© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CSTS -VAP Prevention Data Collection InstructionsPresented by Sean Berenholtz MD, MHS, FCCM June 13, 2012

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Objectives

• To introduce the VAP Prevention Bundle • To go over the instructions for VAP Daily

Rounding Form

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VAP Daily Rounding Form

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Basic Information

• Hospital: Enter the number for your hospital.

• Unit ID#: Enter the number of your ICU unit.

• Date: Enter today’s date as MM/DD/YYYY format (e.g. 06/01/2011).

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For All Bed’s

Bed #: Enter all the bed numbers on the form, whether the patient is on mechanical ventilation or not. Include empty beds.

Intub/Trach & Mech Vent: Is the patient currently receiving mechanical ventilation?

• Enter ‘Y’ if the patient is intubated/trached and mechanically ventilated.

• Enter ‘N’ if the patient is not intubated /trached and mechanically ventilated.

Mechanical ventilation is defined as receiving ventilator support via an ETT or tracheostomy tube. Patients treated with non-invasive ventilation would be counted as ‘N’

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Date of Intubation

Enter the date that the patient was intubated

•MM/DD/YYYY format (e.g. 06/01/2012)

•DO NOT use dates from re-intubation following self-extubation.

•If the patient is re-intubated following <24 hours after extubation, use first intubation date.

Time of Shift

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Enter the shift during which the data was collected.

• Enter ‘AM’ if completed between 12 midnight and 12 noon.

• Enter ‘PM’ if completed between 12 noon and 12 midnight.

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Sub-G ETT Question

Does the patient have a subglottic suctioning endotracheal tube ( Sub- G ETT)?

– Enter ‘Y’ if the patient has a Sub-G ETT.

– Enter ‘N’ if the patient does not have a Sub-G ETT.

– Enter ‘C’ if the use of a Sub-G ETT is contraindicated.

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Sub-G ETT Contraindication Question

What is the contraindication for the use of a Sub-G ETT?

– Enter ‘0’ - Other

– Enter ‘1’ – Tracheostomy

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Sub-G ETT Functionality Question

Does Sub-G ETT Work? Is the subglottic tube functional?

– Enter ‘Y’ if the patient has a functioning Sub-G ETT

– Enter ‘N’ if the patient Sub-G ETT is not functioning.

– Enter ‘N/A’ if the patient does not have Sub-G ETT

Head of Bed Question

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Is the head of the bed (HOB) at or over thirty degrees from the horizontal?

– Enter ‘Y’ if the HOB is at ≥30 degrees .

– Enter ‘N’ if the HOB not at ≥30 degrees.

– Enter ‘C’ if HOB at ≥30 degrees is contraindicated.

Head of Bed Contraindications

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What is the contraindication to placing the head of the bed at an angle of more than or equal to 30 degrees when compared to a horizontal surface?

– Enter ‘0’ - Other – Enter ‘1’ - Hypotension– Enter ‘2’ - Unstable Physiological Status– Enter ‘3’ - Low Cardiac Index – Enter ‘4’ - Cervical, thoracic or lumbar surgery or instability – Enter ‘5’ - LVAD– Enter ‘6’ – RVAD– Enter ‘7’- Intra aortic balloon pump– Enter ‘8’ – Open abdomen

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Oral Care Question

How many times has the patient had oral care without CHG in the last 24 hours? (Q4)

– Enter ‘0’ if Oral Care has not been performed.– Enter ‘1’ if Oral Care has been performed once. – Enter ‘2’ if Oral Care has been performed twice .– Enter ‘3’ if Oral Care has been performed three times.– Enter ‘4’ if Oral Care has been performed four times or

more.– Enter ‘C’ if the use of Oral Care is contraindicated.

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Oral Care Definitions

Oral Care without CHG includes ALL the following four interventions. 1. Perform subglottic suctioning2. Ensure proper ETT cuff inflation3. Clean oral cavity with suction swab using 1.5% hydrogen

peroxide based solution4. Moisturize mucosa with swab

Oral Care Contraindication

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What is the contraindication for oral care?

– Enter ‘0’ - Other

Oral Care with Chlorhexidine –Question

• How many times in the last 24 hours has the patient had Oral Care with CHG? (Q12)

– Enter ‘0’ if Oral Care with CHG has not been performed. – Enter ‘1’ if Oral Care with CHG has been performed once.– Enter ‘2’ if Oral Care with CHG has been performed twice or

more. – Enter ‘C’ if Oral Care with CHG is contraindicated.

