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Safer Critical Care:
Resources to Prevent Ventilator-Associated Pneumonia
(VAP)
and
Central Venous Catheter-Associated Bloodstream Infections
(CVC-BSI)
Practices 19-20
Joan Reischel, RN, BSN, CCRN
Tom Talbot, MD, MPH
Richard J. Wall, MD, MPH
Mary E. Foley, MS, RN
Charles R. Denham, MD
Hayley Burgess, PharmD
© 2008 TMIT
1
Overview
•
•
•
•
•
•
•
•
© 2008 TMIT
Safe Practices Discussion Dr. Charles Denham
CVC-BSI discussion Dr. Tom Talbot
Application of CVC-BSI tools Joanne Reischel
Discussion with Mary Foley
Ventilator bundle Dr. Richard Wall
Application of CVC-BSI tools Joanne Reischel
Discussion with Mary Foley
Question and Answer
2
1
NQF Safe Practices for Better Healthcare:
A Consensus Report
• 30 Safe Practices
Criteria for Inclusion
• Specificity
• Benefit
• Evidence of
Effectiveness
• Generalization
• Readiness
© 2008 TMIT
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Harmonization – The Quality Choir
© 2008 TMIT
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2
Culture SP 1
Culture
2007 NQF Report
Consent & Disclosure
Consent & Disclosure
Workforce
Information Management &
Continuity of Care
Medication Management
Healthcare-Assoc. Infections
Condition- &
Site-Specific Practices
© 2008 TMIT
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Culture
2007 NQF Report
CHAPTER 1: Background
Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas.,
F.B., & Interv.
ID Mitigation
Risk & Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
Life-Sustaining
Treatment
Disclosure
Workforce
CHAPTERS 2-8 :
Practices By Subject
Nursing
Workforce
Direct
Caregivers
ICU Care
Information Management & Continuity of Care
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CPOE
Abbreviations
Medication Management
Med. Recon.
Pharmacist
Central Role
High-Alert
Meds.
Std. Med.
Labeling & Pkg.
Unit-Dose
Medications
Healthcare-Associated Infections
Asp. + VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath.
BSI Prevention
Sx-Site Inf.
Prevention
Condition- & Site-Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
© 2008 TMIT
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback, and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Anticoag.
Therapy
Wrong-site
Sx Prevention
DVT/VTE
Prevention
Periop. MI
Prevention
Contrast
Media Use
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
• Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Healthcare-Associated Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
• Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8: Condition- & Site-Specific Practices
• Evidence-Based Referrals
• Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
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Prevention of Catheter-Associated
Bloodstream Infections
Thomas R. Talbot, MD MPH
Assistant Professor of Medicine and Preventive Medicine
Chief Hospital Epidemiologist
Vanderbilt University School of Medicine
© 2008 TMIT
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Overview
• Review the epidemiology of catheter- associated
infections
• Discuss methods for prevention of CR-BSI
• Highlight data on novel technology and risk of
CR-BSI
© 2008 TMIT
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4
Vascular Catheter-Related
Bloodstream Infections
• 250,000 infections occur in US every year
• Cost $296 million to $2.3 billion
– $18,000 per BSI
• Associated with 2,400-20,000 deaths annually
• Increase LOS by 7-21 days
– 12 days = most recent estimate
© 2008 TMIT
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© 2008 TMIT
10
5
CRBSI per 1000
Catheter Days
Arterial catheters for hemodynamic monitoring
1.7
Nontunneled CVC
2.7
Medicated nontunneled CVC
Minocycline-rifampin
CHG-silver sulfadiazine
1.2
1.6
Tunneled CVC
1.7
P-A catheter
3.7
Long-term, cuffed & tunneled HD catheter
1.6
Port (central)
0.1
Maki D et al Mayo Clin Proc 2006;81:1159+
© 2008 TMIT
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Vascular Catheter Infection:
Prevention
© 2008 TMIT
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CVC-BSI Prevention Bundle
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
• Except VLBW infants
4. Optimal catheter site selection
• Subclavian vein preferred
5. Daily review of line necessity, with
prompt removal of unnecessary lines
© 2008 TMIT
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© 2008 TMIT
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7
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Maximal Barrier Precautions
• For the operator placing the central line
and for those assisting in the
procedure:
–
–
–
–
Wear cap, mask, sterile gown, and gloves
Cap should cover all hair
Mask should cover the nose and mouth tightly.
These precautions are the same as for any other
surgical procedure that carries a risk of infection
• For the patient:
– Cover the patient with a large sterile drape, with
a small opening for the site of insertion.
© 2008 TMIT
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Impact of Maximal
Barrier Precautions
Author/date
Design
Catheter
Odds Ratio
for Infection
w/o MBP
Mermel
1991
Prospective
Cross-sectional
P-A
2.2 (p<0.03)
Raad
1994
Prospective
Randomized
Central
6.3 (p<0.03)
Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205S.
