Addressing JCAHO’s Patient Safety Addressing JCAHO’s Patient Safety Goal #7: Goal #7:

Focus on Key HICPAC Strategies Focus on Key HICPAC Strategies for the Prevention of VAPfor the Prevention of VAP

Robert Garcia, BS, MMT(ASCP), Robert Garcia, BS, MMT(ASCP), CICCIC

Brookdale University Medical Brookdale University Medical Center, NYCenter, NY© 2004, R. Garcia The opinions set forth herein are those of the presentor and do not necessarily represent the opinions of Sage Products, Inc.

The Time for Implementing The Time for Implementing Measures to Prevent Measures to Prevent Ventilator-Associated Ventilator-Associated Pneumonia is Now!Pneumonia is Now!

1. National Quality Issues1. National Quality Issues Agency for Healthcare Research & QualityAgency for Healthcare Research & Quality (AHRQ) (AHRQ)

• Issued review of 73 patient care practices; Issued review of 73 patient care practices; addressed VAP preventionaddressed VAP prevention

Institute of Medicine’sInstitute of Medicine’s (IOM) 1999 (IOM) 1999 “To Err is “To Err is Human: Building A Safer Health System”Human: Building A Safer Health System”• Indicated that up to 98,000 Americans die each Indicated that up to 98,000 Americans die each

year as a result of medical errorsyear as a result of medical errors The National Quality ForumThe National Quality Forum

• Safe Practices for Better Healthcare: A Safe Practices for Better Healthcare: A Consensus Report, May 2003. Consensus Report, May 2003. (national (national voluntary consensus standards, includes Safe voluntary consensus standards, includes Safe Practice #19, “Prevent hospital-acquired Practice #19, “Prevent hospital-acquired respiratory infections”)respiratory infections”)

Garcia R, Barnard B, Kennedy V. The fifth evolutionary era in infection control: Interventional Epidemiology. AJIC Am J Infection Cont, 2000;28:30-43.

2. Global Infection Control Issues2. Global Infection Control Issues

“IE…is essential if the [IC] profession is to deal with the continued need to conserve resources, to lower costs, and to demonstrate improved clinical outcomes and satisfaction scores…it realizes that it is necessary for all projects, plans, activities, and ultimately all decisions stemming from an infection control program to be integrated with a business perspective”

Garcia R, Barnard B, Kennedy V. The fifth evolutionary era in infection control: Interventional Epidemiology. AJIC 2000;28:30-43.

The Practice Arena of Interventional Epidemiologists

Clinical Financial

Customer

Satisfaction

3. Regulatory Issues3. Regulatory Issues

Joint Commission on Accreditation of Joint Commission on Accreditation of Healthcare Organizations (JCAHO)Healthcare Organizations (JCAHO)

• 2004 Standard: 2004 Standard: IC.1.10 “The organization uses a coordinated IC.1.10 “The organization uses a coordinated process to reduce the risks of nosocomial process to reduce the risks of nosocomial infections in patients and health care workers infections in patients and health care workers …”…”

www.jcaho.com/accredited+organizations/svnp/svnp_index.htm

Key 2004 JCAHO IC FocusKey 2004 JCAHO IC Focus Patient Safety Goal #7: Patient Safety Goal #7: Reduce the risk of Reduce the risk of

health care-acquired infectionshealth care-acquired infections

A change from emphasis on surveillance to A change from emphasis on surveillance to one on interventionone on intervention

Effectiveness monitored by meaningful Effectiveness monitored by meaningful performance measuresperformance measures

Core MeasuresCore Measures: Prevention of VAP: Prevention of VAP

Available at http://premierinc.com/all/safety/publications/12-03-downloads/06-IC-2005-standards.doc

JCAHO: PI & ICJCAHO: PI & IC

Improving Organization PerformanceImproving Organization Performance• PI.1.10 – The hospital collects data to monitor its performancePI.1.10 – The hospital collects data to monitor its performance• PI.2.10 – Data are systematically aggregated and analyzedPI.2.10 – Data are systematically aggregated and analyzed• PI.2.20 – Undesirable patterns or trends in performance are PI.2.20 – Undesirable patterns or trends in performance are

analyzedanalyzed• PI.2.30 – Processes for identifying and managing sentinel PI.2.30 – Processes for identifying and managing sentinel

events are defined and implementedevents are defined and implemented• PI.3.10 – Information from data analysis is used to make PI.3.10 – Information from data analysis is used to make

changes that improve performance and patient safety and changes that improve performance and patient safety and reduce the risk of sentinel eventsreduce the risk of sentinel events

