* By definition, ventilator-associated pneumonia (VAP) is an airways infection that must have developed more than 48 hours after the patient was intubated. Preventing pneumonia of any variety seems at first blush to be a laudable goal. However, there are some reasons to be particularly concerned about the impact of pneumonia associated with ventilator use.
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.
In addition, VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU. Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission.
* Source IHI: www.ihi.org
Ventilator Associated Pneumonia
Click on the VAP FAQ Fact Sheet from SHEA to download instructions on how you may help prevent infections in your patient.
FUTURE DIAGNOSTIC SOLUTIONS MUST MAINTAIN ACCURACY AND IMPROVE TURNAROUND TIME
Culture is the current standard of care but future diagnostics will allow more accurate detection of the pathogen .
Developed with the intent of improved turnaround time for diagnosis of pathogens causing disease will enable physician to de-escalate antibiotics within a few hours rather than a few days and will promote a more rational use of antibiotics at a time where the overuse of antibiotics is causing problems with individual patients and public health.
Prevention of VAP involves limiting exposure to resistant bacteria, discontinuing mechanical ventilation as soon as possible, and a variety of strategies to limit infection while intubated. Resistant bacteria are spread in much the same ways as any communicable disease.
Proper hand washing, sterile technique for invasive procedures, and isolation of individuals with known resistant organisms are all mandatory for effective infection control. A variety of aggressive weaning protocols to limit the amount of time a person spends intubation have been proposed. One important aspect is limiting the amount of sedation that a ventilated person receives.
Other recommendations for preventing VAP include raising the head of the bed to at least 45 degrees and placement of feeding tubes beyond the pylorus of the stomach. Antiseptic mouth washes such as chlorhexidine may also reduce the incidence of VAP. One study also suggests that using heat and moisture exchangers instead of heated humidifiers, may also reduce the incidence of VAP.
VAP occurs in up to 25% of all people who require mechanical ventilation. VAP can develop at any time during ventilation, but occurs more often in the first few days after intubation. This is because the intubation process itself contributes to the development of VAP. VAP occurring early after intubation typically involves fewer resistant organisms and is thus associated with a more favorable outcome. Because respiratory failure requiring mechanical ventilation is itself associated with a high mortality, determination of the exact contribution of VAP to mortality has been difficult.
Mortality is more likely when VAP is associated with certain microorganisms (Pseudomonas, Acinetobacter), blood stream infections, and ineffective initial antibiotics. VAP is especially common in people who have acute respiratory distress syndrome.
Guidelines for Preventing Healthcare Associated Pneumonia 2003
(The report in its entirety updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia".)
The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided.
Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of oro-tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions; no recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis.
For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water at temperatures not suitable for amplification of Legionella spp., considering routine culturing of water samples from the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care-associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2--10 day period before illness onset.
In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high -efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection.
In the section on influenza, the new recommendations include the addition of oseltamivir (to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized.
In addition to the revised recommendations, the guideline contains new sections on pertussis and lower respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of severe acute respiratory syndrome.
Because of the high morbidity and mortality associated with health-care--associated pneumonia, several guidelines for its prevention and control have been published. The first CDC Guideline for Prevention of Nosocomial Pneumonia was published in 1981 and addressed the main infection-control problems related to hospital-acquired pneumonia at the time: the use of large-volume nebulizers that were attached to mechanical ventilators and improper reprocessing (i.e., cleaning and disinfection or sterilization) of respiratory-care equipment. The document also covered the prevention and control of hospital-acquired influenza and respiratory syncytial virus (RSV) infection.
In 1994, the Healthcare Infection Control Practices Advisory Committee (HICPAC) (then known as the Hospital Infection Control Practices Advisory Committee) revised and expanded the CDC Guideline for Prevention of Nosocomial Pneumonia to include Legionnaires disease and pulmonary aspergillosis. HICPAC advises the secretary of Health and Human Services and the directors of CDC about the prevention and control of health-care--associated infections and related adverse events. The 1994 guideline addressed concerns related to preventing ventilator-associated pneumonia (VAP) (e.g., the role of stress-ulcer prophylaxis in the causation of pneumonia and the contentious roles of selective gastrointestinal decontamination and periodic changes of ventilator tubings in the prevention of the infection). The report also presented major changes in the recommendations to prevent and control hospital-acquired pneumonia caused by Legionnella spp. and aspergilli.
