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How to Collect and Monitor Ventilator Associated Pneumonia Rates

Contents:

1) CDC Definition of Ventilator Associated Pneumonia Page 2

2) Sample Ventilator Bundle Checklist Page 4

3) Sample Ventilator Bundle Audit Form Page 6

4) Sample Ventilator Bundle Checklist Page 7

5) Measurement Information Form: Ventilator-Associated Pneumonia Rate in ICUPage 8

6) Sample Collection Tool for Ventilator DaysPage 9

7) Sample Collection Tool for Ventilator and CVC Days 0

8) Sample Collection Tool for Device Days Page 11

9) Sample Collection Tool for Device Days Page 12

10) Sample Ventilator Associated Pneumonia BrochurePage 13

CDC/NNIS Ventilator-Associated Pneumonia Definition

Pneumonia must meet at least one of the following criteria:

Criterion 1. Patient has rales or dullness to percussion on physical examination of the chest and at least one of the following:

a. new onset of purulent sputum or change in character of sputum

b. organisms cultured from blood

c. isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

Criterion 2. Patient has a chest radiographic examination that shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion and at least one of the following:

a. new onset of purulent sputum or change in character of sputum

b. organisms cultured from blood

c. isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

d. isolation of virus from or detection of viral antigen respiratory secretions

e. diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for pathogen

f. histopathologic evidence of pneumonia

Criterion 3. Patient < 1 year of age has at least two of the following signs or symptoms: apnea, Tachypnea, bradycardia, wheezing, rhonchi, or cough and at least one of the following:

a. increased production of respiratory secretions

b. new onset of purulent sputum or change in character of sputum

c. organisms cultured from blood or diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for pathogen

d. isolation of an etiologic agent from a specimen obtained by transtracheal aspirate,

bronchial brushing, or biopsy

e. isolation of virus from or detection of viral antigen in respiratory secretions


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Criterion 4: Patient < 1 year of age has a chest radiologic examination that shows new or progressive infiltrate, cavitation, consolidation, or pleural effusion and at least one of the following:

a. increased production of respiratory secretions

b. new onset of purulent sputum or change in character of sputum

c. organisms cultured from blood or diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for pathogen

d. isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

e. isolation of virus from or detection of viral antigen in respiratory secretions


COMMENTS: Expectorated sputum cultured are not useful in the diagnosis of pneumonia but may

help identify the etiologic agent and provide useful antimicrobial susceptibility data. Findings from serial chest x-rays may be more helpful than a single x-ray.

Ventilator-Associated Pneumonia (VAP)

The same measure for ventilator-associated pneumonia was endorsed in both the hospital and the nursing-sensitive care projects. A synopsis of the measure is as follows:4

Adults Numerator: number of ventilator-associated pneumonias x 1000; Denominator:

number of ventilator-days for ICU patients; Exclusions: None

PediatricNumerator: Number of ventilator-associated pneumonias x 1000; Denominator: number of ventilator-days for patients; Exclusions: None

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VENTILATOR BUNDLE CHECKLIST (Individual Patient)

Patient:______________________Admit Date:___________________

ICU Day1 2 3 4 5 6 7 8 9 10

1. Head of the Bed 30O

2. Daily Sedation Vacation

3. Daily Assessment of readiness to wean

4. Daily Spontaneous Breathing Trial 5. PUD Prophylaxis

6. DVT Prophylaxis

4

VENTILATOR BUNDLE CHECKLIST

Date Bed/Pt Initials

HOB >

30O

DailySedation Vacation

Daily assessment

of Readiness

to wean

Daily Spontaneous

breathing trial

PUD Prophylaxis

DVTProphylaxis

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Ventilator Bundle Audit Form

Date PatientSS #

HOB up 30 degrees or

higher

Stress Ulcer Prophylaxis w/in 24 hrs

DVT Prophylaxis w/in 24 hrs

Daily sedation vacation

Daily Assessment of readiness to

wean

Daily Spontaneous

Breathing Trial

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable Yes/Unable Yes/Unable Yes/Unable/ Yes/Unable/NA Yes/Unable/NA6

No No No NANo

No No

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/UnableNo

Yes/UnableNo

Yes/UnableNo

Yes/Unable/NANo

Yes/Unable/NANo

Yes/Unable/NANo

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Patient: DOB: Report Date:

Procedure Date: Date: Date:

Elevate head (and chest) > 30º

TimeInit.