• PI.3.20 – An ongoing, proactive program for identifying and PI.3.20 – An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to reducing unanticipated adverse events and safety risks to patients is defined and implementedpatients is defined and implemented

JCAHO & PIJCAHO & PI

“Performance measurement is used internally by health care organizations to support performance improvement and externally, to demonstrate accountability to the public and other interested stakeholders. Performance measurement benefits the health care organization by providing statistically valid, data-driven mechanisms that generate a continuous stream of performance information. This enables a health care organization to understand how well their organization is doing over time and have continuous access to objective data to support claims of quality. The organization can verify effectiveness of corrective actions; identify areas of excellence within the organization; and compare their performance with that of peer organizations using the same measures.”

http://jcaho.org/pms/index.htm

High Risk, High MorbidityHigh Risk, High Morbidity

VAP FactsVAP Facts

Mechanical ventilation increases risk Mechanical ventilation increases risk of pneumonia 6-21 times (1% per of pneumonia 6-21 times (1% per day)day)

Attributable mortality is 27% and Attributable mortality is 27% and increases to 43% when etiologic increases to 43% when etiologic agent is agent is P.aeruginosaP.aeruginosa or or AcinetobacterAcinetobacter sp. sp.

LOS with VAP is 34 days and 21 days LOS with VAP is 34 days and 21 days without VAPwithout VAP

Cost of VAPCost of VAP Retrospective matched cohort study Retrospective matched cohort study

using data from large U.S. databaseusing data from large U.S. database 9,080 patients; 842 with VAP (9.3%)9,080 patients; 842 with VAP (9.3%) Patients with VAP had significantly Patients with VAP had significantly

longer duration of mechanical longer duration of mechanical ventilation, ICU stay, and hospital stay.ventilation, ICU stay, and hospital stay.

VAP associated with increase of VAP associated with increase of >$40,000>$40,000 in mean hospital in mean hospital chargescharges

Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of VAP in a large US database. Chest 2002;122:2115-2121.

Study FindingsStudy Findings

With VAP Without VAP

Duration of Mechanical Ventilation 14.3 15.5 days 4.7 7.0 days

ICU Stay 11.7 11.0 days 5.6 6.1 days

Hospital Stay 25.5 22.8 days 14.0 14.6 days

Mean Hospital Charges $104,982 $91,080 $63,689 $75,030

Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of VAP in a large US database. Chest 2002;122:2115-2121.

What strategies have been What strategies have been advocated in preventing VAP?advocated in preventing VAP?

Ventilator circuit replacementVentilator circuit replacement Heat and moisture exchanger replacementHeat and moisture exchanger replacement Closed suction catheter replacementClosed suction catheter replacement Semirecumbent positioning of patients Semirecumbent positioning of patients Selective digestive decontamination Selective digestive decontamination Stress ulcer prophylaxisStress ulcer prophylaxis Enteral feeding methodologiesEnteral feeding methodologies WeaningWeaning Oral and dental careOral and dental care

HICPAC Guidelines on Preventing HICPAC Guidelines on Preventing PneumoniaPneumonia

Issued 3/26/04Issued 3/26/04

Evidence-basedEvidence-based

Expert reviewExpert review

Recommendations Recommendations categorizedcategorized

www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

HICPAC CategoriesHICPAC Categories Category IA.Category IA. Strongly recommended for implementation Strongly recommended for implementation

and strongly supported by well-designed experimental, and strongly supported by well-designed experimental, clinical, or epidemiologic studies.clinical, or epidemiologic studies.

Category IB.Category IB. Strongly recommended for implementation Strongly recommended for implementation and supported by certain clinical or epidemiologic studies and supported by certain clinical or epidemiologic studies and by strong theoretical rationale.and by strong theoretical rationale.

Category IC.Category IC. Required for implementation, as mandated Required for implementation, as mandated by federal or state regulation or standard.by federal or state regulation or standard.

Category II. Category II. Suggested for implementation and supported Suggested for implementation and supported by suggestive clinical or epidemiologic studies or by strong by suggestive clinical or epidemiologic studies or by strong theoretical rationale.theoretical rationale.

No recommendation; unresolved issue.No recommendation; unresolved issue. Practices for Practices for which insufficient evidence or no consensus exists about which insufficient evidence or no consensus exists about efficacy.efficacy.

Ventilator CircuitsVentilator Circuits

Humidifier vs. HME technologyHumidifier vs. HME technology HICPAC: HICPAC:

Do not change routinely, on the basis of duration of use, Do not change routinely, on the basis of duration of use, the ventilator circuit (i.e., ventilator tubing and the ventilator circuit (i.e., ventilator tubing and exhalation valve, and the attached humidifier) that is in exhalation valve, and the attached humidifier) that is in use on an individual patient. Change the circuit when it use on an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning. is visibly soiled or mechanically malfunctioning. Cat IA Cat IA [same as for HME - Cat II ].[same as for HME - Cat II ].

