timolol) is a nonselective beta-adrenergic blocker and a class II antiarrhythmic drug, which is used
to treat intraocular hypertension. It has been reported to cause systemic side effects especially in elderly patients with other
comorbidities.These side effects are due to systemic absorption of the drug and it is known that Timolol is measurable in the serum
following ophthalmic use. Chances of life threatening side effects increase if these are coprescribed with other cardiodepressant
drugs like calcium channel or systemic beta blockers. We report a case where an elderly patient was admitted with three side
effects of Timolol and his condition required ICU admission with mechanical ventilation and temporary transvenous pacing.The
case emphasizes the need of raising awareness among physicians of such medications about the potential side effects and drug
interactions. A close liaison among patient’s physicians is suggested.
Congenitally absent Inferior Vena Cava: A rare cause of recurrent DVT and non...Muhammad Asim Rana
In search of a cause for the so-called idiopathic Deep Vein Thrombosis (DVT), researchers have
pointed towards association between recurrent DVT and absent IVC
The best use of systemic corticosteroids in the intensive care units, reviewMuhammad Asim Rana
Corticosteroids are one of the most common medications that are used in the intensive care units (ICUs);
corticosteroids are used for a variety of indications, including septic shock, acute respiratory distress syndrome
(ARDS), bacterial meningitis, tuberculous meningitis, lupus nephritis, severe chronic obstructive pulmonary disease
(COPD) exacerbations and many others.
Corticosteroids are associated with many severe side effects that affect morbidity and mortality of the patients like
increased risk of infections, glucose intolerance, hypokalemia, sodium retention, edema, hypertension, myopathy
etc. In order to make the best use of these medications and to minimize the unwanted side effects we should follow
some particular protocol. Please keep in our mind that there is controversy about dosing and tapering of steroids, so
effort has been made to include the best available evidence.
This review discusses mainly the most common indications of corticosteroids in ICU, dosing of corticosteroids in
those indications and how to taper corticosteroids according to the best evidence that recommends their use.
Literature search was done using Medline, BMJ, Uptodate, Chochrane database, Google scholar and the best
evidence based guidelines in which steroids are recommended to treat ICU related disorders. Sex hormones are not
discussed in this review since its use is rare in the intensive care units.
A very effective, precise and focused presentation for Calcium abnormalities and approach towards management. Targeted to teach the to the point diagnosis and treatment.
It is requested to download the presentation to run the animation as it is a very interactive presentation
A detailed discussion and description on fungal diseases and management. The focus is kept on those facts which frequently come across an intensivist but it is also important for the Internist.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
Transorbital stab injury with retained knife. A narrow escapeMuhammad Asim Rana
An interesting case report about a patient who was admitted with a 13 cm long knife stabbed in his eye and has gone across the mid line. The interesting thing to note is that patient did not develop any neurological deficit.
Multi drug resistant bacteria are a big problem in ICUs now a days. This is a successful case report where we treated an pleural infection b directly instilling the drug colistin in the pleura.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
A brief yet comprehensive description of a very common problem faced in KSA especially during hajj season. It is meant to enhance the awareness among ER and ICU physicians.
A simplified description of ascitic fluid analysis. Aim of the presentation is to give a very clear understanding about the analysis of ascities.
Presentation will help the medical residents diagnose the cause of fluid accumulation in abdomen and thus will guide to adopt the appropriate pathway to solve the issue.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Vap bundle compliance in icu
1. VAP bundle compliance in ICU
Authors
A. Al-Harthy , A. F. Mady , H. Al-Hanafy , W. Al-Etreby , M. Asim Rana
Department of Intensive Care Medicine,
King Saud Medical City, Riyadh, Kingdom of Saudi Arabia.
Corresponding Author
Waleed Tharwat Hashim Al-Etreby
Kingdom of Saudi Arabia, Riyadh, P.O. Box 331140 ZIP code 11373 Al-Shemaisi
Anesth_71@yahoo.com
Lead Consultant
Abdul Rahman Mishal Al-Harthy
King Saud Medical City, Critical Care Department
Riyadh, Kingdom of Saudi Arabia
The Online Journal of Clinical Audits. 2014; Vol 6(2).
Published June 2014.
To subscribe to The Online Journal of Clinical Audits go to:
http://www.clinicalaudits.com/index.php/ojca/user/register
Article submission and authors instructions:
http://www.clinicalaudits.com/index.php/ojca/about/submissions
2. ISSN 2042-4779 ClinicalAudits.com
Abstract: Healthcare associated infection is a major concern worldwide, and ventilator associated
pneumonia (VAP) is the leading cause of mortality among them, VAP is also associated with increased
length of stay in ICU, and increased cost of treatment. Authorities all over the world have issued
guidelines and recommendations for the prevention of VAP in an effort to decrease its incidence.
Aims – To measure the compliance of healthcare providers in ICU with VAP bundle.
