Strategies to Prevent Ventilator

8/18/2019 Strategies to Prevent Ventilator

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Strategies to Prevent Ventilator‐Associated Pneumonia in

Acute Care Hospitals

Susan E. Coffin , MD, MPH; Michael Klompas , MD; David Classen , MD, MS;Kathleen M. Arias , MS, CIC; Kell Pod!orn , "#, MS, CPH$;

Deveric% &. Anderson , MD, MPH; Helen 'urstin , MD; David P. Calfee , MD, MS;

Eri% ". Du((er%e , MD; )ictoria *raser , MD; Dale #. +erdin! , MD;*rances A. +riffin , "", MPA; Peter +ross , MD; Keith S. Kae , MD; Eveln -o , MD;

&onas Marschall , MD; -eonard A. Mermel , D, ScM; -indsa #icolle , MD;

David A. Pe!ues , MD; rish M. Perl , MD; San/a Saint , MD;Cassandra D. Sal!ado , MD, MS; "o(ert A. 0einstein , MD; "o(ert 0ise , MD;

De(orah S. 1o%oe , MD, MPH

*rom the Children2s Hospital of Philadelphia and 3niversit of Pennslvania School of

Medicine, Philadelphia, Pennslvania 4S.E.C.5; the 'ri!ham and 0omen2s Hospital and HarvardMedical School, 'oston 4M.K., D.S.1.5, and the Institute for Healthcare Improvement,

Cam(rid!e 4*.A.+.5, Massachusetts; the 3niversit of 3tah, Salt -a%e Cit 4D.C.5; the

Association for Professionals in Infection Control and Epidemiolo! 4K.M.A.5 and the #ational$ualit *orum 4H.'.5, 0ashin!ton, D.C.; the -oola 3niversit Chica!o Stritch School of

Medicine 4D.#.+.5, the Stro!er 4Coo% Count5 Hospital and the "ush 3niversit Medical Center

4".A.0.5, Chica!o, the &oint Commission, a%(roo% errace 4K.P., ".0.5, and the Hines

)eterans Affairs Medical Center, Hines 4D.#.+.5, Illinois; the Du%e 3niversit Medical Center,Durham, #orth Carolina 4D.&.A., K.S.K.5; the Mount Sinai School of Medicine, #e6 1or%, #e6

1or% 4D.P.C.5; the 0ashin!ton 3niversit School of Medicine, St. -ouis, Missouri 4E.".D., ).*.,

&.M.5; the Hac%ensac% 3niversit Medical Center, Hac%ensac% 4P.+.5 and the 3niversit of

Medicine and Dentistr7#e6 &erse Medical School, #e6ar% 4P.+.5, #e6 &erse; the 0arrenAlpert Medical School of 'ro6n 3niversit and "hode Island Hospital, Providence, "hode

Island 4-.A.M.5; the David +effen School of Medicine at the 3niversit of California, -osAn!eles 4D.A.P.5; the &ohns Hop%ins Medical Institutions and 3niversit, 'altimore, Marland

4.M.P.5; the Ann Ar(or )eterans Affairs Medical Center and the 3niversit of Michi!an Medical

School, Ann Ar(or, Michi!an 4S.S.5; the Medical 3niversit of South Carolina, Charleston

4C.D.S.5; and the 3niversit of Manito(a, 0innipe!, Canada 4E.-., -.#.5.

Address reprint re8uests to the "eprints Coordinator, 3niversit of Chica!o Press, 9:< E. =>th

St., Chica!o, I- =>=?< [email protected]!o.edu5 or contact the /ournal office

[email protected]!o.edu5.

Accepted &une :, >>; electronicall pu(lished Septem(er 9=, >>.

Purpose

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Previousl pu(lished !uidelines are availa(le that provide comprehensive recommendations for

detectin! and preventin! healthcare‐associated infections. he intent of this document is to

hi!hli!ht practical recommendations in a concise format desi!ned to assist acute care hospitals inimplementin! and prioritiBin! their ventilator ‐associated pneumonia 4)AP5 prevention efforts.

"efer to the Societ for Healthcare Epidemiolo! of AmericaInfectious Diseases Societ of

America Compendium of Strate!ies to Prevent Healthcare‐

Associated Infections EFecutiveSummar and Introduction and accompanin! editorial for additional discussion.

Section 1: Rationale and Statements of Concern

&ump o Section...

9.

ccurrence of )AP in acute care facilities.

a.