Kollef MH, Shapiro SD, Fraser VJ, et al. Mechanical Kollef MH, Shapiro SD, Fraser VJ, et al. Mechanical ventilation with and without 7-day circuit ventilation with and without 7-day circuit changes: a randomized controlled trial. changes: a randomized controlled trial. Ann Intern Ann Intern MedMed 1995; 123;168-74. 1995; 123;168-74.

Heat & Moisture Exchangers (HME)Heat & Moisture Exchangers (HME)

Is filter hydroscopic or hydrophobic?Is filter hydroscopic or hydrophobic? HICPAC: HICPAC:

No recommendation can be made for the preferential use No recommendation can be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia of either HMEs or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation.. in patients receiving mechanically assisted ventilation.. (Unresolved Issue). (Unresolved Issue).

Change an HME that is in use on a patient when it Change an HME that is in use on a patient when it malfunctions mechanically or becomes visibly soiled. malfunctions mechanically or becomes visibly soiled. Cat IICat II

Do not routinely change more frequently than every Do not routinely change more frequently than every 48hours an HME that is in use on a patient. 48hours an HME that is in use on a patient. Cat IICat II

Do not change routinely (in the absence of gross Do not change routinely (in the absence of gross contamination or malfunction) the breathing circuit contamination or malfunction) the breathing circuit attached to an HME while it is in use on a patient. attached to an HME while it is in use on a patient. Cat. IICat. II

Davis K, Evans SL, Campbell RS, Johannigman JA, Luchette FA, Davis K, Evans SL, Campbell RS, Johannigman JA, Luchette FA, Porembka DT. Prolonged use of heat and moisture exchangers Porembka DT. Prolonged use of heat and moisture exchangers does not affect device efficiency or frequency rate of does not affect device efficiency or frequency rate of nosocomial pneumonia. nosocomial pneumonia. Crit Care Med Crit Care Med 2000;28:1412-18.2000;28:1412-18.

Closed Suction CathetersClosed Suction Catheters Manufacturers: replace at 24 hoursManufacturers: replace at 24 hours HICPAC: HICPAC:

No recommendation can be madeNo recommendation can be made about the about the frequency of routinely changing the in-line frequency of routinely changing the in-line suction catheter of a closed-suction system in suction catheter of a closed-suction system in use on one patient. use on one patient. (Unresolved issue)(Unresolved issue)

Kollef MH, Prentice D, Shapiro SD, Fraser Kollef MH, Prentice D, Shapiro SD, Fraser VJ, Silver P, Trovillion E, et al. Mechanical VJ, Silver P, Trovillion E, et al. Mechanical ventilation with or without daily changes ventilation with or without daily changes of in-line suction catheters. Am J Resp Crit of in-line suction catheters. Am J Resp Crit Care Med, 1997;156:466-72Care Med, 1997;156:466-72

New Intervention: Redefining the New Intervention: Redefining the Ventilator CircuitVentilator Circuit

Ventilator circuitry was defined by three separate Ventilator circuitry was defined by three separate devices: tubing, HME, in-line suction catheterdevices: tubing, HME, in-line suction catheter

Revised policy to consider circuitry as single closed Revised policy to consider circuitry as single closed system; change when soiled, malfunction, patient system; change when soiled, malfunction, patient transporttransport

Rates: 28.7/1000 VD in 2000; 9.8 in 2001Rates: 28.7/1000 VD in 2000; 9.8 in 2001 Saved >$15,000 per yearSaved >$15,000 per year

• Bertrand M, Zink K, McCormick J, et al. Reducing ventilator Bertrand M, Zink K, McCormick J, et al. Reducing ventilator associated pneumonia by redefining the ventilator circuit associated pneumonia by redefining the ventilator circuit as a single closed unit and eliminating routine component as a single closed unit and eliminating routine component changes. [abstract] 2002 APIC Education Conference, changes. [abstract] 2002 APIC Education Conference, Nashville, TNNashville, TN

Semirecumbent PositioningSemirecumbent Positioning

HICPAC: HICPAC: In the absence of medical contraindication(s), In the absence of medical contraindication(s),

elevate at an angle of 30-45° the head of the bed of elevate at an angle of 30-45° the head of the bed of a patient at high risk for aspiration (e.g., a person a patient at high risk for aspiration (e.g., a person receiving mechanically assisted ventilation and/or receiving mechanically assisted ventilation and/or who has an enteral tube in place) who has an enteral tube in place) Cat IICat II

Drakulovic MB, Torres A, Bauer TT, Nicholas Drakulovic MB, Torres A, Bauer TT, Nicholas JM, Nogue S, Ferrer M. A Supine body position JM, Nogue S, Ferrer M. A Supine body position as a risk factor for nosocomialas a risk factor for nosocomial pneumonia in pneumonia in mechanically ventilated patients: a mechanically ventilated patients: a randomized trial. randomized trial. LancetLancet 1999;354:1851-58. 1999;354:1851-58.

