vap prevention toolkit user manual · web viewencouraging mobility may decrease the propensity...

The Ventilator-Associated Pneumonia Prevention Toolkit:Your Technical Work Plan for Translating Evidence into Practice

Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality

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Table of ContentsIntroduction........................................................................................................................................................3What’s in the toolkit...........................................................................................................................................3Using the TriP model as a framework..............................................................................................................3

Phase 2. Identify barriers to implementation..............................................................................................6Phase 3. Measure performance.....................................................................................................................6Phase 4. Ensure all patients receive the intervention.................................................................................8

The Four E’s........................................................................................................................................................9Engage: How will VAP reduction make the world a better place?.............................................................9Educate: What is the evidence for VAP reduction?...................................................................................11Execute: What do I need to do?...................................................................................................................12Evaluate: How will we know that we added value?..................................................................................17

Getting Help......................................................................................................................................................17References........................................................................................................................................................18Appendices........................................................................................................................................................21

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Introduction Ventilator-associated pneumonia (VAP) is among the most common healthcare-acquired infections (HAI) in the intensive care unit (ICU), is associated with significant morbidity and mortality and contributes 30-50% of the overall public health burden of HAIs1. The median VAP rate among all ICU types according to the CDC ranges from 0.7-7.4 per 1000 ventilator days2.The attributable mortality for VAP may exceed 10%3or 36,000 deaths per year4. The average increase in length of stay is 4-9 days for patients with VAP3

. Tamayo et. al.5 found that VAP is the most significant independent risk factor for mortality among all ICU patients, with an increased hazard ratio in the cardiac surgery population of almost 9%.

These are just some of the reasons why efforts to improve the quality of care in the ICU or any other unit caring for patients on mechanical ventilation and decrease VAP rates are paramount. While most organizations have already devoted significant energy and resources to VAP reduction, significant opportunities for additional improvement often remain. Oftentimes our frontline staff are not aware that their patients are at risk for VAP, what the risk factors associated with VAP are or further, what the VAP rates in their units are. Sharing this information with frontline staff and hospital leadership can often help to engage them in efforts to improve care.

What’s in the toolkitBy implementing this toolkit in your care for mechanically ventilated patients, your team leads the national effort to reduce VAP. However, this toolkit is not a prescription for success. While we have developed a model to support your efforts to implement evidence-based practices, reduce VAP and improve care for all mechanically ventilated patients, the authors of this manual do not work in your ICU or unit. Only your team understands your obstacles and your opportunities for improvement. The materials presented here provide a structure for your efforts to implement evidence-based practice and protect your patients from VAP. Success requires creative energy, persistence, leadership and teamwork.

Using the TriP model as a framework

This toolkit’s structure is based on a model to Translate research Into Practice (TrIP), designed to close the gap between evidence-based guidelines and bedside practice6. For more information about the TrIP model, please see Appendix A. Briefly, the model is composed of four phases, listed below:

1. Develop an evidence-based intervention Identify interventions associated with improved outcomes Select interventions with the largest benefit and lowest burden

2. Identify barriers to implementation3. Measure baseline performance4. Ensure all patients receive the intervention

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Implementation of the TrIP model has been associated with significant reductions in central line-associated blood stream infections7,8 ventilator-associated pneumonias9 in more than 100 Michigan ICUs. The results were sustained for over three years, and were associated with a reduction in mortality among Medicare patients admitted to Michigan ICUs10 and a significant cost savings for hospitals11. Implementation of the same program in Rhode Island ICUs demonstrated similar results12. Most recently implementation of the TriP model has been associated with significant reductions in hospitals in 45 states, including Hawaii and Connecticut13. Develop a method to incorporate evidence-based interventions in your patient care practices

Summarize the available evidence for VAP Prevention. The IHI Ventilator Bundle, used by most sites since its development in 200214, was not written with the express purpose of VAP prevention. It was developed to guide the care for mechanically ventilated patient and included interventions such as stress ulcer and DVT prophylaxis, both not related to VAP prevention.

Within the intervening years after the Ventilator Bundle was developed, four sets of guidelines have been written regarding interventions to use in the prevention of VAP, from the Centers for Disease Control and Prevention15, the American Thoracic Society16, the Society of Healthcare Epidemiology17 the Canadian Critical Care Trials Group from the Canadian Critical Care Society18.

Through a review of these guidelines and of the literature published after they were written (post 2007), we assembled 65 possible interventions for VAP prevention. To determine which candidate interventions to include in a new comprehensive bundle specifically focused on VAP prevention, we assembled a VAP Prevention Committee of 155 healthcare experts in the care of patients on mechanical ventilation. Committee members participated in a modified Delphi process to determine the contents of a new VAP Prevention Bundle. Nineteen interventions were chosen for inclusion in the bundle. There are 5 measures where compliance should be monitored daily. These are items directly related to daily patient care, such as the performance of oral care in patients on mechanical ventilation. The remaining 14 are policy measures. These measures are based on the policies in the hospital and specific unit, such as assuring that non-invasive ventilatory support is available at all times and that caregivers know when and how to use it. The complete contents of the bundle are described in the section entitled, “Educate: What is the evidence for VAP reduction? A list of all the interventions is also included in Appendix B.

Ask your frontline staff how their next patient will be harmed. Frontline providers understand patient safety risks in their ICU or other unit caring for patients on mechanical ventilation. In addition, they likely have thought about solutions to the problems they perceive. We need to tap into frontline providers’ knowledge, and use it to guide our safety

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improvement efforts. Your team can use the Staff Safety Assessment (SSA) (Appendix C) to gather their thoughts. The SSA asks staff how their next patient will be harmed, how they will develop a VAP, and how these complications can be prevented. For more information about the SSA, please see the CUSP for VAP: EVAP manual.

Select interventions with the largest benefit and lowest burden

Your leadership is needed to eliminate VAP in your ICU. At the beginning of the project, most of your efforts will be spent developing a team that includes all players involved in VAP prevention: nursing, respiratory therapy, physicians, and others. While there is no formula for how to select interventions, your team will want to consider a few factors:

How much effort is required to build buy-in for your intervention?

How many resources are required to change local practice?

How to share the evidence supporting the intervention?

Consider choosing a few ‘low hanging fruit’ to gain positive momentum before focusing on the more challenging interventions.

The VAP Prevention Toolkit in practice

We started with oral care. We researched oral care practices provided with the project and designed a protocol that fit our needs. We set up training sessions to bring everyone up to speed. Right now we are auditing the oral care processes our patients are receiving, and when staff are not doing what our protocol has stated, we are retraining. While we have gotten some push back on this, we feel that this was one of the easier VAP prevention interventions to address. The large majority of the staff are excited to have a standardized practice for oral care in place.


We decided to focus on improving the SAT and SBT processes in our unit. Obviously patients were being weaned off the vent, but the process was haphazard and not well documented. Physicians were not always entering the orders and often patients weren’t being extubated as fast as they should have been. Working with the intensivists and respiratory therapists, we have written and instituted protocols to assure that SATs and SBTs are entered into the automatic order set for all patients on vents. We have also made the documentation mandatory in the EMR. This way the physicians can make a faster determination to extubate.

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Phase 2. Identify barriers to implementationClinicians want to achieve the best possible outcomes for their patients. If patients are not receiving the evidence-based intervention your team identified, you will need to understand the barriers to compliance19. Common barriers to implementation of evidence-based interventions include:

Clinicians aren’t aware of the evidence-based intervention

Clinicians don’t agree with the intervention

Clinicians don’t have convenient access to equipment or supplies needed to implement the intervention or implementation is just too burdensome.

The Barrier Identification and Mitigation (BIM) ToolYour team can use the Barrier Identification and Mitigation (BIM) tool to identify and develop a plan to address these barriers. (Appendix D) The tool includes a brief user’s guide to walk you through its five-step process.


Realizing the importance of incorporating sub-glottic endotracheal tubes as normal standard of care for patients on mechanical ventilation in our health system, we used the BIM tool to determine our plan to achieve implementation. We first worked with the health system leadership to make the elimination of VAP a priority. Then we discussed how the use of these tubes is important in patient care. The health system leadership agreed and we have worked together to make these tubes available for clinical use. Next we worked with the Department of Anesthesiology in one of our hospitals to achieve buy in. Next task, the OR, ED and rapid response teams. Now, we have sub-glottic tubes in the ICUs and on code carts in all health system hospitals. We are still working on implementing their use in the ED and OR.

Phase 3. Measure performance

Baseline performanceCollecting baseline performance and sharing your results with clinicians and hospital leadership can go a long way towards identifying opportunities to improve and catalyzing improvement efforts. For VAP prevention, there are several potential strategies to assess baseline performance and progress towards improving patient care, including baseline process and policy measures in the VAP Prevention Bundle, outcome measures, and information derived from quarterly interviews as part of this project.

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Monitor compliance with evidence-based guidelinesFrequent formal and informal audits of compliance with evidence-based care are paramount. Feedback the results from these to all staff involved in this quality improvement process continuously. Through this process you will be able to highlight awareness, establish expectations, create urgency and reward changes in behavior.20-22. Evaluating performance provides an ongoing, real time image of ‘ground truth’ or actual implementation rates23. Areas of poor compliance can be rapidly identified and rectified24. If compliance remains poor in one area, the improvement team should walk the process with staff to gain additional insights into barriers to implementation9. Information on Process and Policy Measures available separately in Appendix A.

Process MeasuresThe process measures within the VAP Prevention Bundle are patient care activities that should happen every day for the patient on mechanical ventilation. Compliance with these measures, such as semi-recumbent positioning, oral care, etc., are tracked every day. The Daily Rounding Form will be used for collecting process measure data including the five process measures listed below. This data will be entered into the CUSP for VAP: EVAP web-based platform. Real time reports on your compliance with these measures will be available on the platform. (Appendix E)

Daily Process Measures1. Maintain elevation of the head of the bed (HOB) to ≥ 30⁰ 2. Perform oral care 6 times daily

3. Use chlorhexidine while performing oral care twice daily

4. Use subglottic suctioning endotracheal tubes (Sub-G ETT) for patients ventilated for > 72 hours

5. Use spontaneous awakening and spontaneous breathing (SAT and SBT) protocols

Policy MeasuresPolicy measures evaluate the extent to which existing nursing, RT, and/or unit or hospital policies address the remaining 14 measures. Information regarding your adoption of the policy measures will be collected semi-annually on the web-based platform. Reports on your adoption of the policy changes listed in the VAP Prevention Bundle will be available on the platform.

Policy Measures1. Perform hand hygiene

2. Avoid supine position

3. Use standard precautions while suctioning respiratory secretions

4. Use orotracheal not nasotracheal for elective intubation

5. Avoid the use of prophylactic systemic antimicrobials

6. Avoid non-essential tracheal suctioning

7. Avoid gastric over-distention

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8. Use a closed ETT suctioning system

9. Change closed suctioning circuits only as needed

10. Change ventilator circuits only if circuits become damaged or soiled

11. Change HME every 5-7 days and as clinically indicated

12. Provide easy access to non-invasive ventilation (NIVV) equipment and institute protocols to promote use

13. Periodically removed condensate from circuits, keeping the circuit drain closed during the removal, taking precautions not to allow condensate to drain toward patient

14. Use an early mobility protocol

Outcome MeasuresYour team will collect National Healthcare Safety Network (NHSN) ventilator-associated event (VAE) surveillance data as your outcome measure and submit it to NHSN.

The new VAE definitions replaced the old PNEU definitions for NHSN reporting in February 201325. In 2012, physicians from the CDC, together with members of critical care societies, infection prevention and respiratory therapy were tasked to develop a new surveillance definition for VAP. This was in response to increasing concern the old PNEU definitions were not sensitive or specific and were extremely subjective. These limitations in the definition made benchmarking or measuring the effectiveness of a quality improvement difficult.

The new surveillance definitions require information that is objective, such as ventilator settings to determine increasing oxygen requirements. In addition, all of the required information required to determine a VAE has the potential to be collected electronically from EMRs and/or other patient databases where the pertinent information is stored.

For most sites, we will download your VAE data from the NHSN site for this project. This may be done directly by us or it may be downloaded by your coordinating entity, such as your state’s hospital association, and transferred to our database electronically. For those sites who are not submitting VAE data to NHSN, we will prepare an upload portal on the database platform for appropriately formatted data.

Implementation of CUSP and the New VAP Prevention BundleInformation on your team’s progress towards implementation of CUSP and the VAP Prevention Bundle will be collected during quarterly phone interviews between AI team members and participating team leaders for each participating unit. We will discuss your progress and any issues that you or your group may have encountered. Information collected through this process will inform future discussions for all participants in the project.

Phase 4. Ensure all patients receive the interventionFinally, reliably deliver evidence-based care to 100 percent of your patients. Ensure that your evidence-based intervention becomes ‘the way things are done around here.’ This phase poses the biggest challenge. While your improvement team implements phases one through three of the TriP model, phase four requires buy-in and involvement from the your unit’s care teams and stakeholders who actually implement the interventions.

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The Four E’s

Drawing from the published literature and experience, clinicians at the Johns Hopkins Hospital developed a “Four E’s” implementation model. The model prompts your team to consider staff engagement, local culture, and contextual factors in a phased plan to embed your intervention in existing care processes. The Four E’s represent the four phases of this expansion model:

Operationalize the Four E’s

Safety efforts succeed through the investment of key stakeholders, including senior leaders, improvement team leaders, and frontline staff. Though stakeholders have different perspectives, hopes, and fears, they often have the same questions about their involvement in the QI process9.

Operationalize the Four E’s model by explicitly addressing four associated questions that your key stakeholders are sure to have:

1. Engage: How will VAP reduction make the world a better place?

2. Educate: What do we need to do to reduce VAP?

3. Execute: How will we reduce VAP in our hospital given local culture and resources?

4. Evaluate: How will we know we made a difference?

For more information about the Four E’s model and the BMI tool6, see Appendix F and Appendix G, in the CUSP for VAP: EVAP toolkit.

Engage: How will VAP reduction make the world a better place? Your staff is likely overwhelmed by the amount of quality improvement initiatives going on in your hospital. You will need to convince them that VAP prevention is not just a “flavor of the month,” but you need to help your staff understand that VAP is associated with significant preventable morbidity, mortality and costs1-4. Patients who are on mechanical ventilation are at a high risk of VAP due to the presence of

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Engage

Win the hearts and minds of your teams

Educate

Teach your teams about your intervention

Execute

Implement your plan with purposeful team participation

Evaluate

Determine how well your intervention has been embedded in care processes

senior leaders by converting rate data into estimates of preventable deaths, excess costs and excess hospital days. Online tools are available to help teams convert their data and quantify the potential impact of efforts to prevent VAP. http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html.

Make performance more visibleQI teams often share process and outcome performance measures with select individuals or improvement groups within their organization. Key stakeholders, including frontline staff and senior leadership, are often unaware of local performance. If you were to ask frontline staff and senior leadership what your VAE rates are, would they know the answer? In most cases, they likely would not.

Give your invested stakeholders feedback by sharing performance on process measures and VAE rates:

Post a trend line of VAE rates in your intensive care units so nurses and physicians can see how VAE rates are changing over time.

Post the number of weeks or months since your last VAE. Be sure to update it regularly.

Share reports of the unit’s compliance with process and policy measures with staff on the unit.

Review VAE, process and policy measure compliance at key meetings

Make sure your staff recognizes that benchmarking your performance against similar hospitals and striving for the 50th percentile is unacceptable for preventable complications. Your goal should be that no patient suffers harm from a preventable complication while in your hospital. You may be able to totally eliminate infections and any infections should be viewed as a defect.

Importantly, feedback will only be meaningful if your clinicians believe the data is valid. Be transparent about your data collection methods and any efforts your team has made to address possible biases.

Recognize staff effortsFinancial incentives to engage staff and leaders, while attractive, are often not feasible or sustainable. Staff recognition using non-financial strategies can go a long way toward engaging your colleagues. Some examples include:

Assign a title for key participants, such as the physician or nurse project leader.

Encourage team members to present their efforts at important committee or board meetings within your organization.

Highlight staff efforts in local newsletters, bulletins or publications.


Mr. Jones is a 48 year-old healthy male, admitted to the ICU status post emergent open cholecystectomy. He has a non-subglottic ETT in place because the anesthesia team was unable to extubate him in the OR due to weakness and he has an abdominal VAC in place. The surgeon requested that the patient lay flat post-operatively.

Post-op Day 4: Mr. Jones remained intubated and did not meeting criteria for the SBT. He developed a fever and delirium. Sputum cultures were sent.

Post-opDay 8: Mr. Jones remained intubated. Documentation audits reflected a large amount of oral and endotracheal secretions. Sputum cultures came back and were positive. For these issues, intensivists obtained consent from the family for a tracheostomy and started antibiotics for his VAE.

Post-op Day 10: Mr. Jones received a percutaneous tracheostomy at the bedside.

Secondary to the VAE and prolonged hospital stay, Mr. Jones was unable to attend his only daughter’s wedding.

