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A Member of Daughters of Charity Health System
Zapping VAP: More than a Bundle Approach
Suzanne Cistulli RN, BSN, CIC Director of Infection Prevention
Member, Daughters of Charity Health System
O’Connor Hospital
Opened in 1889 Daughters of Charity
Member, Daughters of Charity Health System
O’Connor Hospital
First hospital in Santa Clara County
358 beds
Today
Then
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Our Mission
In the spirit of our founders, St. Vincent de Paul, St. Louise de Marillac, and St. Elizabeth Ann Seton, the Daughters of Charity Health System is committed to serving the sick and the poor. With Jesus Christ as our model, we advance and strengthen the healing mission of the Catholic Church by providing comprehensive, excellent healthcare that is compassionate and attentive to the whole person: body, mind and spirit. We promote healthy families, responsible stewardship of the environment, and a just society through value-based relationships and community-based collaboration.
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Objectives
1. The participant will be able to list the components of the VAP bundle.
2. The participant will be able to identify the epidemiology of ventilator associated pneumonia
Member, Daughters of Charity Health System
VAP Bundle
Head of the bed ↑ 30 degrees Daily sedative interruption and daily assessment of
readiness to extubate Peptic Ulcer Disease Prophylaxis (PPI Inhibitor) DVT Prophylaxis Daily oral care with chlorhexidine
Member, Daughters of Charity Health System
Head of the Bed
30 – 45 degrees – Reduces aspiration pneumonia
» GI contents » Oropharyngeal and
nasopharyngeal secretions – Better aeration of the lungs – Decreases atelectasis
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Tips
RT and Nursing collaboration Use a visual cue Family involvement Physician order sets
– HOB – Tube feedings – Oral hygiene
Monitor and post compliance
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Daily Sedation Vacations
Assessment for readiness to extubate
Some exceptions* – head injured, severe sepsis,
ARDS, tetanus, asthma, ACS – prone position or on infusions of
muscle relaxants – Increasing fIO2
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Potential Risks
Patient anxiety – Panic – More aware of environment – Coughing and desaturation
Pain perception – Post op pain – ETT – NG tube
Self extubation
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Tips
Time of day Stay with patient
– Comfort – Reassurance
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Peptic Ulcer Disease Prophylaxis
Recommended for all Critical Care patients – Stress ulcer GI bleeding – ? Reduced rates of VAP in Critical Care patients
PPI or H2 Blocker? – Both suppress gastric acid secretion
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Anatomy and Physiology of GERD
Present in the healthy population (20-40%)
pH of stomach bile – 1-2
Reflux of stomach contents – Hiatal hernia – Stomach contactions – Obesity – Smoking – Pregnancy – Overeating
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Purpose of Stomach Acid
Digestion Keeps bacteria in check
– Acinetobacter baumannii – E. coli – Klebsiella pneumoniae – Morganella morganii – Staph aureus
» MSSA, MRSA – Pseudomonas aeruginosa – Yeast
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Proton Pump Inhibitor
Molecule in certain cells of stomach – Takes one ion out and replaces it – Able to stop the pump action
» Stops acid secretion into stomach
Delayed onset and lasts longer Rebound excessive acid production Common PPIs
– Lansoprazole – Omeprazole – Pantoprazole
» C. difficile
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H2 Blocker
Also suppresses gastric acid secretion – Blocks histamine receptors in stomach
Rapid onset of action (1 hour); lasts 12 hours Common H2 Blockers
– Ranitidine – Cimetidine – Famotidine
Member, Daughters of Charity Health System
Tips
PUD prophylaxis on ICU Admission orders Clinical Pharmacist involvement Interdisciplinary rounds
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Deep Venous Thrombosis Prophylaxis
All Critical Care patients Does VAP Sequential compression
devices (SCDs) Anticoagulant therapy
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Tips
Add to order sets Discuss at daily Interdisciplinary Rounds Empower Clinical Pharmacists
– Review orders – Ensure Rx
Monitor daily Charge Nurse check list
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Daily Oral Care with Chlorhexidine
Oral Hygiene Kits 0.12% CHG Reduces nosocomial
respiratory tract infections Reduces VAP
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Tips
Nursing buy-in with education Oral Hygiene program focus Schedule on the MAR
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The O'Connor Story
2006 VAP rate – Started Interdisciplinary Rounds
» Critical Care Medical Director » Charge Nurse » RT » Microbiology » Pharmacy » Infection Prevention
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Progress!
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1
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3
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5
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10
2005
Qtr
3
2006
Qtr
1
2007
Qtr
1
2008
Qtr
1
2009
Qtr
1
2010
Qtr
1
2011
Qtr
1
2012
Qtr
1
9.46
5.91
CHAIPI
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Infection Control in Action
What happened? VAP Bundle
HOB Sedation vacation PUD prophylaxis DVT prophylaxis Oral care/CHG
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Oral Hygiene
New product + Biotene + Difficult to open + Problems with toothette + = non-compliance with oral
hygiene
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Products Do Make A Difference!!!
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10
2005
Qtr
3
2006
Qtr
1
2007
Qtr
1
2008
Qtr
1
2009
Qtr
1
2010
Qtr
1
2011
Qtr
1
2012
Qtr
1
9.46
5.91
CHAIPI
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Lessons Learned
Continue to monitor Trust your instincts Look at the obvious Turn over every rock Get Nursing buy-in with new
products Get help from other sources Share the data Share your stories
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Questions???
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References and Resources www.ihi.org http://www.mric.org.my/Content/Document/MRICEducationMaterials/VentilatorCareBundle/ImplementationofDailyS
edationVacation.pdf A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals.
http://www.jstor.org/stable/10.1086/591060
