Prevention of Ventilator Associated Pneumonia (VAP) Cindy Lang, RN, BSN, CIC

Senior Infection Control Specialist VA Medical Center, West Palm Beach

DeeP Vein Thrombosis (DVT) ProPhylAxis

Higher incidence of DVT in critical illness•Risk of venous thromboembolism is reduced if prophylaxis is •consistently appliedTARGET: patients undergoing surgery, trauma patients, acutely •ill medical patients, and ICU patientsIt is unclear if there is any association between DVT prophylaxis •and decreasing rates of VAP.Experience shows that when DVT prophylaxis is applied as •part of a package of interventions for ventilator care, the rate of pneumonia decreases precipitously.

DVT ProPhylAxis – risk of bleeDing

Important considerations include that the risk of bleeding •may increase if anticoagulants are used to accomplish the prophylaxis.Often, sequential compression devices •(ie. SCDs, “venodynes” or “pneumoboots”) are not applied to •patients when they go to or return from procedures.

meAsUremenTVAP Rate: The total number of cases of ventilator-associated •pneumoniaforaspecifiedtimeperiod:(Total no. of VAP cases / Ventilator Days) x 1000 = VAP Rate•Ventilator Bundle Compliance: On a given day, the assessment •of all vent patients for compliance with the ventilator bundle:No. receiving ALL components of vent bundle = reliability of•No. on vents for the day of the sample bundle compliance•

bArriers ThAT mAy be encoUnTereD

Fear of Change•Communication Breakdown•Physician and staff “partial buy-in”•(“Justanotherflavoroftheweek?”)•Unplanned extubations (most risky aspect)•

besT PrAcTices To AchieVe A high leVel of comPliAnce AT WPb VAmc icU

Daily Multi-disciplinary Rounds including:•Intensivist / Providers / Residents / Medical students•Lead Unit Facilitator•RN assigned to patient•

Clinical Pharmacist / Pharmacy Residents•Infection Control Specialist•Respiratory Therapist•Registered Dietician•Nurse Case Manager•Quality Management / Utilization Management Specialist•Speech Therapist•Nursing student / Instructor•Use of Ventilator Bundle Audit Tool addressing the bundle items •daily

iPec DATA mAnAgemenT WebsiTeVISN 08 - Station 548 (West Palm Beach, FL) - •FY XXXX - Quarter Unit: Mixed ICU - Month-Year•Count Rate% •VAP audits completed •HOB elevated > 30 degrees •SUD prophylaxis •DVT prophylaxis •Daily sedation vacation •Daily readiness to wean •Daily spontaneous breathing trial •

hAnD hygieneThe best method to prevent healthcare acquired infections •including VAP is to practice good Hand Hygiene including use of :

Antimicrobial soap and water * Alcohol Based Hand Rub when there is no visible soiling on * hands

comPliAnce WiTh isolATion PrecAUTions

Stringent adherence to the use of Personal Protective •Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patientswhenpatientsareidentifiedasrequiringContactandDroplet Precaution

objecTiVesList four key components of the Institute for Healthcare •Improvement (IHI) Ventilator Bundle Describe three signs and symptoms of pneumonia •Explain four procedures used to reduce the risk of VAP in •patientsIdentify two key points for proper ventilator care to reduce •VAP risk

VenTilATor AssociATeD PneUmoniA (VAP)

VAP is the leading cause of nosocomial infection in the ICU •andreflects60%ofalldeathsattributabletonosocomialinfections. Pneumonia rates are much higher in mechanically ventilated •patientsduetotheartificialairway,whichincreasestheopportunity for aspiration and colonization.

