Early Recognition and Management of Sepsis: PneumoniaMeeting 3

Angela Craig APN,MS,CCNSCRMC Clinical Nurse Specialist for ICU

acraig@crmchealth.org

Early Recognition and Management of Sepsis• Welcome• Review of Program Objectives

– Develop and implement an early recognition of sepsis process

– Standardize processes for treatment of patients with early sepsis

– Standardize processes for infection prevention of PNA, CAUTI and CLABSI

– Decrease rate of transfer to a higher level facility – Decrease sepsis mortality rates

• Orientation to training materials

Roles and Responsibilities

• Each facility must have a team identified to do this work– Should include: medical director, director of nursing,

infection prevention nurse at a minimum• Team work through action plan provided in specified

timeframe • Implement screening process• Implement early management of sepsis process• Educate staff on screening and management processes• Collect defined process and outcome data

What we did last meeting

• Sepsis screening education plan• Reviewed screening audit and audit expectation• Reviewed patient and family education

Agenda

• Review PNA prevention strategies– Discuss assessing current practices at your facility– Identify one prevention strategy to implement

• Define next steps: CAUTI prevention

Pneumonia

Pneumonia Objectives

• Define Pneumonia (PNA)• Identify risk factors of PNA• Identify signs and symptoms of PNA• Review PNA prevention strategies

Pneumonia Statistics• Leading cause of death due to infectious disease in

the USA, sixth leading cause of death overall >65, leading cause for NH

• >900,000 CAP cases in population over 65• Mortality rate in USA about 5%• Estimated 33-114 HCAP per 1000 NH residents• 1st or 2nd most common infection in NH (13-48%)• Mortality rate 13-41% if NH resident• Medicare paid 17.4 billion in 2004 for readmissions

(about 17%)

Statistics….

Out of 12 million fee-for-service Medicare beneficiaries:

• 20% readmitted within 30 days• 34% readmitted within 90 days• 54% readmitted within one year• 68.9% discharged with medical condition died

within a year• 53% discharged with surgical condition died within

one year

Pneumonia

• Infection of one or both lungs, lobar, segmental, or bronchial

• More than 30 different causes• Can be serious, even fatal, especially for very

young/very old• Pneumococcal vaccine, influenza vaccine, and

ACE inhibitors may have protective effect

Risk Factors for Pneumonia

• Inadequate oral hygiene• Immobility/Poor functional status• Aspiration• Difficulties in swallowing• Altered Mental Status• Co-morbidities• Lack of immunization• Smoking

The Older Adult At Risk• Cognitively impaired• Diminished swallow and

cough reflex • Functionally dependant• Dry mouth• Multiple medications• High rate tooth decay• Behavioral problems

during oral hygieneResearch Dissemination Core. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 2002 Nov. 48 p.Marik PE. et al. Chest; 2003; 124:328–336

Epidemiological & Risk Factor Categories for Institutional Pneumonia

Residents >75 years old at 6x higher risk 33 out of 1000 nursing home residents require

hospitalization for pneumonia per year vs. 1.14 out of 1000 elderly living in the community per year

Leading cause of death in nursing home residents

Annual cost of nursing home acquired pneumonia exceeds $8 billion dollars

Factors that increase bacterial burden or colonization

Factors that increase risk of aspirationTerpenning M. et al. JAGS 2002;50:584-585Murder RR. Am J Med 1998;105:319-330

Significant Independent Predictors of Aspiration Pneumonia

Dependent for feedingDependent for oral careNumber of decayed teethTube feedingMultiple medical diagnosesNumber of medicationsDry mouthSmoking

Langmore SE. et al. Dysphagia 1998;13:69-81

Pathogenesis Prevention

Germs in Mouth

• Dental plaque provides microhabitat• Bacteria replicate 5x/24 hrs

Aspirated into Lungs

• Most common route• 50% of healthy adults micro-aspirate

in sleep

Weak Defenses

• Poor cough• Immunosuppressed• Multiple co-morbidities

Pathogenesis Prevention

Germs in Mouth

• Comprehensive oral care• Oral care protocol that includes all

patients

Aspirated into Lungs

• Swallow screens• Tube feeding protocols• Head of bed elevated

Weak Defenses

• Lung expansion/mobilize• Adequate nutrition• Serum glucose target range• Immunization

