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

2. 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

3. 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

4. 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 more days in the hospital
And VAP costs over $40,000 per case to treat—all paid for by the facility
Rello, Chest, 2002

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

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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

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

18. 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

19. 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

20. 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

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

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

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

24. 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

25. 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 __________ 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

26. 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

27. 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 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