VENTILATOR ASSOCIATED PNEUMONIA (VAP)

WHAT IS VAP?“ Ventilator-associated pneumonia (VAP) is pneumonia inmechanically ventilated patients that develops later than orat 48 h after the patient has been placed on mechanicalVentilation”

(Foglia, 2007)

RISK FACTORS FOR VAP IN CHILDREN

o Mechanical ventilation > 48 hourso Underlying respiratory diseaseo Genetic syndromeso Immunodeficiencyo Continuous enteral feedingso Transport out of the pediatric intensive care unito Previous use of antibioticso Bloodstream infectionso Gastroesophageal refluxo Altered level of consciousness or comao Use of H2 antagonists, immunosuppressants, neuromuscular blocking agents, narcotics

(Bonsal, 2013)

ISSUES RELATED TO VAP

• VAP is the 2nd most common hospital acquired infection (HAI) in the pediatric and neonatal intensive care units; 18% to 26% of all HAI’s in a pediatric intensive care unit (PICU) are caused by VAP

• VAP results in high morbidity and mortality, increased hospital stay, and high health care costs• Mortality rate is 10% to 20% in the PICU and overall for patients of all ages 33% to 50% • VAP increases length of stay up to 22 days• Costs for patients with VAP are greater than $40,000 per patient per infection• In the PICU, 20% of nosocomial infections are VAP, with an incidence of 4 to 44 per 1000 intubated

children• The mean PICU VAP rate is 2.9 per 1000 ventilator days

(Bonsal, 2013; Eom, 2014; Foglia, 2007)

COMPARISON OF SELECTED POLICIESIssue St Cloud Hospital Minneapolis Children’s

HospitalNational Guideline Clearinghouse

Deep vein thrombosis prophylaxis None Patients over 13 yrs old In policy – age not specified

Drain condensate from ventilator circuit Current policy doesn’t have frequency stated

Policy is every 2-4 hrs and with repositioning

None

Change in-line suction catheter Change 14 French every 72 hrs, other sizes every 24 hrs.

Change only when visibly soiled None

Bed therapy None None Kinetic bed therapy

Daily assessments of readiness to extubate

None Yes Yes

Cuff pressure Maintain pressure at 25-35 mmHg None Maintain cuff pressure at 20-25 mmHg

Oral Care Oral care every 2-4 hrs Oral care at least every 2 hrs Oral care 4 times a day with a 2% Chlorhexidine solution

Continuous aspiration None None Continuous aspiration with an ET tube with a dorsal lumen

(Children’s Hospital and Clinics of Minnesota, 2011; National Guideline Clearinghouse, 2012; Saint Cloud Hospital, 2012.)

RECOMMENDATIONSo Create an order bundle set for patients on a mechanical ventilatoro Create a checklist/bedside flow sheet for increased complianceo Compliance audits weekly on intubated patients to ensure VAP bundle implementationo Patient evaluations daily for compliance of the following:

Head of bed elevation is checked every 4 hours Peptic ulcer prophylaxis medication given daily Deep vein thrombosis prophylaxis provided daily Oral care provided with chlorhexidine solution every 12 hours

o Provide education modules for staff education and awareness

RECOMMENDATIONS:PROPOSED ORDER BUNDLE SET (ORAL CARE)

o Oral care consisting of the following: Assess oral cavity and lips every 6-8 hours as needed for

hydration, infection, pressure points, etc.

Every 12 hours brush teeth with small, soft toothbrush and fluoride toothpaste; suction out toothpaste, but do not rinse out mouth

After brushing teeth rinse mouth with chlorhexidine solution; irrigate with syringe or wipe mucosa with swab; suction excess, but do not rinse out mouth with water

Every 2 hours moisten mouth with swabs soaked in clean water or physiological saline

Every 2 hours and as needed, coat lips with lip balm or petroleum jelly

RECOMMENDATIONS:PROPOSED ORDER BUNDLE SET

Head of bed elevated approximately, equal to or greater than 30 degrees unless currently contraindicated

Perform hand hygiene before and after contact with the patient or ventilator

Drain condensation every 2-4 hours and before repositioning patient

Evaluate need for Kinetic bed therapy Maintain cuff pressure 20-25 mmHg Circuit changes: no routine changes, only when visibly

soiled or malfunctioning Heated humidifiers: no routine changes, only when visibly

soiled or malfunctioning Assess patient for daily sedation reduction Assess for eligibility of daily weaning trials Suction only when clinically indicated

Use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow continuous suction of tracheal secretions in the subglottic area in children > 12

Store oral suction devices in a non sealed plastic bag when not in use

Monitor gastric residuals every 4 hours to prevent aspiration

Change in-line endotracheal suction catheters only when visibly soiled

Deep vein thrombosis prophylaxis Pharmacological Mechanical

Stress ulcer prophylaxis Sucralfate H2 antagonist Proton pump inhibitor

POTENTIAL BENEFITS OF BUNDLE IMPLEMENTATION

o Elimination of VAP in the PICUo Decreased mortalityo Decreased length of hospital stayo Decreased hospital costso Improved patient outcomes

(Bonsal, 2013)

REFERENCESBonsal, V., & Haut, C. (2013). Preventing ventilator-associated pneumonia in children: an evidence-based protocol.

Critical Care Nurse, 33(3), 21-29. http://dx.doi.org/10.4037/ccn2013204Children’s Hospitals and Clinics of Minnesota. (2011). Mechanical ventilation: general assessment, care and documentation 401.00. Eom, J., Lee, M., Chun, H., Choi, H., Jung, S., Kim, Y.,… Lee, J. (2014). The impact of a ventilator bundle on preventing

ventilator-associated pneumonia: a multicenter study. American Journal of Infection Control, 42, 34-37. Foglia, E., Meier, D., & Elward, A. (2007). Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clinical Microbiology Reviews, 20(3), 409-425. doi: 10.11258/CMR.00041-06How-to-guide pediatric supplement: ventilator associated pneumonia [PDF document]. Retrieved from http://www.nichq.org/pdf/VAP.pdfInstitute for Clinical Systems Improvement. (2014). Pneumonia, ventilator-associated, prevention of. Retrieved from

http://www.icsi.org/guidelines_more/catalog_guidelines/catalog_respiratory_guidelines/vap/ Saint Cloud Hospital. (2012). Standards of care: mechanical ventilation, PICU, PPCU.(2012). Prevention of ventilator-associated pneumonia. Health care protocol. Retrieved from http://www.guideline.gov/content.aspx?id=36063