clinical audit project

Clinical Audit Project:

Prevention of Ventilator Associated Pneumonia

Audit team: Lead

Dr. Abdul-Rahman Al-Harthy

Chair-man CCD, KSMC

ICU consultant

Audit team: Members

Dr. Ahmed F. MadiKSMC, ICU consultant

Dr. Hosam Al-HanafiKSMC, ICU fellow

Dr. Waleed Al-EtrebyKSMC, ICU Registrar

Why VAP prevention ?• National target, as indicated by MOH.• Department and specialty priority.• Clinical risk issue.• Patient safety issue.• Involves a wide sector of our customers.• Cost and LOS.

Guidelines and Recommendations

Objectives

• Based on those guidelines, we have set six objectives (criteria):

1. Mechanically ventilated patients who are intubated should be positioned with their upper body elevated (semi-recumbent or sitting) for as much of the time as possible.

2. Oral antiseptics (for example, chlorhexidine) should be included as part of oral hygiene regimens for all patients who are intubated and receiving mechanical ventilation.

• 3. Hand hygiene, in accordance with national hand hygiene guidelines, should be part of the routine clinical care of mechanically ventilated patients.

• Hands should be decontaminated appropriately with soap and water or alcohol hand rub before and after every episode of direct patient contact, after any activity that potentially results in hands becoming contaminated and after removal of gloves.

4. The ventilator circuit should be changed only if soiled or damaged. Scheduled changing of the circuit is not recommended. New circuit tubing should be provided for each patient.

5. Sedation reviewed, and if appropriate stopped each day, and the patient is assessed for weaning and extubation.

6. Use of subglottic secretion drainage in patients likely to be ventilated for more than 48 hours.

Criteria and StandardsEvidence of quality of care or

service (criterion)Standard

(% compliance)Exception(s)

Definitions and instructions for data collection

1 Elevation of head of bed 30 – 45 degrees

100 % Spine injury All ventilated adult patients in ICU

2 Oral hygiene with chlorhexidine 100% Oro-pharyngeal trauma

All ventilated adult patients in ICU

3 Hand Hygiene 100% NONE All ventilated adult patients in ICU

4 Circuit change only when needed 100% NONE All ventilated adult patients in ICU

5 Sedation review and vacation 100% HFO, high ICP, difficult to ventilate

All ventilated adult patients in ICU

6 Subglottic suction 100% Not available All ventilated adult patients in ICU

Methodology:• Time frame: 1/3/2014 - 30/4/2014• Sample size: 88 • Source of data: Patients’ charts, direct observation.• Data collection form: Yes/No tick box form.• Data analysis: