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Zapping VAP

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Change Yankeur and tubing to canister Q 24 hrs (0600) - be sure to label tubing ... Use Y connector on top of suction canister. Sub-Glottic Suctioning ... – PowerPoint PPT presentation

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Title: Zapping VAP


1
Zapping VAP
  • Michelle Farber, RN, CIC, Infection Control
  • Pam Madrid, RN, CCNS Critical Care
  • Mercy and Unity Hospitals
  • March 16, 2005

2
The Beginning
  • Joined IHI IMPACT Collaborative June 2003
  • VAP required measure to report
  • AIM reduce VAP by 50 by 3/31/04
  • Pledged to eliminate infections
  • No historical VAP data
  • New Infection Control practitioner
  • Define VAP
  • Data collection tool

3
Already Well Established
  • Complication prevention
  • DVT and stress ulcer prophylaxis (1999)
  • Interdisciplinary Rounds
  • Bedside at every room door with staff RN and
    interdisciplinary team (1999)
  • Moved to report room with charge nurse reporting
    on each patient (2001)
  • Short ventilator times
  • Median time ranges between 1-2 days
  • Rapid Wean Protocol

4
Implementing Change
  • New collaborative team identified
  • Hospital leadership support
  • Time
  • Financial
  • Bundle concept
  • Ventilator
  • Central line
  • Foley
  • Sepsis
  • What you can do by next Monday
  • ICU interdisciplinary rounds are fundamental

5
Practical Application ICU Rounds
  • Make it a valued time for all disciplines
  • Staff/physician champions
  • Staff RN joined to discuss each patient (2004)
  • Scripting for the staff RN
  • Start small and grow
  • 3X/week
  • MD/nurse only rounds

6
Interdisciplinary Team Members
  • RN caregiver
  • Charge nurse
  • Medical director or designee
  • CNS
  • Pharmacy
  • Dietician
  • Chaplain
  • RT
  • Social services

7
Useful Information for ICU Rounds
  • Safety issues
  • Goal for the day
  • Diagnosis/related procedures
  • LOS
  • Ventilator bundle elements
  • Glucoses
  • Nutritional status
  • Invasive lines
  • Mobility
  • Why does the patient need ICU?

8
Basic VAP Prevention Elements
  • Hand hygiene
  • Ventilator bundle
  • Oral care

9
Hand Hygiene Campaign
  • JCAHO Patient Safety Goal
  • CDC posters in visitor lounge and in ICU
  • http//www.cdc.gov/handhygiene/Education for
    patients and visitors
  • Patient and family educational brochures
  • How to Prevent Infections During your Hospital
    Stay
  • Infection Control info in Visiting Information
    brochure
  • Foam-In and Foam-Out Campaign
  • Alcohol-based foam usage reports
  • Observation audits were impractical
  • Signage at entrance to patients room

10
Laminated Signage
11
Ventilator Bundle Elements
  • HOB elevated gt 30 degrees
  • Scheduled readiness to wean assessment
  • Sedation vacation/appropriate sedation
  • DVT prophylaxis
  • Stress ulcer prophylaxis
  • If patient condition prohibits intervention it
    is NOT counted against the bundle compliance

12
Education on Concept of Bundling
  • Bundles are not guidelines, but rather
    collections of solid science items which when
    integrated into a process have the potential of
    enhancing the underlying guidelines and improve
    the possibility of having superior outcomes.
  • Roger Resar MD-IHI Consultant

13
Practical Application HOB
  • Collaborate with Respiratory Care
  • Add HOB to vent orders and ventilator checks
  • HOB signs in room
  • Daily compliance monitoring
  • Electronic report
  • Visual auditing
  • Degree indicator
  • Marked on the bed frame
  • Protractor
  • Discussed at daily ICU rounds

14
HOB Elevation Signage
15
HOB Education
  • Gravity is our friend
  • Any elevation is better than none
  • Use reverse Trendelenburg if unable to bend at
    hip
  • Exclusion criteria
  • Femoral line - can use reverse Trendelenburg
  • Hypotension, unstable VS
  • Head trauma/spine injuries (needs order from
    Neurosurgery)
  • Seems easy, but can be hardest to get compliance

16
Practical Application Readiness to Wean
Assessment
  • KEY CONCEPT This does NOT mean a weaning trial,
    but rather weaning readiness assessment based on
    clinical condition
  • Automatic wean per RT is an option on ICU
    ventilator pre-printed orders
  • Many weaning protocols available
  • Difficult to get physicians to agree
  • Pulmonologists and Internal Medicine trust RT
    assessment skills
  • Communication has been the key

