1. Prevention of Ventilator Associated Pneumonia (VAP) Cindy Lang, RN, BSN, CIC Senior Infection Control Specialist VA Medical Center West Palm Beach

2. Objectives VENTILATOR ASSOCIATED PNEUMONIA (VAP) List four key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle Describe three signs and symptoms of pneumonia Explain four procedures used to reduce the risk of VAP in patients Identify two key points for proper ventilator care to reduce VAP risk

3. VENTILATOR ASSOCIATED PNEUMONIA (VAP) VAP is the leading cause of nosocomial infection in the ICU and reflects 60% of all deaths attributable to nosocomial infections. Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway, which increases the opportunity for aspiration and colonization.

4. TIMELINE IHI announces Saving 100,000 Lives campaign in December 2004 including practices to reduce VAP and CR-BSI VA agrees to participate based on interest of VISNS and individual sites VISN Directors agree to implement 3 of the 6 practices 5/2005 Kick-off call for Reduction of VAP 1/2006 by IPEC Development of web based database

5. Institute for Healthcare Improvement (IHI) 100,000 Lives Saved Campaign Six Clinical Evidence Based Initiatives Prevention of Ventilator Associated Pneumonia Bundle Prevention of blood borne infections due to central lines Prevention of Surgical Site infections Implementation of Rapid Response Teams Prevention of Adverse Drug events through medication reconciliation Optimization of care for patients with Acute Myocardial Infarctions

6. The Case for Preventing VAP VAP – leading cause of death among hospital –acquired infections High rate of associated mortality: Hosp mortality of vent pts who develop VAP is 46% compared to 32% for ventilated patients who don’t develop VAP VAP prolongs time spent on vent, length of stay in ICU and LOS after DC from ICU

7. COST OF VAP Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission

8. Definitions: VAP Ventilator associated pneumonia: Pneumonia developing >48 hours of initiation of mechanical ventilation or <72 hours after cessation of mv *New progressive infiltrate, with leukocytosis, fever, and purulent sputum *Bronch protected specimen brush with >10 3 CFU, or BAL > 10 4 CFU Counting *Ventilator days/mo is the sum of the number of days each patient was on mechanical ventilation (via ETT/trach tube)

9. Evidence Based Practice Ventilator Associated Pneumonia Care HOB elevated 30 degrees or higher Stress Ulcer Prophylaxis DVT Prophylaxis Daily sedation vacation Daily Assessment of readiness to wean Daily Spontaneous Breathing Trial

10. VENTILATOR BUNDLE AUDIT FORM

11. HOB UP 30 DEGREES OR HIGHER Recommended elevation is 30-45 degrees If semi-recumbent or supine 34% incidence VAP If semi-recumbent position 8% incidence VAP* ↑HOB → ↓risk of aspiration of gastrointestinal contents ↓risk of aspiration of oropharyngeal secretions ↓risk of aspiration of nasopharyngeal secretions ↑HOB improves patients’ ventilation Supine patients have lower spontaneous tidal volumes on PS than those seated in upright position ↑HOB may aid ventilatory efforts and minimize atelectasis

12. Daily “Sedation Vacation” and Daily Assessment of Readiness to Wean Correlated with reduction in rate of VAP Sedation vacation results in significant reduction in time on mechanical ventilation Duration of mv decreased from 7.3 days to 4.9 days-study by Kress et al. NEJM 2000 Weaning is easier when patients are able to assist themselves at extubation with coughing and control of secretions

13. Sedation Vacation Risks Increased potential for self-extubation Increased potential for pain and anxiety Increased tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation

14. Peptic Ulcer Disease (PUD) Prophylaxis Appropriate intervention in all sedentary patients, however, ↑ incidence of stress ulceration in critical illness Decreasing pH of gastric contents may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents

15. PUD Prophylaxis Aspiration causes either pneumonitis or pneumonia and can be prevented Effects of aspirating acidic contents may be worse than those with higher pH. Some studies have shown ↑ risks of VAP with certain agents such as sucralfate while others have not

16. More on PUD Prophylaxis Surviving Sepsis Campaign Guidelines reviewed literature on PUD prophylaxis: “H2 receptor inhibitors are more efficacious that sucralfate and are the preferred agents. Proton Pump Inhibitors have not been assessed in direct comparison with H2 receptor antagonists and, therefore their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.”* Dellinger, RP et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Criit Care Med. Mar 2004;32(3):858-873.

