Safer Critical Care:

Resources to Prevent Ventilator-Associated Pneumonia

(VAP)
and
Central Venous Catheter-Associated Bloodstream Infections
(CVC-BSI)
Practices 19-20
Joan Reischel, RN, BSN, CCRN
Tom Talbot, MD, MPH
Richard J. Wall, MD, MPH
Mary E. Foley, MS, RN
Charles R. Denham, MD
Hayley Burgess, PharmD

© 2008 TMIT 1

Overview

• Safe Practices Discussion Dr. Charles Denham

• CVC-BSI discussion Dr. Tom Talbot
• Application of CVC-BSI tools Joanne Reischel
• Discussion with Mary Foley
• Ventilator bundle Dr. Richard Wall
• Application of CVC-BSI tools Joanne Reischel
• Discussion with Mary Foley
• Question and Answer

© 2008 TMIT 2

1
 NQF Safe Practices for Better Healthcare:
A Consensus Report

• 30 Safe Practices

Criteria for Inclusion

• Specificity
• Benefit
• Evidence of
Effectiveness
• Generalization
• Readiness

© 2008 TMIT 3

Harmonization – The Quality Choir

© 2008 TMIT 4

2
 Culture SP 1

2007 NQF Report Culture

Consent & Disclosure

Consent & Disclosure

Workforce

Information Management &

Continuity of Care

Medication Management

Healthcare-Assoc. Infections

Condition- &
Site-Specific Practices

© 2008 TMIT 5

2007 NQF Report Culture CHAPTER 2: Creating and Sustaining a Culture of

Patient Safety
• Leadership Structures & Systems
Structures Culture Meas., Team Training ID Mitigation
• Culture Measurement, Feedback, and Interventions
CHAPTER 1: Background & Systems F.B., & Interv. & Team Interv. Risk & Hazards
• Teamwork Training and Team Interventions
‰ Summary, and Set of • Identification and Mitigation of Risks and Hazards

Safe Practices
Consent&&Disclosure
Consent Disclosure
CHAPTER 3: Informed Consent & Disclosure
Informed Life-Sustaining • Informed Consent
Disclosure • Life-Sustaining Treatment
Consent Treatment
• Disclosure

CHAPTERS 2-8 : Workforce CHAPTER 4: Workforce

• Nursing Workforce
Practices By Subject • Direct Caregivers
Nursing Direct • ICU Care
ICU Care
Workforce Caregivers

CHAPTER 5: Information Management & Continuity of

Information Management & Continuity of Care Care
• Critical Care Information
Critical Order • Order Read-back
Care Info. Read-back • Labeling Studies
• Discharge Systems
Labeling Discharge
CPOE Abbreviations • Safe Adoption of Integrated Clinical Systems
Studies System including CPOE
• Abbreviations

Medication Management CHAPTER 6: Medication Management

• Medication Reconciliation
• Pharmacist Role
Med. Recon. • Standardized Medication Labeling & Packaging
• High-Alert Medications
Pharmacist High-Alert Std. Med. Unit-Dose • Unit-Dose Medications
Central Role Meds. Labeling & Pkg. Medications

CHAPTER 7: Healthcare-Associated Infections

Healthcare-Associated Infections • Prevention of Aspiration and Ventilator-
Associated Pneumonia
Asp. + VAP • Central Venous Catheter-Related Blood Stream
Prevention Infection Prevention
• Surgical Site Infection Prevention
Influenza Central V. Cath. Sx-Site Inf. • Hand Hygiene
Hand Hygiene
Prevention BSI Prevention Prevention • Influenza Prevention

CHAPTER 8: Condition- & Site-Specific Practices

• Evidence-Based Referrals
Condition- & Site-Specific Practices • Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention
Evidence- Anticoag. DVT/VTE • Perioperative Myocardial Infarct/Ischemia
Based Ref. Therapy Prevention Prevention
• Pressure Ulcer Prevention
Press. Ulcer Wrong-site Periop. MI Contrast • DVT/VTE Prevention
Prevention Sx Prevention Prevention Media Use • Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention

© 2008 TMIT 6

3
 Prevention of Catheter-Associated
Bloodstream Infections

Thomas R. Talbot, MD MPH

Assistant Professor of Medicine and Preventive Medicine
Chief Hospital Epidemiologist
Vanderbilt University School of Medicine

© 2008 TMIT 7

Overview

• Review the epidemiology of catheter- associated

infections
• Discuss methods for prevention of CR-BSI
• Highlight data on novel technology and risk of
CR-BSI

© 2008 TMIT 8

4
 Vascular Catheter-Related
Bloodstream Infections
• 250,000 infections occur in US every year
• Cost $296 million to $2.3 billion
– $18,000 per BSI
• Associated with 2,400-20,000 deaths annually
• Increase LOS by 7-21 days
– 12 days = most recent estimate

© 2008 TMIT 9

© 2008 TMIT 10

5
 CRBSI per 1000
Catheter Days
Arterial catheters for hemodynamic monitoring 1.7
Nontunneled CVC 2.7
Medicated nontunneled CVC
Minocycline-rifampin 1.2
CHG-silver sulfadiazine 1.6
Tunneled CVC 1.7
P-A catheter 3.7
Long-term, cuffed & tunneled HD catheter 1.6
Port (central) 0.1

Maki D et al Mayo Clin Proc 2006;81:1159+

© 2008 TMIT 11

Vascular Catheter Infection:

Prevention

© 2008 TMIT 12

6
 CVC-BSI Prevention Bundle

1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
• Except VLBW infants
4. Optimal catheter site selection
• Subclavian vein preferred
5. Daily review of line necessity, with
prompt removal of unnecessary lines

© 2008 TMIT 13

© 2008 TMIT 14

7
© 2008 TMIT 15

Maximal Barrier Precautions

• For the operator placing the central line

and for those assisting in the
procedure:
– Wear cap, mask, sterile gown, and gloves
– Cap should cover all hair
– Mask should cover the nose and mouth tightly.
– These precautions are the same as for any other
surgical procedure that carries a risk of infection

• For the patient:

– Cover the patient with a large sterile drape, with
a small opening for the site of insertion.

© 2008 TMIT 16

8
 Impact of Maximal
Barrier Precautions
Author/date Design Catheter Odds Ratio
for Infection
w/o MBP
Mermel Prospective P-A 2.2 (p<0.03)
Cross-sectional
1991
Raad Prospective Central 6.3 (p<0.03)
Randomized
1994

Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205S.

Raad, Infect Control Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-238.

© 2008 TMIT 17

Chlorhexidine as Skin Prep

10
9.3
9

8
CVC-BSI per 1000 CVC Days

7.1
7

3
2.3
2

0
2% CHG 10% Povidone 70% Alcohol

© 2008 TMIT 18

9
 Chlorhexidine as Skin Prep

CHG

P-I

© 2008 TMIT 19

Site of Catheter Insertion

• Risk: Upper Extremity << Lower Extremity

• Risk: Subclavian < IJ << Femoral
• Femoral associated with higher rates of
thrombosis
• ? True for pediatric patients
• Use of ultrasound localization
– 88% reduction in mechanical complications

© 2008 TMIT 20

10
 Mermel L, 2000

© 2008 TMIT 21

Femoral vs. Subclavian

CVC Placement

Femoral Subclavian
Infectious Complications 19.8% 4.5%
Thrombotic Complications 21.5% 1.9%

© 2008 TMIT 22

11
 Get the Lines Out

• The longer the line is in, the more the risk for
BSI increases
• Assess for line need daily
• Remove unnecessary lines if possible

© 2008 TMIT 23

© 2008 TMIT 24

12
© 2008 TMIT 25

VUMC Intervention

• Required educational tutorial with quiz

– All nurses, housestaff
– Compliance monitored
• Insertion checklist
• Empower nursing to stop procedure
• Feedback of data
• Standardization of kits

© 2008 TMIT 26

13
© 2008 TMIT 27

MC 2 7 05 (R e v. 06 /04 )

Van derbilt U niv ersity M edic al C enter

Mo nro e C are ll Jr.
OR
atV ander bilt
Nu r sin g C h e ck list :
C entral V en o us C ath et er In s ertio n
NO TE : P le a s e use eithe r bla c k o r blue ink to c o mple te this fo rm.