Risk Factor Categories for Health Care Acquired Pneumonia

• Factors that increase bacterial burden or colonization

• Factors that increase risk of aspiration

Factors that Increase Bacterial Burden or Colonization

• Extreme age, severe underlying condition/ immunosuppression

• Administration of antibiotics

• Agents which raise the gastric pH

• Withholding gastric feeding

• Mechanical ventilation

• Immobility/Microaspiration• Lack of oral care• Poor infection control

practices• Contaminated respiratory

equipment/contaminated condensate

• Saline administration

Oropharyngeal ColonizationMethodology:• 49 elderly nursing home residents admitted to the

hospital• Examined baseline dental plaque scores &

microorganism within dental plaque • Used pulse field gel electrophoresis to compare

chromosomal DNA

Results:• 14/49 adults developed pneumonia• 10 of 14 pneumonias, the causative organism was

identical via DNA analysisEl-Solh AA. Chest. 2004;126:1575-1582

Practices in Oral Care

• Culture cup, ½ H2O2, ½ sterileH2O…little bit of mouthwash

• Lemon glycerin swabs• Toothette with water &/or

mouthwash• No oral care

That’s not the way we do it here!!!

Lemon & Glycerin Swabs• Harmful• Hastens drying of mucosa by

depleting the saliva reserve caused by over-stimulation of salivary glands by lemon juice

• Citric acid has no moisturizing capabilities

• Irritates oral mucosa & decalcifies teeth

• Glycerin is a trihydric alcohol that absorbs water causing drying

Foss-Durant Am et al. Clin Nurs Res. 1997;6(1):90-104Krishnasamy M. Eur J Cancer Care. 1995;4(4):173-177Regnard C et al. Br Med J. 1997;315(7114):1002-1005Van Drimmelen JR et al. Nurs Res 1969;18:327-332

Oral Care Reduces Pneumonia In Nursing Homes

Methodology• 11 nursing homes in Japan over 2 year period• 417 enrolled / 366 residents analyzed (death from other causes)• 184 received oral care program/182 did not• Tooth brushing after each meal (teeth or dentures) & 1x weekly

review by dentist/or hygienist

Results

No Oral Oral Care p valueFebrile 29% 15% p<.01Pneumonia 19% 11% p<.05Death 16% 7% p<.01MMSE Increase p<.05

Yoneyama et al. JAGS. 2002;50:430-433

Oral Care Reduces Pneumonia In Nursing Homes Residents

• Oral care improves swallowing and cough reflex sensitivities

Watando A. et al. Chest, 2004; 126:1066–1070)

Brush & Swab

• 77% more clean proximal sites with brushing• 44% more clean crevice sites with brushing• Benefit of brushing is directly correlated with

technique • Foam swabs could not remove plaque from

sheltered areas on or between teeth

Pearson LS. et. al. J of Adv Nursing. 2002;39(5):480-489

Toothbrush; grade D, Swabs; unresolved, Use of flexible suction catheter post oral cleansing; Grade D (Berry AM et al. AJCC, 2007;16:552-563)

Brushing Removes Plaque• Methodology:

– 34 volunteers– Double-blind crossover study– Examine the amount and % of

plaque removed with a single brushing with 3 solutions (Sodium Bicarb, Crest, Cologate)

• Results:– Significantly higher % of plaque

removed with one minute brush using Sodium Bicarb

Mankodi et al. J Clin Dent. 1998; 9(3):57-60

Proposed Oral Care PlanIndependent

Weekly assessment,encouragement to perform tooth brushing/denture cleaning minimum x2 daily

Dependent on Oral Care

Ability to expectorate

Assist with brushing teeth/clearing out debris &/or cleaning dentures with CPCafter each meal/night & moisturize following cleaning

Unable to expectorate

Brush teeth (dentures) /clear debris using suction toothbrush am & pm with CPC followed by moisturizingAssist oral cleansing (dentures)/clear debris after lunch & dinner using a suction swab with CPC followed by moisturizing denture cleaning

Oral Care Protocol

Your Role in Preventing Pneumonia

• Proper hand hygiene• Comprehensive Oral Care• Prevention of Aspiration• Swallow screens• Proper positioning during

eating/feeding and sleep• Immunizations• Mobility/ Lung expansion• Adequate nutrition

Current State Assessment related to PNA Prevention Practices

PNA Prevention Action PlanStep Who? When? Status

1. Assess current infection prevention practices for PNA

2. Identify gaps in application of PNA prevention practices and develop plan to implement strategies to close gaps

3. Develop an infection prevention education plan for PNA

4. Audit PNA prevention practices5. Identify facility acquired PNA

rates

Sepsis Early Recognition Action Plan

Homework• Continue with the sepsis screening audits• Do current state assessment for PNA prevention• Review oral care protocol with team and begin to

discuss how to implement it

Questions?

Thank you for your participation in this important work