Action: ↑ HOB > 30º

11-7 7-3 3-11

11-7

7-3 3-11

11-7

7-3 3-11

Prophylactic treatment for deep venous thrombosis

TimeInit.

Action: TED socks Turn q _____: 11-7 7-3 3-

1111-7

7-3 3-11

11-7

7-3 3-11

Treatment for peptic ulcer disease

TimeInit.

Action: Rx_________:

11-7 7-3 3-11

11-7

7-3 3-11

11-7

7-3 3-11

Sedation Vacation (interruption of sedation to point of alertness)

TimeInit.

Action: Sedation vacation daily :11-7 7-3 3-

1111-7

7-3 3-11

11-7

7-3 3-11

Assessment for Readiness to Wean Tim

e Init.

Action: : RT to check for readiness to wean11-7

7-3 3-11

11-7

7-3 3-11

11-7 7-3

3-11

Test spontaneous breathing capability daily(T tube or other means)

TimeInit.

Action: : RT to check for spontaneous breath11-7 7-3 3-

1111-7

7-3 3-11

11-7

7-3 3-11

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Insulin therapy to keep blood sugar between80-110

TimeInit.

Action: * Gluc WNL WBG q_______ Insulin coverage11-7 7-3 3-

1111-7

7-3 3-11

11-7

7-3 3-11

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Measurement Information Form:Ventilator-Associated Pneumonia (VAP) Rate in ICU

Per 1000 Ventilator Days

Calculation Details

Numerator Definition: Total number of VAP cases in the ICU during the set time interval

Denominator Definition: Total number of ventilator days in the ICU in same time interval used in numerator

Definition of Terms:

Ventilator-Associated Pneumonia: Nosocomial pneumonia in a patient on mechanical ventilatory support (by endotracheal or tracheostomy) for greater than or equal to 48 hours.

Ventilator Day: Total number of days of exposure to ventilators by all patients in the selected population during the selected time period

Related Websites:

http://www.cdc.gov/ncidod/hip/NNIS/members/pneumonia/Final/PneumoCriteriaV1.pdfhttp://www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitions.pdf

Measurement Period: Measure monthly

Calculate as: (Number of Ventilator-Associated Pneumonias / Number of ventilator days) x 1000 = VAP rate per 1000 ventilator days

Example of VAP Rate

For example, if in February there were 12 cases of VAP, the number of cases would be 12 for that month. Thus, if 25 patients were ventilated during the month and each, for purposes of example, was on mechanical ventilation for 3 days, the number of ventilator days would be 25x3=75. The Ventilator-Associated Pneumonia Rate per 1000 ventilator days then would be 12/75 x 1000 = 160 per 1000 ventilator dates.(Total number of VAP cases/Ventilator Days) x 1000 = VAP Rate

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http://www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitions.pdf

http://www.cdc.gov/ncidod/hip/NNIS/members/pneumonia/Final/PneumoCriteriaV1.pdf

Vent Days

Unit: ____________

Date: ____________

# of Patients

Sunday ___________________

Monday ___________________

Tuesday ___________________

Wednesday ___________________

Thursday ___________________

Friday ___________________

Saturday ___________________

Total: ___________________

Please leave sheet on the unit assignment clipboard for the charge nurse to complete every morning with the day shift assignment

Count the number of patients each day that are on the ventilator.

Sheets should be sent to the Infection Control Department at the end of the month

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VENTILATOR AND CENTRAL VENOUS LINES MONTHLY REPORTThe Infection Control Committee greatly appreciates your help with CVL surveillance. The magnitude of the potential to cause morbidity and mortality resulting from infectious complications has been well documented. Treatment of line related infections are estimated to cost between $34,000 to greater than $56,000 per patient. INSTRUCTIONS:

Please document the date and unit in the appropriate blanks following instructions. Please count the number of patients with central venous lines every day at the same time and

record the number in the second column. A separate column requests the number of patients with catheters for dialysis. Do not include these

in the total number of central lines. Please do the same count of the number of patients on the ventilator. PLEASE NOTE THE UPDATED DEFINITION OF CENTRAL LINES. PLEASE DO INCLUDE THE

FOLLOWING:PICC, Long arm Groshong, Broviac, Hickman, IABP, IJ, Portacath, Double or triple lumen catheters regardless of site and Swan

Please submit this form to Infection Control by the end of the first week of each month. THANKS!

