ventilator associated pneumonia 1

8/7/2019 Ventilator Associated Pneumonia 1

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Ventilator AssociatedVentilator Associated

Pneumonia PreventionPneumonia Prevention

ProgramProgram

Our current and changing practiceOur current and changing practice



Lets make a differenceLets make a difference

Our goal is to reach out to all health careOur goal is to reach out to all health careprofessionals who have direct patient contact.professionals who have direct patient contact.

With a little education and monthly infectionWith a little education and monthly infectioncontrol rates (which will be provided via econtrol rates (which will be provided via e--mail)mail)we can keep track of our current practice andwe can keep track of our current practice andevaluate its effectiveness in minimizing our evaluate its effectiveness in minimizing our

monthly VAP rates.monthly VAP rates.



What is Ventilator associatedWhat is Ventilator associated

pneumonia ?pneumonia ?VAP is a nosocomial pneumonia thatVAP is a nosocomial pneumonia that

develops from patients on mechanicaldevelops from patients on mechanical

ventilatory support for over and equal toventilatory support for over and equal to

48hrs.48hrs.

At Sick Kids the most common way that At Sick Kids the most common way that

we diagnose VAP is by a modified BALwe diagnose VAP is by a modified BAL



Why it matters:Why it matters:

Did you know thatDid you know that Sick kids average infection rate isSick kids average infection rate is3.5 cases per month.3.5 cases per month.

In adults VAP is the leading cause of death amongIn adults VAP is the leading cause of death amonghospital acquired infections. The average mortalityhospital acquired infections. The average mortalityrate is 30% and it·s very expensive due to therate is 30% and it·s very expensive due to the

increase length of stay (app. 13 days) costing anincrease length of stay (app. 13 days) costing anestimated $40,000 per case.estimated $40,000 per case.

A critically ill pt. who develops VAP is said to be twiceA critically ill pt. who develops VAP is said to be twiceas likely to pass away than one without pneumonia. Theas likely to pass away than one without pneumonia. Therisk increases 6.5% if ventilated for over 10 days andrisk increases 6.5% if ventilated for over 10 days and

28% if ventilated for over 30 days28% if ventilated for over 30 days



Simple, Cost effective approachSimple, Cost effective approach

EFFECTIVEEFFECTIVE hand washing and use of PPE.hand washing and use of PPE.Simple, but underused.Simple, but underused.

The infection control team performedThe infection control team performedmonthly hand hygiene audits in the unit.monthly hand hygiene audits in the unit.

Data is based on number of times handData is based on number of times handhygiene was observed vs. the opportunity for hygiene was observed vs. the opportunity for hand hygiene. The average for CCU RN¶shand hygiene. The average for CCU RN¶swas a 54% compliance rate. HSC MD¶s hadwas a 54% compliance rate. HSC MD¶s hada 42% compliance rate and all other healtha 42% compliance rate and all other health

care workers had a 58% compliance rate.care workers had a 58% compliance rate.(Not that great!)(Not that great!)

Suggestion: Put bins for masks and gloves atSuggestion: Put bins for masks and gloves ateach bed spot, as well as hooks to hang faceeach bed spot, as well as hooks to hang faceshields.shields.



ALL patients except for our cardiac population ALL patients except for our cardiac population

with open sternums, should be placed in thewith open sternums, should be placed in thesemisemi--recumbent position to avoid the risk of recumbent position to avoid the risk of

aspiration of upper airway secretions. I.E./aspiration of upper airway secretions. I.E./ HeadHead

of bed elevated 45 degreesof bed elevated 45 degrees



Use restraints and keep endotracheal tubes as secure asUse restraints and keep endotracheal tubes as secure aspossible.possible. This is very important considering our number of This is very important considering our number of accidental extubations in the past year (61 accidentalaccidental extubations in the past year (61 accidentalextubations)extubations)

For cuffed ETTs use minimal occlusive volumes toFor cuffed ETTs use minimal occlusive volumes toeliminate the potential of aspiration. Avoid gastriceliminate the potential of aspiration. Avoid gastricoverdistension for the same reason.overdistension for the same reason.

Extubate as soon as clinically feasible because the ETTExtubate as soon as clinically feasible because the ETTpromotes growth and proliferation of bacteria in thepromotes growth and proliferation of bacteria in thebronchial treebronchial tree



Remove condensate from ventilator Remove condensate from ventilator

circuits and monitor the circuits positioncircuits and monitor the circuits position

because studies show high amounts of because studies show high amounts of

pathogenic bacteria in this fluid which canpathogenic bacteria in this fluid which can

cause pneumonia if aspirated.cause pneumonia if aspirated.