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http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html

http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html

Educate: What is the evidence for VAP reduction? Many healthcare providers are not aware that the interventions outlined in this VAP prevention bundle toolkit can dramatically improve patient outcomes. Some are aware of the interventions, but are not familiar with the evidence supporting their use. We used 4 national guidelines to help develop this VAP Prevention Bundle, written by:

The Centers for Disease Control and Prevention15

The American Thoracic Society16

The Society for Healthcare Epidemiology of America17

The Canadian Critical Care Trials Group18

From these guidelines, their supporting literature and literature published after they were written, we developed a list of 65 candidate interventions for the prevention of VAP. In 2011, we convened a committee of 155 healthcare providers, including critical care physicians and nurses, pulmonologists, infectious disease physicians, infection preventionists and respiratory therapists. Committee members were asked to evaluate each measure for its importance in the prevention of VAP as well as the feasibility of implementation. The strategies listed below are the results from this project. A manuscript is currently being written to describe this process and the results. This work represents the first bundle of interventions specifically designed for VAP prevention and teams in this collaborative are on the leading edge of the science for VAP prevention.

Strategies to employ and evaluate on a daily basis include:

1. Maintain elevation of the head of the bed (HOB) to ≥ 30⁰2. Perform oral care 6 times daily3. Use chlorhexidine while performing oral care twice daily4. Use of subglottic suctioning endotracheal tubes (Sub-G ETT) for patients ventilated for > 72 hours5. Use of spontaneous awakening and spontaneous breathing (SAT and SBT) protocols

Other strategies are “policy based” and include:

1. Perform hand hygiene2. Avoid supine position3. Use standard precautions while suctioning respiratory secretions4. Use orotracheal not nasotracheal for elective intubation5. Avoid the use of prophylactic systemic antimicrobials6. Avoid non-essential tracheal suctioning7. Avoid gastric over-distention8. Use a closed ETT suctioning system9. Change closed suctioning circuits only as needed10. Change ventilator circuits only if circuits become damaged or soiled11. Change HME every 5-7 days and as clinically indicated12. Provide easy access to NIVV equipment and institute protocols to promote use13. Periodically removed condensate from circuits, keeping the circuit drain closed during the

removal, taking precautions not to allow condensate to drain toward patient14. Use an early mobility protocol

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Your team will need to educate staff and leadership about the evidence, explain new processes, answer questions and set performance goals to eliminate VAP26-28. Workshops, hands-on trainings, conferences, slide presentations, interactive discussions are all effective tools to use for staff education; multiple teaching modalities can meet diverse learning styles26, 29. Local champions and topic experts should be responsible for staff education20, 21, 30 which should include both multidisciplinary and specialty specific educational programs31, 32. Sessions must be informative and relevant for the learner. These sessions provide an explanation of why staff need to adopt the new practices, it engages them, and it encourages them to adopt new practices21, 29.. Your team can use the factsheets in Appendix H and slide sets found on the CUSP for VAP: EVAP project website as educational aids.

While educational sessions should be interdisciplinary, some groups such as physicians are likely more receptive to other physicians. The physician champion on your CUSP for VAP team should reinforce physician education efforts. Several education strategies described in the literature focus on changing physician behavior:

Provide physicians with educational information packets consisting of research literature (Appendix I), evidence-based reviews, hospital specific data, and national guidelines.

Introduce educational information at staff meetings or Grand Rounds. Utilize informal educational meetings and networks to disseminate information. Conduct educational outreach visits involving content experts, such as respiratory therapists,

pharmacists, pulmonologists or infection preventionists.

Execute: What do I need to do?

Frame your intervention in the Science of SafetyWithout a doubt, clinicians care deeply about their patients. Yet we are all fallible. No matter how hard we try, we will forget to order an important medication and we will make mistakes. Patient safety research has demonstrated consistently that blaming individual doctors or nurses will not prevent patient harm. Organizational-level factors, functional work area-related factors, team-related factors, task-related factors, and patient-related factors all have a role in patient outcomes. We need to ensure our system is designed to deliver these evidence-based interventions for every patient on every day.

Apply principles of safe system designEvery system is perfectly designed to produce the results it delivers. If we want to achieve substantive and sustainable improvements in patient outcomes, we have to change the flawed systems in which clinicians work. We must redesign systems to produce wellness instead of harm. Other industries teach us that there are clear principles of safe system design:

Standardize care and reduce complexity

Create independent checks along the continuum of care

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Standardize Care and Reduce Complexity: Standardizing care and reducing complexity helps to establish new care processes as “normal behavior” for staff27. One way to incorporate standardization into patient care is to use daily multidisciplinary rounds. Daily rounds should follow a structured format: discuss the patient’s goals for that day and determine what resources and actions are necessary to achieve those goals. Any potential barriers and/or any safety issues should be identified9, 24, 33, 34. The reality is that providers want to do the right thing for their patients. However, the care of a patient on mechanical ventilation is complex and it is often difficult to remember everything we should do in real time.

Create independent checks: Creating independent checks or redundancy involves developing unique and separate system checks for critical procedures. High reliability industries use independent redundancies to monitor those procedures that are highest risk or most likely to cause harm if not done correctly or if not completed at all. We are just beginning to develop independent redundancies in healthcare. The combination of both education and redundancy significantly improves processes of care35. Engaging all caregivers can provide a powerful independent redundancy. Include respiratory, physical and occupational therapists, nurses and pharmacists in the care choices that are made.

In this section we provide several strategies for standardizing care, reducing complexity and creating independent checks. Talk to your frontline providers! They likely have many, many other suggestions for creating a safer system design to ensure patients receive the interventions they should.

Strategies for Daily Evaluation1. Maintain elevation of the HOB to ≥30⁰

Several successful strategies have been published to improve compliance with HOB elevation ≥30 . ⁰These include the use of a bed with a specific attachment that will show the angle at a glance, use of a handheld protractor, a determination of what mark on which bed can signify the correct angle for recline. HOB elevation should be fed back to unit staff on a regular basis. Another strategy is to involve all professionals, like respiratory or physical therapy staff, to ensure the HOB is maintained at the correct angle.

2. Perform oral care 6 times daily

Compliance with oral care practices can be difficult. Many ICUs have developed policies and protocols to standardize oral care. Make sure oral care methods are easy to use and track. Daily oral care tear-off kits that include q12 chlorhexidine are a wonderful way to assure that the supplies are easily available. These kits also make it possible to track compliance by observing how many kits have been used in a day. If only 4 packets have been used out of 6, 2 have not been used during that 24 hour period. Some sites keep a log of oral care episodes on a chart on the wall at the head of the bed. Others have incorporated documentation in their EMR.

3. Use chlorhexidine while performing oral care twice daily

Many of the tear-off oral care kits have the chlorhexidine incorporated into two of the packets. Again, remaining packets can be used both for reminders that the product needs to be used and to track compliance. The other methods mentioned above can also be used for tracking the use of chlorhexidine with oral care.

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4. Use of Sub-G ETTs for patients ventilated for >72 hours

Maintaining a well-stocked supply of Sub-G ETTs enables providers to choose them when clinically appropriate. At our organization, we have replaced standard ETTs in code carts for emergency intubation and in the ICUs all re-intubations. However, in the OR, the determination of which patients are most likely to be mechanically ventilated for more than 72 hours is difficult. Our goal is to learn together how we may best be able to incorporate this evidence into practice while balancing the additional costs of the special ETTs. Nevertheless, the use of these special ETTs has been shown to be exceedingly effective for VAP prevention and economic modeling suggests the use of these tubes may actually reduce overall costs.

5. Use of SAT and SBT protocols

The adoption of SATs and SBTs is paramount to reducing the duration of mechanical ventilation and the risk of VAP. Girard, et. al.36 showed that pairing an SAT with an SBT reduces the duration of ventilation by 3.1 days. SATs and SBTs are much easier to institute if they are considered standard of care. Some sites have added SAT and SBT to a standard order set for patients on mechanical ventilation. Other sites have instituted a standard nursing led protocol for SAT and, if the patient passes the SAT, a respiratory therapy led SBT, and some have incorporated SAT and SBT reminders into computer decision support systems.


As we focused on the SAT, many of our clinical staff were concerned that discontinuing all sedation for mechanically ventilated patients would cause the patients to have increased pain, agitation and delirium. Through education and a review of the literature, clinicians were able to see that the requirement for 4 hours without sedation is just to pass the SAT. If during the trial, the patient developed sustained anxiety, agitation, pain, signs of respiratory or cardiac distress, sedatives could be re-introduced, and the patient would have a new SAT the following day.

Check current policies: Protocol and policies can be an effective strategy to improve adherence with evidence-based practice. We encourage you to review your existing policies, modify and / or implement additional new policies as needed to promote adherence with VAP prevention interventions in your ICU. For instance, consider the following opportunities to align the following policies with your VAP prevention efforts:

1. A policy to assure the availability of NIVV equipment and standardize equipment practices – This policy defined when, where and under what conditions NIVV equipment should be used. It states that the equipment should be easily accessible to the providers working in the unit and that it should be kept in good working condition, with the required supplies. Such a policy, without the ease of access to the equipment, is not practical. Concomitantly, the availability of the equipment without the policy to encourage the use will likely not be effective.

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2. To help prevent colonization of the aerodigestive tract the following policies should be evaluated:a. A policy to encourage the use of orotracheal intubation over nasotracheal whenever orotracheal

intubation is not contraindicated.b. A policy to encourage the use of closed ETT suctioning systems, combined with the removal of open

systems from supplies.c. A policy to discourage the scheduled changing of closed suctioning catheters. These should only be

changed as needed.d. A policy to avoid the use of prophylactic systemic antimicrobials. The use of prophylactic

antimicrobials for VAP is inappropriate and long-term use of antimicrobials is known to lead to antimicrobial resistance. There are situations where prophylaxis is warranted, but these are cases where there is the possibility of a contaminated wound (trauma, surgery, etc.) or prophylaxis due to another comorbidity such as an immunodeficiency and have nothing to do with VAP.

3. To help prevent aspirationa. A policy to keep patients in a semi-recumbent position (≥30 ) whenever possible, unless this ⁰

position is contraindicated.b. A policy to discourage the use of non-essential tracheal suctioning. Place reminders in care areas to

discourage orders for regular suctioning, i.e. q.2 hours.c. Policies to prevent gastric over-distention. Keep feedings to a minimum volume and decompress

the abdomen. For example, assuring the patient has an OGT or NGT in place if there is an anticipation of longer-term intubation.

d. A policy to encourage the use of an early mobility protocol. Encouraging mobility may decrease the propensity to atelectasis and increase clearance of bronchopulmonary secretions. It has also been shown to reduce the length of ventilation (ref).

Several of these policy-related strategies are focused on practices for both nursing staff and respiratory therapists.

1. A policy that promotes the use of standard precautions while suctioning respiratory secretions. This is very important for both the protection of the healthcare provider and for their patients. If the patient does have an infection or is colonized with a communicable organism, standard precautions can protect the healthcare provider and their subsequent patients.

2. Close suctioning catheters should only be changed as needed. This can help prevent the patient from colonization of the lower respiratory tract which might lead to infection. Change only when needed to minimize this risk.

3. In order to protect the patient from inadvertent contamination, the ventilator circuit should be periodically drained. During this procedure, the caregiver should take care not to allow the condensate to drain toward the patient.

4. The ventilator circuits should only be changed if damaged or soiled.5. Heat moisture exchangers (HMEs) should be changed every 5-7 days and as clinically indicated.

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Implementation of these protocols, policies and interventions may look overwhelming and it will take your leadership and dedication to make progress. If you approach the implementation with the goal of VAP reduction and take the policy changes in groups, i.e. all equipment related changes, the process may be easier. Far too many patients suffer preventable harm. Our goal is to eliminate that harm.

Improve communication: One powerful strategy to improve communication and increase the likelihood that patients will receive the therapies they should is the ‘Daily Goals’ form. This form is filled out every day on every patient and has been successfully used in units that house patients on mechanical ventilation. Including the SAT and SBT in the Daily Goals sheet reminds teams to discuss results from the previous day’s trials or how to proceed on the day in question. We will be talking much more about the Daily Goals form during this project. We encourage you to explore the use of the Daily Goals as part of this project and specifically as we work together to prevent VAP.


Through the Daily Rounding Form, we discovered that a patient who had been having regular oral care had suddenly not received any for 2 days. We looked into the issue. It turned out that the patient had returned to the OR for a procedure. When he came back to the ICU, the order for oral care had not been reentered into the system. We have instituted a procedure to assure that this doesn’t happen again.

Account for local culture and resourcesDon’t force a square peg into a round hole. Adapt your intervention to the local culture and context. Intervention success is dependent on organizational culture. Unfortunately, your intervention will fail if it is introduced into a unit with staff who do not trust each other and cannot work together. While your team needs to adapt to constraints and utilize opportunities, the CUSP for VAP: EVAP toolkit will help your team improve safety culture.


Our facility has hired an RN trained quality person who audits all charts daily to see if specific care requirements have been missed. This position was developed about a year ago. If there is an issue with care, she sets up hands-on education with the specific staff members. She adjusts her schedule to be available the next time the particular staff members are working in order to re-educate. We added the elements of the Daily Rounding Form to her list as this project started.

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Evaluate: How will we know that we added value? The final step in the Four E’s model is to evaluate the impact of your interventions. You need to assess whether your efforts are adding value for your staff, your patients and their families.

Monitor compliance with evidence-based guidelines:

Conducting frequent formal and informal audits with continuous timely feedback of process measures to all staff involved in this quality improvement process is essential. To accomplish this, we recommend that you monitor compliance with the evidence-based process measures above and report back to your staff each month. Routinely reporting results allows staff to correlate improvements in performance with a decrease in VAE rates or number of VAE, which serves to remind staff about the new processes and motivates them to improve21. Share the reports for percentages of compliance for each measure with your team to help them track their performance. Also, let your staff know about each month that goes by without a VAP. Celebrate your successes!

Monitor outcome measures:

Following and sharing your VAE rates is important to the care team. With this information, they can celebrate their excellent performance or they can see how their care can impact VAE rates and help develop ways to determine if and/or where their practices aren’t meeting compliance goals or whether all the evidence-based practices have been implemented. Sharing VAE rates will help energize your team to improve their performance.

As part of this project we will be evaluating performance in a number of different ways including collecting data on the process and policy measures mentioned in Appendix A, and VAE outcomes.

We also ask that you collect baseline and prospective monthly VAE rates in your unit for the duration of the project. Enter this information into the NHSN system. We will work with you or your coordinating entity lead to obtain your rates directly from the NHSN system.

For each of these data collection strategies, the project database will allow you to assess your progress, compare your results with others participating in this collaborative as the project continues. Sharing your progress with your frontline staff will help your team focus on your work towards eliminating VAP in your unit.

Getting HelpWe recognize that Ventilator-Associated Pneumonia Prevention Toolkit represents a lot of new material. If you have additional questions, please post them to the VAP project’s social networking site, or email us at [email protected].

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mailto:[email protected]

References

1. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Crit Care Med. 2005;33(10):2184-2193.

2. Edwards JR, Peterson KD, Mu Y, et al. National healthcare safety network (NHSN) report: Data summary for 2006 through 2008, issued december 2009. Am J Infect Control. 2009;37(10):783-805. doi: 10.1016/j.ajic.2009.10.001.

3. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165(7):867-903.

4. Klevens RM, Edwards JR, Richards CL,Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166.

5. Tamayo E, Alvarez FJ, Martinez-Rafael B, et al. Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery. J Crit Care. 2012;27(1):18-25. doi: 10.1016/j.jcrc.2011.03.008

6. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: A model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714.

7. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32.

8. Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB, et al. Sustaining reductions in catheter related bloodstream infections in michigan intensive care units: Observational study. BMJ 2010 Feb 4;340:c309.

9. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32(4):305-314.

10. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: Retrospective comparative analysis. BMJ. 2011;342:d219.

11. Waters HR, Korn R,Jr, Colantuoni E, et al. The business case for quality: Economic analysis of the michigan keystone patient safety program in ICUs. Am J Med Qual. 2011;26(5):333-339.

12. DePalo VA, McNicoll L, Cornell M, Rocha JM, Adams L, Pronovost PJ. The rhode island ICU collaborative: A model for reducing central line-associated bloodstream infection and ventilator-associated pneumonia statewide. Qual Saf Health Care. 2010;19(6):555-561.

13. Eliminating CLABSI, A National Patient Safety Imperative: Final Report: Final Report on the National On the CUSP: Stop BSI Project. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-final/index.html

14. National hospital quality measures - ICU. http://www.jointcommission.org/national_hospital_quality_measures_-_icu/. Updated 2005. Accessed April 3, 2013.

15. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003: Recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep. 2004;53:1-36.

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http://www.jointcommission.org/national_hospital_quality_measures_-_icu/

16. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. doi: 10.1164/rccm.200405-644ST.

17. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals • . Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31-S40.

18. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141(4):305-313.

