Ventilator Associated Ventilator Associated

PneumoniaPneumoniaPneumoniaPneumonia

Sylvie Larocque, RN, BSc, MScADM(c)Sylvie Larocque, RN, BSc, MScADM(c)Dynamics of Critical Care 2009Dynamics of Critical Care 2009

CACCN, Fredericton, CACCN, Fredericton, New BrunswickNew Brunswick

Disclosure Disclosure

�� Nothing to discloseNothing to disclose

Goals & ObjectivesGoals & Objectives

�� By the end of this presentation participants By the end of this presentation participants

will:will:

�� Understand how to prevent VentilatorUnderstand how to prevent Ventilator--Associated Associated

Pneumonia (VAP) by implementing the four Pneumonia (VAP) by implementing the four Pneumonia (VAP) by implementing the four Pneumonia (VAP) by implementing the four

components of care called the: “ VAP bundle”. components of care called the: “ VAP bundle”.

�� Understand how implementation of the VAP Understand how implementation of the VAP

bundle decreases the rate of VAP in ventilated bundle decreases the rate of VAP in ventilated

patients.patients.

About St. Mary’s HospitalAbout St. Mary’s Hospital

�� Hospital is situated in MontrealHospital is situated in Montreal

�� 313 beds313 beds

�� 11 Critical care beds ( 7 ICU, 4 CCU)11 Critical care beds ( 7 ICU, 4 CCU)

St. Mary’s Hospital ICUSt. Mary’s Hospital ICU

VAP: DefinitionVAP: Definition

�� “VAP( Ventilator“VAP( Ventilator--Associated Pneumonia) is Associated Pneumonia) is

defined as a pneumonia occurring in patients defined as a pneumonia occurring in patients

requiring a device intermittently or requiring a device intermittently or

continuously to assist respiration through a continuously to assist respiration through a continuously to assist respiration through a continuously to assist respiration through a

tracheostomy or endotracheal tube.”tracheostomy or endotracheal tube.”11

�� “Further, the device must have been in place “Further, the device must have been in place

within the 48 hour period before onset of within the 48 hour period before onset of

infection and for at least 2 consecutive days.”infection and for at least 2 consecutive days.”11

Why is it importantWhy is it important

�� 1010--20% of patients requiring mechanical 20% of patients requiring mechanical ventilation will develop VAP.ventilation will develop VAP.77

�� The risk is higher during the first 5 days of The risk is higher during the first 5 days of MV.MV.MV.MV.

�� 4.44.4--15.2 cases of VAP are found per 1000 15.2 cases of VAP are found per 1000 ventilator days in adult population.ventilator days in adult population.88

�� VAP is associated with 15% of all nosocomial VAP is associated with 15% of all nosocomial infections and 25% of the deaths associated infections and 25% of the deaths associated with nosocomial infections.with nosocomial infections.99

Why is it importantWhy is it important

�� ICU LOS can be ICU LOS can be ↑ by 4↑ by 4--6 days ( mean 4.3 6 days ( mean 4.3

days) and hospital LOS from 4days) and hospital LOS from 4--9 days ( up to 9 days ( up to

17 days).17 days).1010

�� Often LOS is doubled in patients who have Often LOS is doubled in patients who have �� Often LOS is doubled in patients who have Often LOS is doubled in patients who have

VAP.VAP.1010

�� Mortality rate is very high.( close to 50%)Mortality rate is very high.( close to 50%)

Diagnostic Criteria for VAPDiagnostic Criteria for VAP

�� Diagnostic Criteria as per Safer Health Care Diagnostic Criteria as per Safer Health Care

Now (SHCN)Now (SHCN)

�� New, worsening or persistent infiltrate New, worsening or persistent infiltrate

consolidation or cavitation on CXR compatible consolidation or cavitation on CXR compatible consolidation or cavitation on CXR compatible consolidation or cavitation on CXR compatible

with pneumonia and 1 of:with pneumonia and 1 of:

�� WBC WBC ≥ 12,000 or < 4, 000≥ 12,000 or < 4, 000

�� TT◦◦ > 38> 38◦◦C with no other recognized causeC with no other recognized cause

�� Altered mental status with no other cause, in > 70 year Altered mental status with no other cause, in > 70 year

old.old.