Month and Year: _________________________ Unit: ______________

Date Total # of Patients with Central Lines

Total # Patients with Dialysis Catheters

Total # of Patients on Ventilator

12345678910111213141516171819202122232425262728293031TOTAL

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NATIONAL NOSOCOMIAL INFECTIONS SURVEILLANCE SYSTEMADULT AND PEDIATRIC INTENSIVE CARE UNIT (ICU) MONTHLY REPORT FORM

NNID# ___________ Month and Year: ______________ Hospital’s code for this ICU: _________

Circle type of ICU: Burn Coronary Care CardioThoracic Medical Med/SurgNeurosurgical Pedatric

Respiratory Surgical Trauma Other (specify): _________________________

Number of patients in ICU . . . . . . . First Day of Month: ___________________ First Day of Next Month: ___________________

Number of Patients with:Date # New

Arrivals# Patients Indwelling urinary

catheterCentral line(s) Ventilator

12345678910111213141516171819202122232425262728293031TOTAL

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and m(d)).

Public reporting burden of this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other

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aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0012).

CDC 57.58B REV. 9-00 IDEAS Version 6.06

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Sun Mon Tue Wed Thu Fri Sat

1# pts. with C lines___# of vent pts.______







8

# pts. with C lines___# of vent pts.______
























2005

May

15

Remember to order daily “sedation vacations” on your patients receiving continuous intravenous sedation so that assessment of readiness to wean from mechanical ventilation can be completed on AM rounds. Each day, document in your notes your clinical impressions regarding the patients’ potential for weaning on that day. Remember to order any additional testing (labs, blood gases, CXR, weaning parameters) that you feel will assist you in this assessment process on the next morning rounds with your attending physician. Inform the nurse promptly after placing an order for a spontaneous breathing trial so that it can be initiated promptly.

Peptic ulcer disease (PUD) prophylaxis . The IHI (2005) has found that when PUD prophylaxis is applied as part of a set of interventions for ventilator care, the rate of pneumonia decreases precipitously. What is your role in the process? Please remember to order PUD prophylaxis on all mechanically ventilated patients.

Deep venous thrombosis (DVT) prophylaxis (unless medically contraindicated).

The IHI (2005) has found that when DVT prophylaxis is applied as part of a set of interventions for ventilator care, the rate of pneumonia decreases sharply.

What is your role in the process? Please remember to order DVT prophylaxis on all mechanically ventilated patients.

other mechanisms to reduce vap at the Dayton, VAMC:

Some other interventions that the facility is utilizing to reduce VAP are:

An oral care protocol for all mechanically ventilated patients.

A gastric tube management and tube feeding protocol for mechanically ventilated patients.

A repositioning and head of the bed elevation protocol for mechanically ventilated patients

A trial of endotrachial tubes that have a dorsal lumen to facilitate the removal of subglottic secretions.

thank you!Thank you for your assistance in this process. You will also receive an instruction sheet that will assist you in the ordering of protocols that can make the process easier.

References:1. Drakulovic, M.B., Torres, A., Bauer, T.T., Nicolas, J.M., Nogue, S., & Ferrer, M. (1999). Supine body position as a risk factor for Nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet, 354, 1851 – 1858.

2. Ely, E.W., Baker, A.M., Dunagan, D.P., Burke, H.L., Smith, A.C., Kelly, P.T., et al. (1996). Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. New England Journal of Medicine, 335, 1864 – 1869.

3. Institute for Healthcare Improvement. (2005). Getting started kit: preventing ventilator associated pneumonia. Boston, MA.

4. Kress J.P., Pohlman A.S., O'Connor M.F., & Hall, J. B. (2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine, 20, 1471 – 1477.

5. Rello, J., Ollendorf, D.A., Oster, G., Vera-Llonch, M., Bellm, L., Redman, R., & Kollef, M.H. (2002). VAP Outcomes Scientific Advisory Group: Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest, 6, 2115 – 2121.

6. Richards, M.J., Edwards, J.R., Culver, D.H., & Gaynes, R.P. (2000). Nosocomial infections in combined medical-surgical intensive care units in the United States. Infection Control Hospital Epidemiology, 21, 510 – 515.

