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1 Preventing Ventilator Associated Pneumonia: A Six Year Experience Coretha Weaver, BSN, CIC Erlanger Health System Chattanooga, TN

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Page 1: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

1

Preventing Ventilator Associated Pneumonia: A Six Year Experience

Coretha Weaver, BSN, CIC

Erlanger Health System

Chattanooga, TN

Page 2: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

2

Objectives

The participant will be able to

1. Describe the prevalence, economic and human costs associated with VAP;

2. Discuss best practices implemented during this project to prevent VAPs;

3. Discuss patient outcomes and factors affecting progress;

4. Discuss future work to prevent VAP

Page 3: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

A 533 bed, 5 facility regional teaching health system

Level 1 Trauma Center

68 Adult ICU Beds-

7 Units

Page 4: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

4

Epidemiology of VAP

VAP represents >25% of all ICU-acquired infections

VAP cases occur at a rate of >100,000 cases of annually in the US

VAP accounts for more than one-half the antibiotic use in the ICU

Attributable mortality of VAP can be as high as 50%

Zilberberg M et al. Clinical Infectious Diseases 2010;51(S1):131-135

Dodek et al. Ann Intern Med,2004:141:305-313.

Page 5: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

VAP: TIME COURSEMean Daily Risk Of VAP

0

1

2

3

4

5

0 - 5 6 - 10 11 - 15 16 - 20 21 - 25 26 - 30

Number Days Intubated

PE

RC

EN

TA

GE

Weber, J. 2006 APIC

Page 6: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

6

Pathophysiology

Timing Within 5 days

Bacteriology S. pneumoniae H. influenzae MSSA

Susceptible GNB

Prognosis Less severe, little

impact on outcome

Timing Beyond 5 days

Bacteriology P. aeruginosa Acinetobacter

MRSA

Other multiresistant orgs

Prognosis High attributable

mortality and morbidity

Early VAP Late VAP

Kollef,M. N Eng J Med 1999;340(8): 627-34

Page 7: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

7

Non-Infected

Ventilator Patients

Patients with VAP

ICU LOS 4 days 26 days

Hospital LOS 13 days 38 days

Hospital Costs $21,620 $70,568

Adjusted Attributable

Cost for VAP

$12,000

Economic Impact

Warren et al. Crit Care Med 2003 May;31(5):1312-7

Page 8: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

Organisms causing VAP arising from both endogenous and exogenous

sources

Pathogenesis of VAP

Organisms causing VAP arise from

endogenous and exogenous sources

Page 9: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

9

Risk Factors For VAP

Duration of

intubation

Emergent intubation

Re-intubation

Insufficient oral

hygiene

Elevated gastric PH

Prior antibiotic

therapy

Nasogastric tube

management

Enteral nutrition

Supine position

Transport out of the ICU

Cross contamination of

ventilatory equipment

Nasal intubation

Lack of healthcare

professional training in

VAP prevention

Kollef M. Crit Care Med 2004;32:1396

Page 10: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

Adapted from AACN VAP Practice Alert

Bacterial

colonization

aerodigestive

tract

Aspiration

of

secretions

Altered

host

defenses

Colonization Aspiration Duration of

Ventilation

Pathogenesis of VAP

Adapted from AACN VAP Practice Alert Presentation 2005

Prevention strategies focus on :

____________________________________________________________

Page 11: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

11

What are we doing to reduce VAPs?

How are we doing?