)AP is one of the most common infections ac8uired ( adults and children in

intensive care units 4IC3s5.9,

i.

In earl studies, it 6as reported that 9>G‐>G of patients under!oin!

ventilation developed )AP.?,: More‐recent pu(lications report rates of

)AP that ran!e from 9 to : cases per 9,>>> ventilator ‐das, (ut rates

ma eFceed 9> cases per 9,>>> ventilator ‐das in some neonatal and

sur!ical patient populations.‐ he results of recent 8ualit

improvement initiatives, ho6ever, su!!est that man cases of )AP

mi!ht (e prevented ( careful attention to the process of care.

. utcomes associated 6ith )AP

a.

)AP is a cause of si!nificant patient mor(idit and mortalit, increased

utiliBation of healthcare resources, and eFcess cost.9>‐9?

i.

he mortalit attri(uta(le to )AP ma eFceed 9>G.9:‐

ii.

Patients 6ith )AP re8uire prolon!ed periods of mechanicalventilation,? eFtended hospitaliBations,:,99,9= eFcess use of antimicro(ial

medications, and increased direct medical costs.99,9?,9:

?. Patho!enesis of and ris% factors for )AP

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a.

)AP arises 6hen there is (acterial invasion of the pulmonar parenchma in a

patient receivin! mechanical ventilation.

i.

Inoculation of the formerl sterile lo6er respirator tract tpicallarises from aspiration of secretions, coloniBation of the aerodi!estivetract, or use of contaminated e8uipment or medications.:

ii.

"is% factors for )AP include prolon!ed intu(ation, enteral feedin!,= 6itnessed aspiration,


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i.

Case findin! of )AP is compleF as a result of clinical criteria that var

6ith a!e and other host factors.

ii.

he need for revie6 of or more chest radio!raphs for patients 6ithunderlin! pulmonar or cardiac disease also contri(utes to thedifficulties in identifin! patients 6ith )AP.

iii.

+ram stainin! and semi8uantitative culture of endotracheal secretionsor 8uantitative culture of specimens o(tained throu!h (ronchoalveolar

lava!e should (e performed for a patient suspected to have )AP. he

8uestion of 6hich method is optimal for specimen collection of lo6errespirator tract secretions for dia!nosis of )AP is controversial.,?‐

:

iv.

Information technolo!, such as electronic surveillance tools, canassist in the identification of patients 6ith possi(le )AP (ut cannot

provide definitive identification and are not et 6idel availa(le.:?,::

Section 3: Strategies to Prevent VAP

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9.

EFistin! !uidelines and recommendations

a.

+uidelines to prevent )AP have (een pu(lished ( several eFpert !roups and,

6hen full implemented, improve patient outcomes and are cost‐effective.:‐9

(.

'ecause fe6 studies have evaluated the prevention of )AP in children, the

ma/orit of these recommendations stem from studies that 6ere performed in

adults. he core recommendations are desi!ned to interrupt the ? most common

mechanisms ( 6hich )AP developsJ

i.

Aspiration of secretions

ii.

ColoniBation of the aerodi!estive tract

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iii.

3se of contaminated e8uipment

.

+eneral strate!ies that have (een found to influence the ris% of )AP

a.

+eneral strate!ies

i.

Conduct active surveillance for )AP.,?

ii.

Adhere to hand‐h!iene !uidelines pu(lished ( the Centers for

Disease Control and Prevention or the 0orld Health r!aniBation.,?

iii.

3se noninvasive ventilation 6henever possi(le.:‐=9

iv.

MinimiBe the duration of ventilation.?,=,=?

v.

Perform dail assessments of readiness to 6ean,> and use 6eanin!

protocols.,,?,


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found up to a = and a randomiBed trial.


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inhi(itors for patients 6ho are not at hi!h ris% for developin! a stress

ulcer or stress !astritis.?,? 6ith an antiseptic solution.9>9,9>:‐9>

he optimal fre8uenc for oral care is unresolved.

d.

Strate!ies to minimiBe contamination of e8uipment used to care for patientsreceivin! mechanical ventilation

i.

3se sterile 6ater to rinse reusa(le respirator e8uipment.

ii.

"emove condensate from ventilator circuits. Keep the ventilatorcircuit closed durin! condensate removal.,?,

iii.

Chan!e the ventilator circuit onl 6hen visi(l soiled or

malfunctionin!.9,,99>‐99:

iv.

Store and disinfect respirator therap e8uipment properl. 4See the

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AppendiF.5

Section 4: Recommendations for mplementing Prevention and !onitoring

Strategies

&ump o Section...

