Prevention ofVentilator Associated

PneumoniaDEEPTHI.R, M.S.N

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ObjectivesVENTILATOR ASSOCIATED PNEUMONIA

(VAP)

Identify ventilator-associated pneumonia and its incidence

Prevent ventilator-associated pneumonia by implementing “Ventilator Care Bundle.”

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What is VAP?

A nosocomial pneumonia associated with mechanical ventilation that develops within 48 hours or more of hospital admission and which was not developing at the time of admission.

Crit Care Nurs Q (2004)

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Ventilation-associated pneumonia (VAP)

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Ventilation-associated pneumonia (VAP)

VAP is the most frequent infection occurring in patients after admission to the intensive care unit. In a recent large European observational study, almost 25% of patients developed an ICU-acquired infection, and the respiratory site accounted for 80%ofthese infections. Prevention of VAP is possibly one of the most cost-effective interventions currently attainable in the ICU

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Conti..

VAP is the leading cause of nosocomial infection in the ICU and reflects 60% of all deaths attributable to nosocomial infections.

Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway, which increases the opportunity for aspiration and colonization

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CDC definition of pneumonia

Horan TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-care associated infection and criteria for specific types of infection in the acute care setting 7Deepthi R.MSN

The Bugs

Figure 1 from Park

Park DR. The microbiology of ventilator-associated pneumonia.8Deepthi R.MSN

Who are at risk?.. Risk factors include

Prolonged mech.ventilator days Tracheostomy Multiple central line insertions ReintubationSupine positionImpaired cough/depressed LOCOropharyngeal colonizationPresence of NG/OG tubes and enteral feedingCross contamination by staff

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Pathogenesis

Where do the bacteria come from? Tracheal colonization- via

oropharyngeal colonization or GI colonization

Ventilator systemHow do they get into the lung?

Breakdown of normal host defenses Two main routes

▪ Through the tube▪ Around the tube- micro aspiration

around ETT cuff10Deepthi R.MSN

Why VAP to be prevented?

VAP – leading cause of death among hospital –acquired infections

High rate of associated mortality:

Hospital mortality of ventilated patients who develop VAP is 46% compared to 32% for ventilated patients who don’t develop VAP

VAP prolongs time spent on vent, length of stay in ICU and hospital stay and medical cost

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COST OF VAP

Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission

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How we will identify?

Ventilator associated pneumonia: Pneumonia developing >48 hours of initiation of mechanical ventilation or <72 hours after cessation of mechanical ventilator

*New progressive infiltrate, with leukocytosis, fever, and purulent sputum

*Bronch protected specimen brush with >103 CFU, or BAL > 104 CFU

*Ventilator days/mo is the sum of the number of days each patient was on mechanical ventilation (via ETT/trach tube)

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Care BundleA care bundle is …... “A systematic method of

measuring and improving clinical care processes based on groups of care elements for particular diagnoses and procedures”

NHS Modernization Agency

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Why should we use ventilator care bundle?

This care bundle is derived from evidence-based guidance and expert advice.

The purpose is to act as a way of improving and measuring the implementation of key elements of care.

The risk of VAP increases when one or more elements are excluded or not performed 15Deepthi R.MSN

Ventilator Associated Pneumonia Care Bundle -Evidence Based Practices

Head Of Bed elevated to 30˚-45˚

Daily sedation vacation &daily assessment of readiness to wean

DVT ProphylaxisStress Ulcer ProphylaxisSubglottic secretion drainage

Daily mouth care with chlorhexidine

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1.HOB UP 30 DEGREES OR HIGHER

Recommended elevation is 30-45 degrees

If semi-recumbent or supine 34% incidence VAP

If semi-recumbent position 8% incidence VAP*

↑HOB → ↓risk of aspiration of gastrointestinal contents

↓risk of aspiration of oropharyngeal secretions

↓risk of aspiration of nasopharyngeal secretions

↑HOB improves patients’ ventilation Supine patients have lower spontaneous

tidal volumes on PS than those seated in upright position ↑HOB may aid ventilatory efforts and

minimize atelectasis

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HOB Elevation > 30 Degrees on all Intubated Ventilated Patients

Contraindications Hypotension MAP <70 Tachycardia >150 CI <2.0 Central line procedure Posterior circulation

strokes Cervical spine

instability use reverse trendelenburg

Some femoral lines ie: IABP no higher than 30 degrees use reverse trendelenburg

Increased ICP, No higher than 30 degrees avoid hip flexion

Proning

Contraindications Hypotension MAP <70 Tachycardia >150 CI <2.0 Central line procedure Posterior circulation

strokes Cervical spine

instability use reverse trendelenburg

Some femoral lines ie: IABP no higher than 30 degrees use reverse trendelenburg

Increased ICP, No higher than 30 degrees avoid hip flexion

Proning 18Deepthi R.MSN

2.Daily “Sedation Vacation” and Daily Assessment of

Readiness to Wean

Correlated with reduction in rate of VAP

Sedation vacation results in significant reduction in time on mechanical ventilation

Duration of mv decreased from 7.3 days to 4.9 days-study by Kress et al. (NEJM 2000)

Weaning is easier when patients are able to assist themselves at extubation with coughing and control of secretions

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Conti….