19. Gurses AP, Murphy DJ, Martinez EA, Berenholtz SM, Pronovost PJ. A practical tool to identify and eliminate barriers to compliance with evidence-based guidelines. Jt Comm J Qual Patient Saf 2009 Oct; 35(10):526, 32, 485.

20. Pogorzelska M, Stone PW, Furuya EY, et al. Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit. Int J Qual Health Care. 2011.

21. Bigham MT, Amato R, Bondurrant P, et al. Ventilator-associated pneumonia in the pediatric intensive care unit: Characterizing the problem and implementing a sustainable solution. J Pediatr. 2009;154(4):582-587.e2.

22. Hatler CW, Mast D, Corderella J, et al. Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: A pilot project. Am J Crit Care. 2006;15(6):549-555.

23. Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for increasing patient safety in the intensive care unit: Increasing the implementation rates of proven safety measures. Qual Saf Health Care. 2009;18(1):74-80.

24. Westwell S. Implementing a ventilator care bundle in an adult intensive care unit. Nurs Crit Care. 2008;13(4):203-207.

25. NHSN. National healthcare safety network (NHSN) surveillance for ventilator-associated events (VAE). http://www.cdc.gov/nhsn/acute-care-hospital/vae/index.html. Updated 2013. Accessed April 4, 2013.

26. Hawe CS, Ellis KS, Cairns CJ, Longmate A. Reduction of ventilator-associated pneumonia: Active versus passive guideline implementation. Intensive Care Med. 2009;35(7):1180-1186.

27. Hatler CW, Mast D, Corderella J, et al. Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: A pilot project. Am J Crit Care. 2006;15(6):549-555.

28. Scales DC. Pneumonia in the ICU: A lethal or VAPid complication? Am J Respir Crit Care Med. 2011;184(10):1097-1098.

29. Bouadma L, Deslandes E, Lolom I, et al. Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis. 2010;51(10):1115-1122.

30. Rello J, Lode H, Cornaglia G, Masterton R, VAP Care Bundle Contributors. A european care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med. 2010;36(5):773-780.

31. Salahuddin N, Zafar A, Sukhyani L, et al. Reducing ventilator-associated pneumonia rates through a staff education programme. J Hosp Infect. 2004;57(3):223-227.

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http://www.cdc.gov/nhsn/acute-care-hospital/vae/index.html

32. Mangino JE, Peyrani P, Ford KD, et al. Development and implementation of a performance improvement project in adult intensive care units: Overview of the improving medicine through pathway assessment of critical therapy in hospital-acquired pneumonia (IMPACT-HAP) study. Crit Care. 2011;15(1):R38.

33. Youngquist P, Carroll M, Farber M, et al. Implementing a ventilator bundle in a community hospital.. Jt.Comm.J.Qual.Patient Saf. 2007;33(4):219-25.

34. Zaydfudim V, Dossett LA, Starmer JM, et al. Implementation of a real-time compliance dashboard to help reduce SICU ventilator-associated pneumonia with the ventilator bundle. Arch Surg. 2009;144(7):656-662.

35. Sinuff T, Muscedere J, Cook D, Dodek P, Heyland D, Canadian Critical Care Trials Group. Ventilator-associated pneumonia: Improving outcomes through guideline implementation. J Crit Care. 2008;23(1):118-125.

36. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet. 2008;371(9607):126-134.

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Appendices

Appendix A CUSP for VAP: EVAP Prevention Bundle

Appendix B Oral Care with Chlorhexidine (CHG), Literature Synopsis

Appendix C Subglottic Suctioning and Subglottic ETT, Literature Synopsis

Appendix D Spontaneous Awakening and Spontaneous Breathing Trials, Literature Synopsis

Appendix E Head of Bed (HOB) Factsheet

Appendix F Oral care with Chlorhexidine (CHG) Factsheet

Appendix G Subglottic Suctioning (SS) Factsheet

Appendix H Spontaneous Awakening and Breathing (SAT and SBT) Trials Factsheet

Appendix I Policy Driven Structural Measures Factsheet

Appendix J Definitions and Techniques for Oral Care with Chlorhexidine (CHG)

Appendix K Definitions and Techniques for Spontaneous Awakening and Breathing

(SAT and SBT) Trials

Appendix L Daily Data Collection Sheet and Instructions

Appendix M Quiz Questions for VAP

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Appendix A: CUSP for VAP: EVAPVAP Prevention Bundle

Process Measur

Process Measures: Daily Evaluation

1. Head of bed elevation (HOB) – use of a semi-recumbent position (≥30 )⁰2. Spontaneous awakening and breathing trials (SAT and SBT) – Make a daily assessment

of readiness to wean with the use of the SAT and SBT.3. Oral care – at least 6 times per day4. Oral care with chlorhexidine – 2 times per day5. Subglottic Suctioning – use subglottic suctioning in patients expected to be MV for >72

hours

Policy Bases/Structural Measures

1. Use a closed ETT suctioning system2. Change close suctioning catheters only as needed3. Change ventilator circuits only if damaged or soiled4. Change HME every 5-7 days and as clinically indicated5. Provide easy access to NIVV equipment and institute protocols to promote use6. Periodically remove the condensate from circuits, keeping the circuit closed during the

removal, taking precautions no to allow condensate to drain toward patient7. Use an early mobility protocol8. Perform hand hygiene9. Avoid supine position10.Use standard precautions while suctioning respiratory tract secretions11.Use orotracheal intubation instead of nasotracheal12.Avoid use of prophylactic systemic antimicrobials13.Avoid non-essential tracheal suctioning14.Avoid gastric over-distention

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Appendix B: Oral Care with Chlorhexidine (CHG),Literature Synopsis

Ventilator-Associated Pneumonia Prevention BundleRegular oral care with CHG is associated with decreased colonization of dental plaque, and a decreased incidence of ventilator-associated pneumonia (VAP). Increasing evidence to support this intervention has emerged over the past several years. Of the two most recent guidelines, published in 2008, one states that its use should be considered and one supports the use of regular oral care with an antiseptic solution, however the use of CHG is not specifically addressed.Most recently in 2011, a systematic review and meta-analysis of 12 randomized trials supports the use of oral care with CHG for VAP prevention. Overall, this study found a 38% VAP reduction. Favorable effects were more pronounced in cardiosurgical studies (up to a 59% VAP reduction).

2008- Society for Healthcare Epidemiology of America Guidelines: A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts.1

Perform regular oral care with an antiseptic solution in accordance with product guidelines. While the use of chlorhexidine is not specifically addressed, the 3 studies cited by the guideline below all demonstrated the efficacy of CHG.

Articles Cited in GuidelineStudy Type and Author Results - Details in Annotated Bibliography

0.12% CHG oral rinse vs placebo(DeRiso, 1996) 2

Pro – Study focused on patients undergoing coronary artery bypass grafting, valve or other open heart procedure. Overall nosocomial infection rate decreased by 65%. Respiratory tract infections rate was reduced by 89%.

0.12% CHG oral & nasogastric rinse vs placebo

Segers, 2006) 3

Pro – Study focused on adult patients undergoing elective cardiothoracic surgery. Lower respiratory tract infections and deep SSIs were less common in the CHG group. Decontamination of the nasopharynx and oropharynx with CHG appears to be an effective method to reduce nosocomial infection after surgery.

Peridex (0.12% CHG) vs Listerine(Houston, 2002) 4

Pro – Study focused on patients undergoing aortocoronary bypass or valve surgery requiring cardiopulmonary bypass. . In patients intubated for >24 hours with cultures that showed microbial growth, the rate of pneumonia was 71% lower in the Peridex group than in the Listerine group. Rates of nosocomial pneumonia were lower in patients treated with Peridex.

2004-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of ventilator-associated pneumonia.5

The use of the oral antiseptic chlorhexidine should be considered. Based on 1 level 1 and 2 level 2 trials, the use of the oral antiseptic CHG may decrease the incidence of

VAP. Safety, feasibility, and cost considerations for this intervention are all very favorable.

Articles Cited in Guideline

1

Study Type and Author Results - Details in Annotated Bibliography

0.2% CHG vs placebo(Fourrier, 2005) 6

Con – Study focused on a population of nonedentulous patients requiring endotracheal intubation and mechanical ventilation. Gingival and dental plaque antiseptic decontamination significantly decreased the oropharyngeal colonization by aerobic pathogens. Efficacy was insufficient to reduce the number of respiratory infections due to MDR bacteria. No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days.

0.2% CHG vs standard oral care(Fourrier, 2000) 7

Pro – Study focused on patients admitted to ICU requiring mechanical ventilation with an expected >5 day stay. There was a trend to a reduction of mortality, length of stay and duration of mechanical ventilation. Decreases dental bacterial colonization and may reduce incidence of nosocomial infections.

2% CHG vs 2% CHG+2% colistin vs placebo

(Koeman, 2006) 8

Pro – Study focused on patients needing mechanical ventilation for ≥ 48 hours. Risk of VAP reduced in both CHG groups. CHG+Colistin provided significant reduction in oropharyngeal colonization with both gram-negative and gram-positive microorganisms, whereas CHG mostly affected gram-positive microorganisms. Endotracheal colonization was reduced for CHG+Colistin patients and to a lesser extent for CHG patients..

2004-Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.9

Recommends regular oral care. States that chlorhexidine has prevented hospital-acquired pneumonia in specific populations such as those undergoing coronary bypass grafting, However, also states that routine use is not recommended until more data is available.



Pro – Study focused on patients undergoing coronary artery bypass grafting, valve or other open heart procedure. Overall nosocomial infection rate decreased by 65%. Respiratory tract infections rate was reduced by 89%. (Previously cited in SHEA Guidelines, above)

2003-CDC Guidelines for preventing Health-Care-Associated Pneumonia10

No recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of health-care–associated pneumonia in all postoperative or critically ill patients and/or other patients at high risk for pneumonia (Unresolved issue) (II)



Pro – Study focused on patients undergoing coronary artery bypass grafting, valve or other open heart procedure. Overall nosocomial infection rate decreased by 65%. Respiratory tract infections rate was reduced by 89%. (Previously cited in SHEA Guidelines, above)

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Post Guideline Publications:Post Guideline Publications, 2007-2012

Study Type and Author Results - Details in Annotated BibliographySystematic Review (no meta-analysis)

(CHG and toothbrushing)(Roberts, 2011) 11

Pro – Analyzed RCTs assessing the effectiveness of CHG and toothbrushing to reduce VAP rates. CHG has been proven to be of value in reducing VAP.

Review and Meta-analysis(CHG vs povidone-iodine)

(Labeau, 2011) 12

Pro – Analyzed RCTs of mechanically ventilated adult patients receiving oral care with CHG or povidone-iodine. CHG shown to be effective. Effect more pronounced in cardiac surgery patients.

0.12% CHG vs placebo(Jacomo, 2011) 13

Con – Study focused on children undergoing surgery for congenital heart disease. There was a non-statistical increase of VAP in the treatment group.

Single dose 5 mL CHG w/oral swab vs control (no swab)(Grap, 2011) 14

Pro – Study focused on trauma patients requiring endotracheal intubation. Treatment group had lower CPIS scores at 48 and 72 hours and a statistically insignificant lower rate of VAP. In patients without pneumonia at baseline, the reduction in the incidence of VAP was greater.

Consensus development(Berry, 2011) 15

Con – There is no evidence to support the use of one oral rinse over another in mouth care, exception of CHG in the cardiac surgery population.

Consensus development(Rello-2010) 16

Pro – Used a “bundle development strategy” to choose the most effective interventions to include in a VAP Care Bundle. Oral care with chlorhexidine is number 5 in the European care bundle.

0.12% CHG vs placebo-(Scannapieco, 2009) 17

Neutral – Study focused on intubated patients in a trauma ICU. Nonsignificant reduction in pneumonia rate noted in groups treated with CHG.

0.12% CHG vs placebo(Bellissimo-Rodrigues, 2009) 18

Con – This study does not specifically look at patients on mechanical ventilation. Study focused on patients admitted to the ICU with a prospective length of stay of over 48 hours. Overall incidence of respiratory tract infections similar between treatment and control groups.

0.12% CHG vs placebo(Pedreira, 2009) 19

Pro – Study focused on oral colonization in 65 children receiving mechanical ventilation. On day 2, number of children with an increase in positive samples was higher in the control group. However, the difference was not significant.

0.12% CHG+swab bid, toothbrushing tid, 0.12% CHG+toothbrushing tid and usual

care(Munro, 2009) 20

Pro – Study focused on adult patients enrolled within 24 hours of intubation. Significantly reduced the incidence of pneumonia on day 3. CHG reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

0.12% CHG+gauze application vs 0.12% CHG+electric toothbrush application

(Pobo, 2009) 21

Neutral – This study did not specifically address the effectiveness of CHG, but addressed the appropriate use of CHG. Study focused on adult patients intubated for >48 hours. Groups had similar rates of suspected VAP.

Review and Meta-analysis(Chan, 2007) 22

Pro – This analysis did not specifically address the use of CHG, but addressed the effect of using antibiotics and antiseptics for the prevention of VAP. Analyzed RCTs evaluating the efficacy of daily oral application of antibiotics or antiseptics with no prophylaxis on mechanically ventilated adult patients. Oral decontamination can reduce the incidence of VAP. Of the evaluated studies, only one did not use CHG. CHG efficacy may be dependent on concentration.

Review(Gastmeier, 2007) 23

Pro – Reviewed articles published since 2004 dealing with infection control measures for prevention of VAP. Special emphasis was placed on RCTs, meta-analyses, systematic reviews and studies reviewing multimodal interventions. The data lead to the conclusion that topical use of chlorhexidine for oral care is beneficial.

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Annotated Bibliography1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals • . Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31-S40. Available from: http://www.jstor.org/stable/10.1086/591062. 2. DeRiso AJ,2nd, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109(6):1556-1561.

Pro – 0.12% CHG oral rinse vs placebo – This study looked at all HAIs in 353 cardiac surgery patients ondergoing coronary artery bypass grafting, valve or other open heart procedure. The overall nosocomial infection rate was decreased in the CHG-treated patients by 65% (24/180 vs 8/173; p<0.01). We also noted a 69% reduction in the incidence of total respiratory tract infections in the CHG-treated group (17/180 vs 5/173; p<0.05) . Gram-negative organisms were involved in significantly less (p<0.05) of the nosocomial infections and total respiratory tract infections by 59% and 67%, respectively. No change in bacterial antibiotic resistance patterns in either group was observed. The use of nonprophylactic IV antibiotics was lowered by 43% (42/180 vs 23/173; p<0.05). A reduction in mortality in the CHG-treated group was also noted (1.16% vs 5.56%). Inexpensive and easily applied oropharyngeal decontamination with CHG oral rinse reduces the total nosocomial respiratory infection rate and the use of nonprophylactic systemic antibiotics in patients undergoing heart surgery. This results in significant cost savings for those patients who avoid additional antibiotic treatment. [[ for respiratory infections, NNT= 15.25 ]]

3. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: A randomized controlled trial. JAMA. 2006;296(20):2460-2466.

Pro – 0.12% CHG oral & nasogastric rinse vs placebo – This study looked at all HAIs in 954 cardiac surgery patients. The incidence of nosocomial infection in the chlorhexidine gluconate group and placebo group was 19.8% and 26.2%, respectively (absolute risk reduction [ARR], 6.4%; 95%confidence interval [CI], 1.1%-11.7%; P=.002). In particular, lower respiratory tract infections and deep surgical site infections were less common in the chlorhexidine gluconate group than in the placebo group (ARR, 6.5%; 95% CI, 2.3%-10.7%; P=.002; and 3.2%; 95% CI, 0.9%-5.5%; P=.002, respectively) [[ for lower respiratory tract infections, NNT= 15.38 ]]

4. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. 2002;11(6):567-570.

Pro – Peridex (0.12% CHG) vs Listerine – Study focused on a population of 561 patients undergoing aortocoronary bypass or valve surgery requiring cardiopulmonary bypass. The rate of nosocomial pneumonia was reduced by 52% (4/270 vs 9/291; p=.21) in the Peridex-treated patients. Among patients intubated for more than 24 hours who had cultures that showed microbial growth (all pneumonias occurred in this group), the pneumonia rate was reduced by 58% (4/19 vs 9/18; p=.06) in patients treated with Peridex. In patients intubated for > 24 hours , with cultures showing the most growth, the rate was 71% lower in the Peridex group (2/10 vs 7/10; p=.02). [[ for nosocomial pneumonia, for patients intubated for >24 hours, NNT= 3.45; for pneumonia among patients intubated for more than 24 hours who had cultures that showed microbial growth, NNT=2 ]]

5. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment. J Crit Care. 2008;23(1):138-147. 6. Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: A double-blind placebo-controlled multicenter study. Crit Care Med. 2005;33(8):1728-1735.

