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 PerformSub-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 Comparedto 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 Measurementand 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