Define Ventilator-Associated Pneumonia (VAP) Discuss th

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

• Define Ventilator-Associated Pneumonia (VAP)
• Discuss the risk factors associated with VAP and
• the implications for nursing care of patients
  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

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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

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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
  treatall paid for by the facility
• Rello, Chest, 2002

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Goals

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

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VAP . . .What is it?

• Ventilator-Associated Pneumonia
• Most common nosocomial bacterial infection among
  patients requiring mechanical ventilation

Rello, Chest, 2002
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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
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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 lt 30 degrees

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Risk Factors For Developing VAP

• Colonization of Dental Plaque with respiratory
  pathogens
• Bacterial Colonization of the oropharyngeal area
• Aspiration of subglottic secretions

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Quality

• CDC Guidelines re Prevention ofHealthcare-Associ
  ated PneumoniaDevelop 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

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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

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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

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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

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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

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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

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Impact of Standardized Oral Care Protocol on VAP
Saint Anthony - Crown Point CICU / NSICU
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Good Handwashing
Albert, NEJM 1981 Preston, AJM 1981 Tablan, 1994
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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, 1999,3541851
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Sage - QCare 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

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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

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Brush Teeth

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

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Oropharyngeal Suctioning

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

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Implement Best PracticeVAP / Oral Care Protocol
Inservice Staff Initiate Protocol Implement
QCare Tools. Evaluate Progress - Goal
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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
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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 gt 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 _at_ __________ 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
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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
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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 gt 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 tohydrate the mouth and maintain
mucosal integrity. 9.The Sage oral care kit
will be changed _at_ 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
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