Raad, Infect Control Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-238.
© 2008 TMIT
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Chlorhexidine as Skin Prep
10
9.3
CVC-BSI per 1000 CVC Days
9
8
7.1
7
6
5
4
3
2.3
2
1
0
2% CHG
© 2008 TMIT
10% Povidone
70% Alcohol
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Chlorhexidine as Skin Prep
CHG
P-I
© 2008 TMIT
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Site of Catheter Insertion
• Risk: Upper Extremity << Lower Extremity
• Risk: Subclavian < IJ << Femoral
• Femoral associated with higher rates of
thrombosis
• ? True for pediatric patients
• Use of ultrasound localization
– 88% reduction in mechanical complications
© 2008 TMIT
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10
Mermel L, 2000
© 2008 TMIT
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Femoral vs. Subclavian
CVC Placement
Femoral
Subclavian
Infectious Complications
19.8%
4.5%
Thrombotic Complications
21.5%
1.9%
© 2008 TMIT
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11
Get the Lines Out
• The longer the line is in, the more the risk for
BSI increases
• Assess for line need daily
• Remove unnecessary lines if possible
© 2008 TMIT
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VUMC Intervention
• Required educational tutorial with quiz
– All nurses, housestaff
– Compliance monitored
• Insertion checklist
• Empower nursing to stop procedure
• Feedback of data
• Standardization of kits
© 2008 TMIT
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© 2008 TMIT
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MC 2 7 05 (R e v. 06 /04 )
Van derbilt U niv ersity M edic al C enter
Mo nro e C are ll Jr.
OR
atV ander bilt
Nu r sin g C h e ck list :
C entral V en o us C ath et er In s ertio n
NO TE : P le a s e use eithe r bla c k o r blue ink to c o mple te this fo rm.
CCU
B IC U
MR #:
D a te :
T yp e o f c a the te r:
D o uble lu me n
Trip le lu me n
Intro duc e r
S wa n-G a n z
Va s c a th
Ti me s ta rt
(1 s t nee dle s tic k):
In s e rtio n S ite :
Inte rna l J ugu la r
S ubc la v ia n
F e mo ra l
O the r (s pe cify ):
L is t a ll s ite s wh e re in s e rtio n wa s a tte m p te d.
R IJ
L IJ
RSC
LSC
S id e :
R ight
L e ft
M IC U
P CC U
/
:
RF
NS IC U
O the r
Mask
C h e c k if:
C o ns e nt o bta ine d
P t/F a mily te ac hing do ne
G uide wire e xc ha nge
O the r (s pe cify ):
Yes
Yes
Yes
(5 ) c en tra l
No
D idn’t a s k
No
D idn’t a s k
No *
D idn’t a s k
lin e s e x pe rie n c e?
S te rile to w e ls
D e s c rib e th e lev e l o f tra in in g o f the p e rs o n wh o a c tua lly in s e rte d the lin e ?
M e dic a l S tude nt
Inte rn (P G Y -1 )
R e s ide nt (P G Y -2 +)
F e llo w
Ho w m a n y d iffe re n t ne e d le stic k s d id the pa tie n t rec e iv e (n u m b e r of sk in b re ak s )?
1
2
3
4
5
6+
Unk no w n
W a s th e s te rile fie ld m a in ta in e d th ro ug h ou t the e n tire p ro c ed u re?
Yes
P re -in s e rtio n s k in p re p (c h ec k a n y u se d ):
A lc o ho l
B e ta dine (po vido ne -io dine )
O the r (s pe cify ):
C hlo rhe xi dine
D e s c rib e th e c irc u m s ta n ce s u n de r wh ic h th is lin e wa s p la c e d :
No n-e me rge nt
E me rge nt (life -thre a te ning o r c o de s itua tio n)
F o llo w-u p CX R :
O rde re d
C X R fin d in g s (c he c k a ll th a t a pp ly):
No p ne u mo tho ra x
C a the te r in go o d po s itio n
D re s s in g ap p lie d b y:
N urs e
No ne
Atte ndin g
Nurs e P rac titio ne r
No
P re -e xis ting infe c tio n
P ne u mo tho ra x (de s c ribe a c tio n ta ke n):
C a the te r pos itio n a djus te d (de s c ribe ):
B io -occ lus iv e
C o m p lic a tio n s ?
F ull bo dy dra pe
No t o rde re d (s pe cify re as o n):
T yp e o f d re ss in g :
P a tie n t to le ra ted the p roc e du re we ll?
:
Ti me e nd
(c a the te r s ec ure d):
LF
S IC U
P le ase us e m ilitary tim e
(i.e . 1 :0 0 pm is 13 :00 )
In d ic a tio n s fo r u se :
P re ss o rs
He mo dy na mic mo nit.