In recent years, demand has increased for guidance on preventing and controlling pneumonia and other lower respiratory tract infections in health-care settings other than the acute-care hospital, probably resulting in part from the progressive shift in the burden and focus of health care in the United States away from inpatient care in the acute-care hospital and towards outpatient and long-term care in other health-care settings. In response to this demand, HICPAC revised the guideline to cover these other settings. However, infection-control data about the acute-care hospital setting are more abundant and well-analyzed; in comparison, data are limited from long-term care, ambulatory, and psychiatric facilities and other health-care settings.
This report consists of Parts II and III of a three-part document and contains the consensus HICPAC recommendations for the prevention of the following infections: bacterial pneumonia, Legionnaires disease, pertussis, invasive pulmonary aspergillosis (IPA), lower respiratory tract infections caused by RSV, parainfluenza and adenoviruses, and influenza.
Part III provides suggested performance indicators to assist infection-control personnel in monitoring the implementation of the guideline recommendations in their facilities.
Part I of the guideline provides the background for the recommendations and includes a discussion of the epidemiology, diagnosis, pathogenesis, modes of transmission, and prevention and control of the infections. Part I can be an important resource for educating health-care personnel. Because education of health-care personnel is the cornerstone of an effective infection-control program, health-care agencies should give high priority to continuing infection-control education programs for their staff members.
HICPAC recommendations address such issues as education of health-care personnel about the prevention and control of health-care--associated pneumonia and other lower respiratory tract infections, surveillance and reporting of diagnosed cases of infections, prevention of person-to-person transmission of each disease, and reduction of host risk for infection.
Lower respiratory tract infection caused by Mycobacterium tuberculosis is not addressed in this document; however, it is covered in a separate publication.
The document was prepared by CDC; reviewed by experts in infection control, intensive-care medicine, pulmonology, respiratory therapy, anesthesiology, internal medicine, and pediatrics; and approved by HICPAC. The recommendations are endorsed by the American College of Chest Physicians, American Healthcare Association, Association for Professionals of Infection Control and Epidemiology, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, and Society of Critical Care Medicine.
To view the ENTIRE GUIDELINE, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
In addition, the GUIDELINES FOR THE MANAGEMENT OF ADULTS WITH HOSPITAL-ACQUIRED, VENTILATOR-ASSOCIATED, AND HEALTH CARE PNEUMONIA from the AMERICAN THORACIC SOCIETY, printed in the AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE can be found in their entirety at: http://ajrccm.atsjournals.org/cgi/content/full/171/4/388
THE VENTILATOR BUNDLE
The Institute for Healthcare Improvement writes:
The Ventilator Bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes
than when implemented individually.
The key components of the
Ventilator Bundle are:
A.) Elevation of the Head of the Bed at least 45 degrees
B.) Daily "Sedation Vacations" and Assessment of Readiness to Extubate
C.) Peptic Ulcer Disease Prophylaxis
D.) Deep Venous Thrombosis Prophylaxis
Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence -based practices.
The Institute for Healthcare Improvement writes, regarding Daily “Sedation Vacations” and Assessment of readiness to Extubate:
Using daily "sedation vacations" and assessing the patient’s readiness to extubate is an integral part of the Ventilator Bundle and has been correlated with reduction in the rate of ventilator-acquired pneumonia.
Kress et al. conducted a randomized controlled trial in 128 adult patients on mechanical ventilation, randomized to daily interruption of sedation irrespective of clinical state or interruption at the clinician’s discretion. Daily interruption resulted in a marked and highly significant reduction in time on mechanical ventilation. The duration of mechanical ventilation decreased from 7.3 days to 4.9 days (p=0.004).
It appears that lightening sedation decreases the amount of time spent on mechanical ventilation and therefore the risk of ventilator-acquired pneumonia. In addition, weaning patients from ventilators becomes easier when patients are able to assist themselves at extubation with coughing and control of secretions.
Sedation vacations are not without risks, however. Patients who are not sedated as deeply will have an increased potential for self-extubation. Therefore, the maneuver must be conducted in a careful fashion. In addition, there may be an increased potential for pain and anxiety associated with lightening sedation. Lastly, increased tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation.