Con – 0.2% CHG vs placebo - Study focused on a population of 228 nonedentulous patients requiring endotracheal intubation and mechanical ventilation. The incidence of nosocomial infections was 17.5% (13.2 per 1000 ICU days) in the placebo group and 18.4% (13.3 per 1000 ICU days) in the plaque antiseptic decontamination group (not significant). No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days, mortality, length of stay, and care loads (secondary end points). On day 10, the number of positive dental plaque cultures was significantly lower in the treated group (29% vs. 66%; p < .05). Highly resistant Pseudomonas, Acinetobacter, and Enterobacter species identified in late-onset ventilator-associated pneumonia and previously cultured from dental plaque were not eradicated by the antiseptic decontamination.

7. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med. 2000;26(9):1239-1247.

Pro - 0.2% CHG vs standard oral care - Study focused on patients admitted to the ICU with a medical condition suggesting an ICU stay of 5 days and requiring mechanical ventilation. Sixty patients were included; 30 in the treated group and 30 in the control one (mean age: 51 +/- 16 years; mean Simplified Acute Physiological Score II: 35 +/- 14 points)````. On admission, no significant differences were found between both groups for all clinical and dental data. Compared with the control group, the nosocomial infection rate and the incidence densities related to risk exposition were significantly lower in the treated group (18 vs 33% days in the ICU and 10.7 vs 32.3% days of mechanical ventilation; P < 0.05). These results were consistent with a significant preventive effect of the antiseptic decontamination (Odds Ratio: 0.27; 95% CI: 0.09; 0.80) with a 53% relative risk reduction. There was a trend to a reduction of mortality, length of stay, and duration of mechanical ventilation.

8. Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;173(12):1348-1355.

Pro - CHG vs CHG+Colistin vs placebo - Study focused on 385 patients needing mechanical ventilation for ≥ 48 hours. 130 received placebo, 127 CHG and 128 CHG+Colistin. The daily risk of VAP was reduced in both treatment groups compared with placebo: 65% (hazard ratio [HR] 0.352; 95% confidence interval [CI], 0.160, 0. 791; p _ 0.012) for CHG and 55% (HR _ 0.454; 95% CI, 0.224, 0. 925; p _ 0.030) for CHG+Colistin. CHG+Colistin provided significant reduction in oropharyngeal colonization with both gram-negative and gram-positive microorganisms, whereas CHG mostly affected gram-positive microorganisms. Endotracheal colonization was reduced for CHG+Colistin patients and to a lesser extent for CHG patients.

9. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.

10. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidleines for preventing healthcare-associated pneumonia, 2003: Recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep. 2004;53:1-36.

11. Roberts N, Moule P. Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates. Nurs Crit Care. 2011;16(6):295-302.

Pro – Systematic Review of 17 papers addressing the use of CHG and toothbrushing to reduce VAP rates. The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing. [[Pooled estimates of efficacy not calculated]]

12. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: A systematic review and meta-analysis. Lancet Infect Dis. 2011.

Pro – Review and meta-analysis of 14 papers looking at the effect of oral care with CHG or povidone-iodine vs. standard oral care to reduce VAP rates. 12 studies looked at CHG and 2 at povidone-iodine. Chlorhexidine application was shown to be effective (RR 0·72; 95% CI 0·55–0·94; p=0·02), whereas the effect resulting from povidone-iodine remains unclear (RR 0·39; 95% CI 0·11–1·36; p=0·14). Heterogeneity was moderate (I²=29%; p=0·16) for the trials using chlorhexidine and high (I²=67%; p=0·08) for those assessing povidone-iodine use. Favourable eff ects were more pronounced in subgroup analyses for 2% chlorhexidine (RR 0·53, 95% CI 0·31–0·91), and in cardiosurgical studies (RR 0·41, 95% CI0·17–0·98)

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13. Jacomo AD, Carmona F, Matsuno AK, Manso PH, Carlotti AP. Effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia in children undergoing cardiac surgery. Infect Control Hosp Epidemiol. 2011;32(6):591-596.

Con – CHG vs placebo - Study focused on 160 children undergoing surgery for congenital heart disease. There was no difference between the two groups.CHG vs placebo - The incidence of nosocomial pneumonia was 29.8% versus 24.6% (p=0.46) and the incidence of VAP was 18.3% versus 15% (p=0.57) in the chlorhexidine and the control group, respectively. There was no difference in intubation time (p=0.34), need for reintubation (p=0.37), time interval between hospitalization and nosocomial pneumonia diagnosis (p=0.63), time interval between surgery and nosocomial pneumonia diagnosis (p=0.10), and time on antibiotics (p=0.77) and vasoactive drugs (p=0.16) between groups. Median length of PICU stay (3 vs 4 days; p=0.53), median length of hospital stay (12 vs 11 days; p=0.67), and 28-day mortality (5.7% vs 6.8%; p=0.77) were also similar in the chlorhexidine and the control group.

14. Grap MJ, Munro CL, Hamilton VA, Elswick RK,Jr, Sessler CN, Ward KR. Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients. Heart Lung. 2011;40(5):e115-22.

Pro – Single dose 5 mL CHG w/oral swab vs control (no swab) - Study focused on 145 trauma patients requiring endotracheal intubation. A significant treatment effect was found on CPIS scores both from admission to 48 hours (P =.020) and to 72 hours (P = .027). In those subjects without pneumonia at baseline (CPIS < 6) (n=17), 55.6% of the control patients (10/18) had developed VAP by 48 or 72 hours versus only 33.3% of the intervention patients (7/21). [[ for VAP rates, NNT = 4.5 ]]

15. Berry AM, Davidson PM, Nicholson L, Pasqualotto C, Rolls K. Consensus based clinical guideline for oral hygiene in the critically ill. Intensive Crit Care Nurs. 2011;27(4):180-185.

Pro – Consensus development process - At the present time there is no evidence to support the use of one oral rinse over another in mouth care: The exception is the use of chlorhexidine gluconate 0.12% in the cardiac surgical patient population.

16. Rello J, Lode H, Cornaglia G, Masterton R, VAP Care Bundle Contributors. A european care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med. 2010;36(5):773-780

Pro - Consensus development process - Through a “bundle development strategy” a bundle of interventions for the prevention of VAP was developed. Oral care with CHG was considered to be number 5 in the list of included items for VAP prevention.

17. Scannapieco FA, Yu J, Raghavendran K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care. 2009;13(4):R117.

Neutral – 0.12% CHG once or twice per day vs placebo - This study focused on oral colonization in 175 intubated patients in a trauma unit. 60 patients were dropped due to insufficient data. Using intent-to-treat analysis (n=175), a 41% of reduction in the rate of pneumonia was noted between the treated and placebo group (odds ratio (OR) = 0.54, 95% confidence interval (CI): 0.23 to 1.25, P = 0.1459); however, the differences were found not to be statistically significant. The incidence of pneumonia by survival analysis showed that the onset of pneumonia tended to be delayed in the treated groups when compared with the control group; however, these differences were not statistically significant (hazards ratio (HR) = 0.555, 95% CI: 0.256 to 1.201, P = 0.1348). A nonsignificant reduction in pneumonia rate was noted in groups treated (n=116) with chlorhexidine compared with the placebo group (n=59) (OR = 0.54, 95% CI: 0.23 to 1.25, p= 0.15). No evidence for resistance to chlorhexidine was noted, and no adverse events were observed. No differences were noted in microbiologic or clinical outcomes between treatment arms. However, it did reduce the number of S. aureus in dental plaque of trauma intensive care patients. [[ for VAP rates in the intent-to-treat analysis, NNT = 11.5 ]]

18. Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, et al. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infect Control Hosp Epidemiol. 2009;30(10):952-958.

Neutral – CHG vs placebo - Study focused on patients admitted to the ICU with a prospective length of stay greater than 48 hours, regardless of whether they received mechanical ventilation. This study was not specifically targeted at mechanically ventilated patients. The overall incidence of respiratory tract infections in the treatment group vs placebo was 21 (n=98) and 25 (n=96), respectively (RR, 1.0 [95% CI, 0.63–1.60) and the rates of ventilator-associated pneumonia per 1,000 ventilator-days were similar in both experimental and control groups (22.6 vs 22.3; p=0.95). Respiratory tract infection–free survival time (7.8 vs 6.9 days; p=0.61), duration of mechanical ventilation (11.1 vs 11.0 days; p=0.61), and length of stay (9.7 vs 10.4 days; p=0.67) did not differ between the chlorhexidine and placebo groups. However, patients in the chlorhexidine group exhibited a larger interval between ICU admission and onset of the first respiratory tract infection (11.3 vs 7.6 days; p=0.05). [[ for respiratory tract infections, NNT= 21 ]]

19. Pedreira ML, Kusahara DM, de Carvalho WB, Nunez SC, Peterlini MA. Oral care interventions and oropharyngeal colonization in children receiving mechanical ventilation. Am J Crit Care. 2009;18(4):319-28; quiz 329.

Pro - 0.12% CHG vs placebo - Study focused on 56 children (47 intubated and 9 with < 24 hours intubation) admitted to the PICU. They evaluated colonization of the oropharynx at day 0, 2, 4, and PICU discharge. During the first 48 hours of PICU admission, the number of children colonized with pathogenic microorganisms decreased in the experimental group and increased in the control group. Colonization by pathogenic bacteria did not differ between the 2 groups of children. From day 0 to day 2, the number of children with an increase in the number of samples positive for pathogenic flora was greater in the control group than in the experimental group, but the difference was not significant. Similarly, the colonization of the oral cavity by normal flora did not differ between the 2 groups of children. The 2 groups did not differ significantly in the colonization of normal (P= .72) or pathogenic (P= .62) flora, in the duration of mechanical ventilation (P= .67), or in length of stay in the intensive care (P= .22).

20. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care. 2009;18(5):428-37; quiz 438.

Pro - 0.12% CHG+swab bid, toothbrushing tid, 0.12% CHG+toothbrushing tid and usual care - Study focused on 547 adult patients enrolled within 24 hours of intubation. However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (n=87) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine. Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

21. Pobo A, Lisboa T, Rodriguez A, et al. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;136(2):433-439.

Neutral – This study looks at the effect of adding toothbrushing to care with CHG. Standard care, defined as 0.12% CHG oral care (20 mL applied with gauze and a 10 mL rinse) vs standard care with the addition of an electronic toothbrush - Study focused on adult patients expected to be mechanically ventilated for >48 hours (n=147) The standard care and standard care + toothbrush groups had similar rates of suspected VAP (20.3% vs 24.7%; p _ 0.55). After adjustment for severity of illness and admission diagnosis, the incidence of microbiologically documented VAP was also similar in the two groups (hazard ratio, 0.84; 95% confidence interval, 0.41 to 1.73). The groups did not differ significantly in mortality, antibiotic-free days, duration of MV, or hospital ICU LOS. [[ to assess the effect of toothbrushing added to oral care with CHG, NNT=23

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22. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. BMJ. 2007;334(7599):889.

Pro - This study does not specifically address the use of CHG. Rather, it assesses the effect of antibiotics and antiseptics in general. Study focused on 11 RCTs enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis. In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). Of the evaluated studies, only one did not use CHG. CHG efficacy may be dependent on concentration. Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia.

23. Gastmeier P, Geffers C. Prevention of ventilator-associated pneumonia: Analysis of studies published since 2004. J Hosp Infect. 2007;67(1):1-8.

Pro - Systematic review - Special emphasis was placed on randomized controlled trials (RCTs), meta-analyses or systematic reviews and studies applying multi-module interventions. A total of 15 RCTs and seven meta-analyses or systematic reviews were found. In addition to these, five cohort studies were identified where multi-module programmes were introduced for reducing VAP rates. The data lead to the conclusion that topical use of chlorhexidine for oral care is beneficial and subglottic secretion drainage may lead to delayed onset of VAP. Often simple interventions are useful for the reduction of VAP rates, for which the best chances appeared to be the application of multi-module programmes. On average a reduction of more than 40% seems to be possible.

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Appendix C: Subglottic Suctioning and Subglottic ETT, Literature Synopsis

Ventilator Associated Pneumonia Prevention BundleContinuous or frequent intermittent suctioning of subglottic secretions, via an endotracheal tube (ETT) specially designed with a dorsal lumen to accommodate this, is associated with up to a 50% decreased incidence of aspiration and VAP. Guidelines support the use of subglottic suctioning and drainage for patients dependent on mechanical ventilation. Most recently in 2011, a systematic review and meta-analysis of 13 randomized trials support the use of subglottic drainage for VAP prevention. The 2011 analysis found a 45% reduction of VAP along with a 1.5 days reduction in length of stay and 1.1 days of ventilation.

2008 -Society for Healthcare Epidemiology of America Guidelines: A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts.1

Recommends the use of cuffed ETT with in line subglottic suction to prevent aspiration and reduce VAP risk factor.


Systematic Meta-Analysis Drainage vs. Standard

(Dezfulian, 2005) 2

Pro- Analyzed 5 RCT to assess the efficacy of subglottic secretion drainage in preventing VAP. Study showed that subglottic secretion drainage can reduced the incidence of VAP by nearly half in patients requiring mechanical ventilation.

CDC Guideline- 20033

Pro - If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient’s subglottic area. (See CDC Section)

Review(Kollef, 2004) 4

Pro-This review did not specifically address subglottic suctioning. However, it recommended the use of endotracheal tube with separate dorsal lumen based on the beneficial effect on lowering VAP incidences.

Continuous vs. Closed Lumen Care (Valles, 1995) 5

Pro- Study focused on ICU patients expected to be intubated for >3 days. The study findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues subglottic suctioning through the dorsal lumen.

* Continuous vs. w/o Suctioning (Kollef, 1999) 6

Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that the occurrence of VAP can be significantly delayed with the use of continuous aspiration of subglottic secretion.

Contempo(Cook, 1998) 7

Pro- This article did not focus on suctioning, but summarized 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning.

Drainage vs. Sucralfate (Mahul, 1992) 8

Pro- Study focused patients requiring mechanical ventilation for >3 days. Findings showed subglottic drainage was effective at lowering nosocomial pneumonia, but sucralfate prevention was not.

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2008-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of ventilator-associated pneumonia1

Subglottic Secretion Drainage is recommended for patients requiring to be mechanically ventilated for more than 72hrs.

Articles Cited in Guideline

Study Type and Author Results - Details in Annotated BibliographyDrainage vs. Conventional Oral ETT

(Smulders, 2002)9

Pro- Study focused on ICU patients expected to be mechanical ventilated >72 h. Findings showed that intermittent subglottic secretion drainage reduces the rate of VAP in patient receiving mechanical ventilation.

Drainage vs. Control(Bo, 2000)10

Pro- Study focused on surgical patients who required intubation. Study showed that the morbidity of VAP can be reduced by using subglottic secretion drainage; especially for gram- positive cocci and Haemophilius influenzae caused VAP cases.

Continuous vs. Closed Lumen Care

(Valles, 1995)5

Pro- Study focused on medical and surgical patients requiring prolonged intubation (> 3 days). Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues subglottic suctioning.(Previously cited by SHEA)

Drainage vs. Sucralfate (Mahul, 1992)8

Pro- Study focused on patients who required mechanical ventilation for > 3 days. Findings showed that subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not. (Previously cited by SHEA )

2004-Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. 11

Recommends the use of specifically designed ETT with dorsal lumen for the continues aspiration of subglottic secretion.


Continuous vs. w/o Suctioning (Kollef, 1999) 6

Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that VAP occurrence can be significantly delayed with the use of continuous aspiration of subglottic secretion. (Previously cited by SHEA )

Continuous vs. Closed Lumen Care

(Valles, 1995) 5

Pro- Study focused on patients requiring prolonged intubation (> 3 days) in the medical – surgical ICU. Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues suctioning. (Previously cited by SHEA and ZAP)

Drainage vs. Sucralfate (Mahul, 1992) 8

Pro- Study focused on patients who required mechanically ventilated for more than 3 days. Study showed that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not. (Previously cited by SHEA and ZAP)

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2003- CDC Guidelines for preventing Health-Care-Associated Pneumonia; Evidence-based, clinical practice guidelines for the prevention of healthcare-associated pneumonia, including VAP. 3

Recommends the use of an ETT dorsal lumen above the endotracheal cuff to allow drainage by continuous or frequent intermittent suctioning of tracheal secretion that accumulates in patient’s subglottic area.


Intermittent Drainage vs. Standard ETT(Smulders, 2002) 9

Pro- Study focused on ICU patients expected to be mechanical ventilated >72 h .Findings showed that intermittent subglottic secretion drainage reduces the rate of VAP in patient receiving mechanical ventilation.