Methods – Concurrent snapshot review of the medical files of 88 adults ventilated patients took place,
during April 2014, for evidence of compliance with components of VAP bundle, namely: Hand hygiene,
mouth wash, elevation of head of bed (HOB), sedation vacation, non-routine changing of the ventilator
tubing, and the use of Endotracheal tube (ETT) with subglottic suction port.
Results – compliance with mouth wash and non-routine tubing change was 100%, while compliance with
hand hygiene was 87.5%, compliance with the elevation of HOB was 95.2%, compliance with sedation
vacation was 65.5%, no patients were intubated with ETT with subglottic suction port, so the compliance
was 0%
Conclusions – Awareness and education are required for the VAP bundle, every effort must be made to
minimize load of work on physicians and nurses, periodic preventive maintenance needs to be more
effective, and administration of the ICU will be addressed to provide ETT with subglottic suction ports.
Introduction
Healthcare-associated infection (HAI) is a major patient safety concern all over the
world 1
. The leading cause of death among (HAI) is ventilator associated pneumonia
(VAP), exceeding deaths due to central line infections, severe sepsis, and respiratory
tract infections in non-intubated patients 2
. With mortality rates ranging from 15% to
70% depending on the patient population 1
. And approximately 60% of deaths among
patients with hospital-acquired pneumonia 3
. Studies have also shown higher hospital
mortality rates of ventilated patients who develop VAP (about 46%) compared to
mortality rates of 32% of ventilated patients who do not develop VAP 4
. VAP is not only
associated with high mortality rates, but accounts also to increasing the length of stay
in ICU by an average of 4 to 9 days 3
. And consequently increasing directly
hospitalization costs to up to $40,000 per patient 5
. As well as increasing the duration of
mechanical ventilation, and making it more difficult to wean the patient from the
ventilator 6
.
Because of the seriousness of VAP and its morbid effect on patients’ outcome, many
authorities around the globe, like The Center for Disease Control (CDC), Joint
Commission, and the Leapfrog Group, have identified VAP rates as a measure of the
quality of care provided by an institution 7,8
. Several organizations have recommended
approaches, interventions, and evidence-based guidelines to address that issue 9
. And
many hospitals worldwide implemented a group of patient care practices, to be carried
out by the care team to standardize treatment, named the ventilator bundle or the VAP
bundle 10
. Including King Saud Medical City, Riyadh, KSA. Where this audit was carried
out.
3. ISSN 2042-4779 ClinicalAudits.com
Aims
To measure the compliance of the care providers with the elements of the VAP bundle.
Audit Standards (table 1)
1- Intubated patients should be positioned with their upper body elevated (semi-
recumbent or sitting) for as much of the time as possible, unless contraindicated
like spine injury.
2- Oral antiseptics (for example, chlorhexidine) should be included as part of an
oral hygiene regimen for all patients who are intubated, unless contraindicated
due to oro-pharyngeal trauma.
3- Hand hygiene, in accordance with national hand hygiene guidelines, should be
part of the routine clinical care of mechanically ventilated patients, without
exception.
4- The ventilator circuit should be changed only if soiled or damaged, not on a
routine basis.
5- Sedation reviewed, and if appropriate stopped daily, and the patient is assessed
for weaning and extubation, unless contraindicated due to difficulty of ventilation,
refractory hypoxia, or HFO.
6- Use of subglottic secretion drainage ETT in patients likely to be ventilated for
more than 48 hours.
Table 1: Audit standards and criteria.
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 ETT 100% Not available All ventilated adult
patients in ICU
Methods
The study was carried out at King Saud Medical City (KSMC), Riyadh, Saudi Arabia.
KSMC has a 120 bed state of the art ICU, making it one of the largest ICUs in the
middle east, accepting both medical and surgical cases.
During the month of April 2014, 88 mechanically ventilated adult patients were included
in the study.
Concurrent snap shot data were collected from the patients’ medical records, in a
YES/NO tick box form, concerning the six audit standards stated above. Percentage of
compliance with each standard was calculated separately, by dividing the number of
patients who meet the standard, by the number of patients to whom the standard
applies minus exceptions, multiplied by 100.
4. ISSN 2042-4779 ClinicalAudits.com
Results (table 2, figure 1)
1. Compliance with hand hygiene was observed in 77 cases out of 88 without
exceptions, with a percentage of 87.5%
2. Compliance with mouth wash with chlorhexidine was 100%, no patients were
excluded.
3. Compliance with elevation of head of bed was 81 out of 85 patients, with a
percentage of 95.2%, and 3 patients with unstable spine fracture were excluded.
4. Compliance with sedation vacation was documented in 57 patients out of 87,
with a percentage of 65.5%, while one patient on high frequency oscillation was
excluded.
5. Compliance with non-routine changing of the ventilator tubing was 100% without
exceptions.
6. Compliance with the use of subglottic suction ETT was 0%
Table 2: Summary of results.