Sedative agents should be stopped, but not disconnected from the patient.

Allow the patient to wake. If the patient is co-operative and

able to understand commands leave the sedation off.

Distressed or agitated patients require re-sedating.

Administer boluses as appropriate to achieve safety.

Review the patient’s analgesic requirements if sedation remains off.

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Sedation Vacation Risks

Increased potential for self-extubation

Increased potential for pain and anxiety

Increased tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation

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3.Peptic Ulcer Disease (PUD)

ProphylaxisIt is an appropriate intervention in

all sedentary patientsCritically ill intubated patients lack

the ability to defend their airwayDecreasing pH of gastric contents

may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents

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More on PUD Prophylaxis

Surviving Sepsis Campaign Guidelines reviewed literature on PUD prophylaxis:

“H2 receptor inhibitors are more efficacious that sucralfate and are the preferred agents. Proton Pump Inhibitors have not been assessed in direct comparison with H2 receptor antagonists and, therefore their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.”

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4.Deep Vein Thrombosis (DVT) Prophylaxis

Higher incidence of DVT in critical illness

Risk of venous thromboembolism is reduced if prophylaxis is consistently applied

TARGET: patients undergoing surgery, trauma patients, acutely ill medical patients, and ICU patients

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DVT Prophylaxis – Risk of Bleeding

Important considerations include that the risk of bleeding may increase if anticoagulants are used to accomplish the prophylaxis

Often, sequential compression devices (ie. SCDs, “venodynes” or “pneumoboots”) are not applied to patients when they go to or return from procedures 25Deepthi R.MSN

5.Subglottal Suctioning

Should be done using a 14 Fr sterile suction catheter:Prior to ETT rotationPrior to lying patient supine

Prior to extubation 26Deepthi R.MSN

Suctioning In line suction:

▪ Maintain closed system▪ Use separate suction tubing

Normal saline:▪ Should not be routinely used to suction pts

▪ Causes desaturation▪ Does not increase removal of secretions

▪ Can potentially dislodge bacteria▪ Should be used to rinse the suction catheter after suctioning

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Suctioning

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Barriers That May Be Encountered

Fear of ChangeCommunication BreakdownPhysician and staff “partial

buy-in”“Just another flavor of the

week?”Unplanned extubation (most

risky aspect)Lack of standardization 29Deepthi R.MSN

Barriers to success

Data collection - measurement is impossible - does not submit the data Too many competing demands Prioritization of work and issues Too little cooperation Transforming the culture

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Best Practices to Achieve a High Level of Compliance in ICUs Daily Multi-disciplinary Rounds including:

Head Nurse(Unit in-charge)Reg.Nurse assigned to patientClinical Pharmacist / Pharmacy ResidentsInfection Control SpecialistRespiratory TherapistRegistered DieticianNurse Case ManagerSpeech TherapistNursing student / Instructor

Use of Ventilator Bundle Audit Tool addressing the bundle items daily

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HAND HYGIENE

The best method to prevent healthcare acquired infections including VAP is to practice good Hand Hygiene including use of

Antimicrobial soap and water Alcohol Based Hand Rub (Isagel)

when there is no visible soiling on hands

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Compliance with Isolation Precautions

Stringent adherence to the use of Personal Protective Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions

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MEASUREMENT OF VAP

1. VAP rate=The total number of cases of ventilator-associated pneumonia for a particular time period.

VAP Rate =(Total no. of VAP Cases / Ventilator Days) x 1000

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Conti….

2.Ventilator Bundle Compliance =On a given day, the assessment of all vent patients for compliance with the ventilator bundle

Reliability of bundle compliance

=

No. receiving ALL components of vent bundle

No. on ventilators for the day of the sample

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IMPLEMENTATION

VAP bundle can be initiated in a hospital by applying the following steps:Setting AimsForming the TeamUsing the Model for ImprovementGetting Started 36Deepthi R.MSN

Getting Started…….

Hospitals will not successfully implement the ventilator bundle overnight. If they do, chances are that they are doing something sub-optimally.

A successful program involves careful planning, testing to determine if the process is successful, making modifications as needed, re-testing, and careful implementation. 37Deepthi R.MSN

Select the team and the venue (ICU) Assess where you stand presentlyCollaborate with other department

to begin preparing for changes.(inf.control)

Organize an educational program. Teaching the core principles to the ICU staff (doctors, nurses,

therapists, and others) Introduce the ventilator bundle to

the key stakeholders in the process38Deepthi R.MSN

Hand washing

Hand washing is the single most important (and easiest!!!) method for reducing the transmission of pathogens.

Use of waterless antiseptic preparations is also acceptable and may increase compliance.

Hand Washing can save many Patients and Increases the Safety

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The Programme created by Deepthi R. MSN,

Travancore College of Nursing, Kollam for Benefit of Nursing

Students

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