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Ventilator Associated Pneumonia −ICU Management Strategies−

Christopher L. Bosley BS, AAS, RRT-NPS, RCP Neonatal-Pediatric Transport Clinical Specialist Department of Anesthesia – Respiratory Care Mayo Clinic-Eugenia Litta Children’s Hospital

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Conflict of Interest

•  None

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Acknowledgement

  Deb Rowekamp, MS, RN

Nursing Education Specialist Education and Professional Development Assistant Professor in Nursing Mayo Clinic - Rochester, MN.

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Objectives

• Recognize the significant financial implications of Health Care Associated Infections (HAIs)

• Describe evidence based strategies to decrease Ventilator-associated pneumonia

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What is VAP…?

•  Ventilator-associated pneumonia (VAP) is a lung infection that develops in a person who is on a mechanical ventilator. 1

•  An infection may occur if “germs” enter through the ETT and get into the patient’s lungs. 1,2

•  These germs can be spread in healthcare settings from patient to patient on unclean hands of healthcare personnel or through the improper use or reuse of equipment.1,2

•  VAP is a Healthcare-Associated Infection (HAIs). 1

1. www.cdc.gov/HAI/vap/vap.html#rphp 2. www.cdc.gov/HAI/patientSafety/patient-safety.html

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Healthcare-Associated Infections (HAIs)

• An estimated 1,737,125 Healthcare-associated infections occur annually, the CDC reports inpatient total costs upward of $35.7 to $45 Billion annually (USA). 1

Types of HAIs:2

1.  Ventilator-associated pneumonia (VAP)

2.  Surgical Site Infection (SSI)

3.  Central Line-associated Bloodstream Infection (CLABSI)

4.  Catheter-associated Urinary Tract Infections (CAUTI)

1.  Scott, R.D. The Direct Medical Costs of Healthcare Associated Infections in U.S. hospitals and the Benefits of prevention. U.S. Centers for Disease Control. March 2009.

2.  www.cdc.gov/HAI/infectionTypes.html

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Financial Impact of HAIs

1.  Surgical site infections (33.7% of the total $9.8B cost)

2.  Ventilator-associated pneumonia (31.6%)

3.  Central line–associated bloodstream infections (18.9%)

4.  Clostridium difficile infections (15.4%)

5.  Catheter-associated urinary tract infections (<1%)

Zimlichman E, Henderson D, Tamir O, et al. Health Care–Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013.

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Financial Impact of VAP

• Ventilator-associated pneumonia accounted for $40,144 per patient

•  Length of Stay: (LOS: +8.4-13.1 days)

Zimlichman E, Henderson D, Tamir O, et al. Health Care–Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013.

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Ventilator-associated pneumonia (VAP)

• VAP is the most deadly of the HAIs, with a mean death rate of 35,967 per year 1

• 52,543 cases of VAP occur annually, according to the CDC estimates 2

1.  Stone, P. Economic burden of healthcare-associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res. 2009 October; 9(5): 417–422.

2.  Scott, R.D. The Direct Medical Costs of Healthcare Associated Infections in U.S. hospitals and the Benefits of prevention. U.S. Centers for Disease Control. March 2009

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Solutions for Patient Safety Prevention Bundle Ventilator-Associated Pneumonia (VAP) 1,2

1  Readiness to Extubate

2  Head of Bed Elevation

3  Minimize Disruption of the Circuit

4  Oral Hygiene

1.  Children’s Hospitals’ Solutions for Patient Safety-national Children’s Network 2.  www.solutionsforpatientsafety.org/for-hospitals/hospital-resources/

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Readiness to Extubate

Assess readiness to extubate daily

• PICU Rounding Tool incorporates input from:

 Respiratory Therapy

 Nursing

 Physician

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Head of Bed Elevation

Elevate head of bed to 30-40° for infants and children

Performed minimally once per day

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Head of Bed Elevation Bed Angle

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Head of Bed Elevation Crib Angle

http://www.hardmfg.com Use of a level attached to crib

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Minimize Disruption of the Circuit

Inspect ventilator circuit for gross contamination daily. If soiled, change circuit

Performed minimally once per day

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Minimize Disruption of the Circuit Closed Catheter Suction Devices

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Minimize Disruption of the Circuit Ventilator Circuit Position

Notice how the vent circuit is draped over the head of the

bed, allowing condensation to drain toward the patient’s airway.

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Minimize Disruption of the Circuit Ventilator Circuit Position

Notice how the vent circuit is below the patient’s airway.

Having the circuit positioned along side the bed instead of behind the head of the bed can help with draining condensation/secretions away from patient.

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Oral Hygiene

Perform oral hygiene minimally every 12 hours

Challenges of Oral Hygiene:1,2

1.  Bacterial colonization of the

oropharyngeal area

2.  Aspiration of subglottic secretions

3.  Colonization of dental plaque &

Respiratory Pathogens (Biofilms)

1. www.sageproducts.com 2. Schleder B. et al., J Advocate Health Care 2002.

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Oral Hygiene Suctioning

www.sageproducts.com

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Oral Hygiene Brushing

www.sageproducts.com

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Oral Hygiene Pastes, Rinses, Moisturizer

www.sageproducts.com

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Oral Hygiene (No teeth)

www.sageproducts.com

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Oral Hygiene Assessment

www.sageproducts.com

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Prevention Bundle Element

Recommended Approaches

Readiness to Extubate

(Performed minimally once per day)

•  Ongoing assessment for extubation readiness every 24 hours. •  Daily health care team discussion to evaluate the need to remain

intubate and what steps are needed to work towards extubation.

Head of Bed Elevation

(Performed minimally once per day)

•  Keep HOB elevated to 30-40° for all ventilated patient beyond infancy.

•  Consider use of colored or visual measurement device to ensure proper angle

Minimize Disruption of the Circuit

(Performed minimally once per day)

•  Perform circuit inspection every 8 hours for condensation &/or gross contamination.

•  Visually inspect ventilator for condensation or contamination •  Change circuit for gross contamination •  Drain circuit if fluid has accumulated •  Avoid changing the circuit on a routine basis

Oral Hygiene

(Performed minimally every 12 hours)

•  Brushing teeth & gums with a soft bristle toothbrush & product for plaque removal

•  Use a gauze & sterile water for patients without teeth •  Consider performing oral care before repositioning patient

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Questions & Discussion