CCU M IC U TIC U NS IC U S IC U
B IC U P CC U NIC U O the r

MR #: D a te : / / P le ase us e m ilitary tim e

(i.e . 1 :0 0 pm is 13 :00 )

T yp e o f c a the te r:
Ti me s ta rt
(1 s t nee dle s tic k): : Ti me e nd
(c a the te r s ec ure d): :
D o uble lu me n In s e rtio n S ite : S id e : In d ic a tio n s fo r u se : C h e c k if:
Trip le lu me n Inte rna l J ugu la r R ight P re ss o rs C o ns e nt o bta ine d
Intro duc e r S ubc la v ia n L e ft He mo dy na mic mo nit. P t/F a mily te ac hing do ne
S wa n-G a n z F e mo ra l F luids /b lo o d pro duc ts G uide wire e xc ha nge
Va s c a th O the r (s pe cify ): F re que nt la b dra w s
L is t a ll s ite s wh e re in s e rtio n wa s a tte m p te d.
R IJ L IJ RSC LSC RF LF O the r (s pe cify ):
T h e p rov id e r in s e rtin g th is lin e :
a . Ha n d ed -o ff h is /h e r pa ge r b e fo re the p ro c ed u re ? Yes No D idn’t a s k
b . W a s he d ha n ds im m e d ia te ly p rio r to p ro c ed u re ? Yes No D idn’t a s k
c . Ha s p rev io u s ly p la c e d a t le a s t fiv e (5 ) c en tra l lin e s ? Yes No * D idn’t a s k
* If “ No ” , wa s th is p ro c ed u re s u pe rv is e d b y s om e on e with le a s t fiv e (5 ) c en tra l lin e s e x pe rie n c e?
Yes No D idn’t a s k
B a rrie r p re c au tio n s (ch ec k a n y u se d ):
S te rile glo v es S te rile go w n Mask S te rile to w e ls F ull bo dy dra pe
D e s c rib e th e lev e l o f tra in in g o f the p e rs o n wh o a c tua lly in s e rte d the lin e ?
M e dic a l S tude nt Inte rn (P G Y -1 ) R e s ide nt (P G Y -2 +) F e llo w Atte ndin g
Nurs e P rac titio ne r
Ho w m a n y d iffe re n t ne e d le stic k s d id the pa tie n t rec e iv e (n u m b e r of sk in b re ak s )?
1 2 3 4 5 6+ Unk no w n
W a s th e s te rile fie ld m a in ta in e d th ro ug h ou t the e n tire p ro c ed u re? Yes No
P re -in s e rtio n s k in p re p (c h ec k a n y u se d ):
A lc o ho l B e ta dine (po vido ne -io dine ) C hlo rhe xi dine O the r (s pe cify ):
D e s c rib e th e c irc u m s ta n ce s u n de r wh ic h th is lin e wa s p la c e d :
No n-e me rge nt E me rge nt (life -thre a te ning o r c o de s itua tio n) P re -e xis ting infe c tio n
F o llo w-u p CX R : O rde re d No t o rde re d (s pe cify re as o n):
C X R fin d in g s (c he c k a ll th a t a pp ly):
No p ne u mo tho ra x P ne u mo tho ra x (de s c ribe a c tio n ta ke n):
C a the te r in go o d po s itio n C a the te r pos itio n a djus te d (de s c ribe ):
T yp e o f d re ss in g : B io -occ lus iv e G a u ze O the r (s pe cify ):
D re s s in g ap p lie d b y: N urs e P ro ce dura lis t O the r (s pe cify ):
P a tie n t to le ra ted the p roc e du re we ll? Yes No Co m me nts :
C o m p lic a tio n s ? No ne P la c e me nt uns uc c e s s ful O the r (de s c ribe ):

P le as e file p a ge 2 in pa tie n ts c ha rt a nd re tu rn to p fo rm to the de s ig n a te d lo ca tio n in th e ICU.