Page 12: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

12

0

20

40

60

80

100

120

Jul -

Sep

04

Oct-

Dec

04

Jan-M

ar

05

Apr-

Jun

05

Jul -

Sep

05

Oct-

Dec

05

Jan-M

ar

06

Apr-

Jun

06

Jul-S

ep

06

Nu

mb

er

of

Ve

nt

Pa

tie

nts

Patients w/o VAP VAP Events

Trauma ICU

VAP Event Data

Jul 04-Sep 06

Extracted from Project Impact Data

0

10

20

30

40

50

60

70

80

90

100

Jul -

Sep

04

Oct

-Dec

04

Jan-

Mar

05

Apr

-Jun

05

Jul -

Sep

05

Oct

-Dec

05

Jan-

Mar

06

Apr

-Jun

06

Jul-S

ep 0

6VA

P E

ven

ts P

er 1

000

Ven

t D

ays

Actual Avg UCL LCL NNIS Bench-mark

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0

10

20

30

40

50

60

70

80

Jul-S

ept

04

Oct-

Dec

04

Jan-M

ar

05

Apr-

Jun

05

Jul-S

ep

05

Oct-

Dec

05

Jan-M

ar

06

Apr-

Jun

06

# o

f V

en

t P

ati

en

ts

Patients w/o VAP VAP Events

Surgical ICU

VAP Event Data

Jul 04-Jun 06

Extracted from Project Impact Data

0

10

20

30

40

50

60

70

80

Jul-S

ept 04

Oct-

Dec

04

Jan-M

ar

05

Apr-

Jun 0

5

Jul-S

ep 0

5

Oct-

Dec

05

Jan-M

ar

06

Apr-

Jun 0

6

VA

P E

ven

ts P

er

1000 V

en

t D

ays

Actual Avg UCL LCL NNIS Bench-mark

Page 14: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

14

Historical VAP Data

Unit

Erlanger

1999

Infection Rate/1000 vent days

NHSN

Rate/1000 vent days

Pooled Mean

TICU 15.0 15.2

NNICU 20.0 11.2

MICU 16.5 4.9

SICU NA 9.3

CDC’s NHSN- National Healthcare Safety Network

Page 15: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

15

Formed a multidisciplinary team-2005

Intensivist/Pulmonologist

Infection Preventionists (IP)

Director Critical Nursing

Trauma Surgeon/Critical Care

Critical Care Nurses - Multiple

Critical Care Nurse Manager

Respiratory Director

Respiratory Educator

Monthly team meetings

VAP Prevention Strategy

Page 16: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

16

Search for Best Practices- 2005

Reviewed the literature and practice guidelines

Developed standards of practice elements endorsed by medical staff leadership

Agreed on a surveillance plan

Page 17: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

17

Surveillance for VAP

Utilize NNIS/NHSN definitions for surveillance for VAP

Utilize NNIS/NHSN system to enter and analyze data

Collect compliance data on process indicator priorities and report by unit

Page 18: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

18

Creative Resourcing -2006

Initial VAP surveillance done in TICU, SICU, & MICU by Project Impact Nurses with IP support .

VAP triggers identified by Respiratory therapy to IP from Neuro-ICU,CCU, and Burns for review .

Education on identifying VAPs done by IPs

VAP final reviews and process indicators done by IP

Attempted to set up radiology trigger for case identification

Page 19: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

19

Interventions for Prevention of VAP

1. Education for all staff who manage ventilated patients

2. Daily Sedation Vacation(IHI)

3. Daily assessment for weaning(IHI)

4. Standardize mouth care and teeth brushed daily

5. HOB 30 degrees or greater (IHI)

6. Endotracheal tubes with subglottic suction port for all patients (except day surgery)

CDC Recommendations for Prevention of HA Pneumonia, 2002

Kollef M NEJM 1999: Vol 340:627-634

Page 20: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

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Interventions for Prevention of VAP

7. Patients receive orotracheal intubation

8. Check NG residuals Q4 hours

9. Use non-invasive ventilation and avoid re-intubation where possible

10. Protocol for Peptic ulcer Disease (IHI)

11. Protocol for DVT prevention (IHI)

CDC Recommendations for Prevention of HA Pneumonia, 2002

Kollef M NEJM 1999: Vol 340:627-634

Page 21: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

21

Prioritizing Interventions

Education – Top priority Developed VAP video with test

Curriculum covered all elements of best practices

Required for all staff caring for ventilated patients including residents

Policy development: sedation vacation, revision of RT weaning protocol, standard of care for NG management.