Continuous vs. w/o Suctioning(Kollef, 1999) 6

Pro- Study focused on cardiothoracic c surgery patients requiring mechanical ventilation. Findings showed that the occurrence of VAP can be significantly delayed with the use of continuous aspiration of subglottic secretion. (Previously cited by SHEA and ATS)

Contempo(Cook, 1998)7

Pro- This article did not focus on suctioning, but summarized 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning. (Previously cited by SHEA)

Continuous vs. Closed Lumen ETT

(Valles, 1995) 5

Pro- Study focused on patients requiring prolonged intubation (> 3 days) in the medical – surgical intensive care unit. Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues suctioning. (Previously cited by SHEA, ZAP and ATS}

Drainage vs. Sucralfate(Mahul, 1992) 8

Pro- Study focused on patients who required mechanically ventilated patient for more than 3 days. Study findings conclude that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not. (Previously cited by SHEA, ATS, and ZAP)

Post Guideline Publications:

Post Guideline Publications, 2007-2012Study Type and Author Results - Details in Annotated Bibliography

Systematic Review and Meta-Analysis (Leasure, 2012)12

Pro- Study reviewed 12 original articles and 4 reviews that evaluated the effectiveness of subglottic secretion drainage (SDD) in reducing the occurrence of VAP. The findings of review support the recommendation for use of ETTs with SSD based on a 52% reduction rate.

Systematic Review and Meta-Analysis(Muscedere, 2011) 13

Pro- Study focused on 13 RCTs evaluating subglottic secretion drainage in adult mechanically ventilated patients. Study findings support the use of subglottic endotracheal tube in reduction rate of VAP.

Intermittent Drainage vs. Closed Suctioning System

(Juneja, 2011) 14

Pro - Study focused on patients requiring mechanical ventilation for more than 72 hours. Study findings conclude that intermittent subglottic drainage reduces the incidence of VAP.

Cost Benefit AnalysisConventional Tubes vs. Continuous

Subglottic Suctioning Tubes (Hallais, 2011) 15

Pro- Study in France analyzed the cost benefit of 416 surgical ICU patients receiving mechanical ventilation for 3,487 ventilation days. Finding showed replacing conventional ventilator tubes with continuous subglottic suctioning tubes were cost the cost averted per VAP episode is €1,383.69.

Business CaseContinues ETT vs. Standard ETT

(Speroni ,2011) 16

Pro- Study was focused on medical and surgical ICU patients who were expected to be ventilated for >48 hrs. Study findings recommend the use of Continues -ETT over Standard S-ETT based on the final attributable cost of VAP.

3

Systematic Review(Overend, 2009) 17

Pro- Analyzed 15 RCT and 13 RCO of mechanically ventilated adult patients. Study showed that new evidence continues to be varied in strength for suctioning practice, but the evidence has improved since 2001 suggesting that members of the health care team should incorporate this evidence into their practice.

Literature Review(Depew, 2007) 18

Pro- Review of meta-analysis 2 that looked at 5RCT that compared aspiration of subglottic secretion vs. standard ETT care. Findings conclude that there insufficient outcome evidence to support the use of subglottic technology – aside from the VAP rate reduction.

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Annotated Bibliography

1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals. Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31-S40. Available from: http://www.jstor.org/stable/10.1086/591062.

2. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia:A meta-analysis. American Journal of Medicine. 2005;11-18(118).

Pro- Meta Analysis – Drainage vs. Standard Endtracheal Treatment - Study evaluated 896 patients from 5 RCT who required mechanical ventilation. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia by nearly half (risk ratio [RR] = 0.51; 95% confidence interval [CI]: 0.37 to 0.71), primarily by reducing early-on set pneumonia (pneumonia occurring within 5 to 7 days after intubation). Subglottic secretion drainage appears effective in preventing early-onset ventilator-associated pneumonia among patients expected to require >72 hours of mechanical ventilation .


4. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004;32(6):1396-1405.

Pro- Review - Synthesized the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator- associated pneumonia (VAP) This review did not specifically address subglottic suctioning, but recommends the use of endotracheal tube with separate dorsal lumen based on 4 papers that showed beneficial effect.

5. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Annals of Internal Medicine. 1995(122):179–186.

Pro- Continuous vs. Closed Lumen ETT - Study focused on 190 ICU patients expected to be intubated for >3 days. The incidence rate of VAP was 19.9 episodes/1000 ventilator days in the patients receiving continuous aspiration of subglottic secretions and 39.6 episodes/1000 ventilator days in the control patients (closed lumen ETT) (relative risk, 1.98; 95% CI, 1.03 to 3.82). Episodes of ventilator-associated pneumonia developed later in patients receiving continuous aspiration (12.0 ± 7.1 days) than in the control patients (5.9 ± 2.1 days) (P < 0.001).This difference was due to a significant (P < 0.03) reduction in the number of gram-positive cocci and Haemophilus influenzae organisms in the patients receiving continuous aspiration.

6. Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999;116(5):1339-1346.

Pro- Continuous vs. w/o Suctioning - Study focused on 371 cardiac surgery patient requiring mechanical ventilation in the Cardiothoracic ICU. VAP was seen in 8 patients (5.0%) receiving continues suctioning and in 15 patients (8.2%) receiving routine postoperative medical care without suctioning (relative risk, 0.61%; 95% confidence interval, 0.27 to 1.40; p = 0.238). Episodes of VAP occurred statistically later among patients receiving continuous suctioning ([mean ± SD] 5.6 ± 2.3 days) than among patients who did not receive suctioning (2.9 ± 1.2 days); (p = 0.006) . No statistically significant differences for hospital mortality, overall duration of mechanical ventilation, lengths of stay in the hospital or CTICU, or acquired organ system derangements were found between the two treatment groups. The occurrence of VAP can be significantly delayed among patients undergoing cardiac surgery using this simple-to-apply technique of continuous suctioning.

7. Cook DJ, Kollef MH. Risk factors for ICU-acquired pneumonia. JAMA. 1998;279(20):1605-1606. Pro- This review did not focus on subglottic suctioning intervention, but summarizes 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning.

8. Mahul P, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: Respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Medecine. 1992(18):20-25.

Pro- Drainage vs. Sucralfate - Study focused 145 patients who required mechanically ventilated for > 3 days. Subglottic secretion drainage (SSD) treatment was associated with: a) a twice lower incidence of nosocomial pneumonia (NP) (no-SSD: 29.1%, SSD: 13%); b) a prolonged time of onset of NP (no-SSD: 8.3±5 days, SSD: 16.2±11 days); c) a decrease in the colonization rate from admission to end-point day in tracheal aspirates (no-SSD:+21.3%, SSD:+6.6%) and in subglottic secretions (no-SSD:+33.4%, SSD:+2.1%). Study findings conclude that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.

9. Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest. 2002;121(3):858-862.

Pro- Intermittent Drainage vs. Standard ETT - Study focused on 150 patient expected to be mechanical ventilated >72 h the general ICU. VAP was seen in 3 patients (4%) receiving suction secretion drainage and in 12 patients (16%) in the control group (relative risk, 0.22; 95% confidence interval, 0.06 to 0.81; p = 0.014). Intermittent subglottic secretion drainage reduces the incidence of VAP in patients receiving mechanical ventilation.

10. Bo H. Influence of the subglottic secretion drainage on the morbidity of ventilator associated pneumonia in mechanically ventilated patients. . Chinese J Tuberc Respir Dis. 2000(23):472-4.

Pro- Drainage vs. Control - Study focused on 68 patients who required intubation in the surgical ICU. The morbidity of VAP in the drainage group (n = 35) (23%) was lower than that in the control group (n = 33) (45%) (P < 0.05). The difference was due to the significant reduction of VAP caused by gram-positive cocci and Haemophilus influenzae organisms. However, no difference was observed in the incidence of VAP caused by non-fermental bacteria. After intubation the onset of VAP was delayed in drainage group (14 +/- 8 day) as compared with the control group (6 +/- 4 day) (P < 0.05). The same organisms were isolated among 61% (14/23) patients with VAP as what were previously isolated from the subglottic secretions. The presence of subglottic secretion may be an origin of the pathogenetic organisms of VAP. The morbidity of VAP in mechanically ventilated patients can be reduced by drainage , especially for VAP caused by gram-positive cocci and Haemophilus influenzae organisms. Subglottic secretion drainage may be a simple and effective method for prevention of VAP.


12. Leasure A, Stirlen J, Lu S. Prention of ventilator- associated penyumonia through aspiration of subglottic secreations: A systematic review and meta-analysis. Dimensions of Crital Care Nursing. 2012;31(2):102-117.

Pro- Systematic Review & Meta Analysis - Study reviewed 12 original articles and 4 reviews that evaluated the effectiveness of subglottic secretion aspiration in reducing the occurrence of VAP. Study findings showed that the effectiveness of subglotti secretion aspiration in reducing VAP Rates was 52% across a pooled total of 1701 cases (risk ratio, 0.52; 95% confidence interval, 0.43-0.64 in rates) .

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13. Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med. 2011;39(8):1985-1991.

Pro- Systematic Review – Study focused on 13 RCT‘s studies who reported a reduction in VAP rates in the subglottic secretion drainage arm. The overall risk ratio for ventilator-associated pneumonia was 0.55 (95% confidence interval, 0.46-0.66; p < .00001) with no heterogeneity (I = 0%). The use of subglottic secretion drainage was associated with reduced intensive care unit length of stay (-1.52 days; 95% confidence interval, -2.94 to -0.11; p = .03); decreased duration of mechanically ventilated (-1.08 days; 95% confidence interval, -2.04 to -0.12; p = .03), and increased time to first episode of ventilator-associated pneumonia (2.66 days; 95% confidence interval, 1.06-4.26; p = .001).

14. Juneja D, Javeri Y, Singh O, Nasa P, Pandey R, Uniyal B. Comparing influence of intermittent subglottic secretions drainage with/without closed suction systems on the incidence of ventilator associated pneumonia.. Indian J Crit Care Med. 2011;15(3):168-72.

Pro- Intermittent vs. Continuous suctioning – Study focused on 311 patients requiring mechanical ventilation for more than 72 hours. Data was collected retrospectively for following four groups: group A, no intervention; group B, only continues suctioning ; group C, only intermittent drainage; and group D, intermittent drainage with continues suctioning . Incidence of VAP per 1000 ventilator days in groups A, B, C, and D were 25, 23.9, 15.7 and 14.3, respectively (P=0.04). There was no significant difference in the duration of MV (P=0.33), length of ICU (P=0.55) and hospital stay (P=0.36) and ICU mortality (P=0.9) among the four groups. Intermittent drainage of secretions reduces the incidence of VAP. Continuous suctioning alone or in combination with intermittent has no significant effect on VAP incidence.

15. Hallais C, Merle V, Guitard PG, et al. Is continuous subglottic suctioning cost-effective for the prevention of ventilator-associated pneumonia? Infect Control Hosp Epidemiol. 2011;32(2):131-135.

Cost/benefit analysis - Study analyzed the cost benefit of 416 surgica patients receiving mechanical ventilation for 3,487 ventilation days in the SICU. A total of 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on a hypothesized 29% reduction in the risk of VAP with Continuous Subglottic Suctioning (CSS) Tubes than Conventioal Ventilation (CV) Tubes, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. The cost of a CV tube was €1.01. The cost of a CSS tube (Hi-Lo Evac) was €5.50, and the cost of 1 secretion-receiving bottle was €2.50If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode. Findings conclude that replacement of CV with CSS was a cost-effective method for treatment and for reducing VAP rates.

16. Speroni KG, Lucas J, Dugan L, et al. Comparative effectiveness of standard endotracheal tubes vs. endotracheal tubes with continuous subglottic suctioning on ventilator-associated pneumonia rates. Nurs Econ. 2011;29(1):15-20, 37.

Pro- Business Case – Study focused on 154 intubated adult patients (77 = S-ETT; 77 = CSS-ETT). The Standard -ETT group had one case of VAP; the Continues -ETT group had none. The mean total hospital charges were higher for the S-ETT group ($103,600; CSS-ETT= $88,500) (p = 0.3). Although the average number of intubation days and ICU days were greater for the CSS-ETT group, there were no cases of VAP compared to the Standard -ETT group. Based upon the one Standard -ETT VAP case and the VAP attributable costs, it is cost effective to use the Continues-ETT.

17. Overend T, Anderson C, Brooks D, et al. Updating the evidence-base for suctioning adult patients: A systematic review.. Can Respir J. 2009;16(3).

Pro- Systematic Review- Analyzed 15 RCT and 13 RCO of adult mechanically ventilated patients. Study findings showed that new evidence continues to be varied in strength for suctioning practice, but the evidence has improved since 2001. Study recommends members of the health care team should incorporate this evidence into their practice based on the growing body of evidence for the use of suctioning.

18. Depew C, McCarthy M. Subglottic secretion drainage: A literature review.. AACN Adv Crit Care. 2007;18(4):366-79. Pro – Review of meta-analysis (Dezfulian, 2005)) that looked at 5RCT that compared aspiration of subglottic secretion vs. standard ETT care. Findings conclude that there insufficient outcome evidence to support the use of subglottic technology – aside from the VAP rate reduction.

6

Appendix D: Spontaneous Awakening and SpontaneousBreathing Trials (SAT and SBT), Literature Synopsis

Ventilator-Associated Pneumonia Prevention BundleSpontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length of mechanical ventilation, thereby reducing the risk for developing VAP. Since the guidelines were written (2007) a ground breaking article by (Girard 2008) showed that SAT and SBT protocols result in faster extubation time and earlier discharge date. Most recently in 2012, a review article focusing on the findings of 14 articles recommended that weaning should be considered as early as possible, using a daily screening for readiness to wean protocol (SAT) that includes SBT. (Luetz, 2012)

2008- Society for Healthcare Epidemiology of America Guidelines: A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts.1

Recommends the use of daily sedation interruption (SAT) and daily assessment of readiness wean (SBT, simultaneously.


Quasi-Experimental Study (Resar, 2005) 2

Pro- This study did not specifically focus on weaning or sedation vacation, but the implementation of the IHI ventilation bundle. Findings showed that adherence to bundle led to a significant reduction of VAP. One of the items in the ventilator bundle was use of a sedation vacation protocol.

CDC Guideline -2003(Tablan, 2004) 3

Pro- Recommends the use of use of non-invasive ventilation as part of the weaning process (from mechanically assisted ventilation) to shorten the period of endotracheal intubation.( See CDC Section)

Ventilator Management Protocol vs. Control

(Marelich, 2000) 4

Pro- This article did not focus on sedation vacation intervention, but the use of Ventilator Management Protocol (VMP), including, a twice daily Spontaneous Breathing Trials (SBT).

Sedation Interruption vs. Control(Kress, 2000) 5

Pro- Study focused on adult medical patients who requiring mechanical ventilation and were receiving continuous infusion of sedative drugs. Findings showed that daily interruption of sedative drug infusions decreased the duration of mechanical ventilation and the length of stay in ICU.

Protocol-Directed vs. Non- Protocol (Brook, 1999) 6

Pro- Study focused on adult patients who were admitted into the medical intensive care unit. Findings showed that the use of protocol-directed sedation can reduce the mechanical ventilation, length of stay, and need tracheostomy among critically ill patients with acute respiratory failure.

(American Thoracic Society, 2005) 7

Pro- Recommends the use of daily interruption or lightening of sedation to avoid constant heavy sedation; and also recommends the avoidance of paralytic agents as they can depress cough reflex which increases the risk of HAP. ( See ATS, below)

1

2004-Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. 7

Recommends use of daily interruption or lightening of sedation (SAT) to avoid constant heavy sedation and to facilitate and accelerate weaning.

Does not address SBT.


Sedation Interruption vs. Control(Kress, 2000) 5

Pro- Study focused on adult medical patients requiring mechanical ventilation who were receiving continuous infusion of sedative drugs. Study findings showed that daily interruption of sedative drug infusions decreases the duration of mechanical ventilation and the length of stay in the intensive care unit. ( Cited by SHEA above)

Ventilator Management Protocol vs. Control

(Marelich, 2000) 4

Pro- This article did not focus on sedation vacation intervention, but the use of Ventilator Management Protocol (VMP) which implemented a twice daily Spontaneous Breathing Trials (SBT). ( Cited by SHEA, above)

Protocol Directed vs. Traditional (Brook, 1999) 6

Pro- Study focused on adult patients who were admitted into the medical intensive care unit. Findings showed that the use of protocol-directed sedation can reduce the mechanical ventilation, length of stay, and need tracheostomy among critically ill patients with acute respiratory failure. ( Cited by SHEA above)

2004-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of ventilator-associated pneumonia.8

Guideline excluded studies that evaluated SAT and SBT.


Literature Review (MacIntyre, 2001) 9

Pro- Review supports the use of spontaneous breathing trials and readiness to wean based on recommendation by American College of Chest Physicians & American College of Critical Care Medicine.

2003-CDC Guidelines for preventing Health-Care-Associated Pneumonia, Evidence-based, clinical practice guidelines for the prevention of healthcare-associated pneumonia, including VAP. 3

Does not address SAT and SBT, however supports weaning.

2

Post Guideline Publications:Post Guideline Publications, 2007-2012

Study Type and Author Results - Details in Annotated Bibliography

Review(Luetz, 2012) 10

Pro- Study reviewed the findings of 14 articles to recommend that weaning should be considered as early as possible; a daily screening for readiness to wean should be implemented; and a weaning protocol including a SBT should be used.