17
Practical Application Readiness to Wean
Assessment
  • Compliance at Mercy was already good Unity had
    opportunity for improvement
  • Mercy RT had a culture of proactive weaning
  • Unity improved over a short amount of time
    through collaboration between nursing and RT
  • Timeframe
  • Required in last 24 hrs per IHI
  • To be completed every shift per pre-printed
    ventilator orders
  • Part of ventilator macro for documentation

18
Practical Application Daily Sedation Vacation
  • Does not replace other assessments and
    appropriate weaning of medication
  • Not a true vacation, but a purposeful decrease
  • Allows use of minimum dose with effect
  • Allows complete neuro assessment at least once
    per day
  • Amount of decrease is dependent on the medication
  • Ordered for a set time - between 0800 and 1100

19
Practical Application Daily Sedation Vacation
  • Included in pre-printed sedation orders
  • Exceptions for CLRT, PC ventilation, or
    neuromuscular blockade
  • Culture of not overusing infusions
  • Daily compliance monitoring
  • Electronic report (MAAS score)
  • Discussed at daily ICU rounds

20
Sedation Scale
  • Changing to RASS (Richmond Agitation-Sedation
    Scale) Late spring 2005
  • 10 levels
  • 4 Combative
  • 3 Very agitated
  • 2 Agitated
  • 1 Restless
  • 0 Alert and calm
  • -1 Drowsy
  • -2 Light sedation
  • -3 Moderate sedation
  • -4 Deep sedation
  • -5 Unarousable
  • Linked to ICU Confusion tool

21
Practical Application DVT Prophylaxis
  • Implemented in 1999
  • Mechanical or medication
  • SCDs/TEDs (automatic when ICU Ventilator
    pre-printed orders are used)
  • Aces
  • Anticoagulant
  • Daily monitoring
  • Electronic report
  • Discussed in ICU rounds

22
Practical Application Stress Ulcer Prevention
  • Implemented in 1999
  • Medication or tube feeding
  • Pepcid (automatic on ICU Ventilator pre-printed
    orders)
  • Protonix, etc (by physician order)
  • Tube feeding (when patient tolerating, meds can
    be discontinued)
  • RD consultation automatic and discussed at ICU
    Rounds
  • Daily monitoring
  • Electronic report
  • Discussed in ICU rounds
  • Pharmacy monitors in all ICU patients

23
Vent Bundle Audit Tool
24
Ventilator Bundle
25
Oral Care
  • Developed and implemented protocol in end of year
    2002
  • Teeth brushing Q 8-12 hours
  • Oral care with swabs Q 2-4 hours
  • Sub-glottic suctioning Q 6-8 hours
  • Reinforced in the ICU Standards of Practice
  • Included on pre-printed ventilator orders
  • Products
  • Non-alcohol based antiseptic solution or
    toothpaste (i.e., Perox-A-Mint)
  • Oral suction swabs with mouth moisturizer
  • Suction toothbrushes
  • Sub-glottic suction catheters
  • Covered Yankeur

26
Q2 Kits
  • Supplies for 24 hours of oral care
  • Tooth brushes
  • Swabs
  • Sub-glottic suctioning
  • Covered Yankeur
  • Discard unused supplies
  • Use for patients who are expected to be on vent gt
    24 hours

27
Covered Yankeur
  • Change Yankeur and tubing to canister Q 24 hrs
    (0600) - be sure to label tubing
  • Store properly to prevent risk of environmental
    contamination
  • Keep covered when not in use

28
Y - Connection
  • Use a separate suction tubing for oral care/oral
    suctioning and ETT suctioning
  • Prevents contamination between areas suctioned
  • Keeps system closed
  • Use Y connector on top of suction canister

29
Sub-Glottic Suctioning
  • Sub-glottic suctioning Q 6 hours and PRN
  • 0000, 0600, 1200 1800
  • Prior to repositioning ETT and extubation
    (including CABG patients)

30
When to Perform Sub-glottic Suctioning
  • To ensure that secretions are cleared from above
    the tube cuff
  • Before deflating the cuff of an ETT in
    preparation for removal
  • Before repositioning the tube
  • Routinely every six hours
  • This includes surgical patients (i.e., CABGs,
    vented overnight, etc.)
  • Physician interest in the Hi-Lo Evac tubes