F luids /b lo o d pro duc ts
F re que nt la b dra w s
T h e p rov id e r in s e rtin g th is lin e :
a . Ha n d ed -o ff h is /h e r pa ge r b e fo re the p ro c ed u re ?
b . W a s he d ha n ds im m e d ia te ly p rio r to p ro c ed u re ?
c . Ha s p rev io u s ly p la c e d a t le a s t fiv e (5 ) c en tra l lin e s ?
* If “ No ” , wa s th is p ro c ed u re s u pe rv is e d b y s om e on e with le a s t fiv e
Yes
No
D idn’t a s k
B a rrie r p re c au tio n s (ch ec k a n y u se d ):
S te rile glo v es
S te rile go w n
TIC U
NIC U
/
G a u ze
O the r (s pe cify ):
P ro ce dura lis t
O the r (s pe cify ):
Yes
No
P la c e me nt uns uc c e s s ful
Co m me nts :
O the r (de s c ribe ):
P le as e file p a ge 2 in pa tie n ts c ha rt a nd re tu rn to p fo rm to the de s ig n a te d lo ca tio n in th e ICU.
S ig n a tu re : _ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _
© 2008 TMIT
D a te : _ _ __ __ _ __ __ _ __ __ _
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CVC-BSI Rates, MICU 2000-2005
Confidential and privileged pursuant to the provisions of Section 63-6-219 of
Tennessee Code Annotated, the contractual obligations of Vanderbilt University to
its insurance companies, the attorney-client privilege and other applicable
provisions of law.
© 2008 TMIT
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CVC-BSI Rates, VUH ICUs
January 2004 - December 2005
60
Use of Insertion
Checklist Rolled Out
to all ICUs
Rate per 1,000 CVC Days
50
40
30
20
10
N
O
V
SE
P
JU
L
M
AY
M
AR
JA
N
N
O
V
SE
P
JU
L
M
AY
M
AR
JA
N
0
Confidential and privileged pursuant to the provisions of Section 63-6-219 of
Tennessee Code Annotated, the contractual obligations of Vanderbilt University to
its insurance companies, the attorney-client privilege and other applicable
provisions of law.
© 2008 TMIT
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15
•
•
•
•
•
© 2008 TMIT
103 ICUs in MI
Unit team leaders
CVC bundle
Checklist
Empowerment to stop procedure
31
“It’s Not Just A Checklist”
• How to adapt an effective tool to other
cultures/units
• With the success in the MICU, some ICUs
started using the checklist
– No culture change
– No education/examination/feedback of data
– Initial implementation = minimal success
– Risk labeling the tool a “failure”
© 2008 TMIT
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Antibiotic-Impregnated Catheters
• Two types
– Chlorhexidine-silver sulfadiazine
• 2 generations:
– 1st: Coated only on external surface of lumen
– 2nd: Coated on both internal and external surfaces
– Minocycline-rifampin
• Scads of trials with varying outcomes and
comparator groups
© 2008 TMIT
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Antiseptic CVCs
• 1st generation (external lumen only)
– N = 16 trials
– Most showed reduction in CVC colonization
– Only 2 showed CRBSI reduction
• 2nd generation (Both lumens coated)
– N = 3 trials
– All showed reduction in CVC colonization
– None showed CRBSI reduction
© 2008 TMIT
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17
Antibiotic CVCs
• N = 7 trials
• 3 showed significant CRBSI reduction
• ? Risk of bacterial resistance
•
•
•••
• noncoated comparator
© 2008 TMIT
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• 12 university hospitals
• Adults with CVC expected 3+ days
• Rif-mino vs. 1st gen CHG-SS
© 2008 TMIT
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18
© 2008 TMIT
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BioPatch
• CHG-impregnated
• Designed to surround catheter at skin
insertion site
• Must be “right side up”
© 2008 TMIT
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Catheter or exit-site colonization
Bacteremia
© 2008 TMIT
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Needleless Hubs
• Split septum device
– Blood may back up into infusion catheter
• Leur-activated/mechanical valve device
– Prevents outflow of fluid
– Some with positive pressure displacement
© 2008 TMIT
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Johns Hopkins Experience
© 2008 TMIT
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BSI Rates, U of Nebraska
PPMV Removed
PPMV Hub
Introduced
© 2008 TMIT
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© 2008 TMIT
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Implementing
Central Venous CatheterBlood Stream Infection
Prevention Bundle
Joan Reischel, RN, BSN, CCRN
Clinical Coordinator, Critical Care
The Medical Center of Aurora
© 2008 TMIT
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Background
The Medical Center of Aurora
• Community based 324 bed hospital
• Level II Trauma Center
• Cardiac Center of Excellence
• Intensive Care Unit
• 34 bed general, adult ICU
• Intensivist 24/7
• Trauma coverage 24/7
© 2008 TMIT
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Patient Population at a Glance
11%
7%
Medical
Trauma
Surgical
Neuro
Cardiovascular
5%
8%
69%
© 2008 TMIT
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BSI Initiative
IHI 100,000 lives Campaign
• First meeting April, 2005
• New method of counting central line days
• Intensivists initiated maximal barrier precautions
for all central lines placed in ICU
• Hand washing campaign
• Antimicrobial discs for PICCs
• Multiple methods attempted to track
insertion/dressing change date
• No significant change in rate
• Not much buy in outside the ICU
© 2008 TMIT
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BSI Initiative
Safe Critical Initiative 2006
BSIs revisited
• CL checklist developed
• Staff education through HealthStream
• CL discussed in daily rounds
• Improved culturing technique
• MD accountability for compliance and
documentation
© 2008 TMIT
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Central Line Checklist
Intensive Care Unit
Central Venous Catheter Insertion
• Checklist downloaded
from BSI web cast and
modified for our unit.