Diagnostic Criteria for VAPDiagnostic Criteria for VAP

�� At least 2 of the following:At least 2 of the following:

�� New onset of purulent sputum, or change in character of New onset of purulent sputum, or change in character of

sputum, or increase in respiratory secretions or increase in sputum, or increase in respiratory secretions or increase in

suctioning requirementssuctioning requirements

Altered mental status with no other cause, in the > 70 year Altered mental status with no other cause, in the > 70 year �� Altered mental status with no other cause, in the > 70 year Altered mental status with no other cause, in the > 70 year

old.old.

�� Inspiratory crackles or bronchial breath sounds on Inspiratory crackles or bronchial breath sounds on

auscultationauscultation

�� Worsening gas exchange ( e.g. OWorsening gas exchange ( e.g. O22 desaturation, PaO2/FiO2 desaturation, PaO2/FiO2

< 240, an increase in O2 requirements or an increase in < 240, an increase in O2 requirements or an increase in

minute ventilation).minute ventilation).

VAP CriteriaVAP Criteria

�� CXRCXR

Diagnostic CriteriaDiagnostic Criteria

Difficulties encounteredDifficulties encountered

�� VAP needs to be diagnosed according to set VAP needs to be diagnosed according to set criteria. MDs need to be aware of them.criteria. MDs need to be aware of them.

�� Since we are a small ICU we compiled data on Since we are a small ICU we compiled data on a daily basis. Larger ICUa daily basis. Larger ICU’s ’s sample a volume sample a volume a daily basis. Larger ICUa daily basis. Larger ICU’s ’s sample a volume sample a volume of ventilated patients of approximately 10%.of ventilated patients of approximately 10%.

�� Search of information: data may not be Search of information: data may not be documented ( HOB, SBT, oral tubes, EVAC)documented ( HOB, SBT, oral tubes, EVAC)

�� We therefore added the 4 components of the We therefore added the 4 components of the bundle to our documentation tools.bundle to our documentation tools.

Difficulties encounterdDifficulties encounterd

�� The more people collecting data, the more The more people collecting data, the more

inconsistencies or incomplete data.inconsistencies or incomplete data.

�� MDs in the ICU collect data for VAP diagnostic criteriaMDs in the ICU collect data for VAP diagnostic criteria

�� Assign someone to make sure data is collected daily Assign someone to make sure data is collected daily Assign someone to make sure data is collected daily Assign someone to make sure data is collected daily

including weekends.including weekends.

�� We involved a quality analyst to compile and report We involved a quality analyst to compile and report

the data to SHCN.the data to SHCN.

�� Patients with a tracheostomy only count ventilated Patients with a tracheostomy only count ventilated

days.days.

VAP case studyVAP case study

�� 62 year old man with Respiratory failure 62 year old man with Respiratory failure

secondary to neuromuscular disease and secondary to neuromuscular disease and

narrowed upper airway.narrowed upper airway.narrowed upper airway.narrowed upper airway.

�� Vocal cord paralysis after first intubationVocal cord paralysis after first intubation

�� Bilateral pneumoniaBilateral pneumonia

VAP case studyVAP case study

DateDate 1616 1717 1818 1919 2121 2222

TT◦◦ 3737 37.237.2 3939 38.538.5 38.938.9 38.638.6

WBCWBC 7.07.0 8.38.3 10.910.9 18.918.9 16.816.8

SputumSputum S/A S/A

white white

clearclear

S/A S/A

white white

clearclear

Copious Copious

amounts amounts

yellow yellow

thickthick

M/A M/A

thick thick

beigebeige

LungsLungs Crackles Crackles

at basesat bases

Diffuse Diffuse

RhonchiRhonchi

Inspir. Inspir.

WheezesWheezes

Bronchial Bronchial

breathing, breathing,

↑insp. ↑insp.

wheezeswheezes

VAP case study ABG ( Intubated)VAP case study ABG ( Intubated)

DateDate 1818 2121 2222

PHPH 7.447.44 7.467.46 7.547.54

PaOPaO22 8080 6767 150150PaOPaO22 8080 6767 150150

PCOPCO22 4040 3535 2929

HCOHCO33 2727 2525 2525

SAOSAO22 .96.96 .86.86 1.001.00

VAP case studyVAP case study

�� CXR for study caseCXR for study case

Feb 18: CXR clearFeb 18: CXR clear

Feb 19: LLL opacityFeb 19: LLL opacity

Feb 21: LLL infiltrateFeb 21: LLL infiltrate

VAP BundleVAP Bundle

SHCN has defined a “VAP bundle”, a group of SHCN has defined a “VAP bundle”, a group of

evidenceevidence--based practices that, when based practices that, when

implemented together, should result in implemented together, should result in

dramatic reductions in the incidence of dramatic reductions in the incidence of dramatic reductions in the incidence of dramatic reductions in the incidence of

