logy sepsis
TRANSCRIPT
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© 2008 TMIT 1
Safer Critical Care: Resources to Prevent Ventilator-Associated Pneumonia
(VAP) and
Central Venous Catheter-Associated Bloodstream Infections (CVC-BSI)
Practices 19-20Joan Reischel, RN, BSN, CCRN
Tom Talbot, MD, MPHRichard J. Wall, MD, MPH
Mary E. Foley, MS, RNCharles R. Denham, MD
Hayley Burgess, PharmD
© 2008 TMIT 2
Overview
• 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
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3© 2008 TMIT
NQF Safe Practices for Better Healthcare: A Consensus Report
• 30 Safe Practices
Criteria for Inclusion• Specificity• Benefit• Evidence of
Effectiveness• Generalization• Readiness
4© 2008 TMIT
Harmonization – The Quality Choir
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5© 2008 TMIT
Culture SP 1
Information Management & Continuity of Care
Medication Management
Healthcare-Assoc. Infections
Condition- & Site-Specific Practices
Consent & Disclosure
Culture
Workforce
Consent & Disclosure
2007 NQF Report
6© 2008 TMIT
Information Management & Continuity of Care
Medication Management
Healthcare-Associated Infections
Condition- & Site-Specific Practices
Consent & Disclosure
Wrong-siteSx Prevention
Periop. MIPrevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag. Therapy
Asp. + VAP Prevention
Central V. Cath.BSI Prevention
Sx-Site Inf.Prevention
Contrast Media Use
Hand Hygiene InfluenzaPrevention
PharmacistCentral Role
Med. Recon.
Std. Med. Labeling & Pkg.
High-AlertMeds.
Unit-DoseMedications
Evidence-Based Ref.
Culture
CPOE
OrderRead-back
AbbreviationsDischarge System
CriticalCare Info.
LabelingStudies
Culture Meas.,F.B., & Interv.
Structures& Systems
ID Mitigation Risk & Hazards
Team Training& Team Interv.CHAPTER 1: Background
Summary, and Set of Safe Practices
CHAPTERS 2-8 : Practices By Subject
Nursing Workforce ICU CareDirect
Caregivers
Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care
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
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 Ventilator-
Associated 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
Informed Consent
Life-SustainingTreatment Disclosure
CHAPTER 3: Informed Consent & Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure
Consent & Disclosure
2007 NQF Report
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© 2008 TMIT 7
Prevention of Catheter-AssociatedBloodstream Infections
Thomas R. Talbot, MD MPHAssistant Professor of Medicine and Preventive Medicine
Chief Hospital EpidemiologistVanderbilt University School of Medicine
© 2008 TMIT 8
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
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© 2008 TMIT 9
Vascular Catheter-RelatedBloodstream 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 10
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© 2008 TMIT 11
CRBSI per 1000 Catheter Days
3.7P-A catheter1.6Long-term, cuffed & tunneled HD catheter0.1Port (central)
1.7Tunneled CVC
1.21.6
Medicated nontunneled CVCMinocycline-rifampin
CHG-silver sulfadiazine
2.7Nontunneled CVC1.7Arterial catheters for hemodynamic monitoring
Maki D et al Mayo Clin Proc 2006;81:1159+
© 2008 TMIT 12
Vascular Catheter Infection:Prevention
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© 2008 TMIT 13
1. Hand hygiene2. Maximal barrier precautions3. Chlorhexidine skin antisepsis
• Except VLBW infants4. Optimal catheter site selection
• Subclavian vein preferred 5. Daily review of line necessity, with
prompt removal of unnecessary lines
CVC-BSI Prevention Bundle
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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.