Criteria Exception Compliance Percentage
Hand Hygiene zero 77/88 87.5 %
Mouthwash zero 88/88 100 %
HOB elevation 3 81/85 95.2 %
Sedation vacation 1 57/87 65.5 %
Changing tubing zero 88/88 100 %
Subglottic suction 88 0/88 0 %
Figure 1: Summary of results.
1- Hand hygiene, 2- Mouth wash, 3- HOB, 4- Sedation vacation, 5- change of tubes, 6- subglottic suction tube
5. ISSN 2042-4779 ClinicalAudits.com
Discussion
Mouthwash with chlorhexidine for intubated patients is a part of the daily nursing care in
our ICU, and all patients audited received that intervention, resulting in a compliance
percentage of 100%.
It is also the routine practice of respiratory therapists in the ICU to change tubing only if
they become soiled with secretions or damaged, resulting in a 100% compliance.
Compliance with hand hygiene was 87.5 %, noncompliance was observed in eleven
patients. Out of those eleven episodes of non-compliance, five cases were related to
emergency situations, like sudden desaturation or accidental extubation. Non-
compliance was observed among physicians, either ICU or out of ICU physicians.
Sedation vacation and assessment of readiness of extubation had the lowest
compliance percentage of about 66%, 87 patients were included and one patient on
HFO was excluded.
As for the use of ETT with subglottic suction port, all of the patients were excluded,
resulting in a compliance percentage of zero%
Conclusions
Compliance with the nursing elements of VAP bundle (mouth wash, hand hygiene, and
non-routine changing of the ventilator tubing) is up to standards, while the
inconsistencies were observed from the physicians side. In part due to unawareness
and lack of education about the elements of the bundle, especially between physicians
from outside the ICU, and in part due to the concentration on resuscitation by ICU
physicians in emergency situations, on the expense of policies and recommendations.
The overload of work (be it paper work, or critically ill patients handled by the same
person) make it impossible sometimes for the ICU physician to consider holding
sedation for an intubated patient and start a trial of weaning, which requires his/her
undivided attention and concentration.
Compliance with the standard of elevation of the head of bed, that was breached four
times, was the result of a malfunctioning bed once, and forgetting to return the patient
to semi-sitting position after care three times, which could also be attributed to the
overload of work on the bedside nurse, with many responsibilities and tasks to be
performed.
The zero compliance with the standard of using ETT with subglottic suction port was
simply due to its unavailability in our institution.
Recommendations
• Education, awareness, and enlightening are a must for the successful
implementation of any advocated intervention or practice. A campaign of
awareness of the VAP bundle is required to educate healthcare providers, about
its importance. Different methods can be used like: posters, reminder (pocket)
cards, lectures, group discussions, one-on-one talks …etc.
6. ISSN 2042-4779 ClinicalAudits.com
• Decreasing the load of work on the physician as well as the nurse is
recommended, so that the best care can be provided. Minimizing paper work is a
method, perhaps also recruitment of more personnel.
• Proper maintenance of all ICU equipment, and periodic checking. If a bed is not
functioning, it should not be available for patient admission.
• Administration of the ICU will be addressed to provide the ETT with subglottic
suction port.
References
1. Klevens RM, Edwards JR, Richards C,. Estimating health care-associated infections and deaths in
U.S. Hospitals. Public Health Reports 2007; 122: 160-166.
2. Move Your Dot™: Measuring, Evaluating, and Reducing Hospital Mortality Rates (Part 1). IHI
Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003.
3. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-
care-associated pneumonia: results from a large US database of culture-positive pneumonia. . Chest.
2005; 128(6): 3854-3862.
4. Luna CM, Blanzaco D, Niederman MS, Matarucco W, Baredes NC, Desmery P. Resolution of
ventilator associated pneumonia: prospective evaluation of the Clinical Pulmonary Infection Score as an
early clinical predictor of outcome. Crit Care Med 2003; 31: 676-82.
5. Warren DK, Shukla SJ, Olsen MA. Outcome and attributable cost of ventilatorassociated pneumonia
among intensive care unit patients in a suburban medical center. Crit Care Med 2003; 31(5): 1312-1317.
6. Rubenfeld GD, Caldwell E, Peabody E. Incidence and outcomes of acute lung injury. N Engl J Med
2005; 353: 1685-93.
7. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal
and a deadline for improving health care quality. jama 2006; 295(3): 324-327.
8. Jha AK,Orav EJ, Ridgway AB, Zheng J, EpsteinAM. Does the Leapfrog program help identify high-
quality hospitals?. Jt Comm J Qual Patient Saf. 2008; 34(6): 318-325.
9. Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Abstract: Nursing Adherence with Evidence-Based
Guidelines for Preventing Ventilator-Associated Pneumonia. Critical Care Medicine 2003; 31: 2693-2696.
10. Tolentino-DelosReyes AF, Ruppert SD, Shiao SY. Evidence-based practice: use of the ventilator
bundle to prevent ventilator-associated pneumonia.. Am J Crit Care. 2007; 16(1): 20-27.