"ecommendations for preventin! and monitorin! )AP are summariBed in the follo6in! section.he are desi!ned to assist acute care hospitals in prioritiBin! and implementin! their )AP

prevention efforts. Criteria for !radin! the stren!th of recommendation and 8ualit of evidence

are descri(ed in the a(le.

a(le. Stren!th of "ecommendation and $ualit of Evidence

I. 'asic practices for prevention and monitorin! of )APJ recommended for all acute carehospitals

A. Education

9.

Educate healthcare personnel 6ho care for patients under!oin! ventilation a(out )AP,

includin! information a(out the follo6in! 4A‐II5J

a.

-ocal epidemiolo!

(.

"is% factors

c.

Patient outcomes

.

Educate clinicians 6ho care for patients under!oin! ventilation a(out noninvasive

ventilator strate!ies 4'‐III5.

'. Surveillance of )AP

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9.

Perform direct o(servation of compliance 6ith )AP‐specific process measures 4'‐III5.

a.

)AP‐specific process measures include hand h!iene, (ed position, dail

sedation interruption and assessment of readiness to 6ean, and re!ular oral care.

(. 3se structured o(servation tools at re!ularl scheduled intervals.

. Conduct active surveillance for )AP and associated process measures in units that care

for patients under!oin! ventilation 6ho are %no6n or suspected to (e at hi!h ris% for)AP on the (asis of ris% assessment 4A‐II5.

a.

Collect data that 6ill support the identification of patients 6ith )AP andcalculation of )AP rates 4ie, the num(er of )AP cases and num(er of ventilator ‐

das for all patients 6ho are under!oin! ventilation and in the population (ein!

monitored5.

C. Practice

9.

Implement policies and practices for disinfection, steriliBation, and maintenance of

respirator e8uipment that are ali!ned 6ith evidence‐ (ased standards 4e!, !uidelines

from the Centers for Disease Control and Prevention and professional or!aniBations5 4A‐

II5.

a.

See the AppendiF for a list of recommended practices.

.

Ensure that all patients 4eFcept those 6ith medical contraindications5 are maintained in a

semirecum(ent position 4'‐II5.

?. Perform re!ular antiseptic oral care in accordance 6ith product !uidelines 4A‐I5.

:.

Provide eas access to noninvasive ventilation e8uipment and institute protocols to promote the use of noninvasive ventilation 4'‐III5.

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D. Accounta(ilit

9.

he hospital2s chief eFecutive officer and senior mana!ement are responsi(le for

ensurin! that the healthcare sstem supports an infection prevention and control pro!ram

to effectivel prevent )AP.

.

Senior mana!ement is accounta(le for ensurin! that an ade8uate num(er of trained personnel are assi!ned to the infection prevention and control pro!ram.

?.

Senior mana!ement is accounta(le for ensurin! that healthcare personnel, includin!

licensed and nonlicensed personnel, are competent to perform their /o( responsi(ilities.

:.

Direct healthcare providers 4such as phsicians, nurses, aides, and therapists5 andancillar personnel 4such as house%eepin! and e8uipment‐ processin! personnel5 are

responsi(le for ensurin! that appropriate infection prevention and control practices are

used at all times 4includin! hand h!iene, standard and isolation precautions, cleanin!and disinfection of e8uipment and the environment, aseptic techni8ues 6hen suctionin!

secretions and handlin! respirator therap e8uipment, patient positionin!, sedation and

6eanin! protocols, and oral care5.

. Hospital and unit leaders are responsi(le for holdin! their personnel accounta(le for their

actions.

=. he person 6ho mana!es the infection prevention and control pro!ram is responsi(le for

ensurin! that an active pro!ram to identif )AP is implemented, that data on )AP are

analBed and re!ularl provided to those 6ho can use the information to improve the

8ualit of care 4e!, unit staff, clinicians, and hospital administrators5, and that evidence‐

(ased practices are incorporated into the pro!ram.


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Section ": Performance !easures

&ump o Section...

I. Internal reportin!

hese performance measures are intended to support internal hospital 8ualit improvement

efforts and do not necessaril address eFternal reportin! needs.

he process and outcome measures su!!ested here are derived from pu(lished !uidelines, otherrelevant literature, and the opinions of the authors. "eport (oth process and outcome measures to

senior hospital leadership, nursin! leadership, and clinicians 6ho care for patients at ris% for

)AP.