Page 22: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

22

Prioritizing Interventions

Implementing the IHI Bundle HOB 30

degrees

Weaning protocol

Sedation vacation

Implementation of PUD & DVT protocols

Page 23: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

23

Beyond the IHI Bundle

Hi-low Evac endotracheal tube –2006 (Upgraded to TaperGuard 2009)

Anesthesia

Lifeforce – Air support

Emergency Medicine

Assessing NG residual Q4hrs

Orotracheal intubation

Page 24: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

24

Failure of Initial Surveillance Plan2006

Reasons for failure:

Impact nurses deferred to trauma physician’s designation of VAP (VAP rate of 20 -40 per 1000 vent days

in TICU)

Respiratory care unable to sustain staffing for surveillance

IP unable to sustain efforts due to staffing (2.5 IP

FTEs)

Radiology chest film reads inconsistent & reports never initiated

Page 25: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

25

Patient Safety Leadership Provides Resources - 2007

Dedicated IP nurse to collect VAP data

Dedicated nurse to collect process data, send VAP triggers to IP, and coach staff

Management engineer and data analyst from Process Improvement to support VAP project

Page 26: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

26

New Team Support - 2007

New CNO – Executive Sponsor

New Intensivist/Pulmonologist & project physician champion

Addition of Hospitalist to team

Page 27: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

27

VAP PI Team Work

Meetings every other month –Excellent attendance!

Focus on process data and strategies to improve compliance

Continuous review of literature

Ongoing review of new technology

Page 28: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

28

Initial Process Data Collection

Total bundle compliance = 17%

0%

20%

40%

60%

80%

100%

7/1/2007

July 2007 Data

HOB

Weaning

PUD

DVT

Sed.Vac.

Mouth car

NG Resid.

Page 30: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

Overall Compliance with Best Practices

0

20

40

60

80

100

Jul-

07

Aug Sep Oct Nov Dec Jan-

08

Feb Mar Apr May Jun Jul Aug Sep

Percent

Compliance

2008 Best Practices Improve and VAPs Decrease

Page 31: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

31

Time to Celebrate!!!!!!

Page 32: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

32

Compliance with Process Indicators Oct 07 – Dec 10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-

07

Nov-0

7D

ec-0

7

Jan-0

8F

eb-0

8M

ar-

08

Apr-

08

May-0

8

Jun-0

8Jul-08

Aug-0

8S

ep-0

8O

ct-

08

Nov-0

8D

ec-0

8

Jan-0

9F

eb-0

9

Mar-

09

Apr-

09

May-0

9Jun-0

9Jul-09

Aug-0

9S

ep-0

9

Oct-

09

Nov-0

9

Dec-0

9Jan-1

0F

eb-1

0

Mar-

10

Apr-

10

May-1

0Jun-1

0

Jul-10

Aug-1

0S

ep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Bu

nd

le C

om

plian

ce R

ate

Actual Avg Target

Significant improvement over time for overall

bundle compliance

Page 33: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

VAP Process IndicatorsBased on random surveillance of intubated ICU pts

Desired

Direction Desired

Directio

n

Process Data Through March 2011, Outcomes Data Through March 2011

Current Period (March 2011) YTD (Jul 10 - Mar 11)

Receivi

ng the

Req'd

Treatm

ent

NOT

Receivi

ng the

Req'd

Treatm

ent

Exclud

ed or

Contra

-

Indicat

ed

%

Receivi

ng the

Req'd

Treatm

ent

%

Receivin

g the

Req'd

Treatme

nt Target

Current

FY vs

Previou

s FY

Monthly

Trend

(Jul 09 -

Mar 11)

