Ventilator-Associated Pneumonia Saint Anthony-Crown Point CICU/NSICU Margie Wickert, RN, MSN -Critical Care CNS Lisa R. Kwasigroch RN, BSN

Objectives Define Ventilator-Associated Pneumonia (VAP) Discuss the risk factors associated with VAP and the implications for nursing care of patient’s receiving ventilator therapy Identify the patients who are at risk for VAP Identify contributing factors for development of VAP Discuss the Evidence-Based Practice guidelines to help reduce VAP

Problem Identification Patients that are receiving continuous mechanical ventilation have 6 to 21 times greater risk of developing hospital- associated pneumonia than patients not on mechanical ventilation Tablan OC, “Guidelines for preventing health-care--associated pneumonia, 2003,” Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003. According to an AJCC study, VAP occurs in 10 to 65% of ventilated critical care patients mortality rates between 20 and 70% Sole ML, Am J Crit Care, 2002

Problem Identification A recent, 9,080-patient study found that the average VAP patient spends 9.6 additional days on mechanical ventilation, 6.1 extra days in the ICU, and 11.5 more days in the hospital And VAP costs over $40,000 per case to treat—all paid for by the facility Rello, Chest, 2002

Goals Decrease / Prevent Ventilator Associated Pneumonia (VAP) Decrease LOS in the ICU

VAP . . .What is it? Ventilator-Associated Pneumonia Most common nosocomial bacterial infection among patients requiring mechanical ventilation Rello, Chest, 2002

VAP Increased mortality in critically ill patients (20% - 70%) Increased cost of care: $40,000 additional cost per patient CDC guidelines from Preventing Healthcare Pneumonias, 2003 AACN Practice alert

Risk Factors For Developing VAP Patients at extreme of age spectrum; malnutrition; severe underlying conditions Artificial airway Colonization of dental plaque with respiratory pathogens Bacterial colonization of the oropharyngeal area Aspiration of subglottic secretions Head of bed < 30 degrees

Risk Factors For Developing VAP Colonization of Dental Plaque with respiratory pathogens Bacterial Colonization of the oropharyngeal area Aspiration of subglottic secretions

Quality CDC Guidelines re: Prevention of Healthcare-Associated Pneumonia “…Develop and implement a comprehensive oral hygiene program (that might include use of an antiseptic agent) for patients in acute-care settings or residents in long-term--care facilities who are at risk for health-care--associated pneumonia (II).* Healthcare Facilities Accreditation Program American Thoracic Society Infectious Diseases Society of America American Association of Critical Care Nurses Six Sigma Process * In addition to other interventions Guidelines for preventing health-care associated pneumonia, 2003, Recommendations of CDC and HICPAG

Evidenced Based Practice EVIDENCE LEVEL Level I - High Level II - Moderate Level III - Low Evidence comes from well conducted, randomized control trials Evidence comes from well designed, controlled trials without randomization Evidence comes from case studies and expert opinion; therapy recommendations without clinical data

Create Multi-disciplinary Team Dr. Rebessco - Pulmonologist Margie Wickert, RN, MSN - Critical Care CNS Lisa Kwasigroch, RN, BSN - Purdue MSN Student Unit Director CICU / NSICU Georgine Paulauski - Respiratory Therapy Chris Shakula - Infectious Disease Carolyn Bender - Nursing Quality Nursing Management Carol Schuster Karin Kolisz

Education Goals Increase knowledge and awareness of VAP Change attitudes to value the importance of the role of oral care in the etiology of VAP Change practice

Recommended Best Practice Water based moisturizers provide hydration Non-alcoholic oral rinses Mouthwash with hydrogen peroxide actives naturally occurring peroxidase which resists bacterial colonization in the oral pharynx Nursing Mgt., Vol. 34, Supplement 3, May 2003

Recommended Best Practice Soft bristle toothbrush removes plaque and stimulates the mucosa Sodium bicarbonate toothpaste overcomes odor, dissolves mucous, eliminates breeding ground for bacteria, and reduces acidity Mouthwash with an antiseptic agent has an antimicrobial effect on the oral cavity Nursing Mgt., Vol. 34, Supplement 3, May 2003

Impact of Standardized Oral Care Protocol on VAP Saint Anthony - Crown Point CICU / NSICU

Good Handwashing Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994

HOB at 30-45 degrees In the absence of medical contraindication(s). CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003 Drakulovic et al, Lancet, 1999,354:1851

