Download pdf - Proactively Preventing Ventilator-associated Events (VAE) · Proactively Preventing Ventilator-associated Events (VAE) Suzi M. Burns RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 3/5/2014

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Proactively Preventing Ventilator-associated Events (VAE)

Suzi M. Burns RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP

3/5/2014

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Suzi M. Burns RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP

Professor Emeritus, University of Virginia

Independent consultant

Published author and speaker

AACN Flame of Excellence Award recipient

Copyright © 2014 American Association of Critical-Care Nurses

Webinar Goals

Implement evidence-based VAE prevention strategies right away.

Topics

History of CDC’s ventilator-associated pneumonia (VAP) surveillance definitions and rationale for change

Four new CDC 2013 VAE categories

Evidence-based VAE preventive strategies

Barriers and solutions to implementation

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VAP Impact on Patient Outcomes Increased morbidity, mortality, hospital LOS

*Replaced National Nosocomial Infection Surveillance System (NNIS)

National Healthcare Safety Network (NHSN)* reported for 2013:

>3,525 VAPs

Hospital units: 0.0-5.8 per 1,000 ventilator days


History of VAP Surveillance

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History of VAP

New surveillance criteria implemented

VAP defined as “PNEU” event within 48 hours of mechanical ventilation

1970 1980 1990 2000 2002

CDC’s NNIS starts surveillance for nosocomial pneumonia


Diagnosing VAP Using 2002 Criteria Determined by:

Subjective clinical signs/symptoms

Radiographic evidence

Laboratory data

Not sensitive or specific compared with histopathological “gold standard”


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Consequences of Vague VAP Criteria

Hospitals and even their own units:

Employed divergent and noncomparable approaches to VAP surveillance and reporting

Included some “gaming”



Repercussions for… Clinicians and Researchers Hard to identify effective strategies

to prevent/treat VAP

Public health Healthcare-associated infections at heart

of healthcare policy and prevention initiatives

Hospitals Reimbursement programs linked to

outcomes (Medicare/Medicaid)

Conclusion: Need for accurate, reliable outcome measurement!

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A New Approach


National Quality Forum (NQF)

Role: To set standards for healthcare

Focus: Improve healthcare quality

Asked CDC to reconsider VAP criteria


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CDC Responds

Convenes leaders

from Critical Care

Societies Collaborative

(AACN, ACCP, ATS,

SCCM) and others from

key organizations.

2010 2011

Purpose: Identify objective approach to surveillance/reporting in mechanically ventilated patients

2012 2013


CDC Workgroup Develops surveillance definition algorithm

Identifies broader range of VAEs

Finds most VAEs due to

Pneumonia

ARDS

Atelectasis

Pulmonary edema

All potentially preventable by nurses!

Magill SS, et al. Am J Crit Care. 2013;22(6):469-473.

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Within 2 days before or after onset of worsening oxygenation, patient meets BOTH:

Temperature >38oC or <36oC OR WBC (≥12 or ≤4) AND

New antimicrobials started and continued for ≥4 days

VAE Algorithm: Reportable VAEs

VAC

Following a period of stability ≥2 days:

FiO2 increase ≥20% for ≥2 days OR

PEEP increase ≥3 cm H2O for ≥2 days

IVAC

Widely available criteria; less subject to “gaming”

VAC, ventilator-associated condition

IVAC, infection-related ventilator-associated complication



Either: Purulent secretions AND positive culture

OR: Specific diagnostic findings (purulent secretions not necessary): histopathology, pleural fluid cultures, etc.

VAE Algorithm: Internal QI Reporting Only

Possible VAP

Purulent secretions OR Positive culture

Specific diagnostic criteria

Possible

VAP

Probable

VAP

On or before mechanical ventilation day 3 and within 2 days before or after onset of worsening oxygenation one of the following criteria are met:


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Challenges Related to Changing VAP Criteria

Unknowns

How historical rates based on old definition compare with “possible” and “probable” VAP

Accuracy of previously reported hospital rates comparing pre- and post outcomes of interventions

Makes identifying preventive strategies difficult



What is the relationship of VACs to IVAC, Possible and Probable VAP?

Looking at the Science

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Muscedere J, et al. J Crit Care. 2008;23:138-47.

Study 1: Developing Evidence-based Guidelines for VAP Prevention

Method: Systematic review of science related to prevention of VAP

Sample: All randomized controlled trials (RCTs) and systematic reviews on VAP prevention in adults, published from 1980 to October 2006


Results: Evidence-based Guidelines for Prevention

Consider

Intubate orally

Change ventilator circuit only if soiled

Change airway humidifiers every 5-7 days as indicated

Use closed suctioning system

Change suctioning systems only as needed

Use subglottic secretion drainage for expected ventilation >72 hrs

Set HOB at 45o when possible

Use oral antiseptic (chlorhexidine)

Recommended

Muscedere J, et al. J Crit Care. 2008;23:138-47.