How high is 30 degrees?How high is 30 degrees?

Head of BedHead of Bed

How high is 30 degrees???How high is 30 degrees???• A lot higher then you might thinkA lot higher then you might think• Look at objective gauges or LCD Look at objective gauges or LCD

readoutsreadouts

Can’t make it to 30 degrees?Can’t make it to 30 degrees?

Situations when HOB up 30 degrees may Situations when HOB up 30 degrees may not be possiblenot be possible• Low BP/unstable VSLow BP/unstable VS• Agitated and at risk of falling out of bedAgitated and at risk of falling out of bed• Compromised circulation due to femoral linesCompromised circulation due to femoral lines• Spinal clearance/Spinal cord injury patients – Spinal clearance/Spinal cord injury patients –

MUSTMUST have a physician’s order identifying the have a physician’s order identifying the degree of elevation alloweddegree of elevation allowed

Use combination of HOB up and reverse Use combination of HOB up and reverse Trendelenburg to obtain a 30 degree angleTrendelenburg to obtain a 30 degree angle

Stress Ulcer ProphylaxisStress Ulcer Prophylaxis Theory has it that modifying stomach acid Theory has it that modifying stomach acid

effects the bacterial colonization leveleffects the bacterial colonization level HICPAC: HICPAC:

No recommendation can be made for the No recommendation can be made for the preferential use of sucralfate, H2-antagonists, preferential use of sucralfate, H2-antagonists, and/or antacids for stress-bleeding prophylaxis and/or antacids for stress-bleeding prophylaxis in patients receiving mechanically assisted in patients receiving mechanically assisted ventilation. ventilation. (Unresolved Issue)(Unresolved Issue)

• Livingston DH. Prevention of ventilator-associated Livingston DH. Prevention of ventilator-associated pneumonia. pneumonia. Am J SurgAm J Surg 2000;179(suppl 2A):12S-17S: 2000;179(suppl 2A):12S-17S:

““after all of this time and study, it is likely that after all of this time and study, it is likely that neither drug has any advantage in significantly neither drug has any advantage in significantly maintaining gastric flora and reducing VAPmaintaining gastric flora and reducing VAP.” .”

Selective Digestive DecontaminationSelective Digestive Decontamination

Preventive decolonization on the theory that the Preventive decolonization on the theory that the gut is a major source of VAPgut is a major source of VAP

HICPAC: HICPAC: No recommendation can be made for the routine No recommendation can be made for the routine

selective decontamination of the digestive tract (SDD) of selective decontamination of the digestive tract (SDD) of all critically-ill, mechanically ventilated, or ICU patients. all critically-ill, mechanically ventilated, or ICU patients. (Unresolved issue)(Unresolved issue)

30+ studies to date30+ studies to date

• Eggimann P, Pittet D. Infection control in the ICU. Eggimann P, Pittet D. Infection control in the ICU. ChestChest 2001;120:2059-2093:2001;120:2059-2093:

“… “…this selective pressure on the epidemiology of this selective pressure on the epidemiology of resistance definitely precludes the systematic use of SDD resistance definitely precludes the systematic use of SDD for critically ill patients”for critically ill patients”

WeaningWeaning

Duration, duration, duration!!!Duration, duration, duration!!!

Cook D, Meade M, Guyatt G, Griffith L, Booker L. Criteria for Cook D, Meade M, Guyatt G, Griffith L, Booker L. Criteria for Weaning from Mechanical Ventilation. Evidence Weaning from Mechanical Ventilation. Evidence Report/Technology Assessment No. 23 (Prepared by McMaster Report/Technology Assessment No. 23 (Prepared by McMaster University under Contract No. 290-97-0017). AHRQ Publication No. University under Contract No. 290-97-0017). AHRQ Publication No. 01-E010. Rockville MD: Agency for Health Care Research and 01-E010. Rockville MD: Agency for Health Care Research and Quality. November 2002. Quality. November 2002.

Evidence-Based Guidelines for Weaning and Discontinuing Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. A Collective Task Force comprised of Ventilatory Support. A Collective Task Force comprised of members of the American College of Chest Physicians, the members of the American College of Chest Physicians, the American Association for Respiratory Care and the American American Association for Respiratory Care and the American College of Critical care Medicine. College of Critical care Medicine. ChestChest 2001;120:375S-395S. 2001;120:375S-395S.