31
What Happened in early 2004?
  • In 2003, Mercy reduced VAP rate by 50 and Unity
    rate went to zero
  • By 05/04, Mercy had 2 cases of VAP Unity none in
    407 days
  • Questioning why the difference?
  • One hospital, two campuses
  • Same Policies Procedures
  • Same respiratory equipment

32
Current Practice Compared to CDC Guidelines
  • Suctioning
  • Use only 5 ml saline bullets
  • Education on suctioning
  • Assure use of 72-hr Ballard product
  • Document in-line suction changes q 72 hr
  • Limit saline instillation, if possible
  • Audits
  • New device for condensation removal in vent
    tubing
  • Evidence-based care
  • ICU Journal Club articles

33
Suctioning Education
  • Do hand hygiene before and after
  • Use new clean gloves
  • Closed in-line system preferable
  • Change catheter every 72 hours
  • NO routine suctioning
  • Review CXR or talk to RT
  • Auscultate

34
Suctioning Procedure
  • Advance suction catheter until resistance is felt
  • Withdraw 1 cm (prevents trauma to the carina)
  • Hold down suction for 2 seconds before slowly
    withdrawing catheter slowly over 5-7 seconds or
    patient toleration
  • Use correct port for saline instillation (if
    necessary) and cleansing the catheter
  • Distal vs. proximal

35
Saline Instillation Education
  • No physiologic benefit demonstrated by
    administering saline
  • Does not thin or liquefy secretions
  • Causes small decreases in oxygenation saturation
    SvO2
  • Potentially costly unnecessary procedure
  • Can increase colonization
  • Recommend NO routine saline lavage

Raymond SJ. AJCC 19954267
36
Research on Saline Instillation
  • Purpose To determine the extent to which
    saline instillation and suction catheter
    insertion dislodge viable bacteria from the
    endotracheal tube
  • Results Greater dislodgement of bacteria seen
    with saline and suctioning versus suctioning
    alone

Hagler Traver, AJCC3444-447
37
Cleanse Suction Catheters
  • Rinse suction catheter between each pass
  • Instill sterile saline into port while suction
    depressed

Reduces Sputum Adhering to Inner Lumen
è More Effective Suctioning
38
Saline Bullet Reminders
  • Never leave saline bullet attached to suction
    catheter
  • Discard saline bullet after suctioning series

39
Tube Positioning
  • Reposition ETT Q 24 hours
  • Left , right, or center
  • ETAD (commercial device made by Hollister)
  • Preferred securing device
  • Assess skin and tissue for edema and breakdown
  • Helps prevent unplanned extubation
  • Roles and responsibilities
  • Collaborate with RT
  • Documentation

40
Breathing-Circuit Tube Changes
  • Humid heat device instead of traditional heater
    humidity
  • Change intervals
  • HME changed every 24 hours (manufacturer
    recommendation) and PRN visibly soiled or
    malfunctioning (CDC recommendation)
  • Circuits are changed only when visibly soiled
    (CDC recommendation)

41
CDC Recommended Procedure for Condensate Removal
  • Decontaminate hands before and after procedure
  • Wear new clean gloves
  • Periodically drain and discard any condensate
    that collects in the tubing of mechanical
    ventilator
  • Use sterile trap without opening system
  • DO NOT allow condensate to drain toward the
    patient

42
Feeding Tubes
  • Routinely verify appropriate placement of feeding
    tube
  • Post-pyloric placement best for patients with
  • Gastric problems
  • High residuals
  • High-risk for aspiration
  • Pre-printed order set for post-pyloric placement
  • Assess for continuing need at extubation

43
How the Work Gets Done!
  • Mercy ICU Respiratory Clinical Action Team (CAT)
  • 2 staff RNs
  • CNS
  • Infection Control Practitioner
  • RT Coordinator
  • Pulmonologists (ad hoc)
  • Unity ICU Council
  • Staff RNs
  • Nurse Manager
  • Unit-based Educator
  • CNS
  • Mercy Unity Critical Care Quality Committee
  • Hospital based broader than pulmonary issues
  • More representatives (i.e., ICU medical
    directors, nursing director, nurse manager,
    respiratory care management, reps from both
    hospitals)

44
What Works!
  • Oral care protocol
  • Vent bundle
  • Collaboration - RN, RT, MD, IC
  • Measure current practice vs. evidence-based
    practice
  • PDSA Cycles
  • Celebrate successes!!