IMPORTANT VAP INTERVENTIONS
In 1981, the CDC issued guidelines for preventing hospital-acquired pneumonias and other acute lower respiratory infections, based on an extensive review of the literature. The latest version, published in 2004, includes numerous strategies to decrease the rate of VAP.
Each intervention is rated according to the number and strength of the research studies that support it, the theoretical rationale, and the potential financial impact. These interventions, which are detailed in the following pages are summarized and focus on airway management, gastric reflux prevention, respiratory equipment maintenance, oral care, and cross contamination.
Obviously, the best way to prevent VAP is to limit the amount of time your patient requires mechanical ventilation. The guidelines call for using non-invasive positive-pressure ventilation delivered continuously via a face or nose mask instead of intubation whenever possible. They also advise clinicians to remove a patient's ET tube as soon as possible, and to do everything possible to avoid repeat endotracheal intubation.
A key concern is that an ET tube prevents the glottis from closing, which leaves the airway exposed and allows oropharyngeal secretions that accumulate above the tube cuff to leak into the lungs. Because these secretions increase the risk of aspiration - and therefore of VAP - they must be suctioned out, but they can't be reached by typical oral suctioning methods.
To address this, the CDC suggests using a particular type of ET tube, sometimes referred to as a continuous aspiration of subglottic secretions (CASS) tube. It features an additional lumen that ends with an evacuation port just above the cuff, making it possible to remove secretions from above the cuff by applying continuous or intermittent suction through the extra lumen. Studies have found that the use of a CASS tube can significantly reduce the incidence of VAP.
The CDC also offers this suctioning recommendation: Use only sterile fluid to clear a catheter that you're using to suction secretions from the patient's lower respiratory tract if you are planning to reinsert it into the ET tube.
The guidelines also recommend using orotracheal rather than nasotracheal intubation, unless contraindicated. This is because nasal tubes are associated with a high incidence of sinus infection, a condition that's particularly difficult to diagnose in critically ill patients.
The guidelines suggest implementing a comprehensive oropharyngeal cleaning and decontamination program for all patients at high risk for VAP, but don't outline specific oral care practices.There is, however, one exception: They suggest giving adults who are undergoing cardiac surgery a chlorhexidine gluconate (0.12%) oral rinse during the preoperative period.
GASTRIC REFLUX PREVENTION
Many ventilator patients have nasogastric tubes that predispose them to gastric reflux, which increases the risk of aspiration. The most important intervention to prevent gastric reflux is one that's controlled by nurses: patient positioning. Unless medically contraindicated, the bed of a patient on mechanical ventilation should remain elevated 30 - 45 degrees at all times. Studies have shown that this simple intervention significantly decreases the incidence of VAP, yet one recent study found that a majority of patients for whom bed elevation was indicated had head-of-bed elevation of less than 30 degrees.
The CDC recommends changes of the ventilator circuit (tubing, exhalation valve, and attached humidifier) when the equipment is visibly soiled or malfunctioning. In a related recommendation, the CDC recommends draining and discarding condensate that collects in the ventilator tubing and not allowing it to drain back toward the patient.
Although the guidelines regarding cross contamination remain unchanged, the importance of taking steps to prevent the transmission of microorganisms from healthcare workers to patients cannot be overemphasized. It's critical to observe standard precautions both before and after contact with a patient's mucous membranes, respiratory secretions, or any object that may be contaminated, such as an ET tube.
Additional information regarding Oral Care
Regarding EXPECTED PRACTICES, hospitals should:
Develop and implement a comprehensive oral hygiene program for patients in critical care and acute care settings who are at high risk for healthcare-associated pneumonia.
Brush teeth, gums and tongue at least twice a day using a soft pediatric or adult toothbrush.
In addition to brushing, provide oral moisturizing to oral mucosa and lips every 2 to 4 hours.
Use an oral chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for adult patients who
undergo cardiac surgery. Routine use in other populations is not recommended at this time.
Colonization of the oropharynx has been shown to be a critical factor in the development of nosocomial pneumonia.
Growth of potentially pathogenic bacteria in dental plaque provides a nidus of infection for microorganisms that have been shown to be responsible for the development of ventilator-associated pneumonia (VAP).
Dental plaque provides a microhabitat for organisms and provides opportunity for adherence either to the tooth surface or to other microorganisms. These microorganisms in the mouth translocated and colonize the lung, which can result in VAP.