7. Tablan, O.C., Anderson, L.J., Besser, R., Bridges, C., & Hajjeh, R. (2004). Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care–associated pneumonia, 2003 recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. Morbidity and Mortality Weekly Report Recommendations and Reports, 2004, 53, 1 – 36.

Welcome to the critical care units of the dayton, vamc!

The attending physicians and nurses of the Dayton, VAMC Intensive Care and Coronary Care Units hope that your rotation through our facility will be an enjoyable and sentinel learning experience for you. Our facility has adopted an assertive approach in the prevention of VAP at our institution and we need your help. You are a pivotal element of our process.

WHY SHOULD VAP BE PREVENTED? The Centers for Disease Control and Prevention (CDC) have found that pneumonia causes 15% of all hospital-acquired infections and is the leading cause of nosocomial infection related death (Tablan, Anderson, Besser, Bridges, and Hajjeh, 2003). The mortality rate of patients with VAP is higher than that of uninfected patients (50% versus 34%) and varies between the populations considered (Warren, et al., 2003). Rello, et al. (2002) found that VAP increases a patient’s length of stay in the ICU by 6.1 days and hospitalization by 10.5 days. This study also found length of stay and the additional need for antibiotics significantly impact health care expenditures by adding an estimated $16,050 to $41,294 to the cost of a hospital admission. Additionally, VAP has been reported to be the most common hospital-acquired infection among patients requiring mechanical ventilation in the United States (Richards, Edwards, Culver, and Gaynes, 1999). HOW CAN VAP BE PREVENTED? The Institute for Healthcare Improvement (2005) has developed a system of intervention sets which they term care bundles. Care bundles, in general, are groupings of best evidenced based practices with respect to a disease process that individually improve care. When the groupings are applied together the result is substantially superior improvement.

The Dayton VAMCVentilator Associated Pneumonia (VAP) Reduction Program

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The ventilator bundle is a group of evidence based practices that, when placed into daily practice for all patients on mechanical ventilation, result in a dramatic reduction in the incidence of VAP. With this in mind, our facility has adopted the ventilator bundle into the daily care of ventilated patients in the ICU and CCU of our institution

IHI (2005) PROGRAM OVERVIEW AND YOUR ROLE IN THE PROCESS:The ventilator IHI bundle has four components:

Elevation of the patients’ head of the bed to between 30 and 45 degrees (unless medically contraindicated).

In a randomized controlled trial conducted by Drakulovic, et al. (1999) it was found that when intubated patients on mechanical ventilation were assigned to semi-recumbent positioning (30 to 45 degrees), there were 18% fewer confirmed cases of VAP.

What is your role in the process? Please order that the head of the bed be elevated to between 30 and 45 degrees on all of the ventilated patients that you care for (if not contraindicated). Note the head of the bed position of your ventilated patient during your rounds and remind the nursing staff if the height is too low. Remember, however, that for certain procedures (linen changes, repositioning) nurses do (briefly) lower the head of the bed to prevent back injuries.

Daily “sedation vacation” AND daily assessment of readiness to extubate (unless medically contraindicated).

Kress, Pohlman, O’Conner, and Hall (2000) found that when 128 adults on mechanical ventilation were randomized to daily interruption of sedation per protocol until the patient was awake or interruption only at the clinician’s discretion, the duration of ventilation was decreased from 7.3 days

to 4.9 days in the group randomized to routine awakening per protocol. Ely, et al. (1996) found, in a randomized, controlled trial involving 300 adult patients receiving mechanical ventilation in medical and coronary intensive care units, that daily systematic screening of the respiratory function of adults receiving mechanical ventilation reduced the duration of the mechanical ventilation from a median of 6 days to median of 4.5 days and reduced the hospitalization costs from a median of $20,890 to a median of $15,740. What is your role in the process? When utilizing continuous intravenous sedation, order that the sedation be titrated to a specific sedation level. The critical care units of our facility currently utilize a modified Ramsay Scale to monitor intravenous sedation. We suggest, in most ventilated patients, that a target sedation level of ‘4’ is a good place to start.

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Address 2City, ST ZIP Code

Phone (555)555-0125Fax (555)555-0145Web site address

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