• Checklist attached to every
central line insertion kit.
• When BSI identified
checklist reviewed.
Date:____________
Time:___________
Insertion Site(where catheter was ultimately placed):
◊ Internal Jugular
◊ Subclavian
◊ Femoral
◊ Other (specify):______________
Consent obtained?
Guidewire exchange?
Pt/Family teaching done?
◊ Yes
◊ Yes
◊ Yes
◊ No
◊ No
◊ No
Pre-insertion skin prep (check any used):
◊ Alcohol ◊ Betadine (povidone-iodine)
Barrier precautions (check any used):
◊ Sterile gloves ◊ Sterile gown ◊ Mask
◊ Chlorhexidine
◊ Cap
◊ Other (specify):____________
◊ Body drape
Washed hands immediately prior to procedure?
◊ Yes
Had to break the sterile field during the procedure? ◊ Yes
◊ No
◊ No
List all sited where insertion was attempted (check all that apply).
◊ RIJ ◊ LIJ ◊ RSC ◊ LSC ◊ RF ◊ LF ◊ Other specify):_____________________
How many different needle sticks did the patient receive (number of skin breaks)?
◊1
◊2
◊3
◊4
◊5
◊ 6+
◊ Unknown
Was ultrasound-guidance used?
◊ Yes
◊ No
Describe the circumstances under which this line was placed: ◊ Non-emergent
◊ Emergent (life-threatening)
© 2008 TMIT
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Central Line Checklist
• CL Added to Daily Rounds
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25
How this has helped
• Increased Physician compliance with maximal
barrier precautions, site selection and early
discontinuation of femoral lines or lines placed
emergently.
• Increase staff awareness and identification of
lines that need to be removed.
• Better identification of BSIs through proper
culturing.
© 2008 TMIT
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Bloodstream Infection Rate
3
2.5
2
1.5
BSI Rate
1
0.5
0
© 2008 TMIT
2005
2006
2007
2008
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Obstacles that Remain
• RNs remain uncomfortable requesting that
physicians comply with maximal barrier
precautions.
• Utilization of checklist outside the ICU is low.
• Continued resistance to discontinuing PICC lines
by staff.
• Hardwiring the prevention bundle.
© 2008 TMIT
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Consumer Advocate
Mary E. Foley, MS, RN
Associate Director
Center for Research and Nursing Innovation
University of California, San Francisco (UCSF)
National Patient Safety Foundation Board of Directors
Advisory member, Partnership for Patient Safety (p4ps)
Vice-President, ANA/California state association
© 2008 TMIT
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Opportunities for Patient and
Family Involvement
• Teach patients and families the proper care of the central
venous catheter as well as precautions for preventing infection.
• Teach patients and families to recognize signs and symptoms
of infection.
• Encourage patients to report changes in their catheter site or
any new discomfort.
• Encourage patients and family members to make sure that
doctors and nurses check the line every day for signs of
infection.
• Invite patients to ask staff if they have washed their hands prior
to treatment.
• Encourage patients and family members to ask questions
before a central line is placed.
WHO CVC-BSI recommendation document. Field review by
The Joint Commission.
© 2008 TMIT
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Ventilator-Associated Pneumonia (VAP)
Prevention Strategies
Richard J. Wall, MD MPH
Pulmonary, Critical Care, & Sleep Disorders Medicine
Southlake Clinic, Valley Medical Center, Renton, WA
University of Washington, Seattle, WA
© 2008 TMIT
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© 2008 TMIT
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Overview
• CDC changed the definition for VAP in 2007
– VAP no longer needs the “48 hour” criterion
• Discuss various VAP preventive strategies
– Review the evidence
– Acknowledge that some data are conflicting &
uncertainty still exists for strategies
• Algorithms for diagnosing and treating VAP
© 2008 TMIT
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VAP Definition
• Most recent studies defined VAP as an infection
occurring > 48 hours after hospital admission in a
mechanically ventilated patient with a
tracheostomy or endotracheal tube.