Dental plaque can be removed by brushing. Whereas there are no data associated with critically ill patients, the American Dental Association recommends that healthy people brush teeth twice daily to remove plaque from all tooth surfaces.
The use of an oral care protocol (brushing with a pediatric toothbrush, mouthwash, and moisturizing gel) reduced oral
inflammation and improved oral health.
Chlorhexidine oral rinse reduced respiratory infections in cardiac surgery patients who received chlorhexidine before
intubation as well as postoperatively and reduced nosocomial pneumonia in patients who were Intubated for more than 24 hours.
HHS Action Plan to Prevent Healthcare-Associated Infections: Prevention - Prioritized Recommendations
Due to marked severity and high mortality of VAP, HHS published a prioritization that focuses on the subset of VAP -relevant recommendations within the broader category of healthcare-associated pneumonia prevention.
The CDC Guideline for Preventing Healthcare Associated Pneumonia was published in 2003. Additional recommendations included in Module 1 of this prioritization are derived from the 2008 SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals and therefore do not carry HICPAC evidence ratings.
Priority Module 1 – Recommendations for Routine Care of Patients Requiring Mechanical Ventilation Related Recommendations from 2008 SHEA/IDSA Compendium of Strategies:
Use non-invasive ventilation whenever possible
Use orotracheal rather than nasotracheal intubation when possible
Minimize the duration of ventilation; Perform daily assessments of readiness to wean from ventilation
Prevent aspiration by maintaining patients in a semi-recumbent position (30-45 degree elevation of head of bed) unless otherwise contraindicated
Use a cuffed endotracheal tube with an endotracheal cuff pressure of at least 20cm H2O and in-line or subglottic suctioning
Perform regular oral care with an antiseptic solution
Priority Module 2 – Recommendations for Appropriate Cleaning, Disinfection, and Sterilization of Ventilator Equipment Related HICPAC Recommendations:
HICPAC Recommendation: Thoroughly clean all equipment and devices to be sterilized or disinfected (Category 1A)
a. Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat pasteurization at >158°F (>70°C) for 30 minutes for reprocessing semi-critical equipment or devices (i.e., items that come into direct or indirect contact with mucous membranes of the lower respiratory tract) that are not sensitive to heat and moisture (Category 1A)
b. Use low-temperature sterilization methods (as approved by the Office of Device Evaluation, Center for Devices and Radiologic Health, Food and Drug Administration [FDA]) for equipment or devices that are heat - or moisture-sensitive (Category 1A)
c. After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items in the process (Category 1A)
HICPAC Recommendation: Preferentially use sterile water for rinsing reusable semi-critical respiratory equipment and devices when rinsing is needed after they have been chemically disinfected; If this is not feasible, rinse the device with filtered water (i.e., water that has been through a 0.2µ filter) or tap water, and then rinse with isopropyl alcohol and dry with forced air or in a drying cabinet (Category 1B)
HICPAC Recommendation: Between uses on different patients, clean reusable components of the breathing system or patient circuit (e.g., tracheal tube or face mask) inspiratory and expiratory breathing tubing, y-piece, reservoir bag, humidifier, and tubing, and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers' instructions (Category 1B)
HICPAC Recommendation: Between treatments on the same patient clean, disinfect, rinse with sterile water (if rinsing is needed), or dry small-volume in-line or hand-held medication nebulizers (Category 1B)
HICPAC Recommendation: Between their uses on different patients, sterilize or subject to high-level disinfection portable respirometers and ventilator thermometers (Category 1B)
Priority Module 3 – Recommendations for Appropriate Maintenance of Ventilator Circuit and Associated Devices Related HICPAC Recommendations:
HICPAC Recommendation: Drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient (Category 1B)
HICPAC Recommendation: Use only sterile fluid for nebulization and dispense the fluid into the nebulizer aseptically (Category 1A)
HICPAC Recommendation: Use only sterile (not distilled, non sterile) water to fill reservoirs of devices used for nebulization (Category 1A)
STRATEGIES TO PREVENT VAP
The following strategies to prevent ventilator-associated pneumonia in acute care hospitals were published in a supplement from Infection Control and Hospital Epidemiology, October 2008, Vol. 29, Supplement 1 S31-S40. Authors are: Coffin SE, Klompas M, Classen D, Arias KM, et al.
