A Quick Review: Preventing Ventilator-Associated Pneumonia (VAP) Hannah Dowling University of South Florida

Audience: Staff (nurses, CNAs, physicians, midlevel providers) and students working in critical care and emergency room environments Objectives: At the end of the presentation, the learner will be able to identify risk factors for VAP; list interventions to prevent VAP; and identify what constitutes a VAP bundle Audience & Objectives

What is VAP? A type of hospital-acquired pneumonia (HAP) Occurs in mechanically-ventilated patients Diagnosed by a positive culture after intubation A culture before intubation is recommended What is VAP? Ventilator-associated pneumonia is a sub-type of hospital-acquired pneumonia (HAP) which occurs in people who receive mechanical ventilation. A diagnosis of VAP is made when a patient has a positive culture after intubation and it is not restricted to any particular organism. In order to appropriately categorize the causative agent or mechanism, it is recommended to obtain a culture before initiating mechanical ventilation as a reference. What is VAP?

Microbiology & Mortality VAP is the leading cause of death among hospital-acquired infections VAP mortality is 46%, compared to 32% for ventilated patients without VAP (IHI) Most common organisms: p. aeruginosa, k. pneumoniae, s. marescens, enterobacter, citrobacter, and MRSA VAP is the leading cause of death amongst hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. Perhaps the most concerning aspect of VAP is the high associated mortality. Hospital mortality of ventilated patients who develop VAP is 46 percent compared to 32 percent for ventilated patients who do not develop VAP. The most common causes of VAP are : pseudomonas aeruginosa, klebsiella pneumoniae, serratia marescens, enterobacter, citrobacter, and MRSA. Many of the organisms are multi-drug resistant, especially those found in immunocompromised patients Microbiology & Mortality

Host-related: COPD, ARDS, immunosuppression, patient positioning, LOC, sedation. Device-related: ET tube, ventilator circuit, NG or OG tubes. Personnel-related: hand washing, maintaining contact precautions Any patient with an endotracheal tube in place for more than 48 hours is at risk, but certain patients are at higher risk. We divide the risk factors for VAP into 3 categories: Host-related risk factors include preexisting conditions such as immunosuppression, COPD, and acute respiratory distress syndrome. Other host-related factors include patients’ body positioning, level of consciousness, number of intubations, and medications, such as sedatives and antibiotics. Device-related risk factors include the endotracheal tube, the ventilator circuit, the presence of a nasogastric or an orogastric tube, secretions pooling around the cuff and microaspiration from decreased cuff pressures. Personnel-related risk factors include Improper hand washing and failure to wear proper personal protection, which can result in the cross-contamination of patients. Risk Factors

VAP Bundles VAP bundle recommended by IHI: 1. Elevate HOB 2. Daily sedation vacation 3. PUD Prophylaxis 4. DVT Prophylaxis 5. Oral Care The Institute for Healthcare Improvement recommends a five-fold ventilator bundle for use in all adult ICUs. 1. Elevate HOB greater than 30 degrees at all times to reduce aspiration. 2. Daily sedation vacation to assess neurological function and readiness to extubate. 3. Peptic ulcer disease Prophylaxis to prevent gastric ulcers 4. Deep Vein Thrombosis Prophylaxis (either mechanical, pharmacological, or both depending on the patient). 5. Oral Care regularly as detailed in the next slide. VAP Bundles

Oral Care Mouthcare every 2 hours Use of chlorhexidine mouth wash frequently Subglottic and ET suctioning before lying the patient flat Use of silver-coated ET tubes Supraglottic secretion drainage systems It is recommended that nurses perform Oral care on ventilated patients every 2 hours with soft foam swabs, mouthwash, and lip moisturizers. Many facilities also use chlorhexidine mouthwash to reduce the bacterial burden in the mouth, as recommended by the Institute for Healthcare Improvement. Before lying a patient flat, any tube feeds should be shut off and suctioning should be done (subglottic and through the ET tube). Some facilities are reporting decreased rates of VAP using silver-coated ET tubes. American and Canadian guidelines strongly recommend the use of supraglottic secretion drainage (SSD) tracheal tubes with an extra suction lumen such as the EVAC tracheal tube from Covidien.   Oral Care Hi-Lo Evac™ by Covidien

VAP is not one of the core measures, but VAP rates are reported to the state as a measure of quality of a hospital VAP adds approx. $40,000 to the cost of a hospital stay CMS and other insurance companies believe the should not reimburse a facility for the cost of treating VAP Many hospitals in the US choose to report their rates of hospital-acquired infections for the public to view. This includes the Joint Commissions’ Core Measures (such as CHF, myocardial infarction, and community-acquired pneumonia). As of 2008, the Centers for Medicare and Medicaid no longer reimburse hospitals for costs associated with infections acquired in the hospital. It remains under debate whether or not VAP is to be reimbursed. The medical community continues to debate the guidelines and definitions of VAP. VAP can add up to $40,000 in treatment costs to a hospital stay. Therefore, It is imperative that nursing staff follow their hospital protocols to prevent VAP and decrease patient mortality. Reimbursement

Centers for Disease Control (2012). Retrieved from http://www. cdc First Do No Harm.(2011). Retrieved from http://www.firstdonoharm.com/HAC/reimbursement/ Institute for Healthcare Improvement.(2012). Retrieved from http://www.ihi.org/knowledge/pages/changes/implementtheventil atorbundle.aspx References