Prevention or Modulation of Prevention or Modulation of Oropharyngeal ColonizationOropharyngeal Colonization

HICPAC:HICPAC:

Oropharyngeal cleaning and decontamination with an Oropharyngeal cleaning and decontamination with an antiseptic agent: develop and implement a antiseptic agent: develop and implement a comprehensive oral-hygiene program (that might comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term-care acute-care settings or residents in long-term-care facilities who are at high risk for health-care-associated facilities who are at high risk for health-care-associated pneumonia. pneumonia. Cat. IICat. II

Schleder B, Stott K, Lloyd RC. The effect of a Schleder B, Stott K, Lloyd RC. The effect of a comprehensive oral care protocol on patients at risk for comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia. J Advocate Health ventilator-associated pneumonia. J Advocate Health 2002;4:27-30.2002;4:27-30.

Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-3.Soc 2002;50:430-3.

Is there evidence that supports the

implementation of a comprehensive Oral and Dental Care Program?

1. Oral Cavity vs. Gastric Colonization I1. Oral Cavity vs. Gastric Colonization I

Research over 20 years on influence of Research over 20 years on influence of stomach and oropharyngeal colonization stomach and oropharyngeal colonization on respiratory infectionon respiratory infection

• Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, Sclemmer B. Oropharyngeal or gastric colonization Popoff N, Sclemmer B. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care MedAm J Respir Crit Care Med 1997;156:164 1997;156:164

• Bonten MJM, Gaillard GA, Van Tiel H, Smeets GGW, Van Der Bonten MJM, Gaillard GA, Van Tiel H, Smeets GGW, Van Der Geest S, Stobberingh EE. The stomach is not a source for Geest S, Stobberingh EE. The stomach is not a source for colonization of the upper respiratory tract and pneumonia in colonization of the upper respiratory tract and pneumonia in ICU patients. ICU patients. ChestChest 1994;105:878-84. 1994;105:878-84.

2. Oral Cavity vs. Gastric Colonization2. Oral Cavity vs. Gastric Colonization II II

“…“…decolonization approaches in the prevention of decolonization approaches in the prevention of nosocomial pneumonia strongly suggests that nosocomial pneumonia strongly suggests that oropharyngeal decontamination, indeed, oropharyngeal decontamination, indeed, represents the effective part of SDD [selective represents the effective part of SDD [selective digestive decontamination], and that the majority digestive decontamination], and that the majority of antibiotic use in SDD is unlikely to add of antibiotic use in SDD is unlikely to add beneficial effects”beneficial effects”

• Bergmans DCJJ, Bonten MJM, Gaillard CA, Paling JC, van Bergmans DCJJ, Bonten MJM, Gaillard CA, Paling JC, van der Geest S, van Tiel F, Besens AJ, et al. Prevention of der Geest S, van Tiel F, Besens AJ, et al. Prevention of ventilator-associated pneumonia by oral ventilator-associated pneumonia by oral decontamination. A prospective, randomized, double-decontamination. A prospective, randomized, double-blind, placebo-controlled study. blind, placebo-controlled study. Am J Resp Crit Care MedAm J Resp Crit Care Med 2001;164:382-88.2001;164:382-88.

3. Link Between Oral Pathogens & 3. Link Between Oral Pathogens & Respiratory InfectionRespiratory Infection

A review articleA review article 6 articles cited as 6 articles cited as

support for a support for a relationship between relationship between poor oral health and poor oral health and respiratory infectionrespiratory infection

Bacteria from Bacteria from colonized dental colonized dental plaque may be plaque may be aspirated into the aspirated into the lower airwaylower airway

Scannapieco, FA. Role of oral bacteria in respiratory infection. J Periodontol 1999;70:794-802

4. Dental Plaque as a Contributor to VAP4. Dental Plaque as a Contributor to VAP

Fourrier E, Duvivier B, Boutigny H, Roussel-Fourrier E, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Delvallez M, Chopin C. Colonization of dental Colonization of dental plaque: a source of nosocomial infections in plaque: a source of nosocomial infections in intensive care patients.intensive care patients. Crit Care Med Crit Care Med 1998;26:301-8.1998;26:301-8.

• Study on dental plaque colonization and ICU nosocomial Study on dental plaque colonization and ICU nosocomial infs.infs.