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Oral Care with Chlorhexadine –Definition

Oral Care with CHG includes ALL the following four interventions; 1. Perform oral care as in “oral care without CHG”2. Chlorhexidine

a. Use alcohol free CHGb. 10cc – squirt 5cc on right side of mouth between cheek

and gum, being sure to get upper and lower teeth, front to back, pharynx and tongue

c. Swab with toothette if needed to reach tongue/gumsd. Suction out pools in mouthe. Repeat on left side with remaining 5ccf. If patient requires nystatin, give CHG and nystatin 6

hours apartg. Or, use your manufacturers directions for use

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Oral Care with Chlorhexidine –Contraindications

• What is the contraindication for the use of CHG in the oral care regimen?

– Enter ‘0’ –Other

– Enter ‘1’ If the patient is known to have an allergic or hypersensitivity reaction to chlorhexidine

– Enter ‘2’ if the patient is < 2 months of age.

– Enter ‘3’ if the patient might come in direct contact with CHG through the meninges.

– Enter ‘4’ if all oral care is contraindicated. Armstrong Institute for Patient Safety and Quality

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Spontaneous Awakening Trials Question

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Has the patient had a Spontaneous Awakening Trial (SAT) in the last 24 hours?

Spontaneous Awakening Screen and Trial

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Spontaneous Awakening Trial Contraindication

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What is the contraindication for this patient having a Spontaneous Awakening Trial?

– Enter ‘0’ –Other

– Enter ‘1’ if the patient is receiving a sedative infusion for active seizures or alcohol withdrawal.

– Enter ‘2’ if the patient is receiving neuromuscular blockers.

– Enter ‘3’ if the patient has had evidence of active myocardial ischemia in the previous 24 h.

– Enter ‘4’ if patient has evidence of increased intracranial pressure .

Spontaneous Breathing Trial Question

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Has this patient had a Spontaneous Breathing Trial (SBT) within the last 24 hours? – Enter ‘Y’ if the patient has had a SBT within the previous

24 hours.– Enter ‘N’ if the patient has not had a SBT within the

previous 24 hours.– Enter ‘C’ if the use of a SBT is contraindicated and

documented in the medical record.

Spontaneous Breathing Screen

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SBT Safety Screen: – Patients pass the screen if:

• They have passed the SAT trial or are responsive to verbal stimuli

• They have adequate oxygenation (SpO2>=88% or an F2O2 of <=50% and a PEEP <=cm H2O)

• They have any spontaneous inspiratory effort within a 5-min period

• There is an abrupt change in mental status• There is currently no significant use of vasopressors or

inotropes• There is no evidence of increased intracranial pressure

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• SBT Trial:• Ventilatory support is removed• Patient breathes through T-tube circuit of ventilator circuit

with CPAP of 5cm H2O or pressure support of < 7cm H2O.• Patients pass if they don’t develop failure criteria for >= 120

minutes.– Respiratory rate of > 35 or < 8 breaths per minute or

longer– Hypoxemia (SpOs < 88% for >=5 min)– Abrupt change in mental status– An acute cardiac arrhythmia– Two or more signs of respiratorydistress

» Tachycardia» Bradycardia» Use of accessory muscles» Abdominal paradox» Diaphoresis» Marked dyspnea

Spontaneous Breathing Trial Contraindication

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What is the contraindication for this patient having a Spontaneous Breathing Trial?

– Enter ‘0’ –Other – Enter ‘1’ if the patient is receiving a sedative

infusion for active seizures or alcohol withdrawal.– Enter ‘2’ if the patient is receiving

neuromuscular blockers.– Enter ‘3’ if the patient has had evidence of active

myocardial ischemia in the previous 24 h. – Enter ‘4’ if patient has evidence of increased

intracranial pressure .

Spontaneous Breathing Trial Contraindication

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What is the contraindication for this patient having a Spontaneous Breathing Trial?– Enter ‘0’ –Other – Enter ‘1’ if the patient didn’t pass the SAT safety

screen.– Enter ‘2’ if the patient did not meet adequate

oxygenation [SpO2 < 88% on an F1O2 of <= 50%and a PEEP of <=3 cm H2O .

– Enter ‘3’ if the patient did not meet criteria of no spontaneous inspiratory effort in a 5-min period

– Enter ‘4’ if patient has acute agitation requiring escalating sedative doses.

– Enter ‘5’ if patient has significant use of vasopressors or inotropes.

– Enter ‘6’ if patient has increased intracranial pressure

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Reports

• % Compliance for each Process Measure

• Comparison Reports with other CSTS Site’s

• VAP Rates over Time

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Next Steps

• Start Data Collection – Time – We are ready when you are.– Limit Number of Data Collectors to Improve

Accuracy of Data Collection

• Send Scanned Copies– Email : csts@jhmi.edu – Fax :

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Questions ?

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