• In 2007, CDC revised their VAP definition:
– The new criteria state there is no minimum period of time
the ventilator must be in place in order to diagnose VAP.
– This important change must be kept in mind when
examining future studies.
CDC. MMWR Rec Rep 2004;53(RR-3):1-36.
CDC. NHSN Manual, May 2007. (see references)
© 2008 TMIT
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Epidemiology of VAP
• Common & serious problem in the ICU
– 2nd most common nosocomial infection
• 15% of all hospital acquired infections
– Attributable mortality may approach 20%
– Estimated cost of $5,000-20,000 per episode
• Increased ICU & hospital length of stay
ATS. Am J Respir Crit Care Med 2005;171:388-416.
Warren DK et al. Crit Care Med 2003;31:1312-7.
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Shifting Views on VAP
• No longer an unfortunate occurrence
• Viewed as a preventable medical error by:
–
–
–
–
Institute of Medicine
Leapfrog
JCAHO
Centers for Medicare & Medicaid Services (CMS)
• Starting in 2009, CMS will limit reimbursements for
conditions not present at admission (e.g., VAP).
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf
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31
Adult Ventilator Bundle
VAP prevention measures
1.
2.
3.
4.
5.
6.
Hand hygiene
Patient positioning
Daily “Sedation Vacation”
Daily assessment of readiness to extubate
Oral care
Management of secretions
General measures to improve care
⇒ Peptic ulcer prophylaxis
⇒ Deep vein thrombosis (DVT) prophylaxis
© 2008 TMIT
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Hand Hygiene
• Strict hand hygiene before and after handling
patient or patient’s equipment or supplies
© 2008 TMIT
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Patient Positioning
• RCT of 86 adult intubated patients
• Semi-recumbent (45o) vs. supine position
Suspected VAP
Semi-recumbent
Supine
8%
34%
(90% CI for difference 10-42%; p=0.003)
Confirmed VAP
5%
23%
(90% CI for difference 4-32%; p=0.018)
Drakulovic MB. Lancet.1999;354:1851-1858.
© 2008 TMIT
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Patient Positioning
• Elevate head of bed 30-45o
– Flex bed or reverse Trendelenberg
– Reduces chance of gastric reflux & aspiration
• Proper position in bed
– minimize abdominal compression
– keep joints in neutral, semi-flexed position
Drakulovic MB. Lancet.1999;354:1851-1858.
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Patient Positioning
• Precautions
– Hypovolemia - possible hypotension
– Transporting patients
– Spine precautions
• Consider reverse trendelenberg
Drakulovic MB. Lancet.1999;354:1851-1858.
© 2008 TMIT
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Positioning DO’s and DON’Ts
Do:
• Maintain HOB > 30
degrees unless
contraindicated.
Don’t:
• Leave patient in
supine position for
prolonged periods.
• Forget to turn off
tube feedings if
placing patient in
supine position.
• Continue Q 2 hour
turning schedule.
© 2008 TMIT
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Sedation Vacation
• Daily discontinuation of sedation until patient is
responsive (i.e., awake)
• RCT of 128 adults on MV randomized to daily
sedation vacation or usual care (controls).
• Duration of MV:
Sedation vacation
4.9 days
Controls
7.3 days
(p=0.004)
• Complication rates:
Sedation vacation
2.8%
Controls
6.2%
(p=0.04)
Kress JP et al. N Engl J Med 2000;342:1471-7.
Schweickert WD et al. Crit Care Med 2004;32:1272-6.
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Wake-up AND Breathe
• “Wake-up & Breathe” Trial
• RCT of 336 MV patients at 4 hospitals
– n = 168 received a spontaneous breathing trial (SBT)
– n = 168 received 1st a sedation vacation and 2nd a SBT
• Intervention group:
– 3.1 fewer ventilator-days (p=0.02)
– 3.8 fewer ICU days (p=0.01)
– 4.3 fewer hospital days (p=0.04)
• Patients in the intervention group were also less
likely to die in the next 12 months: HR 0.68
(p=0.01)
Girard TD et al. Lancet 2008 12;371:126-34.
Ely EW et al. NEJM 1996;335:1864-9
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Oral Care
• Rationale: oral pathogens contaminate secretions
that eventually migrate into the lungs.
• 2 recent meta-analyses demonstrated a lower risk
of VAP with oral chlorhexidine
– RR 0.74 (0.56-0.96)
– RR 0.61 (0.45-0.82)
• Safe, feasible, & cheap.
REC: Consider oral antisepsis with chlorhexidine.
Chlebicki MP. Crit Care Med 2007;35:595-602.
Chan EY et al. BMJ 2007;334:889.
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Oral Care
• Method of chlorhexidine (CHX) application
matters!