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© 2008 TMIT 17
Impact of MaximalBarrier Precautions
6.3 (p<0.03)CentralProspectiveRandomized
Raad1994
2.2 (p<0.03)P-AProspectiveCross-sectional
Mermel1991
Odds Ratio for Infection
w/o MBP
CatheterDesignAuthor/date
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 18
Chlorhexidine as Skin Prep
2.3
9.3
7.1
0
1
2
3
4
5
6
7
8
9
10
2% CHG 10% Povidone 70% Alcohol
CVC-
BSI p
er 1
000
CVC
Day
s
10
© 2008 TMIT 19
CHG
P-I
Chlorhexidine as Skin Prep
© 2008 TMIT 20
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
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© 2008 TMIT 21
Mermel L, 2000
© 2008 TMIT 22
Femoral vs. Subclavian CVC Placement
Femoral Subclavian
Infectious Complications 19.8% 4.5%
Thrombotic Complications 21.5% 1.9%
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© 2008 TMIT 23
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
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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
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LF
Time end (cathete r secured):
MR #:
Check if:
Femora l
Internal Jugu la r
/ / Date :
Type of catheter:
Trip le lume n Introducer Swan-Ganz
Insertion Site :
Subclav ian
Other (specify):
P t/Family teaching done Consent obta ined
Pre-insertion skin prep (check any used): Alcohol Betadine (povidone-iodine) Chlo rhexidine Other (specify ):
Describe the circum stances under which th is line was placed: Non-e mergent Emerge nt (life -threatening or code s itua tion)
Please file page 2 in patients chart and return top form to the designated location in the ICU.
List all s ites where insertion was attempted. Other (specify ):
: Time sta rt (1st needle s tick): :
Ho w m any different needle sticks did the patient receiv e (number of skin breaks)? 1 Unknown
The prov ider inserting th is line:
* If “No”, was this procedure superv ised by som eone with least five (5) central lines experience? Yes No Didn’t ask
Yes No
P lease use m ilitary tim e (i.e . 1 :00 pm is 13 :00)
a. Handed-off h is/her pager before the procedure? Yes No b. W ashed hands im mediately prior to procedure? Yes No *
D idn’t ask D idn’t ask D idn’t ask c. Has prev iously placed a t least five (5 ) central lines?
Describe the level of tra ining of the person who actually inserted the line? Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending
Barrier precautions (check any used): Sterile gloves Ste rile gown Mask Ste rile towe ls Full body drape
Side: Right Left
2 3 4 5 6+
Follo w-up CXR: Ordered Not ordered (specify reason): CXR findings (check all that apply):
No pneumothorax Pneumothorax (describe action taken): Cathe ter in good position Catheter pos ition adjusted (describe):
Type of dress ing: Bio -occ lus ive Gauze Other (specify ):
Patient to lerated the procedure well? Yes No
W as the sterile field m aintained throughout the entire procedure? Yes No
Com plications? None Other (desc ribe):
Dressing applied by: Nurse Proceduralis t Other (specify ):
Nursing C hecklist: Central Venous Catheter Insertion
Vanderbilt U niversity M edical C enter
RIJ L IJ RSC LSC RF
Guidewire exchange
P lacement unsuccessful
MC 2705 (R ev. 06 /04)
NO TE: P lease use eithe r black o r blue ink to comple te this form.
Comme nts:
Vascath
Signature: ______________________________________________ Date : _________________
Indications for use: Pressors He modyna mic mo nit. F luids/b lood products Frequent lab draws
Pre-exis ting infection
Nurse Prac titioner
Double lume n
atVanderbilt
Monroe Care ll Jr. O R
CCU MICU SICU BICU PCCU NIC U
NSIC U TIC U Other
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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 30
0
10
20
30
40
50
60
JAN
MARMAY
JUL
SEPNOV
JAN
MARMAY
JUL
SEPNOV
CVC-BSI Rates, VUH ICUs January 2004 - December 2005
Use of Insertion Checklist Rolled Out
to all ICUs
Rate
per
1,0
00 C
VC D
ays
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.