The article's purpose was not to serve as an in depth discussion of recommendations for detecting and preventing healthcare-associated pneumonia but rather offer a concise and practical listing of recommendations to assist acute care hospitals to highlight ventilator-associated pneumonia prevention strategies. The article also gives criteria for grading the strength of recommendation and quality of evidence described.
It briefly summarizes the article's 5 major sections. For complete discussion, tables, references and a Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals visit the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America:
Section 1: Rationale and Statements of Concern
In this section the authors discuss the occurrence, outcomes, pathogenesis and risk factors associated with VAP. The occurrence of VAP in acute care facilities has been identified as the most common infection acquired by adults and children in intensive care units (ICUs) but with quality improvement initiatives it might be preventable.
Under the outcomes section it was noted that VAP requires increased utilization of healthcare resources and costs as well as being a significant cause of patient morbidity and mortality. VAP extends hospitalization and increases the use of antimicrobial medications; with an overall increase in medical costs.
The pathogenesis of VAP shows that it is multifactorial and occurs when bacteria invade and colonize the respiratory tract of a patient receiving mechanical ventilation. It can also be caused by aspiration of secretions, colonization of the aero digestive tract, use of contaminated equipment and use of contaminated medications.
Risk factors contributing to the developing VAP are prolonged intubation, enteral feeding, witnessed aspiration, paralytic agents, underlying illness and extremes of age.
Section 2: Strategies to Detect VAP
Under strategies to detect VAP the definition and methods of surveillance are discussed. The authors note that there appears to be a lack of a consistent definition of VAP and that the definition is subjective. Most hospital epidemiologists and infection prevention and control professionals use the National Healthcare Safety Network VAP definition.
Methods for surveillance of VAP need to be ongoing to accurately identify VAP. Surveillance requires not only review of 2 or more chest radiographs but also appropriate laboratory culturing of endotracheal secretions or specimens from bronchoalveolar lavage. Methodology for specimen collection remains controversial; while, electronic surveillance tools which are not yet widely available but can be used in the identifying patients with possible VAP.
Section 3: Strategies to Prevent VAP
In this section the authors refer to existing guidelines as a way to improve patient outcomes and cost effectiveness; they also recommend different strategies that decrease the risk of developing VAP which include prevention of aspiration, reduce colonization (aero-digestive tract) and minimization of equipment contamination used to care for patients receiving mechanical ventilation.
A majority of the current recommendations are from adult patient studies since there are few studies which have evaluated prevention of VAP in children. Aspiration of secretions, colonization of the aero digestive tract and use of contaminated equipment are the 3 most common causes of VAP.
General strategies that decrease the risk developing of VAP are active surveillance, adherence to hand-hygiene guidelines, use of noninvasive ventilation (when feasible), minimizing ventilator time, daily assessment for readiness to wean, the use weaning protocols and lastly VAP education to all healthcare personnel.
Specific strategies to prevent aspiration include maintaining patients in a semi-recumbent position, unless contraindicated; avoiding gastric over distention, unplanned extubation and re-intubation, and using a cuffed endotracheal tube with in-line or subglottic suctioning.
Strategies to reduce colonization of the aero-digestive tract include orotracheal intubation and avoidance of nasotracheal intubation. Avoid histamine receptor 2 (H2)–blocking agents and proton pump inhibitors unless the patient is at high risk for developing a stress ulcer or stress gastritis. The use of sucralfate or H2-blocking agents is still unresolved and the frequency of performing oral care with an antiseptic solution remains in question.
Strategies to minimize contamination of equipment used to care for patients receiving mechanical ventilation include use rinsing reusable respiratory equipment with sterile water, keeping ventilatory circuits free of condensation, maintaining a closed ventilator circuit during condensate removal, changing the ventilator circuit only when necessary eg. visible soil or malfunctioning and lastly store and disinfect respiratory therapy equipment properly.
Section 4: Recommendations for Implementing Prevention and Monitoring Strategies
This section contains a table that categorizes and grades the strength of the recommendations and the quality of evidence that currently exits. It also offers recommendations for implementing basic practices for prevention and monitoring of VAP in acute care hospitals.
The topics discussed were education of healthcare personnel (individuals who care for patients undergoing ventilation) and the appropriate surveillance of VAP which includes performing direct observation of compliance with VAP specific process measures (hand hygiene, bed position, daily sedation interruption and assessment of readiness to wean and regular oral care).