– Completely clean mouth & oropharynx prior to CHX
– Avoid brushing/mouthwashes for 2 hours after CHX
– Caveat: may cause tooth discoloration
• Can be removed at next dental cleaning = reversible
• Explain rationale to families
• No need to use expensive commercial oral care
products
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Oral Care Protocols
• Numerous protocols are published in the literature
& online
• Practice patterns vary considerably between ICUs
• Pick one, develop a guideline for your ICU, &
implement it!
– Oral care is more likely to be performed if you make a protocol
– Consider making it a part of routine ventilator care
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Management of Secretions
• Proper management of secretions is essential
• To prevent aspiration of pooled secretions,
perform hypopharyngeal suctioning before:
– suctioning ETT
– repositioning ETT
– deflating the cuff
– repositioning patient
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Management of Secretions
• Type of suctioning system (open vs. closed)
does not affect VAP.
– Closed system is likely safer for providers.
• Scheduling changes of the closed suctioning
systems does not affect VAP incidence.
– Cost considerations favor less frequent changes.
REC: Use a closed suctioning system & change
system as clinically indicated.
Rabitsch W et al. Anesth Analg 2004;99:886-92.
Topeli A et al. J Hosp Infect 2004;58:14-9.
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Suctioning Equipment Issues
• Keep ETT cuff pressure at desired level
(~20 cm H2O)
• Keep end of vent circuit, suction
catheter/Yankauer, & manual ventilation bag off
the bed. Hang them up or place them on a
sterile paper.
• Keep vent circuit free from accumulated water
by draining away from the patient.
• Change suction canister and mouth care kit
every 24h.
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PUD Prophylaxis
• Reduces acid production in stomach & the
consequent risk of bleeding.
• Some studies suggest increased rates of VAP in
patients on prophylactic treatments, with a trend
toward lower VAP with sucralfate (vs. H2
blockers).
• Proton pump inhibitors may be more efficacious
than H2 blockers and sucralfate, but there is a
paucity of data comparing the various regimens.
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PUD Prophylaxis
2008 Surviving Sepsis Campaign Guidelines:
“We recommend that stress ulcer prophylaxis using a
H2 blocker (grade 1A) or proton pump inhibitor (grade 1B)
be given to patients with severe sepsis to prevent upper
gastrointestinal (GI) bleed.
The benefit of prevention of upper GI bleed must be
weighed against the potential effect of an increased
stomach pH on development of ventilator-associated
pneumonia.”
Dellinger RP. Crit Care Med 2008; 36:296–327
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DVT Prophylaxis
Systematic review of risks of venous
thromboembolism and its prevention:
“We recommend, on admission to the intensive care
unit, all patients be assessed for their risk of VTE.
Accordingly, most patients should receive
thromboprophylaxis (Grade 1A).”
Geerts WH. Chest 2004;126:338S-400S.
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Other Preventive Strategies
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Route of Intubation
• 2 routes of intubation: oral & nasal
• Orotracheal route is associated with reduced
VAP (vs. nasotracheal route)
– Also, orotracheal route has less sinusitis
– VAP incidence higher if patient develops sinusitis
REC: Orotracheal route of intubation should be
used whenever possible.
Holzapfel L et al. Crit Care Med 1993;21:1132-8.
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Ventilator Circuit Changes
• The frequency of ventilator circuit changes does
not affect VAP
• 2 trials show no benefit
• Cost considerations favor less frequent changes
REC: Do not schedule ventilator circuit changes.
– However, do provide a new circuit for each patient and
any time the circuit becomes soiled or damaged.
Kollef JH et al. Ann Intern Med 1995;123:168-74.
Lorente L et al. Inf Cont Hosp Epidemiol 2004;25:1077-82.
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Airway Humidification
• No VAP difference between heat and moisture
exchanger (HME) vs. heated humdifier
• However, if using HME, less frequent changes
may lead to slightly less VAP, and it is cheaper.
REC: If using HME, change every 5-7 days, or as
clinically indicated.
Davis K et al. Crit Care Med 2000;28:1412-8.
Thomachot L et al. Crit Care Med 2002;30:232-7.
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Subglottic Suctioning
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Subglottic Suctioning
• Several trials show reduced VAP with use of a
tube that drains subglottic secretions.
– Most cost-effective when used in patients who are anticipated
to require prolonged MV.
• Caveat: animal studies suggest possible
tracheal injury from certain tubes (due to
erosion by the suction port).
REC: Consider a tube with subglottic secretion
drainage if the patient is expected to be
intubated > 3 days.
Smulders K et al. Chest 2002;121:858-62.
Lorente L et al. Am J Resp Crit Care Med 2007;176:1079-83.
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Early Tracheostomy
• Early (vs. late) tracheostomy does not affect
incidence of VAP.
– The few positive studies had methodological issues.
• Even if a small benefit is demonstrated, the risk &
cost of tracheostomy need to be justified.