45
What Works!
  • Education EVERYWHERE and EVERYONE!
  • Department newsletters
  • Bulletin boards
  • High traffic areas (staff bathroom)
  • Formal inservices
  • Modified orientation
  • Measurement and Feedback

46
Measurement VAP Data Collection
  • Collection Tool
  • User friendly tool developed
  • RCAT review charts
  • Definitions imbedded in tool
  • Used as worksheet
  • Archived after data collated

47
VAP Data Collection Tool
48
NNIS Criteria
  • URL for the pneumonia criteria is on page 15-18
  • http//www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitio
    ns.pdf
  • Timing
  • An infection in a NNIS ICU patient that was not
    present or incubating at patients admission to
    ICU but became apparent during ICU stay or within
    48 hours after transfer from ICU.
  • An infection in a patient with a device (e.g.,
    ventilator or central line) that was used within
    the 48-hour period before onset of infection.
  • If interval is longer than 48 hours, there must
    be compelling evidence that infection was
    associated with device use.
  • Continue surveillance for 48 hours after
    extubation
  • Reference http//www.apic.org/AM/Template.cfm?Sec
    tionSurveillance_Definitions_Reports_and_Recommen
    dationsTemplate/CM/ContentDisplay.cfmContentFil
    eID26
  • AJIC 1997, Horan T, Emori G Definitions of key
    terms used in the NNIS System

49
NNIS Definition of Ventilator
  • A device to assist or control respiration
    continuously through a tracheostomy or by
    endotracheal intubation.
  • Lung expansion devices such as those that provide
    intermittent positive pressure breathing, nasal
    positive end-expiratory pressure, and continuous
    nasal positive airway pressure are not considered
    ventilators unless they provide assistance or
    control through tracheostomy or endotracheal
    intubation.

50
VAP Measurement and Feedback
  • Surveillance
  • VAP rates/1000 vent days
  • Ventilator hours per month/24
  • of patients on ventilator at midnight
  • Device utilization ratio (DUR)
  • of patients on ventilator/total ICU patient
    days
  • Benchmarking NNIS rates depends on type of ICU
  • VAP rate for non-teaching M/S ICU 5.1/1000
    ventilator days
  • DUR rate for non-teaching M/S ICU 0.37
  • http//www.cdc.gov/ncidod/hip/NNIS/2004NNISreport.
    pdf

51
Other VAP Measurement and Feedback
  • Grid on a shared nursing leadership drive
  • Contains information on VAPs in ICU
  • Vent hours, who/where intubated, date of
    infection, diagnosis details, intervention/outcome
  • Bundle compliance
  • Timeframe is in place at 24 hours
  • Audits - spot checks
  • Suctioning
  • Oral care documentation
  • Oral care product usage

52
Critical Event Analysis
  • New in 2005 review of VAP case
  • Look for contributing factors
  • Reported back to interdisciplinary staff
  • Elements
  • Patient description
  • Hospital course
  • Positive Findings Celebrate!
  • Opportunities for Improvement
  • Lessons Learned

53
Results!
  • Retrospective review of all of 2003
  • Comparing 2003 to 2004
  • 50 reduction at Mercy and Unity
  • Well below than NNIS benchmark of 5.1/1000
    ventilator days in 2004 for M/S ICU
  • Mercy finished 2004 with no further VAP

54
Resources
  • AACN Practice Alert VAP
  • http//www.aacn.org/AACN/practiceAlert.nsf/Files/V
    APi/file/VAP.pdf
  • Guidelines for Preventing Health-Care-Associated
    Pneumonia, 2003
  • http//www.cdc.gov/mmwr/PDF/RR/RR5303.pdfCDC
    Recommendations
  • Guideline for Hand Hygiene in Health-Care
    Settings
  • http//www.cdc.gov/mmwr/PDF/RR/RR5116.pdf

55
Our Next Steps
  • Sustain compliance
  • Continue staff recognition
  • Advanced Pulmonary Education Day
  • Sharing/continuing our process
  • Safest in America
  • MHA
  • Allina Collaborative
  • IHI 100K Lives
  • Establish critical event analysis
  • Investigate use of Hi-Lo Evac ETTs
  • Evaluate evidence around use of sterile solutions
    for oral care and gastric instillations

56
Your Next Steps
  • Gap analysis
  • Current practice vs. evidence-based care
  • Identify low hanging fruit
  • Find your champions!
  • What can you do by next Monday?
  • Just do it (try something)!

57
Questions?
  • Michelle Farber, RN, CIC
  • Email Michelle.Farber_at_Allina.com
  • Pam Madrid, RN, CNS Critical Care
  • Email Pamela.Madrid_at_Allina.com
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