Patients with Pneumonia Present on Admission 17

V

A

P

P

r

o

c

e

s

s

I

n

d

i

c

a

t

o

r

s

h 197 3 100% 99% 90%

Daily Weaning Parameter Assessment h 122 0 78 100% 96% 90% -0.2%

PUD Prophylaxis Protocol Ordered h 195 0 5 100% 98% 90% 0%

DVT Prophylaxis Protocol Ordered h 113 2 85 98% 97% 90% 1%

Daily Sedation Vacation Documented h 28 0 172 100% 97% 90% 0%

Appropriate Mouth Care h 168 28 4 86% 83% 90% -1%

Complete Bundle Compliance h 166 34 0 83% 78% -0.7%

Hi-Lo Tube Used During Intubation h 57 6 90% 90% 0%

NG Residuals Assessed and Documented h 124 72 63% 66% 1%

HOB 30 Degrees -0.3%

Page 34: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

34

Keys to Improvement of Processes

Supported by executive leaders and medical staff

IHI influence

Nursing, Respiratory Care, and physicians are all engaged and taking ownership of processes

Processes are hardwired in critical care standards of practice; No physician order needed to implement bundle

Dedication of staffing resources

Page 35: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

35

Other Improvements and Considerations

Critical care consult for all ventilated patients within 48 hours

Hardwire communication process between nursing and RT for sedation vacation

Increased inventory and use of non-invasive ventilation devices (BIPAP)

Trial of 24 hour mouth care kits (100K)

Rewarding staff for efforts

Discussed early trachs to decrease VAP – not clearly supported by the literature but does improve patient comfort

Page 36: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

36

Ventilator Length Of StayJan 07 – Dec 10All Units

Average LOS

R2 = 0.3658

0

1

2

3

4

5

6

7

8

Jan-0

7F

eb-0

7M

ar-

07

Apr-

07

May-0

7Jun-0

7Jul-07

Aug-0

7S

ep-0

7O

ct-

07

Nov-0

7D

ec-0

7Jan-0

8F

eb-0

8M

ar-

08

Apr-

08

May-0

8Jun-0

8Jul-08

Aug-0

8S

ep-0

8O

ct-

08

Nov-0

8D

ec-0

8Jan-0

9F

eb-0

9M

ar-

09

Apr-

09

May-0

9Jun-0

9Jul-09

Aug-0

9S

ep-0

9O

ct-

09

Nov-0

9D

ec-0

9Jan-1

0F

eb-1

0M

ar-

10

Apr-

10

May-1

0Jun-1

0Jul-10

Aug-1

0S

ep-1

0O

ct-

10

Nov-1

0D

ec-1

0

Len

gth

of

Ven

tila

tor

Sta

y (

Days)

Page 37: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

37

Overall VAP Rate Oct 07 – Dec 10

Analysis of overall rate shows no statistical

improvement over time

Page 38: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

38

VAP Trends by Unit

Page 39: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

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VAP Organism Summary 2008-2010

N=117

48% (56) had no organism identified

VAPs with organisms identified

32% MSSA/MRSA

15% Pseudomonas Aeruginosa

11% Haemophilis

10% S. Pneumo

Data reported to NHSN

Page 40: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

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Improved processes not translating to

decreased VAPS???

Limitations in identifying VAPs even with the same IPs surveying the unit

Inconsistent compliance with basic IP (e.g hand hygiene, disinfection of devices between patients)

Nursing turnover in ICUs

Continued low compliance with mouth care

Poor compliance with assessment of NG residuals

Lag time to good compliance with subglottic suction ETT (TaperGuard)

Page 41: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

41

Limitations in Identifying VAP

Surveillance definitions and clinical diagnosis is neither sensitive nor specific

Many clinical conditions mimic VAP (e.g.ARDS)

Page 42: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

Diagnosis of VAP

Clinical + Microbiological

• fever

• tachycardia

• leukocytes

• increased RR or

FIO2

• purulent secretions

+Chest X ray

• new infiltrates

• new consolidation• BAL

NOTE: Identification of VAPs using surveillance definitions by Infection Control

can differ from clinical diagnosis

Page 43: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

43

BAL…Gold Standard for Diagnosing VAP?