REC: Do not perform early tracheostomy if the only
reason is VAP prevention.
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Kinetic Beds
• Immobility is associated with increased VAP.
– Kinetic beds employ rotational therapy to prevent and
treat respiratory complications.
• Meta-analysis of kinetic beds Æ decreased VAP.
– No effect on ventilator days, ICU days, or mortality.
REC: Consider use of kinetic beds to reduce VAP.
Goldhill DR et al. Am J Crit Care 2007;16:50-61.
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Prophylactic Antibiotics
• Some studies suggest prophylactic antibiotics may
decrease VAP:
– Intranasal mupirocin (Staph aureus)
– Aerosolized
– Intravenous
• No effect on MV days, ICU days, or mortality.
– Potential for emergence of antibiotic resistance.
REC: Do not use prophylactic antibiotics.
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Tips For Success
• Set an Aim: “Improve the health & well-being of
ventilated patients by reducing the VAP rate.”
• Set goal: “Reduce VAP rate by 50% by August
2008.” “Implement use of ventilator bundle with
> 95% reliability.”
• Plan Well: Adopt a change methodology that
accelerates improvement.
• Benchmark: Use a national benchmark (e.g.,
National Healthcare Safety Network)
Nelson EC, Batalden PB, Ryer JC. Clinical Improvement Action Guide. JCAHO, Oakbrook, IL, 1998
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5 VAP Algorithms
• Diagnosis of VAP in 4 populations:
1) Adults
2) Immunocompromised
3) Children (1-13yo)
4) Neonates (<1yo)
• Initial empiric treatment of VAP
Source: Wall RJ, Ely EW, Talbot TR, et al. Evidence-based
algorithms for diagnosing and treating ventilator-associated
pneumonia. Journal of Hospital Medicine 2008 (in press).
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Wall RJ et al. J Hospital Medicine 2008 (in press).
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Wall RJ et al. J Hospital Medicine 2008 (in press).
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Wall RJ et al. J Hospital Medicine 2008 (in press).
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Wall RJ et al. J Hospital Medicine 2008 (in press).
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Wall RJ et al. J Hospital Medicine 2008 (in press).
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Selected References
1.
2.
3.
ATS. Guidelines for the management of adults with hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388-416.
CDC. Guidelines for preventing health-care--associated pneumonia, 2003: Recommendations
of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR
2004;53(RR-3):1-36.
CDC. The National healthcare safety network (NHSN) manual: Patient safety component
protocol (updated May 2007).
www.cdc.gov/ncidod/dhqp/pdf/nhsn/NHSN_Manual_Patient_Safety_Protocol052407.pdf
4.
5.
6.
7.
8.
9.
© 2008 TMIT
Cook D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill
patients. Ann Intern Med 1998 Sep 15;129(6):433-40.
Kollef M. Epidemiology and outcomes of healthcare-associated pneumonia: results from a large
US database of culture-positive pneumonia. Chest 2005;128:3854-62.
Langley JM, Bradley JS. Defining pneumonia in critically ill infants and children. Pediatr Crit
Care Med 2005;6[supp]:S9-S13.
Muscedere J and the Canadian Critical Care Trials Group. Comprehensive evidence-based
practice guidelines for ventilator-associated pneumonia: Prevention. J Crit Care 2008;23:126-37.
Muscedere J and the Canadian Critical Care Trials Group. Comprehensive evidence-based
practice guidelines for ventilator-associated pneumonia: Diagnosis & treatment. J Crit Care
2008;23:141-50.
Wall RJ et al. Evidence-based algorithms for diagnosing and treating ventilator-associated
pneumonia. J Hospital Medicine 2008 (in press).