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© 2008 TMIT 31
• 103 ICUs in MI• Unit team leaders• CVC bundle• Checklist• Empowerment to stop procedure
© 2008 TMIT 32
“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”
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© 2008 TMIT 33
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 34
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
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© 2008 TMIT 35
Antibiotic CVCs
• N = 7 trials• 3 showed significant CRBSI reduction• ? Risk of bacterial resistance
••••
•
• noncoated comparator
© 2008 TMIT 36
• 12 university hospitals• Adults with CVC expected 3+ days• Rif-mino vs. 1st gen CHG-SS
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BioPatch
• CHG-impregnated• Designed to surround catheter at skin
insertion site• Must be “right side up”
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© 2008 TMIT 39
Catheter or exit-site colonization
Bacteremia
© 2008 TMIT 40
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
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© 2008 TMIT 41
Johns Hopkins Experience
© 2008 TMIT 42
BSI Rates, U of Nebraska
PPMV Hub Introduced
PPMV Removed
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© 2008 TMIT 43
© 2008 TMIT 44
Implementing Central Venous Catheter-Blood Stream Infection
Prevention Bundle
Joan Reischel, RN, BSN, CCRNClinical Coordinator, Critical Care
The Medical Center of Aurora
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© 2008 TMIT 45
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 46
Patient Population at a Glance
69%
8%
5%
7%
11%
MedicalTraumaSurgicalNeuroCardiovascular
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© 2008 TMIT 47
BSI InitiativeIHI 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 48
BSI InitiativeSafe 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
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© 2008 TMIT 49
Central Line Checklist
• Checklist downloaded from BSI web cast and modified for our unit.
• Checklist attached to every central line insertion kit.
• When BSI identifiedchecklist reviewed.
Intensive Care Unit Central Venous Catheter Insertion
Date:____________ Time:___________ Insertion Site(where catheter was ultimately placed): ◊ Internal Jugular ◊ Subclavian ◊ Femoral ◊ Other (specify):______________ Consent obtained? ◊ Yes ◊ No Guidewire exchange? ◊ Yes ◊ No Pt/Family teaching done? ◊ Yes ◊ No Pre-insertion skin prep (check any used): ◊ Alcohol ◊ Betadine (povidone-iodine) ◊ Chlorhexidine ◊ Other (specify):____________ Barrier precautions (check any used): ◊ Sterile gloves ◊ Sterile gown ◊ Mask ◊ Cap ◊ Body drape Washed hands immediately prior to procedure? ◊ Yes ◊ No Had to break the sterile field during the procedure? ◊ Yes ◊ 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 50
• CL Added to Daily Rounds
Central Line Checklist
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© 2008 TMIT 51
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 52
0
0.5
1
1.5
2
2.5
3
2005 2006 2007 2008
BSI Rate
Bloodstream Infection Rate
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© 2008 TMIT 53
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 54
Consumer Advocate
Mary E. Foley, MS, RNAssociate Director
Center for Research and Nursing Innovation University of California, San Francisco (UCSF)
National Patient Safety Foundation Board of DirectorsAdvisory member, Partnership for Patient Safety (p4ps)
Vice-President, ANA/California state association
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© 2008 TMIT 55
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 56
Ventilator-Associated Pneumonia (VAP)Prevention Strategies
Richard J. Wall, MD MPHPulmonary, Critical Care, & Sleep Disorders MedicineSouthlake Clinic, Valley Medical Center, Renton, WA
University of Washington, Seattle, WA
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© 2008 TMIT 57
© 2008 TMIT 58
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
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© 2008 TMIT 59
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 60
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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© 2008 TMIT 61
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
© 2008 TMIT 62
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© 2008 TMIT 63
Adult Ventilator Bundle
VAP prevention measures1. Hand hygiene2. Patient positioning3. Daily “Sedation Vacation”4. Daily assessment of readiness to extubate 5. Oral care 6. Management of secretions
General measures to improve care⇒ Peptic ulcer prophylaxis⇒ Deep vein thrombosis (DVT) prophylaxis
© 2008 TMIT 64
Hand Hygiene
• Strict hand hygiene before and after handling patient or patient’s equipment or supplies
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© 2008 TMIT 65
Patient Positioning
• RCT of 86 adult intubated patients• Semi-recumbent (45o) vs. supine position
Semi-recumbent SupineSuspected VAP 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 66
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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© 2008 TMIT 67
Patient Positioning
• Precautions– Hypovolemia - possible hypotension– Transporting patients– Spine precautions
• Consider reverse trendelenberg
Drakulovic MB. Lancet.1999;354:1851-1858.
