American Association of Critical-Care Nurses: Practice Alert Ventilator Associated Pneumonia Audra Brooks Sydonie Stock Jana Snider

Purpose To demonstrate how to evaluate nursing resources and integrate the information into standards of care Improve quality and safety of health care delivery The purpose of this presentation is to demonstrate how to evaluate nursing resources and integrate the information into standards of care; the ability to consume research will improve quality and safety of health care delivery.

American Association of Critical-Care Nurses Mission “AACN drives excellence because nothing less is acceptable” Services The American Association of Critical-Care Nurses was established in 1969 and represents more than 5 hundred thousand critical care nurses. They invest in research and educate nurses through memberships to their two journals, presenting at conferences, and by providing practice alerts. To paraphrase the AACN mission, patients turn to nurses when they need help, so acute and critical care nurses turn to AACN for the guidance and education needed to give that help. “AACN drives excellence because nothing less is acceptable”.

AACN Practice Alerts What is it? Level of evidence Practice alerts are directives that are supported by authoritative evidence to maintain excellent practice and safe work. Level of evidence “AACN Practice Alerts™ are succinct, dynamic directives that are supported by authoritative evidence to ensure excellence in practice and a safe and humane work environment.” What this means is AACN finds evidence based research in a particular area of critical care nursing that needs attention and disseminates the practice recommendations in order to improve care quality and safety for patients and nurses. All of the resources used by the AACN in forming this practice alert were level 6. They were clinical studies in a variety of patient populations and situations to support recommendation.

Ventilator Associated Pneumonia Ventilator Associated Pneumonia or VAP occurs when gastric secretions are aspirated by a patient on ventilation, causing pneumonia Practice Alert statements put out by the AACN Elevate head of bed 30°. Use an endotracheal tube on constant suction to remove secretions from the ventilator cuff. Ventilator circuit tubing does not need to be changed. Ventilator acquired pneumonia (VAP), is a lung infection that is developed in a person who is on a ventilator. A ventilator is a machine that helps a patient breathe by giving the patient oxygen through a tube. Patients who are on mechanical ventilation are at a higher risk for aspiration and the possibility of developing VAP. Gastric acid secretions may be aspirated, causing the pneumonia. This can be prevented by elevating the head of the bed to at least 30 degrees. Another source of infection could be secretions pooling above the ventilator cuff travel down into the lungs. This risk is reduced by using an endotracheal tube with continuous suction from the dorsal lumen above the cuff. It is thought, though not enough research has been conducted, that oral hygiene may play a role in VAP as well, so oral care is necessary with a ventilated patient. Studies show that the ventilator circuit does not need to be changed unless it is visibly soiled or malfunctioning. Fluids, or condensation, does accumulate in the ventilation tubes and must be periodically drained out. Make sure the fluid does not return to the patient’s lungs, as this can cause VAP as well. Hand washing, as always, is an important method of infection control.

Ventilator circuit Ventilator cuff The image to the left shows the ventilator cuff, or the balloon that holds the endotracheal tube in place, and the secretions that can slip past and into the lungs. The picture on the right is an example of a ventilator circuit. http://www.biomedsearch.com/attachments/00/21/99/64/21996487/cc10352-3.jpg http://img.hisupplier.com/var/userImages/2010-10/21/tenhoo_124217015_s.jpg

Implementing In order to decrease cases of VAP in your critical care unit, ensure these practice alerts are transcribed in: Written practice documents Policies Standards of care The AACN urge all critical care units to include their three recommendations in the policy and procedure manuals. Again the three recommendations are to always keep mechanically ventilated patients’ head of bed elevated to at least 30 degrees unless medically contraindicated; if the patient is expected to be intubated for greater than 48 hours, an ET tube with continuous suction above the cuff should be used; and do not routinely change ventilator cuffs. These three nursing practice actions will improve patient outcomes and reduce the length of hospital stay. These techniques will improve the safety for patients on a ventilator by possibly preventing these hospital acquired infections, thus improving patient outcomes and the cost saving for the patient and facility for treatment. These recommendations represent what should be considered the new standards of care for ventilated patients in order to prevent VAP.

Measuring Measure compliance via audit provided by AACN If compliance is < 90° the AACN offers suggestions on how to develop a plan for improvement. Unless there is a sound medical reason not to, all ventilated patients should be cared for following the practice alert recommendations. Compliance to the policy changes should be measured and the AACN provides an audit tool to examine the head of bed compliance. If the audit reveals compliance less than 90%, steps need to be taken toward improvement. Some suggestions the AACN makes are to form a multidisciplinary team to investigate causes of low compliance, education of staff on VAP and the importance of these interventions, and incorporate these measures in new nurse orientations and in initial and annual competency verifications. Reminders to staff should be posted and visible to alert the staff of the steps they should be taking to reduce VAP in their patients.

Conclusion Elevate HOB 30° Suction ventilator cuff Do not change ventilator circuit VAP is a preventable hospital acquired infection. In 2008, the AACN provided critical care nurses around the country with best practice standards to implement into their critical care units. These standards include elevating the head of bed to 30 degrees or more, unless contraindicated, using a continuous suction above the ventilator cuff, and not changing the ventilator circuit unless it is visibly soiled or malfunctioning.

References American Association of Critical-Care Nurses. (2014). Key statements, beliefs and philosophies behind the American Association o Critical-Care Nurses (AACN). http://www.aacn.org/wd/publishing/content/pressroom/aacnfactsheet.pcms?menu=publications# American Association of Critical-Care Nurses. (2014). Ventilator-associated pneumonia (VAP). http://www.aacn.org/wd/practice/content/vap-practice-alert.pcms?menu=practice American Association of Critical-Care Nurses. (2008). Ventilator associated pneumonia. AACN Practice Alert. http://www.aacn.org/wd/practice/docs/practicealerts/vap.pdf