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Implementing VAP
Prevention
Bundle
Joan Reischel, RN, BSN, CCRN
Clinical Coordinator, Critical Care
The Medical Center of Aurora
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VAP Initiative
• VAP identified as high priority for IHI initiative
• Team Goal: Zero VAPs
• Team included
RT
Nursing
Physical Therapy
Pharmacy
Quality
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VAP Rate 2005-2007
The Medical Center of Aurora
Control Chart for
Ventilator Associated Pneumonia
Lower is better
20
10
8.77
8.51
6.97
2.90
0.00
07
O
ct
-0
6
N
ov
-0
6
D
ec
-0
6
Ja
n-0
7
Fe
b07
6
Ju
l-0
6
Au
g -0
6
Se
p06
06
3.06
0.00 0.00 0.00 0.00 0.00 0.00
Ju
n-0
06
06
Ap
r-
M
ay
-
M
ar
-
N
ov
-0
5
D
ec
-0
5
Ja
n-0
6
Fe
b06
5
05
0.00 0.00 0.00 0.00
Ju
l-0
5
Au
g -0
5
Se
p -0
5
O
ct
-0
5
05
Ap
r-
0.00
M
ar
-
2.46
2.31
0.00
M
ay
-
Ja
n-0
5
Fe
b05
M
ar
-0
5
5.85
3.44
2.79
0
6.93
6.08
5.85
5.80
Ju
n-0
Number Of VAPs per 1000 ventilator days
30
Time in Month/Year
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VAP Initiative
• Education provided to staff regarding ventilator
bundle
• Reminders created and posted at the HOB
• RT Documentation revised to include bundle
• Ventilator bundle added to daily rounds
• Hi/Lo Evac endotrtacheal tubes added
• Oral Care protocol to Q 2 Hrs
• Chlorhexidine oral rinse bid
• Data provided to providers monthly
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Laminated Signs for Rooms
ZAP VENTILATOR-ASSOCIATED PNEUMONIA
REMEMBER:
Elevation of the HOB to between 30 & 45o
Oral Care
Daily “sedation vacation” and daily assessment of readiness to extubate
Peptic ulcer disease (PUD) prophylaxis
Deep venous thrombosis (DVT) prophylaxis (unless contraindicated)
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Daily Rounds Ventilator
Information
• Daily Rounds form
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Accomplishments
• 224 days without a VAP
• VAP Team awarded First Prize at TMCA Quality
Days for PI Project
• Ready for Phase II
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Safe Critical Care Initiative
•
•
•
•
© 2008 TMIT
Utilization of Algorithm
Development of chart audit tool
Physician involvement of case review
Focus on safety culture
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VAP Algorithm
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Use of Algorithm
• Algorithm shown to the Critical Care Division in
the fall of 2006.
• To be used for the diagnosis of VAP.
• At that time we had gone 6 months without a
VAP.
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VAP Audit Tool
Ventilator Associated Pneumonia Review Sheet
Initial Review
Admission Date
On Mech v ent >48hr?
Date first on Vent
Sputum sent within 48 hr of intubation?
BAL or trach
Type of culture:
Result of culture:
Date of repeat culture
Type of culture:
BAL or Trach Asp
Result of culture:
Aspiration suspected?
Immuno comp pt? (neutropenia; leukemia; lymphona; HIV;
splenectomy; organ tx on immunosupp therapy, High dose steroids;
cytotoxic chemo)
Pt. Age >= 13
Final Review
Comments
If YES Immunocompromised Pt., Use Algorithm 2
Yes No
If yes, continue:
IF THE FOLLOWING FOUR ARE NO, NOT A VAP
Fev er (38C or 100.4F) w/o other cause?
Leukopenia (<4000 WBC/m3)
Leukocytosis ( >12000 WBC/m3)
Altered Mental Status with no other cause
IF ANY TWO of the FOLLOWING ARE YES, THEN COMPLETE THE ALGORITHM: IF NO, THEN NOT A VAP
Change in the character of the sputum? (new onset purulent,
incr. secretions, incr. suction)
New or worsening cough, dyspnea or tachypnea?
Crackles or bronchial breath sounds?
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VAP Audit Tool
Worsening Gas exchange (O2 desat, increased Vent
requirements)
Laboratory criteria that support the diagnosis of VAP
One Positive chest radiograph? (shows new or progressive
infiltrate, consolidation, or cavitation)
Date first positive chest radiograph:
Does this case meet CDC VAP guidelines for VAP dx?
VAP ABX Algorithm if YES for presumptive VAP:
ABX Therapy? (w/n 4 hr. of presumptive VAP dx)
Risk Factors? (Prior ABX w/n 3 mo; current hosp. >=5 days; known resis tance; immunosupp; recent NH; hemodialysis;
home wound care or infusion therapy, family member known infection)
If Risk Factors NO, Appropriate Drug Therapy:
Single Drug Therapy
If Risk Factors YES , Appropriate Drug Therapy:
Triple Drug Therapy
Pt. has underlying Cardiopulmonary Disease? (Resp. distress;
pulm edema; bronchopulmonary dysplasia; COPD)
Second (serial) positive chest radiograph? (persistence of
findings on prior film(s)
Compliance with VAP Bundle. If no, please comment
HOB > 30o
Hi Lo ET Tube to suction
Sedation Vacation
Weaning Protocol? Tolerating weans?
PUD/DVT
Oral Care
Chlorhexidine Rinse BID
Pt Sticker:
Outcomes:
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Going Forward
•
•
•
•
© 2008 TMIT
Hardwire Bundle Compliance
Reinforce staff’s leadership role in this initiative
Encourage staff to drive change in the future
Find another Collaborative
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Consumer Advocate
Mary E. Foley, MS, RN
Associate Director
Center for Research and Nursing Innovation
University of California, San Francisco (UCSF)
National Patient Safety Foundation Board of Directors
Advisory member, Partnership for Patient Safety (p4ps)
Vice-President, ANA/California state association
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Q&A
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