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Critical care areas work to decrease
Langdale and Rebecca Weil
As the medical center focuses on reducing infection rates across all
aspects of clinical care, the success in reducing infection from
ventilator assistance is particularly noteworthy.
The decrease in infections also has resulted in fewer days in the
hospital, which helps cut the cost of medical care for patients. Of
particular concern is ventilator associated pneumonia (VAP), an often
fatal complication in long-term ventilator assistance therapy.
A study conducted by the Hospital Acquired Complications (HAC)
committee revealed that VAP has decreased by more than 80 percent
during the past two years in MICU alone, which in turn has cut the
number of inpatient stays by more than five days.
Mangano, left, and Sara Speakman replaces the cover of a Yankuer
suction catheter. The devise is used with an intubated
patient in the MICU. The covered catheter reduces infection by limiting
exposure to contaminated surfaces.
The HAC committee is an interdisciplinary team with members from
nursing, respiratory therapy and pharmacy, along with Infection Control
(IC), which has assisted the intensive care unit staff in decreasing
the overall VAP rate. The overall VAP rate for the institution has
decreased from 5.7 episodes of VAP per 1000 ventilator days (for the
time period sampled, March 2006 through February 2007) to a rate of 5.2
for the past 12 months. This decrease has been driven by drop in VAP
rates for MICU, PICU, NNICU and PCICU.
The success of this project can be directly attributed to the great
teamwork provided by all patient care members.
VAP is of particular concern for patients whose injuries or illnesses
require intensive care in ICUs. Data indicate that the length of time a
patient spends in the ICU can be decreased by preventing hospital
acquired complications, such as VAP.
According to the Centers for Disease Control (CDC), VAP infections are
directly responsible for increased ventilator days; increased length of
stay (LOS) both in the intensive care unit and overall hospital visit;
increased cost (average $40,000 per patient); and an increased risk of
mortality. Approximately 15 percent of all ventilated
patients will develop VAP. Fifty percent of patients who develop VAP
will die. In fact, VAP is the leading cause of death from a known
hospital acquired complication.
The importance of preventing VAP is recognized by the Institute for
Healthcare Improvement (IHI) and its 5 Million Lives Campaign. The IHI
was instrumental in the development of a VAP prevention bundle, which
was implemented at MUSC in 2005 through participation in the University
Health System Consortium (UHC) Commit to Action VAP Project.
The VAP prevention bundle consists of a complete package of
evidence-based interventions that, when implemented for patients on
mechanical ventilation, has demonstrated a dramatic reduction in the
incidence of VAP. This bundle consists of protocols including: head of
the bed elevation to 30 degrees; daily “sedation vacation” and
assessment of readiness to wean patient from the ventilator;
spontaneous breathing trials; peptic ulcer disease prophylaxis; and
oral care such as tooth brushing. (All measures in the bundle must be
implemented to decrease the risk of developing VAP.)
Implementation of the bundle required the cooperative efforts of a
multi-disciplinary team of physicians, nurses, pharmacy, respiratory
therapists, clinical associates and infection control practitioners. In
addition, order sets, policies, supplies and bedside practices were
changed to ensure the VAP bundle became a standard of care in all of
MUSC’s critical care units. Currently, the new DDICU in Ashley River
Tower (ART) is adopting this bundle into their routine practices.
The Children’s Hospital also has formed a multidisciplinary task force
chaired by Beth Rhoton, an infection control practitioner; to develop a
specific VAP bundle for the pediatric and neonatal patient populations.
The VAP bundles for the Children’s Hospital ICUs emphasize frequent
oral care, safe respiratory therapy practices and monitoring of
As a routine practice, oral care can reduce VAP by almost 57 percent.
MUSC’s clinical associates are responsible for delivery of oral care
every two hours as well as tooth brushing once every 12 hours. Mouth
care is one of the biggest impacts on reducing the VAP rate in NSICU
and all staff have committed to improvement. Janet Byrne, MICU nurse
manager said the oral care practice continues to evolve according to
best practice standards.
Appropriate sedation management also is crucial to the ventilated
patient. Use of a daily sedation vacation, or reducing sedation, can
help the patient avoid a constant heavily-sedated state and
inappropriate use of paralytic agents, both of which can suppress a
patient’s cough reflex and increase the potential for VAP. Nurses
maintain a patient’s sedation based upon a sedation score parameter
ordered by the patient’s physician.
Mechanically ventilated patients should also undergo a daily assessment
to determine if ventilator settings can be weaned based on
pre-determined criteria. These patients are also at increased risk for
gastrointestinal bleeding and should receive stress ulcer prophylaxis
(SUP). They also are at risk for thromboembolism and should receive
some form of pharmaceutical or mechanical prophylaxis. In response to
this need, critical care PharmDs and physicians have collaborated to
change order sets to include appropriate SUP and DVT prophylaxis.
Mechanical ventilation also increases patient risk of aspiration. To
assist in preventing aspiration, each staff member must maintain the
head-of-bed (HOB) elevation at 30 degrees. (Neonates and infants should
have the head-of-bed elevated 15 to 30 degrees.) Elevating HOB to at
least 30 degrees is associated with at least 26 percent risk reduction
of clinically suspected nosocomial pneumonia.
The Infection Control and Prevention Department, which monitors VAP and
other infection rates, has taken several steps to improve the
identification of VAP. The Respiratory Therapy Department provides a
daily listing of patients on the ventilator. Using this list, the ICPs
review each patient’s CXR reports. If positive findings are found, the
ICP looks further for evidence that the patient meets the CDC
definition. Respiratory cultures are not a part of the definition.
However, the culture findings are noted if VAP criteria are met.
Ongoing education on the VAP bundle is provided by the Infection
Control and Prevention Department. General and clinical orientation
presentations by IC staff cover the VAP bundle as well as presentations
to individual units as needed. The IC staff supports efforts to further
reduce VAP risks.
Friday, May 30, 2008
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