• Dental plaque occurred in 40% of pts.Dental plaque occurred in 40% of pts.• Colonization of dental plaque was highly predictive of Colonization of dental plaque was highly predictive of

nosocomial infectionnosocomial infection• Salivary, dental, and tracheal aspirates cultures were Salivary, dental, and tracheal aspirates cultures were

closely linkedclosely linked

5. Oral Decolonization: Use of 5. Oral Decolonization: Use of ChlorhexideneChlorhexidene

DeRiso AJ II, Ladowski JS, Dillon TA, Justice JW, Peterson ACDeRiso AJ II, Ladowski JS, Dillon TA, Justice JW, Peterson AC. . Chlorhexidene gluconate 0.12% oral rinse reduces the Chlorhexidene gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients nonprophylactic systemic antibiotic use in patients undergoing heart surgery. undergoing heart surgery. ChestChest 1996;109:1556-61. 1996;109:1556-61.

• 353 pts undergoing coronary bypass surgery353 pts undergoing coronary bypass surgery• Used chlorhexidine gluconate (0.12%) as oral rinse to prevent Used chlorhexidine gluconate (0.12%) as oral rinse to prevent

nosocomial infectionsnosocomial infections• Randomized to receive CHG or placeboRandomized to receive CHG or placebo• Overall reduction in nosocomial infections of 65% when using Overall reduction in nosocomial infections of 65% when using

CHGCHG• Respiratory infections were reduced 69% in CHG groupRespiratory infections were reduced 69% in CHG group

Chlorhexidine Oral RinseChlorhexidine Oral Rinse

HICPAC:HICPAC:

No recommendation can be made for the No recommendation can be made for the routine use of an oral chlorhexidine rinse for routine use of an oral chlorhexidine rinse for the prevention of health-care-associated the prevention of health-care-associated pneumonia in all postoperative critically ill pneumonia in all postoperative critically ill patients and/or other patients at high risk for patients and/or other patients at high risk for pneumonia. pneumonia. (Unresolved issue)(Unresolved issue)

Alcohol content; staining of teeth; Alcohol content; staining of teeth; brushingbrushing

Airway SuctioningAirway Suctioning

Subglottic Subglottic suctioningsuctioning• Yankauers don’t Yankauers don’t

reachreach• Routinely done Routinely done

every 2 hoursevery 2 hours• Before repositioning Before repositioning

ETTETT• Special ETT Special ETT

tubes???tubes???

Subglottic Secretion SuctioningSubglottic Secretion Suctioning HICPAC: HICPAC:

If feasible, uIf feasible, use an endotracheal tube with a dorsal se an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate suctioning) of tracheal secretions that accumulate in the patient’s subglottic area. in the patient’s subglottic area. Cat. IICat. II

• Valles J, Artigas A, Rello J, et al. Continuous aspiration of Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator associated subglottic secretions in preventing ventilator associated pneumonia. Ann Intern Med 1995;122:179-86.pneumonia. Ann Intern Med 1995;122:179-86.

• Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous subglottic suctioning in cardiac surgery patients. continuous subglottic suctioning in cardiac surgery patients. Chest Chest 1999; 116:1339-46.1999; 116:1339-46.

A Case StudyA Case Study

Reduction of Microbial Colonization in Reduction of Microbial Colonization in the Oropharynx and Dental Plaque the Oropharynx and Dental Plaque

Reduces VAPReduces VAP

R Garcia, L Jendresky, L Colbert

Brookdale University Medical Center, Brooklyn NY

Abstract accepted for the 2004 APIC Education Conference, Phoenix, AZ

MethodsMethods

The Brookdale University Medical Center

Prioritization & ActionPrioritization & Action Comparison of VAP rates with NNIS data Comparison of VAP rates with NNIS data

indicated MICU rate above 50indicated MICU rate above 50thth percentile percentile (6.0 cases per 1000 VD)(6.0 cases per 1000 VD)

Interventions taken prior to 2002 did not Interventions taken prior to 2002 did not have sufficient effect to reduce rate below have sufficient effect to reduce rate below the benchmarkthe benchmark

ICP conducting VAP surveillanceICP conducting VAP surveillance

Interventional Epidemiology methodology Interventional Epidemiology methodology applied: interviews and observationsapplied: interviews and observations

VAP Surveillance FormVAP Surveillance Form

VAP Reduction Task ForceVAP Reduction Task Force

Director of Nursing, Critical CareDirector of Nursing, Critical Care Nurse Manager, Critical CareNurse Manager, Critical Care Front line nursesFront line nurses Medical Director, Critical CareMedical Director, Critical Care Emergency Room physiciansEmergency Room physicians Respiratory Therapy Respiratory Therapy Materials ManagementMaterials Management Infection ControlInfection Control