Systematic Review(Blackwood, 2011) 11

Pro- Study focused on 11 RCT that evaluated the effect of weaning protocols on the duration of mechanical ventilation in 1,971 critically ill patients in ICU’s. Study findings showed that weaning protocol was associated with significant reduction for duration of mechanical ventilation, length of weaning, and length of stay in the ICU.

Randomized Clinical TrialPressure Support vs. Spontaneous Breathing

(Gnanapandithan, 2011) 12

Con- Study focused on adult patients requiring mechanically ventilation for > 24 hrs. Study findings show that weaning by gradual pressure support without an initial spontaneous breathing trial (SBT) was associated with better outcomes (in terms of higher weaning trial successes, shorter ICU stay and trend towards quicker time to extubation than weaning by PS-supported with Spontaneous Breathing Trial s.

Systematic Review(Jackson, 2010) 13

Pro- Study focused on 23 studies that reported data on the impact of sedation practice of adult patients, sedated and on mechanical ventilation in the ICU. Findings showed that introduction of guidelines and protocols, was associated with improvements in outcomes including ICU and hospital length of stay, duration of mechanical ventilation, costs, mortality and reduction of nosocomial infections incidences.

National Nursing Survey(Guttomson, 2010) 14

Pro- Study focused on surveying members of the American Association of Critical Care Nurses. Findings show that nursing attitudes toward the mechanical ventilation had a moderate positive correlation with sedation practices and intent to administer sedation to all mechanical ventilated patients.

Survey of SCCM(Tanious, 2009) 15

Pro- Study focused on surveying 12,994 physician, nurse, and pharmacist members of Society of Critical Care Medicine. Findings showed that nurse attitude toward the efficacy of sedation for mechanically ventilated patients was positively correlated with nurses’ report of the sedation practice.

Randomized Trial Sedation & Weaning vs. Control

(Girrard, 2008) 16

Pro- Study focused on adult mechanically ventilated patients in the intensive care unit who required ventilation for 12h or more. Finding show that a paired sedation and weaning protocol consisting of daily (spontaneous awakening trials) SATs plus (spontaneous breathing trials) SBTs were better at reducing length of mechanical ventilation.

Quasi- ExperimentalNurse Implemented Sedation Intervention

(Quenot, 2007) 17

Pro- Study focused on 423 adult patient requiring mechanical ventilation for ≥ 48 h and infused with midazolam or propofol. Study findings showed that nurse-implemented sedation protocol decreased the rate of VAP and duration of mechanical ventilation.

3

Annotated Bibliography

1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals . Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31-S40. Available from: http://www.jstor.org/stable/10.1086/591062.

2. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243-248.

Pro- Systematic Review – This review did not specifically sedation vacation protocol, but reviewed the use of the IHI ventilator bundle. Review focused on 21 teaching hospitals 40 community hospitals that were made up 44 medical ICU's and 12 surgical ICU's. Data from 35 units showed a decrease in VAP rated with increased adherence to ventilator bundle. One of four bundle items was the use of a sedation vacation protocol.


4. Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: Effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000;118(2):459-467.

Pro-VMP Protocol vs. Control- This article did not focus on sedation vacation intervention, but the use of Ventilator Management Protocol (VMP) which used Spontaneous Breathing Trials (SBT).Study findings were based on 335 patients from the medical and surgical ICU’s that required mechanical ventilation. The duration of mechanical ventilation for patients was decreased from a median of 124 h for the control group to 68 h in the Ventilator Management Protocol group (p = 0.0001).

5. Kress J, Pohlman A, O'Connor M, Hall J. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N.Engl.J.Med. 2000;342:1471-1477.

Pro – Sedation Interruption vs. Control- Study focused on 128 adult patients who were receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. In the intervention group, the sedative infusions were interrupted until the patients were awake, on a daily basis; in the control group, the infusions were interrupted only at the discretion of the clinicians in the intensive care unit. The median duration of mechanical ventilation was 4.9 days in the intervention group, as compared with 7.3 days in the control group (P=0.004), and the median length of stay in the intensive care unit was 6.4 days as compared with 9.9 days, respectively (P=0.02). Findings show that daily interruption of sedative drug infusions decreased the duration of mechanical ventilation and the length of stay in the intensive care unit.

6. Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-2615.

Pro – Protocol-Directed vs. Non-Protocol Directed Sedation- Study was focused on 321 adult patients who were admitted into the medical intensive care unit. The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxon's test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7 ± 5.9 days vs. 7.5 ± 6.5 days; p = .013) and hospital (14.0 ± 17.3 days vs. 19.9 ± 24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5 ± 4.0 days vs. 5.6 ± 6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038).


8. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment. J Crit Care. 2008;23(1):138-147.

9. MacIntyre N. Evidence-based guidelines for weaning and discontinuing ventilatory support: A collective task force facilitated by american college of chest physicians; the american association for respiratory care;; american college of critical care medicine. Chest. 2001;120:375-396.

Pro- Review supports the use of spontaneous breathing trials and readiness to wean based on recommendation by American College of Chest Physicians & American College of Critical Care Medicine. Recommendation #2: Patient receiving mechanical ventilation for respiratory failure should undergo a formal assessment of discontinuation to test capability to initiate an inspiratiotory effort. Recommendation #8: Weaning/discontinuation protocols that are designed for nonphysical healthcare profession should be developed and implemented by ICUs.

10. Luetz A, Goldman A, Weber-Castens S, Spies C. Weaning from mechanical ventilation and sedation. Curr.Opin.Infect.Dis. 2012;25(2):164-9.

Pro –Literature Review – Article focused on the findings of 14 articles to recommend that weaning should be considered as early as possible; a daily screening for readiness to wean should be implemented; and a weaning protocol including a SBT should be used.

11. Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O'Hallaran P. Use of weaning protocols for reducing duration of mechancal ventilatoin in critically ill adult patients: Cochran systematic review and meta-analysis. BMJ. 2011;Jan 13.

Pro- Systematic Review- Study focused on 11 RCT that evaluated the effect of weaning protocols on the duration of mechanical ventilation in 1, 971 critically ill patients in the ICU. Study findings showed that weaning protocol was associated with significant reduction in the mean duration of mechanical ventilation by 25% (95% confidence interval 9% to 39%, P=0.006; 10 trials); the duration of weaning was reduced by 78% (31% to 93%, P=0.009; six trials); and length of stay in the intensive care unit by 10% (2% to 19%, P=0.02; eight trials).

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12. Gnanapandithan K, Agarwal RA, AN., Gupta D. Weaning by gradual pressure support (PS) reduction without an intial spontaneous breating trial(SBT) versus PS-supported SBT; a pilot study. Rev. Port Penumol. 2011;17(6).

Con-RCT- Study focused on 120 adult patients requiring mechanically ventilation for > 24 hrs to evaluate the effectiveness of weaning by gradual pressure support (PS) with initial spontaneous breathing trial (SBT) versus PS-supported SBT. Findings show that weaning by gradual reduction of PS without an SBT was associated with better outcomes in terms of higher weaning trial successes, shorter ICU stay and trend towards quicker time to extubation than weaning by PS-supported with SBTs. The median duration of ventilation prior to weaning was 80.2 (50.5-175.6)h. The baseline characteristics were similar in the two groups except the PaO(2)/FiO(2) ratio, which was significantly higher in SBT group. The rates of successful weaning trial (89.7% versus 69.4%) were significantly higher in the PS group. The median duration of weaning (66h versus 81.5h, P=0.05) and the median duration of ICU stay (8 days versus 9.4 days, P=0.027) were lower in the PS group.

13. Jackson D, Proudfoot C, Cann K, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, cost and patient safety. Crit.Care. 2010;14(2).

Pro-Systematic Review –Study focused on 23 studies that reported data on the impact of sedation practice of adult patients, sedated and mechanically ventilated in the ICU. The introduction of guidelines and protocols, or daily interruption of sedation , were associated with reduction of length of ventilation from 10% to 70 %, weaning times , length of stay in the ICU from 35%- to 65 % , length of hospital say and sedation duration from 39% to 50%.

14. Guttormson J,ChlanL., Weinert C., Savik K. Factors influencing nurse sedation practices with mechanically ventilated patients: A U.S national survery. Intensive Crit.Care Nurs. 2010;26:44-50.

Pro- Study surveyed 423 members of the American Association of Critical Care Nurses to describe factors that influence nurse sedation administration to mechanically ventilated patients and to identify individual or workplace characteristic that impact sedation practices. Self-reported sedation administration subscale scores were higher for respondents using a sedation assessment scale (median: 3.67, IQR : 3.33-3.89) than those without ( median : 3.56, IQR: 3.33-3.79); z (407) = -2.565, p=.o1). Respondents that utilized sedation scale indicated stronger agreement that three items indicated undersedation: reaching for endotracheal tube (ETT) or lines, trachypnea and ventilator dysynchrony. The majority of nurse respondents felt that sedation was necessary for patients comfort and characterized mechanical ventilation as uncomfortable and stressful. The attitudes influence nurses' self-reported sedation administration.

15. Tanios M, de Wit M, Epstein S, Devlin J. Perceived barriers to the use of sedation protocols and daily sedation interruption: A multidisciplinary survey. Journal Critical Care. 2009;24:66-73.

Pro- Study focused on surveying 916 physician, nurse, and pharmacist members of the Society of Critical Care Medicine. The goal was to determine current use of sedation protocols and Daily Sedation Interruption (DIS), along with the perceived barriers to each. Of 64% having sedation protocol, 78% used it for > 50 % of ventilated patients. Reasons for lack of protocol use include no physician order (35%), lack of nursing support (11%) and fear of over sedation (7%). Daily sedation interruption was used by only 40%. Barriers to DSI included lack of nursing acceptance (22%), concern about about risk of patient imitated device removal (19%), and inducement of either respiratory compromise ( 26%) of or patient discomfort (13%). Clinicians who prefer propofol were more likely to use DSI than those who prefer benzodiazepines.

16. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomized controlled trial. Lancet. 2008;371(9607):126-134.

Pro- Sedation & Weaning vs. Control - Pro- Study focused on 336 adult mechanically ventilated patients in the intensive care unit who required ventilation for 12h or more. Patients in paired sedation & weaning group spent more days breathing without assistance during the 28-day study period than did those in the control group (14·7 days vs 11·6 days; mean difference 3·1 days, 95% CI 0·7 to 5·6; p=0·02) and were discharged from intensive care (median time in intensive care 9·1 days vs 12·9 days; p=0·01) and the hospital earlier (median time in the hospital 14·9 days vs 19·2 days; p=0·04).

17. Quenot J, Ladoire S, Devoucoux F, et al. Effect of a nurse-implemented sedation protocol on the incidence of ventilator associated pneumonia. Crit Care Med. 2007;35(9):2031-9.

Pro- Study focused on 423 adult patient requiring mechanical ventilation for ≥ 48 h and infusion with either midazolam or propofol. The incidence of VAP was significantly lower in the nurse-implemented protocol (NIP) group compared with the control group (6% and 15%, respectively, p = .005). By univariate analysis (log-rank test), only use of a NIP was significantly associated with a decrease of incidence of VAP (p < .01). Additionally, NIP was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model (hazard rate, 0.81; 95% confidence interval, 0.62-0.95; p = .03). The median duration of mechanical ventilation was significantly shorter in the NIP (4.2 days; interquartile range, 2.1-9.5) compared with the control group (8 days; interquartile range, 2.2-22.0; p = .001), representing a 52% relative reduction. Nurses used dosage table to administer medication by weight for initial and adjustment of sedatives. Level of sedation was determined using Cambridge score used to assess consciousness levels every 3 hours

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Appendix E: VAP Prevention – Head of Bed (HOB)Things you should know!

The elevation of the head of bed to a semi-recumbent position (≥30 degrees) is associated with a decreased incidence of aspiration and Ventilator- Associated Pneumonia (VAP).

The intervention is supported unanimously by all four leading guidelines, and newer publications since 2008.

Since the last guideline was written (2007), the majority of studies have been focused on determining the appropriate angle for the HOB elevation (between 30o and 45o).

2008-Society for Healthcare Epidemiology of America A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts.

\\

Recommends the use semi-recumbent position (30-45 degrees) as a strategy to prevent aspiration.

2004-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of ventilator-associated pneumonia.

Recommends the head of bed elevation to be 45 degrees, as long as not contraindicated.

2004-Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia.

Recommends that patients should be kept in a semi-recumbent position (30-45 degrees) rather than supine to prevent aspiration.

2003-CDC Guidelines for Preventing Healthcare-associated Pneumonia

In the absence of medical contraindication(s), elevate the HOB at an angle of 30–45 degrees for patients with a high risk for aspiration (e.g., a person receiving mechanically assisted ventilation)

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Appendix F:VAP Prevention – Oral care with Chlorhexidine (CHG)

Things you should know! Regular oral care with CHG is associated

with decreased colonization of dental plaque, and a decreased incidence of ventilator-associated pneumonia (VAP).

Guidelines for VAP prevention, published before 2008, do not address the use of CHG for oral care. Increasing evidence to support this intervention has emerged over the past several years.

In 2011, a systematic review and meta-analysis of 12 randomized trials supported the use of oral care with CHG for VAP prevention. Overall, this study found a 38% VAP reduction. Favorable effects were more pronounced in cardiosurgical studies (up to a 59% VAP reduction).

Since guidelines below were written, 11 other peer reviewed publications have been written supporting the effectiveness of the use of CHG for oral care in the prevention of VAP


Perform regular oral care with an antiseptic solution in accordance with product guidelines. Did not specify CHG.

All cited studies demonstrated the effectiveness of oral care with CHG, specifically in the cardiac surgery population.


The use of the oral antiseptic chlorhexidine should be considered.

Based on 1 level 1 and 2 level 2 trials, the use of the oral antiseptic CHG may decrease the incidence of VAP. Safety, feasibility, and cost considerations for this intervention are all very favorable.

2004-Guidelines for the Management of adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia.

Recommends regular oral care. States that chlorhexidine has prevented hospital-acquired pneumonia in specific populations such as those undergoing coronary bypass grafting, However, also states that routine use is not recommended until more data is available.

2003-CDC Guidelines for preventing Healthcare-associated Pneumonia

No recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of healthcare–associated pneumonia in all postoperative or critically ill patients and/or other patients at high risk for pneumonia

1

Appendix G: VAP Prevention – Subglottic Suctioning (SS)Things you should know!

Continuous subglottic suctioning (CSS) and frequent intermittent subglottic suctioning drainage (I-SSD) of subglottic secretions, via an endotraceal tube is associated with up to a 50% decrease in incidence of aspiration of VAP.

The use of cuffed endotracheal tube (ETT) with in line dorsal lumen is associated with decrease in gastric content aspiration. ETT usage alone has been associated with up to 50% decrease of VAP.

Most recently in 2011, a systematic review and meta-analysis of 13 randomized trials support the use of subglottic drainage for VAP prevention. Over all study found 45% reduction of VAP along with a 1.5 days reduction in length of stay and 1.1 days of ventilation.


Recommends the use of cuffed ETT with in line subglottic suction to prevent aspiration and reduce VAP risk factor.


Subglottic Secretion Drainage is recommended for patients requiring to be mechanically ventilated for more than 72hrs.


Recommends the use of specifically designed ETT with dorsal lumen for the continues aspiration of subglottic secretion.


Recommends the use of an ETT dorsal lumen above the endotracheal cuff to allow drainage by continuous or frequent intermittent suctioning of tracheal secretion that accumulates in patient’s subgltottic area.

1

Appendix H: VAP Prevention –Spontaneous Awakening and Breathing (SAT and SBT) Trials Things you should know!

Spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length of mechanical ventilation, thereby reducing the risk for developing VAP.

Since the guidelines were written (2007) a ground breaking article by (Girard 2008) showed that when used in conjunction, SAT and SBT protocols result in faster extubation time and an earlier discharge.

Most recently in 2012, a review article focusing on the findings of 14 articles recommended that weaning should be considered as early as possible, using a daily screening for readiness to wean protocol (SAT) that includes SBT. (Luetz, 2012)


Recommends the use of daily assessment of readiness wean (SBT) and daily sedation interruption (SAT), simultaneously.


Guideline excluded studies that evaluated SAT and SBT.


Recommends use of daily interruption or lightening of sedation (SAT) to avoid constant heavy sedation and to facilitate and accelerate weaning.

Does not address SBT.


Does not address SAT and SBT, however supports weaning.

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Appendix I: Policy Driven Structural MeasuresVentilator Associated Pneumonia Prevention Bundle

1. Use a closed ETT suctioning system.

SHEA1 Pro- Recommends the use a cuffed endotracheal tube with in-line or subglottic suctioning.

ZAP2 Pro- Recommends the use of closed endotracheal suctioning system.

ATS3 Makes No Recommendations

CDC4 Makes No Recommendations

2. Change closed suctioning catheters only as needed. All Guidelines Makes No Recommendations

AARC Evidence - Based Guidelines

(Hess, 2003 )5

Pro- Recommends that ventilator circuits should not be changed routinely for infection control purposes. Also, notes that the use of closed suction catheters should be considered part of a VAP prevention strategy. When closed suction catheters are used, they do not need to be changed daily for infection control purposes.