© 2008 TMIT 68
Do:Positioning DO’s and DON’Ts
• Leave patient in supine position for prolonged periods.
• Continue Q 2 hour turning schedule.
• Maintain HOB > 30 degrees unless contraindicated.
Don’t:
• Forget to turn off tube feedings if placing patient in supine position.
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© 2008 TMIT 69
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
• Complication rates:Sedation vacation 2.8% Controls 6.2%
Kress JP et al. N Engl J Med 2000;342:1471-7.Schweickert WD et al. Crit Care Med 2004;32:1272-6.
(p=0.004)
(p=0.04)
© 2008 TMIT 70
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.
© 2008 TMIT 72
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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© 2008 TMIT 73
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
© 2008 TMIT 74
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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© 2008 TMIT 75
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.
© 2008 TMIT 76
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 increasedincreased rates of VAP in patients on prophylactic treatments, with a trend toward lower VAP with sucralfate (vs. H2blockers).
• Proton pump inhibitors may be more efficacious than H2 blockers and sucralfate, but there is a paucity of data comparing the various regimens.
© 2008 TMIT 78
2008 Surviving Sepsis Campaign Guidelines: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
PUD Prophylaxis
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© 2008 TMIT 79
DVT Prophylaxis
Systematic review of risks of venous Systematic review of risks of venous thromboembolism and its prevention: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.
© 2008 TMIT 80
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.
© 2008 TMIT 82
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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© 2008 TMIT 83
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.
© 2008 TMIT 84
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.
© 2008 TMIT 88
Kinetic Beds
• Immobility is associated with increased VAP.– Kinetic beds employ rotational therapy to prevent and
treat respiratory complications.• Meta-analysis of kinetic beds 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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© 2008 TMIT 89
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.
© 2008 TMIT 90
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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© 2008 TMIT 91
5 VAP Algorithms
• Diagnosis of VAP in 4 populations:1) Adults 2) Immunocompromised3) Children (1-13yo)4) Neonates (<1yo)
• Initial empiric treatment of VAP
Source: Wall RJ, Ely EW, Talbot TR, et al. Evidence-basedalgorithms for diagnosing and treating ventilator-associatedpneumonia. Journal of Hospital Medicine 2008 (in press).
© 2008 TMIT 92Wall RJ et al. J Hospital Medicine 2008 (in press).
47
© 2008 TMIT 93Wall RJ et al. J Hospital Medicine 2008 (in press).
© 2008 TMIT 94Wall RJ et al. J Hospital Medicine 2008 (in press).
48
© 2008 TMIT 95Wall RJ et al. J Hospital Medicine 2008 (in press).
© 2008 TMIT 96Wall RJ et al. J Hospital Medicine 2008 (in press).
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© 2008 TMIT 97
Selected References1. 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. 2. 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.
3. 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. 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.
5. Kollef M. Epidemiology and outcomes of healthcare-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005;128:3854-62.
6. Langley JM, Bradley JS. Defining pneumonia in critically ill infants and children. Pediatr Crit Care Med 2005;6[supp]:S9-S13.
7. 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.
8. Muscedere J and the Canadian Critical Care Trials Group. Comprehensive evidence-based practice guidelines for ventilator-associated pneumonia: Diagnosis & treatment. J Crit Care2008;23:141-50.