AssessmentAssessment

Interviews of front line workersInterviews of front line workers Observation of proceduresObservation of procedures Review of productsReview of products Review of policiesReview of policies Review of literature, guidelinesReview of literature, guidelines

Communication Between Providers

People Procedures

VAP

PoliciesEquipment & Devices

VAP surveillance rounds (observational periods between IC and nurses)

Physicians

Nurses

Intubation/Extubation

Cleaning & maintenance of ventilator and components

Definition of VAP

Oral & Dental Care

Cleaning of ventilator/other devices

Closed suction system, oral suction catheters, water, other suction devices, suction canisters/tubing

Mechanical ventilator (Heated humidifier or HME)

Tracheostomy devices

Closed suctioning

Use of H2 antagonists/sucralfate

Handwashing

Filters

Pharmacists

Intubation/Extubation

Analysis of System Components Influencing the Occurrence of Ventilator-Associated Pneumonia

Nutritional Specialists

Nasogastric tubes

Placement & maintenance of nasogastric tube

Respiratory Therapists

Handwashing

Suctioning (closed/oral)

Oral Care

Vent circuits, filters

Nebulizers

Multidose vials

Laryngoscopes

Resusitation bags

Barrier equipment

Ventilator circuitsTracheostomy care

Cleaning of laryngoscopes Nebulizers

Suction canisters Resuscitation bags

Placement and care of nasogastric tubes

Enteral feeding Weaning

Self-extubation

Semi-recumbent positioning

Relay surveillance data to healthcare providers

Feedback from healthcare providers

Identification of NeedsIdentification of Needs

A uniform education program for A uniform education program for nurses and respiratory therapistsnurses and respiratory therapists

Standards for oral assessmentStandards for oral assessment Standards for oral careStandards for oral care Standards for dental careStandards for dental care Standardization of oral care solutionsStandardization of oral care solutions Keeping a closed system CLOSEDKeeping a closed system CLOSED Reduce environmental exposureReduce environmental exposure

Key Strategy #1: EducationKey Strategy #1: Education Handout created, includesHandout created, includes

answers to the following questions:answers to the following questions:• Why is prevention of VAP important?Why is prevention of VAP important?• What is hospital’s (unit’s) current rate?What is hospital’s (unit’s) current rate?• How do you compare with national benchmark?How do you compare with national benchmark?• What are major interventions implemented to What are major interventions implemented to

date?date?• What role does bacterial colonization play in What role does bacterial colonization play in

the development of respiratory infection?the development of respiratory infection?• What new products/techniques will be What new products/techniques will be

implemented to address oral bacterial implemented to address oral bacterial colonization?colonization?

Tip: Applicable HICPAC RecommendationTip: Applicable HICPAC Recommendation

I. Staff Education and Involvement in I. Staff Education and Involvement in Infection PreventionInfection Prevention

• Educate health-care workers about the Educate health-care workers about the epidemiology of, and infection-control epidemiology of, and infection-control procedures for, preventing health-care—procedures for, preventing health-care—associated bacterial pneumonia to ensure associated bacterial pneumonia to ensure worker competency according to the worker’s worker competency according to the worker’s level of responsibility in the health-care level of responsibility in the health-care setting, and involve the workers in the setting, and involve the workers in the implementation of interventions to prevent implementation of interventions to prevent health-care—associated pneumonia by using health-care—associated pneumonia by using performance improvement tools and performance improvement tools and techniques. techniques. Cat IACat IA

Key Strategy #2: Reduce Oral and Key Strategy #2: Reduce Oral and Dental ColonizationDental Colonization

Initial AssessmentInitial Assessment Et tube holdersEt tube holders Bite blocksBite blocks Need to be able to Need to be able to

fully visualize the fully visualize the mouth to assess for mouth to assess for problems problems

Assess oral cavity for Assess oral cavity for inflammation, inflammation, bleeding, areas of bleeding, areas of breakdown, pressure breakdown, pressure points, candidiasis, points, candidiasis, secretions, and secretions, and salivary flow (dryness)salivary flow (dryness)

Maintaining a Closed SystemMaintaining a Closed System

Covered YankauerCovered Yankauer

Policy: Use as needed

YankauerYankauer

Proper storageProper storage Keep Yankauer covered Keep Yankauer covered

when not in usewhen not in use Assists in decreasing the Assists in decreasing the

risk of environmental risk of environmental contamination contamination

Replace every day and Replace every day and PRNPRN

Suction CatheterSuction Catheter

Policy: Every 4 hrs. or as needed*the device manufacturer does not market or approve of its use below the vocal cords

Toothbrush with Sodium BicarbonateToothbrush with Sodium Bicarbonate

Policy: 2 X per day

BrushingBrushing Mechanically removes Mechanically removes

debris and plaque debris and plaque H2O2 and sodium H2O2 and sodium

bicarbonate helps bicarbonate helps break apart mucusbreak apart mucus

Gently brush gums Gently brush gums and tongue to ensure and tongue to ensure removal of plaque removal of plaque

Apply suction as Apply suction as needed to prevent needed to prevent aspiration of cleaning aspiration of cleaning solutionsolution

Suction Swab with MoisturizerSuction Swab with Moisturizer

Policy: Every 6 hrs.