Eliminate and/or decrease the unnecessary usage of Eliminate and/or decrease the unnecessary usage of

antibiotics to prevent antibioticantibiotics to prevent antibiotic--resistant nosocomialresistant nosocomial

infections.infections.

Routine prophylactic antibiotic therapy should be givenRoutine prophylactic antibiotic therapy should be givento ventilated pt¶s that have neutropenic fevers untilto ventilated pt¶s that have neutropenic fevers until

neutrophil recovery occurs. This will decrease febrileneutrophil recovery occurs. This will decrease febrile

periods and reduce the risk of infectionperiods and reduce the risk of infection related eventsrelated events



Promote proper oral hygiene. Use pinkPromote proper oral hygiene. Use pink

dental swabs and moisten them with water dental swabs and moisten them with water

and/or sterisol oral rinse to control dentaland/or sterisol oral rinse to control dental

plaque bacteria. Use chlorhexidine for plaque bacteria. Use chlorhexidine for

immunocomprimised pt¶s. Avoid overusageimmunocomprimised pt¶s. Avoid overusage

to prevent chlorhexidineto prevent chlorhexidine--resistantresistantpathogens.pathogens.



Costly options that may be lookedCostly options that may be looked

into:into: Inline VS open suction catheters. (Does notInline VS open suction catheters. (Does notprevent nosocomial pneumonia¶s but is moreprevent nosocomial pneumonia¶s but is morecost effective with less environmental crosscost effective with less environmental crosscontamination)contamination)

Purchasing HiPurchasing Hi--Lo Evac Tubes for our older kidsLo Evac Tubes for our older kidswith cuffed ETTs. (Has a dorsal lumen attachedwith cuffed ETTs. (Has a dorsal lumen attachedto the subglottic region which aspirates pooledto the subglottic region which aspirates pooledsecretions.)secretions.)

Give pneumococcal and Influenza vaccinationsGive pneumococcal and Influenza vaccinationsprior to discharge for patient¶s at risk of prior to discharge for patient¶s at risk of reoccurring resp. infections including VAP.reoccurring resp. infections including VAP.



SUMMARYSUMMARY

Wash handsWash hands

Elevate the head of bed 45 degreesElevate the head of bed 45 degrees

Keep ETT¶s secureKeep ETT¶s secure Prevent gastric overdistensionPrevent gastric overdistension

Remove condensate from ventilator Remove condensate from ventilator circuitscircuits

Decrease unnecessary antibiotic usageDecrease unnecessary antibiotic usage

Practice proper oral hygienePractice proper oral hygiene



Monthly TableMonthly Table

Number Rate

September October September October

Admissions 120 151

Total Infections 12 8 10.00 5.3

Infected patients 8 8 6.67 5.30

BSI - Other 0 1 0 0.7

BSI - CVL 2 1 2.91/1000 CVL

days

1.49/1000 CVL

days

Gastro 0 0 0 0

VAP 4 4 5.29/1000 Vent days 5.15/1000 Vent days

Lets use this evidence based practice in our unit to see if Lets use this evidence based practice in our unit to see if

we can reduce ventilator associated pneumonia rates bywe can reduce ventilator associated pneumonia rates by

next month.next month.



ReferencesReferencesVan Saene H.K.F., Baines P.B., Kollef M.H. (1999). TheVan Saene H.K.F., Baines P.B., Kollef M.H. (1999). The

prevention of Ventilator prevention of Ventilator--Associated Pneumonia N Engl J Associated Pneumonia N Engl JMed 341: 293Med 341: 293--294294

Wray, R. (2004Wray, R. (2004--2005). Infection Control Rates from the2005). Infection Control Rates from theCCU Infection Control Committee Minutes. The HospitalCCU Infection Control Committee Minutes. The Hospital

for Sick Childrenfor Sick Children

Kovach, D. (2004Kovach, D. (2004--2005) Hand Hygiene Audits performed2005) Hand Hygiene Audits performedat the Hospital for Sick Childrenat the Hospital for Sick Children

Pictures:Pictures:www.nursingassistanteducation.comwww.nursingassistanteducation.com

www.chimed.it/ettube.htmwww.chimed.it/ettube.htm

www.sher.co.uk/_antibiotics/www.sher.co.uk/_antibiotics/

www.cancerhelp.org.ukwww.cancerhelp.org.uk

www.amershamhealth.comwww.amershamhealth.com

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