A. Process measures

9.

Compliance 6ith hand‐h!iene !uidelines for all clinicians 6ho deliver care to patients

under!oin! ventilation

a. Collect data on a sample of healthcare personnel from all disciplines 6ho

provide hands‐on care to patients under!oin! ventilation, includin! phsicians,

nurses, respirator therapists, and radiolo! technicians. Perform o(servations atre!ular intervals 4e!, 9 set of measurements per 6ee%5. he fre8uenc of

o(servations can (e ad/usted on the (asis of compliance rates 4e!, as compliance

improves, less fre8uent o(servations ma (e needed5.

(. Preferred measure for hand‐h!iene compliance

i.

#umeratorJ num(er of o(served appropriate hand‐h!iene episodes

performed ( healthcare personnel.

ii.

DenominatorJ num(er of o(served opportunities for hand h!iene.

iii.

Multipl ( 9>> so that the measure is eFpressed as a percenta!e.

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.

Compliance 6ith dail sedation interruption and assessment of readiness to 6ean

a.

Assessment should (e performed ( chart revie6 of a sample of all patients

currentl under!oin! ventilation. Evidence of dail documentation on the patient2s chart, (edside paper6or%, or electronic medical record of a sedation

interruption and assessment of readiness to 6ean should (e present unlessclinicall contraindicated. Perform assessments at re!ular intervals 4e!, 9 set of

measurements per 6ee%5. he fre8uenc of o(servations can (e ad/usted on the

(asis of compliance rates 4e!, as compliance improves, less fre8uento(servations ma (e needed5.

(.

Preferred measure of compliance 6ith sedation interruption and assessment of

readiness to 6ean

i.

#umeratorJ num(er of patients under!oin! ventilation 6ith dail

documentation of consideration of sedation interruption andassessment of readiness to 6ean or contraindication.

ii.

DenominatorJ num(er of patients under!oin! ventilation.

iii.


?.

Compliance 6ith re!ular antiseptic oral care

a. Assessment should (e performed ( chart revie6 of a sample of all patients

currentl under!oin! ventilation. Perform assessments at re!ular intervals 4e!, 9

set of measurements per 6ee%5. he fre8uenc of o(servations can (e ad/usted

on the (asis of compliance rates 4e!, as compliance improves, less fre8uento(servations ma (e needed5.

(.

Preferred measure of assessment of compliance 6ith antiseptic oral care

i.

#umeratorJ num(er of patients under!oin! ventilation 6ith dail

documentation of re!ular oral care accordin! to product instructions.


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ii.

DenominatorJ num(er of patients under!oin! ventilation.

iii.


:.

Compliance 6ith semirecum(ent positionin! for all eli!i(le patients

a.

Assessment should (e performed for all patients currentl under!oin!

ventilation, ( direct o(servation of the position of the head of (ed. Perform

assessments at re!ular intervals 4e!, 9 set of measurements per 6ee%5. he

fre8uenc of o(servations can (e ad/usted on the (asis of compliance rates 4e!,as compliance improves, less fre8uent o(servations ma (e needed5.

(.

Preferred measure of assessment of semirecum(ent positionin! compliance

i.

#umeratorJ num(er of patients under!oin! ventilation 6ho are in a

semirecum(ent position 4?>‐: elevation of the head of the (ed5 at

the time of o(servation.

ii.

DenominatorJ num(er of patients under!oin! ventilation 6ho are

eli!i(le to (e in a semirecum(ent position.

iii.


'. utcome measures

Perform on!oin! surveillance of the incidence densit of )AP on units that care for

patients under!oin! ventilation 6ho are %no6n or suspected to (e at hi!h ris% for )AP, to

permit lon!itudinal assessment of process of care.

9.

Incidence densit of )AP, reported as the num(er of episodes of )AP per 9,>>>

ventilator ‐das.

a.

Preferred measure of )AP incidence densit


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i.

#umeratorJ num(er of patients under!oin! mechanical ventilation

6ho have )AP, defined usin! #ational Healthcare Safet #et6or%definitions.

ii.

DenominatorJ num(er of ventilator ‐das.

iii.

Multipl ( 9,>>> so that the measure is eFpressed as cases per 9,>>>

ventilator ‐das.

II. EFternal reportin!

here are man challen!es in providin! useful information to consumers and other sta%eholders6hile preventin! unintended adverse conse8uences of pu(lic reportin! of healthcare‐associated

infections.9? "ecommendations for pu(lic reportin! of healthcare‐associated infections have

(een provided ( the Hospital Infection Control Practices Advisor Committee,9?= theHealthcare‐Associated Infection 0or%in! +roup of the &oint Pu(lic Polic Committee,9?