TimelineIHI announces Saving 100,000 Lives campaign in December •2004 including practices to reduce VAP and CR-BSIVA agrees to participate based on interest of VISNS and •individual sitesVISNDirectorsagreetoimplement3ofthe6practices5/2005•Kick-offcallforReductionofVAP1/2006byIPEC•Development of web based database•

insTiTUTe for heAlThcAre imProVemenT (ihi) 100,000 liVes sAVeD cAmPAign

Six Clinical Evidence Based Initiatives•Prevention of Ventilator Associated Pneumonia Bundle•Prevention of blood borne infections due to central lines•Prevention of Surgical Site infections•Implementation of Rapid Response Teams•Prevention of Adverse Drug events through medication •reconciliationOptimization of care for patients with Acute Myocardial •Infarctions

The cAse for PreVenTing VAPVAP – leading cause of death among hospital –acquired •infectionsHigh rate of associated mortality:•HospmortalityofventptswhodevelopVAPis46%compared•to 32% for ventilated patients who don’t develop VAPVAP prolongs time spent on vent, length of stay in ICU and •LOS after DC from ICU

cosT of VAPStrikingly, VAP adds an estimated cost of $40,000 to a typical •hospital admission

DefiniTions: VAPVentilator associated pneumonia: Pneumonia developing >48 •hours of initiation of mechanical ventilation or <72 hours after cessation of mv

Newprogressiveinfiltrate,withleukocytosis,fever,and* purulent sputum*Bronch protected specimen brush with >10* 3 CFU, or BAL > 104 CFU

Counting•Ventilator days/mo is the sum of the number of days each * patient was on mechanical ventilation (via ETT/trach tube)

eViDence bAseD PrAcTice VenTilATor AssociATeD PneUmoniA cAre

HOB elevated 30 degrees or higher•Stress Ulcer Prophylaxis•DVT Prophylaxis•Daily sedation vacation•Daily Assessment of readiness to wean•Daily Spontaneous Breathing Trial•

VenTilATor bUnDle AUDiT form

hob UP 30 Degrees or higherRecommended elevation is 30-45 degrees•If semi-recumbent or supine 34% incidence VAP•If semi-recumbent position 8% incidence VAP*•↑HOB→↓riskofaspirationofgastrointestinalcontents•↓riskofaspirationoforopharyngealsecretions↓riskofaspirationofnasopharyngealsecretions↑HOBimprovespatients’ventilation• Supine patients have lower spontaneous tidal volumes on PS • than those seated in upright position↑HOBmayaidventilatoryeffortsandminimizeatelectasis•

DAily “seDATion VAcATion” AnD DAily AssessmenT of reADiness To WeAn

Correlated with reduction in rate of VAP•Sedationvacationresultsinsignificantreductionintimeon•mechanical ventilationDuration of mv decreased from 7.3 days to 4.9 days-study by •Kress et al. NEJM 2000Weaning is easier when patients are able to assist themselves •at extubation with coughing and control of secretions

seDATion VAcATion risksIncreased potential for self-extubation•Increased potential for pain and anxiety •Increased tone and poor synchrony with the ventilator during •the maneuver may risk episodes of desaturation

PePTic Ulcer DiseAse (PUD) ProPhylAxis

Appropriate intervention in all sedentary patients, however,•↑incidenceofstressulcerationincriticalillness•Decreasing pH of gastric contents may protect against •greaterpulmonaryinflammatoryresponsetoaspirationofgastrointestinal contentsAspiration causes either pneumonitis or pneumonia and can be •preventedEffects of aspirating acidic contents may be worse than those •with higher pH.Somestudieshaveshown↑risksofVAPwithcertainagents•such as sucralfate while others have notSurviving Sepsis Campaign Guidelines reviewed literature on •PUD prophylaxis:

“H2receptorinhibitorsaremoreefficaciousthatsucralfate* and are the preferred agents. Proton Pump Inhibitors have not been assessed in direct comparison with H2 receptor antagonistsand,thereforetheirrelativeefficacyisunknown.They do demonstrate equivalency in ability to increase gastric pH.”*

*Dellinger, RP et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Criit Care Med. Mar 2004;32(3):858-873.

While it is unclear if there is any association between PUD •prophylaxis and decreasing rates of VAP, experience shows that when PUD prophylaxis is applied as part of a package of interventions for vent care, the rate of pneumonia decreases precipitously.