BAL culture quality can be affected by

Prior antibiotic therapy

Contamination with endotracheal and oropharyngeal colonizers

Missing the segment of lung with active disease/highest concentration of organisms

Lack of data related to the effects of multiple bronchoscopes on single patient

Page 44: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

44

Distribution of BAL Specimens

Page 45: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

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Physician Diagnosis Poor

84 ICU patients with abnormal chest x-rays and purulent sputum Evaluated by 7 physicians

True diagnosis established by histology or quantitative bronchoscopy cultures

32% found to have VAP

Physicians disagreed on presence or absence of VAP in 35/84(42%) of patients

The “best” doc missed 28% of true VAPs

The “worst” doc missed 50% of true VAPs

Both labeled ~20% of patients without VAP as having VAP

Fagon et al. Chest 1993; 103:547-53; slide courtesy of Michael Klompas, MD, MPH,FRCP

From presentation given by Shelly Magill,MD,PhD, DHQP, CDC

Page 46: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

46

Agreement Among Infection Preventionists - Fair

50 Ventilated patients with respiratory deterioration reviewed by 3 IPs: 2 using conventional approach (C) & 1 using quantitative approach (Q) C-IP – 11VAPs

C-IP – 20 VAPs

Q-IP – 15 VAPs

62% agreement among IPsKlomas, AJIC 2010:38:237

Page 47: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

Review of data with Trauma Surgery

VAPs- Called

by both

Trauma and

Infection

Prevention

No-per IP &

Radiologist

read

(yes-

infiltrate per

Trauma)

Disease

process on

admission to

unit (48hr rule)

or prior to

intubation-

includes

transfers

No CXR

changes-

but yes

per + BAL

Did not

meet

IC/CDC

surveillanc

e criteria

Total – 8

33%

Total- 8

33%

Total- 5

21%

Total-1

4%

Total -2

8%

Jan 09 - Feb 09

•Trauma called 24 VAPS

•Infection Prevention called 8 VAPS

Page 48: Preventing Ventilator Associated Pneumonia (VAP)asp.pharmacyonesource.com/images/sentri7/VAPSixYear.pdf · Preventing Ventilator Associated Pneumonia: A Six ... human costs associated

48

Implications for Ongoing VAP Surveillance at Erlanger

Rates are dependent upon:

The observer

Diagnostic tools used

Methods for sampling lower respiratory tract will impact VAP rates

Frequency of mimicking conditions in the ICU Prevalence of ARDS or pulmonary edema rates.

Compliance with basic infection prevention practices

Klomas, AJIC 2010:38:237; Morris, Thorax 2009;64:516;Klompas et al.Clin.Infect Dis 2008;46:1443

Adapted from slide from presentation by Shelly Magill,MD,PhD, DHQP, CDC

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CDC Assessment of the Future of VAP Surveillance

Recognize current definitions won’t work in current environment Too burdensome and case finding too

variable

Recognize inaccuracies in VAP diagnosis in NHSN and in clinical settings Validity is going to be a problem no

matter what

Adapted from slide from presentation by Shelly Magill,MD,PhD, DHQP, CDC

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New VAP Definition from CDC

Focus on a surveillance definition that is objective, streamlined, reliable, and potentially automated

Not a clinical definition but ideally has clinical credibility

Draft of ventilator-associated lower respiratory infection (VALORI) being reviewed by experts

Pilot in near future

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Future Plans @ Erlanger to Decrease VAP/ Improve Patient Outcomes

Implement chlorhexidine gluconate (CHG) mouth rinsing in TICU and NNICU

Implement CHG bathing in selected ICUs

Implement Pressure EZ cuff monitoring device for all ventilated patients

Improve assessment of re-intubation events

Increase IP Staffing

Work with frontline to improve basic IP practices

To cover new organizational and process improvement and reporting priorities

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Future Considerations

Partner with Trauma services to improve IP case finding

Partner with Radiology to develop a trigger from radiologic procedures

Partner with Respiratory Care and critical care physicians to improve routine practice for spontaneous breathing trials for all vent patients and use of non-invasive ventilation

Continue to search literature for new evidence based practices to decrease vent LOS

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Thanks!!!

Questions???