VentilatorVentilator--Associated Pneumonia.”Associated Pneumonia.”22

VAP BundleVAP Bundle

�� The SHCN VAP bundle has 4 key The SHCN VAP bundle has 4 key components:components:

�� HOB between 30HOB between 30--45 45 ◦◦

�� Daily “sedation vacation” and assessment of Daily “sedation vacation” and assessment of Daily “sedation vacation” and assessment of Daily “sedation vacation” and assessment of readiness to extubate by performing a Spontaneous readiness to extubate by performing a Spontaneous breathing trial (SBT).breathing trial (SBT).

�� Use of oral versus nasal tubes for access to trachea Use of oral versus nasal tubes for access to trachea or stomachor stomach

�� Use of EVAC tubes for the drainage of subglottic Use of EVAC tubes for the drainage of subglottic secretionssecretions

HOB elevation rationaleHOB elevation rationale

�� HOB > 30HOB > 30--4545◦◦

Drakulovic et al:Drakulovic et al:22

�� Randomized controlled trial in 86 ventilated Randomized controlled trial in 86 ventilated

patients assigned to semipatients assigned to semi--recumbent or supine recumbent or supine patients assigned to semipatients assigned to semi--recumbent or supine recumbent or supine

position.position.

�� Trial demonstrated that suspected cases of VAP in Trial demonstrated that suspected cases of VAP in

supine position has an incidence of 34%, while in supine position has an incidence of 34%, while in

semisemi--recumbent position suspected cases had an recumbent position suspected cases had an

incidence of 8% (p=0.003)incidence of 8% (p=0.003)

HOB elevation rationaleHOB elevation rationale

�� HOBHOB

�� Other benefits: Other benefits:

�� Minimize atelectasisMinimize atelectasis

�� Improve overall patientImprove overall patient’s ventilation’s ventilation�� Improve overall patientImprove overall patient’s ventilation’s ventilation

HOB elevation implementationHOB elevation implementation

�� At St. Mary’s Hospital: (SMHC)At St. Mary’s Hospital: (SMHC)

�� HOB documentation is included in the ICU flow HOB documentation is included in the ICU flow sheet and RT flow sheet. (Q1H)sheet and RT flow sheet. (Q1H)

�� We used measuring device on the electric bedsWe used measuring device on the electric beds

�� Posters at bedside to encourage all staff, family Posters at bedside to encourage all staff, family members to maintain HOB elevatedmembers to maintain HOB elevated

�� InIn--service done with staff May 2007. Reinforced service done with staff May 2007. Reinforced thereafter.thereafter.

�� Communication: Compliance rate with HOB Communication: Compliance rate with HOB posted in unit Q month.posted in unit Q month.

Sedation Vacation/SBT trial Sedation Vacation/SBT trial

rationalerationale

�� Daily sedation vacation and assessment of Daily sedation vacation and assessment of

readiness to extubate by performing SBT:readiness to extubate by performing SBT:

�� Kress et al;Kress et al;33

Conducted a randomized controlled trial in 128 Conducted a randomized controlled trial in 128 �� Conducted a randomized controlled trial in 128 Conducted a randomized controlled trial in 128

adults patients ventilated, randomized to daily adults patients ventilated, randomized to daily

interruption of sedation irrespective of clinical interruption of sedation irrespective of clinical

state or interruption at the clinician’s discretionstate or interruption at the clinician’s discretion

Sedation Vacation/SBT trial Sedation Vacation/SBT trial

rationalerationale

�� SBTSBT

�� Daily interruption resulted in a marked and highly Daily interruption resulted in a marked and highly

significant reduction in time on mechanical significant reduction in time on mechanical

ventilation. ventilation. ventilation. ventilation.

