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Prevention of Ventilator Associated Pneumonia:

Prevention of Ventilator Associated Pneumonia DEEPTHI.R, M.S.N Deepthi R.MSN 1


Objectives VENTILATOR ASSOCIATED PNEUMONIA (VAP) Identify ventilator-associated pneumonia and its incidence Prevent ventilator-associated pneumonia by implementing “ Ventilator Care Bundle .” 2 Deepthi R.MSN

What is VAP?:

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) 3 Deepthi R.MSN

Ventilation-associated pneumonia (VAP):

Ventilation-associated pneumonia (VAP) 4 Deepthi R.MSN

Ventilation-associated pneumonia (VAP):

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 5 Deepthi R.MSN


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 6 Deepthi R.MSN

CDC definition of pneumonia:

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 7 Deepthi R.MSN

The Bugs:

The Bugs Figure 1 from Park Park DR. The microbiology of ventilator-associated pneumonia. 8 Deepthi R.MSN

Who are at risk?..:

Who are at risk?.. Risk factors include Prolonged mech.ventilator days Tracheostomy Multiple central line insertions Reintubation Supine position Impaired cough/depressed LOC Oropharyngeal colonization Presence of NG/OG tubes and enteral feeding Cross contamination by staff 9 Deepthi R.MSN


Pathogenesis Where do the bacteria come from? Tracheal colonization- via oropharyngeal colonization or GI colonization Ventilator system How do they get into the lung? Breakdown of normal host defenses Two main routes Through the tube Around the tube- micro aspiration around ETT cuff 10 Deepthi R.MSN

Why VAP to be prevented?:

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 11 Deepthi R.MSN


COST OF VAP Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission 12 Deepthi R.MSN

How we will identify?:

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 > 10 3 CFU, or BAL > 10 4 CFU *Ventilator days/mo is the sum of the number of days each patient was on mechanical ventilation (via ETT/trach tube) 13 Deepthi R.MSN

Care Bundle:

Care Bundle A 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 14 Deepthi R.MSN

Why should we use ventilator care bundle? :

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 15 Deepthi R.MSN

Ventilator Associated Pneumonia Care Bundle -Evidence Based Practices:

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 Prophylaxis Stress Ulcer Prophylaxis Subglottic secretion drainage Daily mouth care with chlorhexidine 16 Deepthi R.MSN


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 17 Deepthi R.MSN

HOB Elevation > 30 Degrees on all Intubated Ventilated Patients :

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 18 Deepthi R.MSN

2.Daily “Sedation Vacation” and Daily Assessment of Readiness to Wean:

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 19 Deepthi R.MSN


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. 20 Deepthi R.MSN

Sedation Vacation Risks:

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 21 Deepthi R.MSN

3.Peptic Ulcer Disease (PUD) Prophylaxis:

3.Peptic Ulcer Disease (PUD) Prophylaxis It is an appropriate intervention in all sedentary patients Critically ill intubated patients lack the ability to defend their airway Decreasing pH of gastric contents may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents 22 Deepthi R.MSN

More on PUD Prophylaxis:

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.” 23 Deepthi R.MSN

4.Deep Vein Thrombosis (DVT) Prophylaxis:

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 24 Deepthi R.MSN

DVT Prophylaxis – Risk of Bleeding:

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 25 Deepthi R.MSN

5.Subglottal Suctioning:

5.Subglottal Suctioning Should be done using a 14 Fr sterile suction catheter: Prior to ETT rotation Prior to lying patient supine Prior to extubation 26 Deepthi 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 27 Deepthi R.MSN


Suctioning 28 Deepthi R.MSN

Barriers That May Be Encountered:

Barriers That May Be Encountered Fear of Change Communication Breakdown Physician and staff “partial buy-in” “Just another flavor of the week?” Unplanned extubation (most risky aspect) Lack of standardization 29 Deepthi R.MSN

Barriers to success :

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 30 Deepthi R.MSN

Best Practices to Achieve a High Level of Compliance in ICUs:

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 patient Clinical Pharmacist / Pharmacy Residents Infection Control Specialist Respiratory Therapist Registered Dietician Nurse Case Manager Speech Therapist Nursing student / Instructor Use of Ventilator Bundle Audit Tool addressing the bundle items daily 31 Deepthi R.MSN


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 32 Deepthi R.MSN

Compliance with Isolation Precautions:

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 33 Deepthi R.MSN


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 34 Deepthi R.MSN

Conti…. :

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 35 Deepthi R.MSN


IMPLEMENTATION VAP bundle can be initiated in a hospital by applying the following steps: Setting Aims Forming the Team Using the Model for Improvement Getting Started 36 Deepthi R.MSN

Getting Started……. :

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. 37 Deepthi R.MSN

PowerPoint Presentation:

Select the team and the venue (ICU) Assess where you stand presently Collaborate 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 process 38 Deepthi R.MSN

Hand washing:

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:

Hand Washing can save many Patients and Increases the Safety Deepthi R.MSN 40

PowerPoint Presentation:

The Programme created by Deepthi R. MSN , Travancore College of Nursing, Kollam for Benefit of Nursing Students Deepthi R.MSN 41

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