Sage - Q•Care® Oral Cleansing and Suctioning System q4h Content Kit 24 Hours: 1 Suction Handle; Covered Yankauer; Y-Connector 2 Suction toothbrush with Sodium Bicarbonate, Antiplaque Solution, Mouth Moisturizer, Applicator Swab 4 Suction swab with Sodium Bicarbonate; Perox-A-Mint® Solution, Mouth Moisturizer and Applicator Swab 2 Suction Catheter

Oral Cavity Suction the oral cavity Swab the oral cavity every 4 hours and PRN to cleanse and maintain oral mucosal integrity Moisturize oral cavity every 4 hours

Brush Teeth Brush teeth 2 times per day to remove dental plaque 0800 2000

Oropharyngeal Suctioning Suction every 12 hours to remove secretions from the oropharyngeal area above the vocal cords.

Implement Best Practice VAP / Oral Care Protocol Inservice Staff Initiate Protocol Implement Q•Care® Tools. Evaluate Progress - Goal

Ventilator Associated Pneumonia (VAP) Oral Care Protocol Name: ____________________ Ventilator Associated Pneumonia (VAP) Oral Care Protocol Post-Inservice Review 1. What is the additional average cost of Ventilator Associated Pneumonia to the hospital per case? a.$10,000 b.$20,000 c.$40,000 d.$75,000 2. What is the mortality rate for a patient who develops VAP? 3.List three major risk factors associated with the development of Ventilator Associated Pneumonia? 1.______________________________ 2.______________________________ 3.______________________________ 4. What is the CDC recommendation for all ventilated patients? 5.Critical care nurses can prevent Ventilator Associated Pneumonia. a. True b. False

Ventilator Associated Pneumonia (VAP) Oral Care Protocol Name: ____________________ Ventilator Associated Pneumonia (VAP) Oral Care Protocol Post-Inservice Review 6. What is the St. Anthony Critical Care Unit Protocol for frequency of Oral Care on patients receiving mechanical ventilation > 24 hours? a. every hour b.every 2 hours c.every 4 hours d.every 8 hours 7. Using the Oral Care Protocol, how often should the critically ill vented patient's teeth be brushed? a. every 4 hours b. every 8 hours c. every 12 hours d. once a day 8. The purpose of the Sage mouth moisturizer is to: _______________________________. 9.The Sage oral care kit will be changed @ __________ AM every __________. 10. The goal of providing a comprehensive oral care program to ventilated patients is to ma intain integrity of the oral mucosa, decrease or prevent ventilator associated pneumonia and decrease the ICU length of stay. a. True b. False

Ventilator Associated Pneumonia (VAP) Oral Care Protocol Name: ____________________ Ventilator Associated Pneumonia (VAP) Oral Care Protocol Post-Inservice Review ANSWER SHEET 1. What is the additional average cost of Ventilator Associated Pneumonia to the hospital per case? a.$10,000 b.$20,000 c.$40,000 d.$75,000 2. What is the mortality rate for a patient who develops VAP? 20-70% 3.List three major risk factors associated with the development of Ventilator Associated Pneumonia? 1. Colonization of dental plaque with respiratory pathogens 2. Bacterial colonization of the oropharyngeal area 3. Aspiration of subglottic secretions 4. What is the CDC recommendation for all ventilated patients? Develop and implement a comprehensive oral hygiene program 5.Critical care nurses can prevent Ventilator Associated Pneumonia. a. True b. False

Ventilator Associated Pneumonia (VAP) Oral Care Protocol Name: ____________________ Ventilator Associated Pneumonia (VAP) Oral Care Protocol Post-Inservice Review ANSWER SHEET 6. What is the St. Anthony Critical Care Unit Protocol for frequency of Oral Care on patients receiving mechanical ventilation > 24 hours? a. every hour b.every 2 hours c.every 4 hours d.every 8 hours 7. Using the Oral Care Protocol, how often should the critically ill vented patient's teeth be brushed? a. every 4 hours b. every 8 hours c. every 12 hours d. once a day 8. The purpose of the Sage mouth moisturizer is to:hydrate the mouth and maintain mucosal integrity. 9.The Sage oral care kit will be changed @ 0600 AM every day. 10. The goal of providing a comprehensive oral care program to ventilated patients is to maintain integrity of the oral mucosa, decrease or prevent ventilator associated pneumonia and decrease the ICU length of stay. a. True b. False