�� Duration of MV Duration of MV ↓ from 7.3 days to 4.9 days ↓ from 7.3 days to 4.9 days

( p=0.004)( p=0.004)

Sedation Vacation/SBT trial Sedation Vacation/SBT trial

rationalerationale

�� SBTSBT

�� Risk of sedation vacation: Risk of sedation vacation:

�� selfself--extubationextubation

�� Pain & anxiety associated with lightening Pain & anxiety associated with lightening �� Pain & anxiety associated with lightening Pain & anxiety associated with lightening

sedationsedation

SBT implementationSBT implementation

�� At St. Mary’s Hospital:At St. Mary’s Hospital:

�� Standardized the performance of SBTs with Standardized the performance of SBTs with

ventilated patients. Done by RT before ventilated patients. Done by RT before

09:00a.m. if patient not too sick09:00a.m. if patient not too sick09:00a.m. if patient not too sick09:00a.m. if patient not too sick

�� Results shared at medical roundsResults shared at medical rounds

�� Use of Ramsay score to avoid overUse of Ramsay score to avoid over--sedationsedation

�� SBT compliance posted monthly on bulletin SBT compliance posted monthly on bulletin

board.board.

Orogastric tubes rationaleOrogastric tubes rationale

�� Use of oral versus nasal tubes for trachea or stomach Use of oral versus nasal tubes for trachea or stomach

accessaccess

�� Rationale: Reduces the frequency of nosocomial Rationale: Reduces the frequency of nosocomial

sinusitis and possibly VAPsinusitis and possibly VAPsinusitis and possibly VAPsinusitis and possibly VAP

�� Holzapfel LHolzapfel L44 and colleagues randomized 300 patients and colleagues randomized 300 patients

between nasal and oral endotracheal intubation.between nasal and oral endotracheal intubation.

�� Sinusitis was observed in 78 patients. (45 from nasal group Sinusitis was observed in 78 patients. (45 from nasal group

and 33 from oral group.)and 33 from oral group.)

�� Nosocomial pneumonia was observed in 26 patients. 17 in Nosocomial pneumonia was observed in 26 patients. 17 in

the nasal group and 9 in the oral groupthe nasal group and 9 in the oral group

Oral tubes ImplementationOral tubes Implementation

�� At St.Mary’s:At St.Mary’s:

�� We insert oral tubes for all patients mechanically We insert oral tubes for all patients mechanically

ventilated in the ICUventilated in the ICU

�� We asked ER and OR to adopt our policy when We asked ER and OR to adopt our policy when �� We asked ER and OR to adopt our policy when We asked ER and OR to adopt our policy when

possible. possible.

�� Some exceptions have been made with OR patients.Some exceptions have been made with OR patients.

�� If the tube is not in right place we change it.If the tube is not in right place we change it.

�� Nutritionist are on boardNutritionist are on board

�� Communication: Results posted on bulletin boardCommunication: Results posted on bulletin board

EVAC rationaleEVAC rationale

�� EVAC tubes.EVAC tubes.

�� The accumulation of contaminated oropharyngeal The accumulation of contaminated oropharyngeal secretions above the endotracheal tube cuff is a secretions above the endotracheal tube cuff is a risk of aspiration.risk of aspiration.

If the subglottic region is suctioned to remove If the subglottic region is suctioned to remove �� If the subglottic region is suctioned to remove If the subglottic region is suctioned to remove these secretions this may reduce the risk of these secretions this may reduce the risk of aspiration and VAPaspiration and VAP

�� EVAC tubes allow subglottic aspiration . It EVAC tubes allow subglottic aspiration . It contains a separate lumen that opens into the contains a separate lumen that opens into the subglottic region.subglottic region.

EVAC tubesEVAC tubes

�� A recent metaA recent meta--analysisanalysis55 of 5 studies including a total of 5 studies including a total

of 896 patients showed that subglottic secretion of 896 patients showed that subglottic secretion

drainage reduced the incidence of VAP by nearly half drainage reduced the incidence of VAP by nearly half

by reducing early onset pneumoniaby reducing early onset pneumonia

�� Cost differance:Cost differance:

�� EVAC 7.74$ EVAC 7.74$ ±± eacheach

�� Regular tube: 1.96$ Regular tube: 1.96$ ±± eacheach

�� Available in all sizesAvailable in all sizes

�� 0.8 mm larger in outer diameter.0.8 mm larger in outer diameter.

EVAC tubeEVAC tube

�� EVAC tube implementationEVAC tube implementation

�� Purchased in May 2007.Purchased in May 2007.