3. Change ventilator circuits only if circuits become damaged or soiled.

SHEA Pro- Recommends the change of ventilator circuit only when visibly soiled or malfunctioning.

ZAPPro-Recommends the use of new circuits for each patient, and changes if the circuits become soiled or damaged, but no scheduled ventilator circuit changes.

ATS Makes No Recommendations

CDCPro- Recommends the change of circuit when it is visibly soiled or mechanically malfunctioning.

4. Change HME every 5-7 days and as clinically indicated.

SHEA Pro-Recommend the change of humidifier circuit when it is visibly soiled or mechanically malfunctioning humidifier, not on the basis of duration of use.

ZAP Pro-Recommend changes of HMEs every 5 to 7 days or as clinically indicated.


CDCPro- Recommend the change of HME when it malfunctions mechanically or becomes visibly soiled, but not more frequently than every 48 hours.

5. Provide easy access to NIVV equipment and institute protocols to promote use.

SHEA Pro-Recommends the use of noninvasive ventilation whenever possible.

ZAP Makes No Recommendations

ATSPro-Recommends that noninvasive ventilation should be used whenever possible in selected patients with respiratory failure.

1

CDC Makes No Recommendations

6. Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient.

SHEA Pro- Recommends the removal of condensate from ventilator circuits while keeping the ventilator circuit closed during condensate removal.

ZAP Makes No Recommendation

ATSPro – Recommends that contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers.

CDC Makes No Recommendation

2

7. Use early mobility protocol.All Guidelines Makes No Recommendations

Early ICU Mobility Therapy (Morris, 2008) 6

Pro- Findings of this study showed that mechanically ventilated acute respiratory failure patients who underwent early intensive mobility therapy had a shorter ICU and hospital stay than similar patients who received standard physical therapy.

Receiving Early Mobility in ICU (Morris, 2011) 7

Pro-The aim of this study was to determine the post hospital outcomes of implementing early mobility protocol. This study finding showed that patients who received early ICU mobility therapy had fewer hospital readmissions and deaths in 12 months post discharge period.

Early Physical Medicine and Rehabilitation

(Needham, 2010) 8

Pro- This quality improvement program found that the incorporation of early mobility into the daily care of ICU patients substantially reduced length of stay.

8. Perform hand hygiene.

SHEA Pro- Recommends the adherence to hand-hygiene guidelines published by the Centers for Disease Control and Prevention / World Health Organization.


ATSPro- Recommends the use of effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with MDR pathogens.

CDCPro- Recommends the decontamination of hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water or by using an alcohol-based waterless antiseptic agent.

9. Avoid supine position.

SHEA Pro- Recommends the maintenance of patients in the semirecumbent position (30-45 degrees) unless medically contraindicated.

ZAP Makes No Recommendation

ATSPro – Recommends that patients should be kept in the semirecumbent position 30-45degrees rather than supine.

CDC Pro- Recommends the elevation of head of the bed to an angle of 30-45 degrees.

11. Use orotracheal intubation instead of nasotracheal.

SHEA Pro- Recommends orotracheal intubation over nasotracheal intubation based on the increased risk of sinusitis.

3

10. Use standard precautions while suctioning respiratory tract secretions.

SHEA Pro - Recommends appropriate infection prevention and control practices are used at all times, including aseptic techniques when suctioning secretions and handling respiratory therapy equipment.




ZAPPro- Recommends the use of the orotracheal route for intubation when intubation is necessary.

ATSPro- Recommends orotracheal intubation over nasotracheal intubation based on a trend toward reduction in VAP rates and sinusitis.

CDCPro- Recommends the use of orotracheal intubation over nasotracheal intubation unless contraindicated.

12. Avoid the use of prophylactic systemic antimicrobials.

SHEA Pro- Recommends prophylactic aerosolized or systemic antimicrobials should not be used for routine VAP prevention.




13. Avoid non-essential tracheal suctioning.

All Guidelines Make No Recommendations

New South Wales Statewide Guideline for Intensive Care

(Rolls, 2009) 9

Pro – Recommends that tracheal tube suctioning should not be carried out on a routine basis, but rather out of clinical need to maintain the patency of the tracheobronchial tree.

14. Avoid gastric over-distention.SHEA Pro- Recommends the avoidance of over distention.




2

Bibliography

1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator Associated pneumonia in acute care hospitals‐ . Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare Associated Infections in ‐Acute Care Hospitals):pp. S31-S40.

2. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment. J Crit Care. 2008;23(1):138-147.



5. Hess DR, Kallstrom TJ, Mottram CD, et al. Care of the ventilator circuit and its relation to ventilator associated pneumonia. Respiratory Care. 2003;9(48):869-79.

6. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243.

7. Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011;341(5):373-377.

8. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil. 2010;91(4):536-542.

9. Rolls K, Smith K, Jones P, et al. Suctioning an adult with a tracheal tube. NSW Health Statewide Guidelines for Intensive Care. 2007.

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Appendix J: Definitions and Techniques for Oral Carewith Chlorhexidine (CHG) Protocol

Our protocol for performing oral care states that:1. Oral care should be provided a total of 6 times a day at a Q4H interval. 2. Two of the 6 oral care instances need to include the use of CHG (every 12 hours).

Considering the vast amount differences in the techniques, process, and local culture of the intervention we have decided to highlight several as example for oral care from the literature with Examples 1-7, as listed below.

Our Recommended Protocol: MHA Keystone: ICU Oral Care Checklist 1

Oral Care with CHG includes ALL of the following four interventions; 1. Perform subglottic suctioning2. Ensure proper ETT cuff inflation3. Brush teeth > 2 minutes

a. Use of toothpaste is optionalb. Use soft toothbrush making small circular movementsc. Remove all visible plaque and soft debrisd. Clean tongue, gums and palate

4. Clorhexidinea. Use alcohol free CHGb. 10cc – squirt 5cc on right side of mouth between cheek and gum, being sure to get upper and lower teeth,

front to back, pharynx and tonguec. Swab with toothette if needed to reach tongue/gumsd. Suction out pools in mouthe. Repeat on left side with remaining 5ccf. If patient requires nystatin, give CHG and nystatin 12 hours apart

Oral Care Proposed Timeline:

Example 1 Scannapieco et al., 2009 - A randomized trial of Chlohexidne gluconate oral bacterial pathogens in mechanically ventilated patients. 2

1

= Oral Care = Oral Care +CHG

Figure 1: Timeline of 24 Hour Shift

0h 4h 8h 12h 20h 24h16h

This protocol does use CHG but it only requires oral care two times per day as opposed to our recommended six. While it doesn’t meet our recommendations, we have included it as it does describe the specific steps this group uses to provide oral care to their patients.

1. CHG was applied using a rinse-saturated oral foam applicator twice each day (in the morning at about 8 AM and in the evening at about 8 PM).

2. Applications were for one minute with about 1 oz of 0.12% CHX.3. The ICU staff nurses performed CHG application to all teeth, the oral soft tissues including buccal mucosa,

vestibule, gingival, and the floor of the mouth and tongue dorsum by swabbing.4. Excess rinse was suctioned out of the subject’s mouth after one minute. 5. Briefly, routine oral care included use of a suction toothbrush twice a day and as needed to brush teeth and the

surface of the tongue, for approximately one to two minutes, and applying suction at completion and as needed during the brushing.

6. Also, deep suctioning was performed to assist in removing oropharyngeal secretions pooled on top of the cuff of the endotracheal tube every 12 hours and following position changes.

Example 2 Mori et al., 2006 - Oral Care Reduces Incidence of Ventilator Associated Pneumonia in ICU Population 3 Oral care was provided three times daily or once in every nursing shift, according to the protocol shown below by a set of two members of the medical staff including a dentist and nurses who were trained to provide oral care.

This protocol does not use CHG and requires oral care only three times per day as opposed to our recommended six. While it doesn’t meet our recommendations, we have included it as it does describe the specific steps this group uses to provide oral care to their patients.

Oral Care Protocol: 1. Check vital signs, then increase cuff pressure of the tracheal tube to 100 mmHg, and provide suction to remove

oropharyngeal secretions in the oral cavity and portion of the trachea above the cuff.2. Position the patient’s head to the side and have the patient open his/her mouth; observe inside the oral cavity and

assess the condition of soft and hard tissues.3. Cleanse the oral cavity using a swab soaked in 20-fold diluted povidone-iodine gargle 4. Cleanse the oral cavity using a tooth brush carefully and rinse with 300 ml weakly acidic water (rinsing alone is

performed for patients without teeth on those with bleeding tendency).5. Repeat cleansing of the oral cavity using a swab soaked in 20-fold diluted povidone-iodine gargle 6. Provide suction of the oral cavity and portion of the trachea above the cuff and restore the cuff pressure.7. Perform the entire procedure 3 times daily or once in every nursing shift.

Example 3 Mercy Medical Center, Springfield, MA Hutchins et al. 2007 - Comprehensive Oral Care Program Reduces Rates of VAP in ICU4

This protocol uses CHG during with every oral care (6 times per day). While it doesn’t specifically meet our recommendations, we have included it as it does describe how this group uses CHG in their oral care for their patients.

Perform Oral Care at Q4h and as needed with the following instructions:1. Replace suction liner, tubing, and covered oral suction device Q242. Brush teeth using suction toothbrush with CHG; brush 1-2 minutes applying suction at completion and as needed by

gently brush surface of tongue. 3. Use suction swabs with hydrogen peroxide solution Q4h on even hours to clean teeth and tongue.4. Apply mouth moisturizer to mucous membranes, buccal cavity, and lips Q4h after completion of oral ca

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5. Perform deep-oral pharyngeal suctioning with disposable oropharyngeal suction catheter Q12.6. Use suction catheters to assist in controlling secretions prior to major position changes, extubation, cuff deflation,

repositioning of tube, and as needed.

Example 4American Association of Critical Care Nursing -2010 Practice Alert 5

This protocol does use CHG but it only requires oral care two times per day as opposed to our recommended six. While it doesn’t meet our recommendations, we have included it as it does describe the specific steps this group uses to provide oral care to their patients.

1. Brush teeth, gums and tongue at least twice a day using a soft pediatric or adult toothbrush. 2. Provide oral moisturizing to oral mucosa and lips every 2 to 4 hours 3. Use an oral CHG (0.12%) rinse twice a day.

Example 5Segers P, et al. (2007) Decontamination of the nasopharynx and oropharynx with chlorhexidine reduced nosocomial infections in cardiac surgery. 6

This protocol does use CHG but it only requires oral care four times per day as opposed to our recommended six. It is designed to provide oral care for all patients, intubated or not. While it doesn’t meet our recommendations, we have included it as it does describe the specific steps this group uses to provide oral care to their patients.

1. Patients were administered an oropharyngeal rinse (10 mL) containing CHG. 2. The oropharyngeal solution was used as a mouth rinse and applied to buccal, pharyngeal, gingival, and tooth

surfaces for 30 seconds 4 times daily. 3. If the patient was unable to follow the protocol independently, the nurse performed the procedures with the aid of a

sponge. 4. The protocol was continued until the nasogastric tube was removed, usually the day after surgery.

Example 6Munro, C., et al (2009 ) Chlohexidne , Tooth brushing, and Preventing Ventilator Associated pneumonia in critically ill adults. 7

This protocol does use CHG but it only requires oral care three times per day as opposed to our recommended six. While it doesn’t meet our recommendations, we have included it as it does describe the specific steps this group uses to provide oral care to their patients.

1. Patients received a 0.12% solution of chlorhexidine gluconate (CHG) 5 mL by oral swab twice daily (at 10 AM and 10 PM)

2. Toothbrushing 3 times a day (at 9 AM, 2 PM, and 8 PM) a. Each patient’s mouth was divided into 4 dental quadrants (right upper, right lower, left upper, left lower),

and each quadrant was brushed in a defined pattern. b. In each quadrant, every tooth was brushed for 5 strokes on lingual, buccal, and biting surfaces with a soft

pediatric toothbrush and toothpaste (Biotene toothpaste, Laclede, Inc, Rancho Dominguez, California).c. The palate and tongue were also brushed. Each quadrant, the palate, and the tongue were rinsed with

mouthwash (Biotene), 2.5 mL per area, by using a transfer pipette. 3. A Yankauer suction catheter was used as needed to suction excess saliva and water from the mouth as the

intervention was performed. 4. Finally, a measured amount of moisturizing gel (OralBalance, Laclede, Inc) was applied to all soft surfaces of the

oral cavity and lips by using a green Toothette swab (Sage Products, Inc, Cary, Illinois).

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Example 7Tantipong, H et al. (2008) Randomized Controlled Trial and Meta‐analysis of Oral Decontamination with 2% Chlorhexidine Solution for the Prevention of Ventilator‐Associated Pneumonia 8

This protocol does use CHG but it only requires oral care four times per day as opposed to our recommended six. While it doesn’t meet our recommendations, we have included it as it does describe the specific steps this group uses to provide oral care to their patients.

1. Patients received oral care 4 times per day that involved brushing the teeth, suctioning any oral secretions, and rubbing the oropharyngeal mucosa with 15 mL of a 2% chlorhexidine solution.

2. The oropharyngeal cleaning with 2% chlorhexidine solution was continued until the endotracheal tube was removed.

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Bibliography 1. MHA Keystone ICU Group. Oral care checklist. 2003.

2. Scannapieco FA, Yu J, Raghavendran K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care. 2009;13(4):R117. doi: 10.1186/cc7967.

3. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med. 2006;32(2):230-236. doi: 10.1007/s00134-005-0014-4.

4. Hutchins K, Karras G, Erwin J, Sullivan K. Comprehensive oral care program reduces rates of VAP in ICU . Mercy Medical Center, Springfield, MA. (unpublished / poster presented only).

5. American Association of Critical Care Nurses. Oral care in critically ill. AACN Practice Alerts. 2010.

6. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: A randomized controlled trial. JAMA. 2006;296(20):2460-2466. doi: 10.1001/jama.296.20.2460.

7. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care. 2009;18(5):428-37; quiz 438. doi: 10.4037/ajcc2009792.

8. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2008;29(2):131-136. doi: 10.1086/526438.

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Appendix K: Definition and Techniques for Spontaneous Awakening (SAT) and Spontaneous Breathing Trial

(SBT) ProtocolIntroduction - Reducing the number of days a patient is on mechanical ventilation has been shown to reduce the risk of VAP. 1-4 Strategies for weaning patients off of mechanical ventilation are often not handled well as the spontaneous awakening (SAT) and spontaneous breathing trials (SBT) are viewed separately. A wake up and breathe protocol using both the SAT and SBT can significantly reduce the number of days patients are on mechanical ventilation. Girard et. al.5 showed that paired, the SAT and SBT reduced the number of days patients were on mechanical ventilation (3.1 mean difference, 95% CI 0.7-5.6; p=0.02), with a concomitant reduction in the length of hospital stay (4 day difference) when compared to SBT alone. This same technique, often called a readiness-to-wean or sedation protocol, has been used in other institutions with much success. 4, 6, 7 We are using the model Girard et. al. developed in 2008 for this project.

The SAT consists of two parts, a safety screen and the trial. (Please see flow diagram below.) The safety screen attempts to assure the trials will not be used when contraindicated. Patients pass the screen unless:

1. They are receiving a sedative infusion for active seizures or alcohol withdrawal2. They are receiving escalating doses of sedative for agitation3. They are receiving neuromuscular blockers4. They have evidence of active myocardial ischemia in prior 24 hours5. They have evidence of increased intracranial pressure

If the patient passes the safety screen, all sedatives and analgesics used for sedation are stopped. Analgesics used for pain are continued. The goal is that the patient can open their eyes to verbal stimuli or can go without sedation for 4 hours or more without the following:

1. sustained anxiety2. agitation3. pain4. a respiratory rate of 35 breaths/minute for >= 5 minutes5. an SpO2 of less than 88% for >=5 minutes6. an acute cardiac dysrhythmia7. two or more signs of respiratory distress

a. tachycardiab. bradycardiac. use of accessory musclesd. abdominal paradoxe. diaphoresisf. marked dyspnea

If a patient fails the SAT, sedatives are started at one half the prior dosage and titrated up as needed.

If a patient passes the SAT, the patient is assessed for the SBT safety screen. Patients pass if:

1. they have adequate oxygenation (SpO2 >=88% on an F1O2 of <=50% and a PEEP <=8 cm H2O)2. any spontaneous inspiratory effort in a 5-min period3. no agitation4. no significant use of vasopressors or inotropes5. no evidence of increased intracranial pressure

1

If a patient fails, he is reassessed for SAT the following day. If the patient passes, they undergo the SBT. Ventilatory support is removed. Patient is allowed to breathe through either a T-tube circuit of a ventilatory circuit with CPAP of 5cm H2O or pressure support ventilation of less than 7cm H2O. Patients pass the trial if they don’t develop any of the following failure criteria for 120 minutes.