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Ac#no$ledgments

&ump o Section...

*or Potential Conflicts of Interest statements and information on financial support, please see the

Ac%no6led!ments in the EFecutive Summar, on pa!e S> of this supplement.

Appendi%

Sterili&ation' Disinfection' and !aintenance of Respirator( )*uipment' +ased on

Healt,care nfection Control Practices Advisor( Committee Recommendations

&ump o Section...

he Healthcare Infection Control Practices Advisor Committee sstem for cate!oriBation of

recommendations is as follo6sJ

Cate!or IAJ Stron!l recommended for implementation and stron!l supported ( 6ell‐

desi!ned eFperimental, clinical, or epidemiolo!ic studies.

Cate!or I'J Stron!l recommended for implementation and supported ( someeFperimental, clinical, or epidemiolo!ic studies and a stron! theoretical rationale.

Cate!or ICJ "e8uired for implementation, as mandated ( federal or state re!ulation orstandard.

Cate!or IIJ Su!!ested for implementation and supported ( su!!estive clinical or

epidemiolo!ical studies or a theoretical rationale.

9.

+eneral measures

a.

horou!hl clean all respirator e8uipment to (e steriliBed or disinfected4cate!or IA5.

(. 0henever possi(le, use steam steriliBation or hi!h‐level disinfection ( 6et heat

pasteuriBation at temperatures hi!her than C 49*5 for ?> minutes for

reprocessin! semicritical e8uipment or devices 4ie, items that come into direct or indirect contact 6ith mucous mem(ranes of the lo6er respirator tract5. 3se

http://www.jstor.org/stable/10.1086/591062#rf52http://www.jstor.org/stable/10.1086/591062#rf52


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lo6‐temperature steriliBation methods 4as approved ( the ffice of Device

Evaluation, Center for Devices and "adiolo!ic Health, 3S *ood and Dru!

Administration5 for e8uipment or devices that are heat or moisture sensitive.

After disinfection, proceed 6ith appropriate rinsin!, drin!, and pac%a!in!,

ta%in! care not to contaminate the disinfected items 4cate!or IA5.

c.

Preferentiall use sterile 6ater to rinse reusa(le semicritical respirator

e8uipment and devices 6hen rinsin! is needed after chemical disinfection. If this

is not feasi(le, rinse the device 6ith filtered 6ater 4ie, 6ater that has (een

throu!h a >.‐Lm filter5 or tap 6ater, and then rinse 6ith isopropl alcohol and

dr 6ith forced air or in a drin! ca(inet 4cate!or I'5.

d. Adhere to provisions in the 3S *ood and Dru! Administration2s enforcement

document for sin!le‐use devices that are reprocessed ( third parties 4cate!or

IC5.

.

Mechanical ventilators

a.

Do not routinel steriliBe or disinfect the internal machiner of mechanicalventilators 4cate!or II5.

?.

'reathin! circuits, humidifiers, and heat‐moisture eFchan!ers

a. Do not, on the (asis of duration of use, routinel chan!e the (reathin! circuit 4ie,

ventilator tu(in! and eFhalation valve and the attached humidifier5 that is in use

( an individual patient. Chan!e the circuit 6hen it is visi(l soiled or

mechanicall malfunctionin! 4cate!or IA5.

(. Periodicall drain and discard an condensate that collects in the tu(in! of a

mechanical ventilator, ta%in! precautions not to allo6 condensate to drainto6ard the patient 4cate!or I'5.

c.

0ear !loves to perform the a(ove procedure or handle the fluid 4cate!or I'5.

d.

Decontaminate hands 6ith soap and 6ater 4if hands are visi(l soiled5 or 6ith


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an alcohol‐ (ased hand ru(, after performin! the procedure or handlin! the fluid

4cate!or IA5.

e.

3se sterile 4not distilled nonsterile5 6ater to fill (u((lin! humidifiers 4cate!orII5.

f.

Chan!e a heat‐moisture eFchan!er that is in use ( a patient 6hen it

malfunctions mechanicall or (ecomes visi(l soiled 4cate!or II5.

!.

Do not routinel chan!e more fre8uentl than ever : hours a heat‐moisture

eFchan!er that is in use ( a patient 4cate!or II5.

Strategies to Prevent Ventilator

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