�� Installed on all crash cart in ICU, CCU, ERInstalled on all crash cart in ICU, CCU, ER

�� Instructed OR that for all expected cases to go to Instructed OR that for all expected cases to go to �� Instructed OR that for all expected cases to go to Instructed OR that for all expected cases to go to

the ICU an EVAC tube must be usedthe ICU an EVAC tube must be used

�� Education program done for staff in May 2007Education program done for staff in May 2007

�� Communication: Compliance rate with EVAC Communication: Compliance rate with EVAC

tubes posted in ICU bulletin board monthly.tubes posted in ICU bulletin board monthly.

OtherOther

�� Oral decontaminationOral decontamination

�� SMHC purchased the oral decontamination kit in SMHC purchased the oral decontamination kit in

January 2008.January 2008.

�� Staff inStaff in--services done in February 2008.services done in February 2008.�� Staff inStaff in--services done in February 2008.services done in February 2008.

�� New implementation protocol for use of oral New implementation protocol for use of oral

decontamination prodoucts to be established in decontamination prodoucts to be established in

October 2009 to standardize practice.October 2009 to standardize practice.

Where to startWhere to start

�� First Form a teamFirst Form a team

�� Our team is composed of:Our team is composed of:�� Head NurseHead Nurse

�� MD ICU DirectorMD ICU Director

�� Clinical Nurse EducatorClinical Nurse EducatorClinical Nurse EducatorClinical Nurse Educator

�� ICU nursesICU nurses

�� Respiratory TherapistRespiratory Therapist

�� NutritionistNutritionist

�� PharmacistPharmacist

�� QA analyistQA analyist

�� OT/PTOT/PT

�� Infection Control NurseInfection Control Nurse

Assess where you stand presently.Assess where you stand presently.

�� In May 2006 In May 2006

�� Pilot study of 56 patients was observed over 10 Pilot study of 56 patients was observed over 10

days by nursing students.days by nursing students.

�� 36/56 patients were intubated36/56 patients were intubated�� 36/56 patients were intubated36/56 patients were intubated

�� Compliance ResultsCompliance Results

�� HOBHOB> 30> 30◦◦: 64 %: 64 %

�� SBT: 30% SBT: 30%

�� OroOro--gastric intubation: 5%gastric intubation: 5%

�� EVAC: 0%EVAC: 0%

Set a GoalSet a Goal

As per SHCNAs per SHCN

First set your VAP rate:First set your VAP rate:

Total # VAP cases Total # VAP cases x 1000 = VAP ratex 1000 = VAP rate

# ventilation days # ventilation days

VAP rate what it meansVAP rate what it means

�� Represents the total number of cases of VAP Represents the total number of cases of VAP for a particular time period.for a particular time period.

�� Needs to take into consideration the total Needs to take into consideration the total number of days that patients are on a ventilatornumber of days that patients are on a ventilatornumber of days that patients are on a ventilatornumber of days that patients are on a ventilator

�� Example:Example:

�� 7 cases of VAP for June7 cases of VAP for June

�� Total Mechanically ventilation days for each Total Mechanically ventilation days for each patient total 168patient total 168

�� 7/168 x 1000 =41.67/168 x 1000 =41.6

SMHC VAP rateSMHC VAP rate

�� We calculated our VAP rate for a 3 month We calculated our VAP rate for a 3 month

period in 2007 ( per 1000 ventilation days)period in 2007 ( per 1000 ventilation days)

�� February 2007 VAP=10.42% February 2007 VAP=10.42%

�� March 2007 VAP = 29.4%March 2007 VAP = 29.4%�� March 2007 VAP = 29.4%March 2007 VAP = 29.4%

�� April 2007 VAP = 17.9 %April 2007 VAP = 17.9 %

Average for 3 month VAP rate = 19 Average for 3 month VAP rate = 19

Aim set at 50% reduction = VAP rate Aim set at 50% reduction = VAP rate ↓ to 9.5↓ to 9.5

Difficulties encounteredDifficulties encountered

�� We could not do a retrospective study to We could not do a retrospective study to

evaluated the number of VAPs due to Medico evaluated the number of VAPs due to Medico

system.system.

�� We decided to take a 3 month sample in a We decided to take a 3 month sample in a �� We decided to take a 3 month sample in a We decided to take a 3 month sample in a

year.year.

�� Our goal was then set from this sample.Our goal was then set from this sample.

Set a GoalSet a Goal

As per SHCN!As per SHCN!