Practices and policies that need to be in place to ensure appropriate patient care for patients with VAP are listed. The need for accountability by the hospital's chief executive officer and senior management team to ensure that the healthcare system effectively supports a program to prevent VAP is addressed. It further lists the other levels of hospital employees involved and their roles in preventing VAP.
A section on approaches discusses both those that should not be considered a routine part of care as well as special approaches that should be considered for its prevention. And lastly, a list of unresolved issues that are still open for discussion and research as to their impact on the prevention VAP.
Section 5: Performance Measures
In this section performance measures and compliance calculations are discussed. These measures and compliance calculations are intended to support hospital quality improvement efforts.
The 4 procedural techniques included in the performance measure are:
Compliance with hand-hygiene guidelines for all clinicians who deliver care to patients undergoing ventilation
Compliance with daily sedation interruption and assessment of readiness to wean unless clinically contraindicated.
Compliance with regular antiseptic oral care
Compliance with semi recumbent positioning (30° - 45° elevation of the head of the bed; at the time of observation) for all eligible patients
Process (performance) measures:
Preferred measure of the above assessment of compliance
Numerator: Number of observed episodes of hand-hygiene or the number of patients undergoing ventilation with daily documentation of sedation interruption and assessment of readiness to wean or contraindication; regular oral care; semi recumbent position procedure.
Denominator: Number of patients undergoing ventilation or the number of observed instances of caregiver activity
Multiply by 100 so that the measure is expressed as a percentage.
Perform ongoing surveillance of the incidence density of VAP for patients undergoing ventilation to permit longitudinal assessment of process of care.
Incidence density of VAP, reported as the number of episodes of VAP per 1,000 ventilator-days.
Preferred measure of VAP incidence density
Numerator: number of patients undergoing mechanical ventilation who have VAP, defined using National Healthcare Safety Network definitions.
Denominator: number of ventilator-days.
Multiply by 1,000 so that the measure is expressed as cases per 1,000 ventilator-days.
The document contains recommendations for public reporting of healthcare-associated infections which have been provided by the Hospital Infection Control Practices Advisory Committee, the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee, and the National Quality Forum.
Because of the difficulties in diagnosing VAP, the validity of comparing VAP rates between facilities is poor, and external reporting of rates of VAP is not recommended.
The appendix section categorizes statements regarding sterilization, disinfection, and maintenance of respiratory equipment based on the healthcare infection control practices advisory committee recommendations and contains The Healthcare Infection Control Practices Advisory Committee system for categorization.
The Healthcare Infection Control Practices Advisory Committee system for categorization of recommendations is as follows:
Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB: Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and a strong theoretical rationale.
Category IC: Required for implementation, as mandated by federal or state regulation or standard.
Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale.
In 2008, SHEA released their Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. This poster highlights FAQs regarding these potentially dedaly infections.
For more information, visit: http://www.shea-online.org/about/compendium.cfm
HELPFUL INFORMATION AND RESOURCES FOR THE FAMILY OF YOUR PATIENT WHEN A
LOVED ONE IS ATTACHED TO A VENTILATOR
WHAT IS A VENTILATOR?
A ventilator (pictured here) is a machine that helps a patient to breathe. Patients are usually placed on a ventilator because of a medical problem that makes it hard for them to breathe well on their own.
While on the ventilator, the body is able to rest so that it can heal. The ventilator can help with breathing or totally breathe for the patient.
WHAT SHOULD I EXPECT?
Your loved one may feel frustrated or anxious because he or she can’t talk while on the ventilator but there are several ways to help promote communication.
You can speak with the nurses about what might work best for your loved one. Also, some patients have periods of drowsiness or disorientation because of the medicine they are receiving.
EATING AND ACTIVITY
Your loved one will be fed through an IV (intravenous) feeding tube while on the ventilator. However, some patients without tracheostomy tubes are able to eat by mouth. If your loved one is strong enough, he or she may sit up in a chair while on the ventilator.
WHAT YOU CAN DO
There are many things you can do to comfort your loved one. Try talking to him or her as you normally would or let your loved one know you’re near by touching or holding his or her hand. You may be able to bring items from home,like a pillow or robe. Please check with the nurse first. Some patients need special instructions for their visitors,such as special visiting times or a time limit to the visit. Please follow these instructions. They are in place to allow the patient care team to give your loved one the care he or she needs.
