1. Safer Healthcare Now! Ventilator Acquired Pneumonia Presented by Amanda Thompson, Safer Healthcare Now Facilitator April 12, 2007

2. Safer Healthcare Now! Background  Largest patient safety initiative in Canadian history  Adopted from IHI  Over 600 teams registered across Canada  Goal to improve health care delivery through 6 initiatives

3. Safer Healthcare Now! Initiatives  Acute Myocardial Infarction (AMI)  Ventilator Associated Pneumonia (VAP)  Central Line Associated Infection (CLI)  Prevention of adverse drug events through Medication Reconciliation (Med. Rec)  Prevention of Surgical Site Infection (SSI)  Rapid Response Teams (RRT)

4. VAP - Ventilator Associated Pneumonia DEFINITION – “An airway infection developed more than 48 hours after a patient was intubated” Leading cause of death Increased ICU stay Increased hospital stay Increased costs

5. Signs & Symptoms of VAP New, worsening or persistent infiltrate on CXR compatible with pneumonia and 2 of the following: WBC > 11 or neutropenia Temp > 38 Change in sputum Pathogen isolated form sputum in last 48 hrs Increasing O2 requirements for > 2 hrs Note: Presence of crackles or bronchial breathing, and confusion in older pt’s is a good indicator of pneumonia.

6. Goals  Decrease VAP by 50% in one year

7. VAP Bundle  HOB increased 30 – 45°  Daily sedation vacation with SBT  OG vs. NG  EVAC tubes

8. VAP Bundle cont’d “Teams that have unfailingly accomplished every bundle element, on every patient, every time,have gone months without a single case of pneumonia associated with the ventilator”.

9. Initiation of VAP Required: –Closed systems –Good mouth care Oral decontamination –Proper hand washing

10. Head of Bed (HOB) Constant HOB elevation Decreased VAP by 78% Decreased risk of aspiration Pt’s in supine position have lower spontaneous tidal volumes on pressure support Minimize atelectasis

11. Sedation Vacation with SBT  Stopping sedation at regular times every day. For example: morning assessment  RT to do a SBT  Decreases MV time from 7.3 days to 4.9 days  Weaning becomes easier  Use Riker Scale

12. Oral vs. Nasal  Oral endotracheal as well as oral gastric  Reduces frequency of nosocomial sinusitis from 73% to 34%  Nosocomial infections is a leading cause of death

13. EVAC Tubes  Removes pooled secretions from subglottic region  Reduces VAP from 39.6 to 19.9

14. Additional Components of Quality Ventilator Care –Peptic Ulcer Disease (PUD) prophylaxis  Decreased PH of gastric contents, may protect against pulmonary inflammatory response to aspiration  Decreased hospital stay –Deep Venous Thrombosis (DVT) prophylaxis  Decreased complications = Decreased Hospital Stay –Early Nutrition  Shown to decrease nosocomial infections

15. VAP Checklist Date/TimeBed#, Pt. Initials HOB ≥30 ° If HOB not Elevated Why OG & Oral Tracheal Tube If No OG Or Oral ETT Why Mouth Care q4h/ Brushing BID Sedation Vacation- Daily SBT If no SBT Why EVAC tube If no why     HOB: HI = Hemodynamic Instability SP = Spinal Precautions PR = Undergoing Procedure AG= Agitated NR = No Reason OG: OT= Oral Trauma SU = Post Oral Surgery TR = Trach Insitue NGS = NG Sutured PE= Planned Extubation SBT: CNM = Criteria Not Met EVAC: NA = Not Available SI = ETT size > 6.0 TR = Trached *Adapted from a tool created by Dominical Hospital (Santa Cruz, CA) March 20, 2007

16. VAP Improvement  Since implementing 2 of the 4 elements, VAP has decreased.  With continued use and implementation of all bundle elements, we can and will decrease VAP dramatically.

18. Questions?

19. Contact Information Amanda Thompson 709-292-2647 athompson@cwhc.nl.ca www.saferhealthcarenow.ca

20. Thank You!