�� Second set your VAP bundle compliance Second set your VAP bundle compliance

# receiving ALL 4 components of VAP bundle= # receiving ALL 4 components of VAP bundle= Bundle complianceBundle compliance# receiving ALL 4 components of VAP bundle= # receiving ALL 4 components of VAP bundle= Bundle complianceBundle compliance

# on ventilators for the day of the sample# on ventilators for the day of the sample

Target for SHCN is 95%Target for SHCN is 95%

VAP Bundle ComplianceVAP Bundle Compliance

what it meanswhat it means

�� On a given day, select all ventilated patients On a given day, select all ventilated patients

and assess them for compliance with the VAP and assess them for compliance with the VAP

bundlebundle

�� HOB > 30HOB > 30◦◦�� HOB > 30HOB > 30◦◦

�� EVAC tubesEVAC tubes

�� Orogastric tubesOrogastric tubes

�� SBT/Sedation vacationSBT/Sedation vacation

Difficulties encounterdDifficulties encounterd

�� If you do not have compliance with one element of If you do not have compliance with one element of the bundle for example SBT then your overall the bundle for example SBT then your overall compliance will be affected.compliance will be affected.

�� You can not choose to implement only one You can not choose to implement only one component of the bundle but you must implement all component of the bundle but you must implement all component of the bundle but you must implement all component of the bundle but you must implement all 4 to be compliant and effective to 4 to be compliant and effective to ↓ overall VAP rate.↓ overall VAP rate.

�� Surgical patients: for surgical reasons gastric tubes Surgical patients: for surgical reasons gastric tubes may not be able to be inserted in the mouth.may not be able to be inserted in the mouth.

�� EVAC tubes: Not all patients admitted from OR have EVAC tubes: Not all patients admitted from OR have the EVAC tubethe EVAC tube-- unexpected crashing patient.unexpected crashing patient.

Difficulties encounteredDifficulties encountered

�� Transfers from ER may not comply with EVAC or Transfers from ER may not comply with EVAC or orogastric tubes.orogastric tubes.

�� Risk or discomfort caused to patients if EVAC tubes Risk or discomfort caused to patients if EVAC tubes or nasogastric tubes have to be changed.or nasogastric tubes have to be changed.

EVAC tracheostomy tubes were not purchased and EVAC tracheostomy tubes were not purchased and �� EVAC tracheostomy tubes were not purchased and EVAC tracheostomy tubes were not purchased and available then.available then.

� There was some reluctance of doctors to do SBT due to severity of patient illness but we are now allowed to say patients are too sick to try SBT and still count as compliant with the bundle.

Difficulties encounteredDifficulties encountered

�� Difficulty in benchmarking amongst Difficulty in benchmarking amongst

institutions. If there is good medical reason institutions. If there is good medical reason

why not to do part /all of the bundle the patient why not to do part /all of the bundle the patient

is considered compliant as per SHCN criteria. is considered compliant as per SHCN criteria. is considered compliant as per SHCN criteria. is considered compliant as per SHCN criteria.

VAP rate resultsVAP rate results

Our target 9.5 ( 50% reduction)Our target 9.5 ( 50% reduction)

YearYear February, March, February, March,

April April

20072007

April 1April 1--

March 31, March 31,

20072007--88

April 1April 1--

March 31 March 31

20082008--9920072007 20072007--88 20082008--99

VAP RateVAP Rate 1919 1212 8.78.7

VAP rate resultsVAP rate results

12

14

16

18

20

0

2

4

6

8

10

12

2007 2007-8 2008-9

VAP rate

Results Bundle ComplianceResults Bundle Compliance

Bundle Bundle

componentcomponent

2006 Pilot2006 Pilot 20072007--88 20082008--99

HOB > 30HOB > 30◦◦ 64%64% 95.8%95.8% 98.8%98.8%

SBTSBT 30%30% 61.1%61.1% 95.3%95.3%SBTSBT 30%30% 61.1%61.1% 95.3%95.3%

EVACEVAC 0%0% 80.7%80.7% 99%99%

Orogastric Orogastric

tubestubes

5%5% 91.1%91.1% 98.3%98.3%

OverallOverall 51%51% 94%94%

Bundle ComplianceBundle Compliance

60

70

80

90

100

HOB

0

10

20

30

40

50

60

2006

Pilot

2007-8 2008-9

HOB

SBT

EVAC

Oral tubes

AccomplishmentsAccomplishments

�� Over the last 6 months we have had 100% Over the last 6 months we have had 100%

compliance with the 4 components of the compliance with the 4 components of the

Bundle compliance.Bundle compliance.