9. Wall RJ et al. Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia. J Hospital Medicine 2008 (in press).
© 2008 TMIT 98
Implementing VAP Prevention
Bundle
Joan Reischel, RN, BSN, CCRNClinical Coordinator, Critical Care
The Medical Center of Aurora
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© 2008 TMIT 99
VAP Initiative
• VAP identified as high priority for IHI initiative• Team Goal: Zero VAPs• Team included
RTNursingPhysical TherapyPharmacyQuality
© 2008 TMIT 100
VAP Rate 2005-2007
The Medical Center of AuroraControl Chart for
Ventilator Associated PneumoniaLower is better
5.80
2.79
0.00
2.31
5.85
0.00
8.51
3.44
6.976.08
8.77
5.85
0.00 0.00 0.00 0.00
2.463.06
0.00 0.00 0.00 0.00 0.00 0.00
2.90
0.00
6.93
0
10
20
30
Jan-0
5
Feb-05
Mar-05
Apr-05
May-05
Jun-0
5Ju
l-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-0
6
Feb-06
Mar-06
Apr-06
May-06
Jun-0
6Ju
l-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-0
7
Feb-07
Mar-07
Time in Month/Year
Num
ber O
f VA
Pspe
r 100
0 ve
ntila
tor d
ays
51
© 2008 TMIT 101
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
© 2008 TMIT 102
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)
Laminated Signs for Rooms
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© 2008 TMIT 103
Daily Rounds Ventilator Information
• Daily Rounds form
© 2008 TMIT 104
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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© 2008 TMIT 105
Safe Critical Care Initiative
• Utilization of Algorithm• Development of chart audit tool• Physician involvement of case review• Focus on safety culture
© 2008 TMIT 106
VAP Algorithm
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© 2008 TMIT 107
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.
© 2008 TMIT 108
VAP Audit ToolInitial Review Final Review Comments
Admission DateOn Mech vent >48hr?
Date first on VentSputum sent within 48 hr of intubation? Type of culture: BAL or trach Result of culture:
Date of repeat cultureType 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 Yes No If yes, continue:
Fever (38C or 100.4F) w/o other cause?Leukopenia (<4000 WBC/m3)Leukocytosis ( >12000 WBC/m3)Altered Mental Status with no other cause
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?
Ventilator Associated Pneumonia Review Sheet
IF ANY TWO of the FOLLOWING ARE YES, THEN COMPLETE THE ALGORITHM: IF NO, THEN NOT A VAP
If YES Immunocompromised Pt., Use Algorithm 2
IF THE FOLLOWING FOUR ARE NO, NOT A VAP
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© 2008 TMIT 109
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?
ABX Therapy? (w/n 4 hr. of presumptive VAP dx)Risk Factors? (Prior ABX w/n 3 mo; current hosp. >=5 days; known resistance; immunosupp; recent NH; hemodialysis;home wound care or infusion therapy, family member known infection)
Single Drug Therapy
Triple Drug TherapyPt. 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 commentHOB > 30o
Hi Lo ET Tube to suctionSedation VacationWeaning Protocol? Tolerating weans?PUD/DVTOral CareChlorhexidine Rinse BID
Outcomes: Pt Sticker:
If Risk Factors YES , Appropriate Drug Therapy:
If Risk Factors NO, Appropriate Drug Therapy:
VAP ABX Algorithm if YES for presumptive VAP:
© 2008 TMIT 110
Going Forward
• 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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© 2008 TMIT 111
Consumer Advocate
Mary E. Foley, MS, RNAssociate Director
Center for Research and Nursing Innovation University of California, San Francisco (UCSF)
National Patient Safety Foundation Board of DirectorsAdvisory member, Partnership for Patient Safety (p4ps)
Vice-President, ANA/California state association
© 2008 TMIT 112
Q & A