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Sinuff T, et al. Crit Care Med.2013;41:15-23.

Study 2: Implementing VAP Prevention Guidelines: Correlation with Guideline Adherence and VAP Rates

Design: Prospective study: 2007-2009

Sample: 11 community and academic medical center ICUs; 30 adults/site (330 total) for each of 4 time periods Total=1,320 patients

Method: Implementation of 14 VAP evidence-based diagnostic, treatment and prevention guidelines



Results: Increased Adherence to VAP Guidelines Correlates With Decreased Incidence of VAP

Sinuff T, et al. Crit Care Med. 2013;41:15-23.

Change from baseline

Adherence to VAP Guidelines (P=0.007)

VAP Rates (P=0.003)

15.8% 38.3%

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Study 3: Determining the Relationship Between VACs, IVACs and VAP—and Clinical Impact

Methods:

Retrospectively applied VAC and IVAC definitions to data from Study 2

1,320 patients (previously described)

Muscedere J, et al. Chest. 2013;144:1453-1460.



VAC intentionally broad: captures some pneumonia and pulmonary edema, ARDS, atelectasis

IVAC (subset of VAC): plus suggestive of infection. Not all are VAP

Not all VAP patients meet VAC criteria

Results: VAP, VAC and IVAC Criteria Identify Somewhat Different Patients

VAC

IVAC

VAP & IVAC

VAP & VAC VAP

Muscedere J, et al. Chest. 2013;144:1453-1460.

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Conclusions

Poor agreement between VAC, IVAC and VAP

Patients with a VAC or IVAC:

Significantly more Ventilator days

Hospital days

Antibiotic days

Higher hospital mortality than those with neither condition

Higher adoption of VAP preventative measures lower VAP and VAC rates


Preventing VAEs

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How VACs Occur Particularly IVAC and Possible/Probable VAP

Sterile lower respiratory tract breeched from:

Aspiration of secretions

Colonization of aerodigestive tract

Contaminated equipment or medications



Associated Risk Factors

Prolonged intubation

Enteral feeding

Witnessed aspiration

Paralytic agents/sedation

Underlying illness (immune-suppressed)

Extremes of age Evidence-based approach is needed:

Target key risk factors for lung contamination

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Adapted from: The Society for Healthcare Epidemiology of America (SHEA). 2008. Muscedere J, et al. J Crit Care. 2008:23:138-147.

AACN Practice Alert. Ventilator-associated pneumonia (VAP). 2008.

Recommendations: Levels of Evidence

Levels Implementation Supported by

STRONG

Strongly recommended

Well-designed experimental, clinical, or epidemiologic studies

MODERATE Some experimental, clinical, or epidemiologic studies and strong theoretical rationale

S

M


Recommendations: General Interventions

1. Educate clinicians about their role in prevention

2. Emphasize hand hygiene and surveillance

3. Prevent complications of immobility (VTE, UTI, PU)

Use nursing interventions and prophylaxis

S M

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Barriers

Inconsistent

Hand hygiene (better when observed)

Knowledge of VAP prevention

Insufficient attention to “interventional hygiene” (targeting mobility, VAP, BSI, UTI, PU)

McGuckin, et al, nurses fail to:

Adequately understand value of interventional hygiene

Take ownership

Blot SI, et al. Intensive Care Med. 2007;3:1463-1467. Cason CL, et al. Am J Crit Care. 2007:16;28-37.

McGuckin M, et al. Am J Infect Control. 2008;36:59-62.



Solutions

Reinforce education regularly

Provide tools, resources, processes to facilitate interventional hygiene

Develop a culture of accountability

Example: “Intentional Rounds”

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Intentional Rounds Promote Culture Change

Don’t tell me—show me at the bedside!

APN selects patient(s)

APN discusses all aspects of care

Focus: Prevention and key nurse sensitive metrics

Very popular and well attended!

Mahanes D, et al. Intensive Crit Care Nurs. 2013;29(5):256-260.


Recommendation 2: Prevent Aspiration

Use cuffed tube and continuous aspiration of subglottic secretions (CASS)

Maintain cuff pressures ~20 cm H2O

Maintain HOB (or backrest elevation) at 30-45o

Prevent gastric overdistension

M

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Barriers

CASS tubes considered too expensive; not always available (recommended if >72 hours of ventilation)

HOB elevation rarely maintained

Cuff pressures vary with changes in position

Grap MJ, et al. Am J Crit Care. 1999;8:475–480. van Nieuwenhoven CA, et al. Crit Care Med. 2006;34:396–402.

Ballew C, et al. Am J Crit Care. 2011;20:395-399.