Maintain Oral Tissues MoistMaintain Oral Tissues Moist

Apply moisturizing gel to Apply moisturizing gel to sponge swab and gently sponge swab and gently massage onto the massage onto the mucous membranes of mucous membranes of the patient's mouththe patient's mouth

Cracked or dry mucus Cracked or dry mucus membranes can lead to membranes can lead to bacterial growthbacterial growth

Provides comfortProvides comfort

Feeling fuzzy???Feeling fuzzy???

ResultsResults

VAP Rates, MICU, BUMC, 2002-2003VAP Rates, MICU, BUMC, 2002-2003

0

2

4

6

8

10

12

14

16

Jan-

02

Feb

-02

Mar

-02

Apr

-02

May

-02

Jun-

02

Jul-0

2

Aug

-02

Sep

-02

Oct

-02

Nov

-02

Dec

-02

Jan-

03

Feb

-03

Mar

-03

Apr

-03

May

-03

Jun-

03

Jul-0

3

Aug

-03

Sep

-03

Oct

-03

Nov

-03

Dec

-03

VA

P c

as

es

pe

r 1

00

0 v

en

t d

ay

s

Pre-intervention Period Post-intervention Period

Mean Rate

VAP Cases & Vent DaysVAP Cases & Vent Days

PeriodPeriod # Pts# Pts # VAP # VAP CasesCases

VDVD Rate Rate (VAP/(VAP/

1000 1000 VD)VD)

% Pts % Pts with with VAPVAP

Jan-Dec Jan-Dec 0202 377377 2020 26412641 7.67.6 5.35.3

Jan-Dec Jan-Dec 0303 360360 1111 24902490 4.44.4 3.13.1

Cost SavingsCost Savings

Attributable cost of a healthcare-Attributable cost of a healthcare-acquired pneumonia is estimated to acquired pneumonia is estimated to be $40,000 (Rello, be $40,000 (Rello, Chest, Chest, 2002).2002).

Based on the avoidance of 9 VAP Based on the avoidance of 9 VAP cases per year, BUMC estimates that cases per year, BUMC estimates that the annual avoided extra cost to the the annual avoided extra cost to the institution to be $360,000.institution to be $360,000.

ConclusionConclusion

High-morbidity, high-cost infections High-morbidity, high-cost infections are an ever-increasing focus of are an ever-increasing focus of patient safety and quality patient safety and quality improvement initiativesimprovement initiatives

Infection control programs must Infection control programs must consider new strategies based on consider new strategies based on review of the literature in preventing review of the literature in preventing VAP.VAP.

HICPAC RecommendationHICPAC Recommendation Part III: Performance IndicatorsPart III: Performance Indicators To assist infection control personnel in To assist infection control personnel in

assessing personnel adherence to the assessing personnel adherence to the recommendations, the following recommendations, the following performance measures are suggested:performance measures are suggested:

Monitor rates of VAP; can use established Monitor rates of VAP; can use established benchmarks and definitions of pneumonia benchmarks and definitions of pneumonia (e.g., NNIS definitions and rates). Provide (e.g., NNIS definitions and rates). Provide feedback to the staff about the facility’s VAP feedback to the staff about the facility’s VAP rates and reminders about the need for rates and reminders about the need for personnel to adhere to infection-control personnel to adhere to infection-control practices that reduce the incidence of VAPpractices that reduce the incidence of VAP

Summary: Major InterventionsSummary: Major Interventions

Limit manipulation of devicesLimit manipulation of devices Discontinue mechanical ventilation Discontinue mechanical ventilation

as soon as possibleas soon as possible Implement dental and oral care Implement dental and oral care

protocols, including deep oral protocols, including deep oral suctioningsuctioning

Don’t forget to wash your hands!Don’t forget to wash your hands!

A special thanks to Linda Jendresky, the IC staff, the

wonderfully dedicated staff at BUMC, and the individuals at Sage Products who made it

all happen.

Thank you!

Robert Garcia, BS, MMT(ASCP), CIC

Infection Control Department

Brookdale University Medical Center

One Brookdale Plaza

Brooklyn, NY 11212

718-240-5924

rgarcia@brookdale.edu