17. PUD Prophylaxis While it is unclear if there is any association between PUD prophylaxis and decreasing rates of VAP, experience shows that when PUD prophylaxis is applied as part of a package of interventions for vent care, the rate of pneumonia decreases precipitously.

18. Deep Vein Thrombosis (DVT) Prophylaxis Higher incidence of DVT in critical illness Risk of venous thromboembolism is reduced if prophylaxis is consistently applied TARGET: patients undergoing surgery, trauma patients, acutely ill medical patients, and ICU patients

19. DVT Prophylaxis It is unclear if there is any association between DVT prophylaxis and decreasing rates of VAP. Experience shows that when DVT prophylaxis is applied as part of a package of interventions for ventilator care, the rate of pneumonia decreases precipitously.

20. DVT Prophylaxis – Risk of Bleeding Important considerations include that the risk of bleeding may increase if anticoagulants are used to accomplish the prophylaxis. Often, sequential compression devices (ie. SCDs, “venodynes” or “pneumoboots”) are not applied to patients when they go to or return from procedures.

21. MEASUREMENT VAP Rate: The total number of cases of ventilator-associated pneumonia for a specified time period: (Total no. of VAP cases / Ventilator Days) x 1000 = VAP Rate Ventilator Bundle Compliance: On a given day, the assessment of all vent patients for compliance with the ventilator bundle: No. receiving ALL components of vent bundle = reliability of No. on vents for the day of the sample bundle compliance

22. Barriers That May Be Encountered Fear of Change Communication Breakdown Physician and staff “partial buy-in” (“Just another flavor of the week?”) Unplanned extubations (most risky aspect)

23. Best Practices to Achieve a High Level of Compliance at WPB VAMC ICU Best Practices to Achieve a High Level of Compliance at WPB VAMC ICU Daily Multi-disciplinary Rounds including: Intensivist / Providers / Residents / Medical students Lead Unit Facilitator RN assigned to patient Clinical Pharmacist / Pharmacy Residents Infection Control Specialist Respiratory Therapist Registered Dietician Nurse Case Manager Quality Management / Utilization Management Specialist Speech Therapist Nursing student / Instructor Use of Ventilator Bundle Audit Tool addressing the bundle items daily

24. IPEC Data Management Website VISN 08 - Station 548 (West Palm Beach, FL) - FY 2007 - Quarter 4 Unit: Mixed ICU JUL 2007 AUG 2007 SEP 2007 Count Rate% Count Rate% Count Rate% VAP audits completed HOB elevated > 30 degrees SUD prophylaxis DVT prophylaxis Daily sedation vacation Daily readiness to wean Daily spontaneous breathing trial

25. HAND HYGIENE The best method to prevent healthcare acquired infections including VAP is to practice good Hand Hygiene including use of : Antimicrobial soap and water Alcohol Based Hand Rub (Isagel) when there is no visible soiling on hands

26. Compliance with Isolation Precautions Stringent adherence to the use of Personal Protective Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions

27. QUESTIONS??????? Thank you, Cindy Lang, RN, BSN, CIC Senior Infection Control Specialist 2008 Chairperson Healthcare Emergency Response Coalition of Palm Beach County (HERC) 2007 President Florida Professionals in Infection Control (FPIC) 2007 Syndromic Surveillance Chairperson (HERC) Department of Veterans Affairs Medical Center 7305 North Military Trail West Palm Beach, FL 33410-6400 Office 561-422-7358 Digital Pager 561-604-0208 FAX 561-422-6863