It is imperative that the patient IS NEVER ALLOWED TO LIE DOWN FLAT. The head of the bed should be always at a 30 - 45 degree angle. Doing so will ensure that they are at the least risk for acquiring ventilator-associated pneumonia.
Several studies have shown reduced rates of ventilator associated pneumonia with the frequent and vigorous use of oral care. Other studies have demonstrated the benefit of implementing oral care protocols that incorporate tooth brushing and oral suctioning in reducing oropharyngeal and plaque colonization, including gram-positive and gram-negative bacteria. Ask your nursing staff if you can perform oral care on your patient to help prevent potential colonization and infection.
ALARMS, ALERTS AND WARNINGS
Even though there may not be a care team member at the patient’s bedside, there are a number of devices that will alert the staff of any problems or changes. The monitor is a small screen above the patient’s bed. It helps keep track of things like the patient’s heart rhythm and blood pressure. Both the monitor and the ventilator are equipped with alarms. Each of the alarms will alert a staff member if a change has taken place in the patient’s condition. Each sound refers to a different condition. Often when an alarm sounds, there is no great cause for concern. The problem may correct itself, and this will be monitored from the nurses station. Other times, a care team member may come to check the alarm.
COMING OFF THE VENTILATOR
The ventilator brings oxygen into the lungs and helps get rid of carbon dioxide from the patient’s body. Sometimes a patient may become dependent on a ventilator because of his or her medical problems. This may make it difficult to get the patient off the ventilator. When the patient’s medical problems have improved and he or she is well enough, a process termed “weaning” will begin. Weaning is the process of getting the patient off the ventilator. This is also known as a “weaning trial” or “CPAP trial.” If these trials go well, the patient may be removed from the ventilator. At this point, the breathing tube may be removed from his or her throat (extubation). Trach patients will probably need additional time before the trach tube can be removed.
Following are some terms you may hear while your patient is being ventilated:
Alveoli (al-VEE-o-lie): tiny sac-like air spaces in the lungs where carbon dioxide and oxygen are exchanged
Arterial Blood Gas (ABG): A sample of blood takenfrom an arery (usually in the wrist) to measure the oxygen and carbon dioxide levels. This is different from theplace where blood is usually taken from, which is a vein.
Atelectasis (at-a-LEK-tay-sis): condition when a portion of the lung collapses, or is compressed because of blockages in the airway
Bronchi (BRON-key): large airways of the lungs
Bronchioles (BRON-key-ols):smaller airways of the lungs
Bronchodilator (bronk-oh-DY-lay-tor):a drug that relaxes the smooth muscles in the airways to help make breathing easier
Endotracheal (en-doh-TRAY-kee-ul) tube: a flexible plastic tube that is inserted through the mouth or nose down into the trachea (the large airway from the mouth to the lungs). The endotracheal tube can be connected to a ventilator
Extubation (ex-too-BAY-shun): taking the breathing tube out of the windpipe (trachea)
Intubation (in-too-BAY-shun): putting the breathing tube into the windpipe (trachea)
Pneumonia (nu-MO-nya): swelling and redness of the lungs caused by an infection
Pulse oximeter (ox-IM-eh-tur): a probe that is placed on a finger, toe, or earlobe to measure the amount of oxygen in the blood
Respiratory (RES-per-uh-tor-ee) failure: a medical condition where a person cannot get enough oxygen or get rid of enough carbon dioxide by normal breathingThis condition may require the help of a ventilator.
Restraints: soft ties used to restrict movement so that your loved one does not pull out important breathing tubes or medicine lines
Suctioning (SUK-shun-ing): using a small plastic tube, called a suction catheter, to remove secretions from the breathing tube and the patients airways
Tracheostomy (tray-key-OS-tuh-me) or Trach(TRAKE): an opening in the neck through which a breathing tube is placed. This may or may not be in place for a long time.
Ventilation (ven-tuh-LAY-shun): the exchange of air between the lungs and the atmosphere leading to an exchange of oxygen and carbon dioxide in the bloodstream
Ventilator settings: readings that show how much oxygen is given, how often the ventilator is “breathing” for the patient, and how big each breath is
Ventilator: a machine that breathes for the patient
Weaning trials: a process in which the ventilator breathing is slowly cut back to take the patient off the ventilator