Solutions

Compare costs related to CASS tubes with VAP-related costs

Audit and provide education frequently on:

Use of bed-level indicators and appropriate backrest elevation

Monitor and maintain cuff pressures (evaluate in different positions)

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Recommendation 3: Reduce Gastric Colonization

Perform regular oral care (timing/type unresolved)

Orotracheal vs nasal intubation (risk of sinusitis)

S M


Barriers

Oral care takes time

Other aspects of care considered more important

Protocol for intubations may not stress use of oral route.

Other units (ED, etc.) may not know about preference for oral route


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Solutions

Oral Care

Educate staff on importance of oral care

Determine consistent approach including time/type (unresolved evidence for frequency)

Make it easy to accomplish and provide reminders

Identify champions

Take ownership of oral care


Solutions (continued)

Orotracheal vs nasal intubations

Educate staff to request oral intubation

Collaborative with other units (ED, anesthesia, etc.) to assure oral intubations

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Recommendation 4: Reduce Risk of Contamination of Respiratory Equipment

Wash hands

Change tubing and equipment only when visibly soiled

Use sterile water when rinsing reusable respiratory equipment

Properly store and disinfect

S


Barriers and Solutions

Barrier

Lack of policies governing care and cleaning of equipment

Solution

Collaborate with Respiratory Care to ensure recommendations are implemented and monitored

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Recommendation 5: Prevent Complications of Mechanical Ventilation

*View August 2013 Pain and Sedation webinar for additional information

Consider noninvasive ventilation (easy access/protocols to promote use)

Prevent unplanned extubations and reintubations

Minimize sedation; discontinue early

Perform daily “Wake Up and Breathe Trials”

Use protocols for sedation withdrawal and spontaneous breathing trials (SBTs)*

S


Barriers Non-invasive ventilation and unplanned extubation Noninvasive ventilation is:

Often considered too late

Hard to apply effectively in emergencies

Rates of unplanned extubations/reintubations often unknown

Result: lack of prevention strategies to reduce rates

Misconception that physical restraints may prevent unplanned extubation


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Solutions Noninvasive ventilation and unplanned extubation

Noninvasive ventilation: develop protocols for indications and uses; educate staff

Instead of physical restraints (which do not prevent unplanned extubation):

Use pharmacologic agents sparingly

Assess for delirium

Do not delay SBTs if indicated


Barriers Limiting sedation

Misperceptions:

Patients prefer to be sedated

Sedation promotes patient comfort

It’s better if patients don’t remember being ventilated

Withdrawing sedation causes psychological stress

Sedation best via infusion to deliver steady state of the drug

Guttormson JL, et al. Crit Care Nurs, 2010;26(1):44-50. Kress JP, et al. Am J Respir Crit Care Med. 2003;168(12):1457-1461.

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Solutions Limiting sedation Educate staff about use of sedation, misconceptions,

and potential complications, eg:

Prolonged ventilation

Adverse clinical outcomes (delirium, cognitive dysfunction etc.)

Treat pain first

Start sedation only if clearly indicated (eg, anxiety, paralytic use).



Barriers and Solutions “Wake Up and Breathe Trials”

Barriers

Time consuming

Difficult to ensure they are performed

Solution

Nurses, therapists and physicians must consider optimal timing of trials for all involved

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Summary


Summary

New CDC VAE algorithm designed to make surveillance of VAEs (including VAP) more accurate.

Accuracy of definitions will help establish validity of preventive strategies

Strategies associated with lower rates of VAP and VAC include:

Preventing aspiration

Reducing gastric colonization

Reducing risk of contamination of respiratory equipment

Weaning off ventilator ASAP


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Prevention of VAEs is possible and nurses can make a difference! Our patients’ lives depend on it!

As Yoda said….

"Do or not do. There is no try!”


AACN Implementation Tools and Resources

Tools and Tactics: Blue Print for Reducing VAEs

A Gap Analysis for Reducing VAEs

AACN Practice AlertsTM: Oral Care for Patients at Risk for VAP Prevention of Aspiration Audit of HOB Elevation in Intubated Patients Assessing Pain in the Critically Ill Adult

SAS and RASS Sedation Assessment Tools

BPS and CPOT Pain Assessment Scales

Nurse-driven Pain and Sedation Protocol

Wake Up and Breathe Protocol

Early Progressive Mobility Protocol

Designed to help you apply these practices in your environment

Find these tools on the VAE webinar information page at www.aacn.org.

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Prevent Ventilator Associated Events Now— Improve Patient Outcomes

1. Download the Implementation Tools. Find them on the VAE webinar information page at www.aacn.org.

2. Discuss the tools and recommended practices with your colleagues.

3. Implement practices that are suitable for your unit.

4. Join the Webinar Series Learn Network online discussion forum to continue the conversation.