1. respiratory rate of more than 35 or less that 8 breaths per min for 5 min or longer2. hypoxemia (SpO2 < 88% for >=5 min)3. abrupt change in mental status4. an acute cardiac arrhythmia5. two or more signs of respiratory distress

a. tachycardiab. bradycardiac. use of accessory musclesd. abdominal paradoxe. diaphoresisf. marked dyspnea

If a patient fails the SBT, he is reassessed for SAT the following day. If a patient passes, the patient’s physicians are notified for possible extubation.

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Bibliography

1. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335(25):1864-1869.

2. Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-2615.

3. Kress J, Pohlman A, O'Connor M, Hall J. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N.Engl.J.Med. 2000;342:1471-1477.

4. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet. 2008;371(9607):126-134.

5. Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O'Hallaran P. Use of weaning protocols for reducing duration of mechancal ventilatoin in critically ill adult patients: Cochran systematic review and meta-analysis. BMJ. 2011;Jan 13.

6. Quenot J, Ladoire S, Devoucoux F, et al. Effect of a nurse-implemented sedation protocl on the incidence of ventilator associate penumonia. Crit Care Med. 2007;35(9):2031-9.

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Appendix L: Instructions for “CUSP for VAP: EVAP - Daily Rounding Form”

Please complete this form at least once a day, every day. If possible, complete it around the same time each day, hopefully during patient rounds.

Patients are considered to be mechanically ventilated on a specific day if they were mechanically ventilated at the time of observation.

All of the contraindications are listed on the back of the data collection sheet. Please print the data collection sheet with the contraindications on the back of the sheet for ease of data collection.

Hospital: Enter the number for your hospital.

ICU: Enter the number of your unit.

Date: Enter today’s date as MM/DD/YYYY format (e.g. 06/01/2011).

BED #: Enter all the bed numbers on the form, whether the patient is on mechanical ventilation or not. Include empty beds.

Intub/Trach & Mech Vent: Is the patient currently receiving mechanical ventilation? (Enter for all patients. If the bed is empty, leave blank.) Mechanical ventilation is defined as receiving ventilator support via an ETT or tracheostomy tube.

Patients treated with non-invasive ventilation would be counted as ‘N’ Enter ‘Y’ if the patient is currently intubated/trached and mechanically ventilated. Enter ‘N’ if the patient is not currently intubated /trached and mechanically ventilated. Enter ‘E’ if there is no patient in the bed.

For any specific patient, if the patient is not currently intubated/trached AND on mechanical ventilation, STOP. Do not enter any more information regarding that bed for this date.

Date of Intubation: Enter the date that the patient was intubated using a MM/DD/YYYY format (e.g. 06/01/2012)(Only for patients currently intubated/trached and mechanically ventilated)

DO NOT use dates from re-intubation following self-extubation. If the patient is re-intubated following <24 hours after extubation, use first intubation date.

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Shift: Enter the shift during which the data was collected. (Only for patients currently intubated/trached and mechanically ventilated.)

Enter ‘AM’ if data sheet was completed during the AM hours. (Between 12 midnight and 12 noon) Enter ‘PM’ if data sheet was completed during the PM hours. (Between 12 noon and 12 midnight)

Sub-G ETT: Does the patient have a subglottic suctioning endotracheal tube (ETT)? (Only for patients currently intubated/trached and mechanically ventilated)

Enter ‘Y’ if the patient has a subglottic suctioning ETT. Enter ‘N’ if the patient does not have a subglottic suctioning ETT. Enter ‘C’ if the use of a subglottic suctioning ETT is contraindicated

Sub-G ETT Con: What is the contraindication for the use of a sub-glottic suctioning endotracheal tube? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘C’ entered in Sub-G)If ‘C’ was entered in the Sub-G ETT column, answer this question. Enter the number associated with the answer in the box. For example, enter ‘1’ for tracheostomy.

Contraindications listed on the back of the data collection sheet.

Does Sub-G ETT Work?: Is the suctioning function working on the subglottic ETT? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘Y’ entered in the Sub-G ETT column)A working subglottic ETT is defined as having a patent suction lumen and connected to continuous or intermittent suctioning.

Enter ‘Y’ if the patient has a functioning subglottic suctioning tube. Enter ‘N’ if the patient has a subglottic tube, but it is not functioning. Enter ‘N/A’ if the patient does not have a subglottic tube.

Location of Intubation: Where was the patient intubated? (Only for patients currently intubated/trached and mechanically ventilated)

Locations are listed with the contraindications on the back of the data collection sheet.

HOB @ ≥30: Is the head of the bed at or over thirty degrees from the horizontal? (Only for patients currently intubated/trached and mechanically ventilated)

Enter ‘Y’ if the head of the patient’s bed is at ≥30 degrees at the time of observation. Enter ‘N’ if the head of the patient’s bed is not at ≥30 degrees at the time of observation and before correction. Enter ‘C’ if having the head of the patient’s bed at ≥30 degrees is contraindicated.

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HOB Con: What is the contraindication to placing the head of the bed at an angle of more than or equal to 30 degrees when compared to a horizontal surface? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘C’ entered in the HOB @≥30 column) If ‘C’ was entered in the HOB @ ≥30 column, answer this question. Enter the number associated with the answer into the box. For example, enter ‘1’ for Hypotension.


Oral care: How many times has the patient had oral care in the last 24 hours? Please include the total number of times the patient has had oral care, including the number of times the patient has had oral care with CHG. (Q4 hours)(Only for patients currently intubated/trached and mechanically ventilated)Oral Care includes ALL of the following interventions;

1. Perform subglottic suctioning2. Ensure proper ETT cuff inflation3. Clean oral cavity with suction swab using supplies contained in your oral care kit.

Answers: Enter the number of times the patient has had oral care in the last 24 hours.

o If the patient has not had oral care and there is no contraindication, enter ‘0’ for the number of times the patient had oral care. Enter ‘2’, “No oral care, no contraindication.”

Oral care con: What is the contraindication for oral care? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘0’ entered in the Oral Care column) If ‘0’ was entered in the Oral Care column, answer this question. Enter the number associated with the answer into the box. For example, enter ‘0’ for Other. Enter ‘2’, “No oral care, no contraindication.”


CHG: How many times in the last 12 or 24 hours has the patient had oral care with CHG? (Q12 hours)(Only for patients currently intubated/trached and mechanically ventilated) Oral Care with CHG includes ALL of the following interventions;

5. Perform subglottic suctioning6. Ensure proper ETT cuff inflation7. Use Chlorhexidine as directed by manufacturer

Answers: Enter the number of times the patient has had oral care with CHG in the last 24 hours.

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o If the patient has not had oral care w/CHG and there is no contraindication, enter ‘0’ for the number of times the patient had oral care w/CHG. Enter ‘6’, “No oral care w/CHG, no contraindication.”

CHG Con: What is the contraindication for the use of CHG in the oral care regimen?(Only for patients currently intubated/trached and mechanically ventilated AND with ‘0’ entered in the CHG column)If ‘0’ was entered in the CHG column, answer this question. Enter the number associated with the answer into the box. For example, enter ‘1’ if Patient is known to have an allergic or hypersensitivity reaction to chlorhexidine. Enter ‘6’, “No oral care w/CHG, no contraindication.”


SAT: Has the patient had a Spontaneous Awakening Trial (SAT) in the last 24 hours? (Evaluated every 24hrs for patients receiving full vent support.)SAT definition and data entry: The goal here is to adjust or hold sedation every day until patients can follow simple commands. A brief overview of the decision process for the data collection portion of this measure is listed below. These are not the clinical procedures to be followed.

Question #1 : Has the patient been awake enough such that he/she can do three out of four simple tasks on request: open their eyes, look at their caregiver, squeeze the hand or put out their tongue at any time in the past 24 hours?

If Yes - Enter ‘Y’ in SAT Column. If No – Proceed to Question #2.

Question #2 : Has the patient received any medication for sedation in the past 24 hours, including Lorazepam, Midazolam, Propofol, Fentanyl, Morphine, Demerol, Dilaudid, Haldol, Precedex?

If No - Enter ‘C/NI’ for Contraindicated/Not indicated in SAT Column, Stop. This patient will not be included in computation of your compliance rate.

If Yes –Proceed to Question#3.

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Question#3 : Have medications for sedation been held during the past 24hrs (SAT)? If Yes- Enter ‘Y’ in SAT column. If No- Enter ‘N’ in SAT ColumnIf Contraindicated/Not indicated – Enter ‘C/NI’ in SAT column. This patient will not be included in computation of your compliance

rate for this measure.

SAT Con: What are the contraindications/not indicated conditions for this patient having a Spontaneous Awakening Trial? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘C/NI’ entered in the SAT column) If ‘C/NI’ was entered in the SAT column, answer this question. Enter the number associated with the answer into the box. For example, enter ‘1’ if the patient is currently receiving a sedative infusion for active seizures or alcohol withdrawal.


SBT: Has the patient had a Spontaneous Breathing Trial in the last 24 hours? (Only for patients currently intubated/trached and mechanically ventilated.)SBT definition: To conduct a trial of spontaneous breathing, ventilatory support is removed and the patient is allowed to breathe through either a T-tube circuit or a ventilatory circuit with low levels of PS (5–8 cmH2O in adults) with or without 5 cmH2O PEEP. No changes are required in the fraction of inspired oxygen or the level of positive end-expiratory pressure.(Evaluated every 24hrs for patients receiving full vent support.)

Enter ‘Y’ if the patient had a SBT. Enter ‘N’ if the patient did not have a SBT. Enter ‘C/NI’ if the use of a SBT is contraindicated/not indicated.

SBT Con: What is the contraindication for this patient having an SBT? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘C’ entered in the SAT column)If ‘C/NI’ was entered in the SBT column, answer this question. Enter the number associated with the answer into the box.


Please enter data from this paper-based data collection form in the CECity web-based reporting system at least once per week.

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If you are collecting PEEP and FiO2 by hand, please use the following columns. This information is for your own use. This information will NOT be entered into the online CUSP for VAP: EVAP data portal.

Collect only if needed. Do not enter into the online database portal

PEEP – Enter the minimum PEEP for the last 24 hours. (Only for patients currently intubated/trached and mechanically ventilated.)Enter PEEP in cm H2O. – Example: 8

FiO2 – enter the minimum FiO2 for the last 24 hours.(Only for patients currently intubated/trached and mechanically ventilated.)Enter FiO2 as a decimal. – Example: 0.70

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VAP Daily Rounding FormHospital ID# ___________ Unit ID#___________ Date (mm/dd/yyyy) ___________

Fill out for all beds

Fill out only if intubated/trached and mechanically ventilated Only if needed

Bed #

Intub/Trach & Mech Vent

Date of intubation

(mm/dd/yyyy)

Shift Sub-G ETT

Sub-G ETT Con

Location of intubation

Does Sub-G tube work?

HOB @ ≥30o

HOB

Con

Oral Care

Oral CareCon

Oral Care with CHG

CHGCon

SAT SAT Con

SBT SBT Con

PEEP FiO2

Y N E / / AM/PM Y N C Y N N/A Y N C Y N C/NI Y N C/NI























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Contraindications and Locations – Enter the appropriate number (Only enter contraindications if you have marked C or C/NI of ‘0’ (if a numerical column))

Sub-G ETT Contraindications

0) Other 1) Tracheostomy

HOB Contraindications

0) Other1) Hypotension 2) Unstable Physiological Status3) Low Cardiac Index4) Cervical, thoracic or lumbar surgery or instability5) LVAD6) RVAD7) Intra aortic balloon pump8) Open abdomen9) Patient refusal

Oral Care Contraindications

0) Other1) Patient refusal2) No oral care, no contraindication

Oral care with CHG Contraindications

0) Other 1) Patient is known to have an allergic or hypersensitivity reaction to chlorhexidine2) Patient is < 2 months of age3) There is a possibility of direct contact of CHG with meninges4) ALL oral care is contraindicated. (In this case, the answer in the Oral Care column

for this patient should also be “C”.) 5) Patient refusal 6) No oral care w/ CHG , no contraindication

SAT Contraindications

0) Other 1) Patient is receiving a sedative infusion for active seizures or alcohol withdrawal.2) Patient is receiving escalating sedative doses due to ongoing agitation.3) Patient is receiving neuromuscular blockers.4) Patient has had evidence of active myocardial ischemia in the previous 24 hrs.5) Patient has had evidence of increased intracranial pressure in the previous 24 hours.6) Patient is not receiving sedation medications.

SBT Contraindications

0) Other 1) Doesn’t have adequate oxygenation [SpO2 < 88% on an FiO2 of ≤ 50% and a PEEP

of ≤3 cm H2O] 2) No spontaneous inspiratory effort in a 5-min period. 3) Acute agitation requiring escalating sedative doses.4) Significant use of vasopressors or inotropes. 5) Patient has had evidence of increased intracranial pressure in the previous 24 hours.

Location of Intubation

0) Your ICU/unit1) Another ICU/unit in your hospital2) Outside hospital3) OR4) Rapid Response Team (RRT)5) ED6) Cardiovascular and Interventional Laboratory (CVDL)7) During a code on the floor8) Another location not listed above

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Appendix M: Questions for VAP:

Select the best answer for the following questions:

1. The mortality rate associated with VAP is approximately 36,000 deaths per year. a. Trueb. False

2. What is the estimated cost of VAP to the health care system per episode?a. $5000b. $15,000c. $23,000d. $32,000

3. What percentage of ventilated patients develop VAP?a. 5%-10%b. 10%-20%c. 15%-25%d. 25% - 35%

4. Which of the following are risk factors for acquiring VAP?a. Prolonged mechanical ventilation b. Suctioning using by a closed suctioning techniquec. Recent hospitalization within last 45 days d. All of the above

5. What kind of infection is VAP?a. Airway b. Internal c. Skind. Yeast

6. To reduce the risk of VAP, the head of the bed (HOB) should be placed at a. 5-10 degreesb. 10-15 degreesc. 20-25 degreesd. > =30 degrees

7. Which of the following is not a contraindication for the appropriate elevation of patient head of bed?

a. Hypotensionb. Lowerback Injuryc. Open abdomen d. Intubation

8. The Head of Bed elevation can be replaced with Reverse Trendelenburg position? a. Trueb. False

9. Which of the following interventions helps lower pulmonary aspiration of gastric contents?a. Head of Bed Elevation b. Subglottic Suctioningc. Oral Care with CHG

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d. Spontaneous Awakening and Breathing Trialse. a and bf. a and d

10. What kind of endotrachel suctioning system should be used for patient expected to be mechanically ventilated?

a. Standard b. Circular c. Open d. Closed

11. How often should Oral Care with CHG be performed?a. Q2b. Q4c. Q6d. Q12

12. How often should Oral Care alone be performed?a. Q2b. Q4c. Q6d. Q12e. a or b

13. How often should the ventilation circuitry be changed?a. Daily b. Weekly c. Only if damaged or soiledd. B and C

14. How often should you change the HME?a. Daily b. Every 5-7 Days c. Clinically Indicated d. B and C

15. How often should you attempt Spontaneous Awakening and Breathing Trial?a. Daily b. Weekly c. Monthly d. Never

16. Which of the following safety criteria are not contraindications for attempting the Spontaneous Awakening and Breathing Trials?

a. Patient receives sedative infusion for active seizures or alcohol withdrawal b. Patient receiving escalating doses of sedative for agitationc. Patient receiving neuromuscular blockers d. Patient receiving antihistamine blockers

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17. What is the benefit of performing Spontaneous Awakening Trial & Spontaneous Breathing Trial?

a. Reduces the number of days patients are on mechanical ventilation. b. Reduces the microbiological burden. c. Decreased the need for suctioning. d. None of the above.

18. What is the benefit of performing Oral Care?a. Reduces microbiological burden.b. A good practicing of hygiene.c. Decreasing the need for suctioning.d. Decrease gastric content aspiration.

19. Sedation vacation and weaning protocol can be performed with the use Spontaneous Awaking and Spontaneous Breathing Trials?

a. True b. False

20. During a Spontaneous Breathing Trial ventilator support is removed?a. True b. False

21. What kind of endotracheal tubes are recommended for the prevention of VAP?a. Silver coated endotracheal tubes.‐b. Antiseptic impregnated endotracheal‐ tubes.c. Cuffed endotracheal tube with in line dorsal lumen. d. All

22. Which of the following policies should be used to help prevent colonization of the aerodigestive tract?

a. A policy to encourage the use of orotracheal intubation over nasotracheal whenever orotracheal intubation is not contraindicated.

b. A policy to encourage the use of open ETT suctioning systems, and remove closed systems from supplies.

c. A policy to use selective digestive decontamination. d. A policy to promote the use of prophylactic systemic antimicrobials.

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Answers

1. A2. C3. C4. A5. A6. D7. D8. B9. E10. D11. D12. E13. C14. D15. A16. D17. A18. A19. A20. A21. C22. A

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