�� We have managed to decrease our VAP rate by We have managed to decrease our VAP rate by �� We have managed to decrease our VAP rate by We have managed to decrease our VAP rate by

50%50%

�� Decrease overall mortality and LOSDecrease overall mortality and LOS

Accomplishments / Future Goals Accomplishments / Future Goals

�� Project adopted for life!Project adopted for life!

�� After 6 months of compliance reached for bundle After 6 months of compliance reached for bundle compliance and VAP rate aim reached, SHCN only compliance and VAP rate aim reached, SHCN only ask that we do spot check 4 times a year but we ask that we do spot check 4 times a year but we continue daily data collection.continue daily data collection.continue daily data collection.continue daily data collection.

�� Documentation tool changed to integrate bundle Documentation tool changed to integrate bundle compliance elements to facilitate data collection ( RT compliance elements to facilitate data collection ( RT sheets)sheets)

�� Integrated in daily routine (MD do data collection on Integrated in daily routine (MD do data collection on rounds)rounds)

Accomplishments / Future GoalsAccomplishments / Future Goals

�� Oral decontamination incorporated with VAP Oral decontamination incorporated with VAP

protocol .protocol .

�� Hand Hygiene reinforced.Hand Hygiene reinforced.

�� Other SHCN initiatives in process:Other SHCN initiatives in process:�� Central line infectionCentral line infection

�� Sepsis bundle.Sepsis bundle.

�� Acute MIAcute MI

Thank youThank you

Questions?Questions?

References:References:

��11Safer Healthcare Now! Campaign, How Safer Healthcare Now! Campaign, How ––to guide: to guide: Prevention VentilationPrevention Ventilation--Associated Pneumonia. May Associated Pneumonia. May 2007 p12007 p1--40.40.

��22Drakulovic et al. Supine body position as a risk Drakulovic et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically factor for nosocomial pneumonia in mechanically factor for nosocomial pneumonia in mechanically factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 1999; ventilated patients: a randomized trial. Lancet 1999; 354 (9193): 1851354 (9193): 1851--1858.1858.

��33Kress et al. Daily interruption of sedative infusions Kress et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine 2000; ventilation. New England Journal of Medicine 2000; 342 (20): 1471342 (20): 1471--14771477

ReferencesReferences

��33Kress and al. The longKress and al. The long--term psychological effects of term psychological effects of

daily sedative interruption on critically ill patients. daily sedative interruption on critically ill patients.

American Journal Respiratory Critical Care American Journal Respiratory Critical Care

Medicine. 2003 Dec 15, 168(12): 1457Medicine. 2003 Dec 15, 168(12): 1457--1461.1461.

��44HolzapfelL and al. A randomized study assessing HolzapfelL and al. A randomized study assessing

the systematic search for maxillary sinusitis in the systematic search for maxillary sinusitis in

nasotracheally mecahnically ventilated patients. nasotracheally mecahnically ventilated patients.

Influence of nosocomial maxillary sinusitis on the Influence of nosocomial maxillary sinusitis on the

occurance of ventilator associated pneumonia. Am J occurance of ventilator associated pneumonia. Am J

Respir Crit Care Med 1999; 159:695Respir Crit Care Med 1999; 159:695--701.701.

ReferencesReferences

��55Dezfulian and al. Subglottic secretion Dezfulian and al. Subglottic secretion

drainage for preventing ventilatordrainage for preventing ventilator--associated associated

pneumonia: a metapneumonia: a meta--analysis. The American analysis. The American

Journal of Medicine 2005; 118: 11Journal of Medicine 2005; 118: 11--18. 18. Journal of Medicine 2005; 118: 11Journal of Medicine 2005; 118: 11--18. 18.

��77SafdarN and al. The pathogenesis of SafdarN and al. The pathogenesis of

ventilatorventilator--associated pneumonia; its relevance associated pneumonia; its relevance

to developing effective strategies for to developing effective strategies for

prevention. Respir Care 2005;50; 725prevention. Respir Care 2005;50; 725--3939

ReferencesReferences

��88National Nosocomial Infections Surveillance National Nosocomial Infections Surveillance

(NNIS). National Nosocomial Infection (NNIS). National Nosocomial Infection

Surveillance (NNIS) System Report,data Surveillance (NNIS) System Report,data

summary from January 1992 through June summary from January 1992 through June summary from January 1992 through June summary from January 1992 through June

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