S ig n a tu re : _ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ D a te : _ _ __ __ _ __ __ _ __ __ _

© 2008 TMIT 28

14
 CVC-BSI Rates, MICU 2000-2005

Confidential and privileged pursuant to the provisions of Section 63-6-219 of

Tennessee Code Annotated, the contractual obligations of Vanderbilt University to
its insurance companies, the attorney-client privilege and other applicable
© 2008 TMIT provisions of law. 29

CVC-BSI Rates, VUH ICUs

January 2004 - December 2005
60
Use of Insertion
50 Checklist Rolled Out
Rate per 1,000 CVC Days

to all ICUs
40

30

20

10

0
V

V
AR

AR
N

N
AY

AY
P

P
L

L
JU

JU
O

O
JA

SE

JA

SE
M

M
N

Confidential and privileged pursuant to the provisions of Section 63-6-219 of

Tennessee Code Annotated, the contractual obligations of Vanderbilt University to
its insurance companies, the attorney-client privilege and other applicable
© 2008 TMIT provisions of law. 30

15
 • 103 ICUs in MI
• Unit team leaders
• CVC bundle
• Checklist
• Empowerment to stop procedure

© 2008 TMIT 31

“It’s Not Just A Checklist”

• How to adapt an effective tool to other

cultures/units
• With the success in the MICU, some ICUs
started using the checklist
– No culture change
– No education/examination/feedback of data
– Initial implementation = minimal success
– Risk labeling the tool a “failure”

© 2008 TMIT 32

16
 Antibiotic-Impregnated Catheters

• Two types
– Chlorhexidine-silver sulfadiazine
• 2 generations:
– 1st: Coated only on external surface of lumen
– 2nd: Coated on both internal and external surfaces
– Minocycline-rifampin
• Scads of trials with varying outcomes and
comparator groups

© 2008 TMIT 33

Antiseptic CVCs

• 1st generation (external lumen only)

– N = 16 trials
– Most showed reduction in CVC colonization
– Only 2 showed CRBSI reduction
• 2nd generation (Both lumens coated)
– N = 3 trials
– All showed reduction in CVC colonization
– None showed CRBSI reduction

© 2008 TMIT 34

17
 Antibiotic CVCs

• N = 7 trials
• 3 showed significant CRBSI reduction
• ? Risk of bacterial resistance

•
•
•••

• noncoated comparator

© 2008 TMIT 35

• 12 university hospitals
• Adults with CVC expected 3+ days
• Rif-mino vs. 1st gen CHG-SS

© 2008 TMIT 36

18
© 2008 TMIT 37

BioPatch

• CHG-impregnated
• Designed to surround catheter at skin
insertion site
• Must be “right side up”

© 2008 TMIT 38

19
 Catheter or exit-site colonization

Bacteremia

© 2008 TMIT 39

Needleless Hubs

• Split septum device

– Blood may back up into infusion catheter
• Leur-activated/mechanical valve device
– Prevents outflow of fluid
– Some with positive pressure displacement

© 2008 TMIT 40

20
 Johns Hopkins Experience

© 2008 TMIT 41

BSI Rates, U of Nebraska

PPMV Removed

PPMV Hub
Introduced

© 2008 TMIT 42

21
© 2008 TMIT 43

Implementing
Central Venous Catheter-
Blood Stream Infection
Prevention Bundle

Joan Reischel, RN, BSN, CCRN

Clinical Coordinator, Critical Care
The Medical Center of Aurora

© 2008 TMIT 44

22
 Background

The Medical Center of Aurora

• Community based 324 bed hospital
• Level II Trauma Center
• Cardiac Center of Excellence
• Intensive Care Unit
• 34 bed general, adult ICU
• Intensivist 24/7
• Trauma coverage 24/7

© 2008 TMIT 45

Patient Population at a Glance

11%

7%
Medical
5% Trauma
Surgical
8%
Neuro
Cardiovascular
69%

© 2008 TMIT 46

23
 BSI Initiative
IHI 100,000 lives Campaign
• First meeting April, 2005
• New method of counting central line days
• Intensivists initiated maximal barrier precautions
for all central lines placed in ICU
• Hand washing campaign
• Antimicrobial discs for PICCs
• Multiple methods attempted to track
insertion/dressing change date
• No significant change in rate
• Not much buy in outside the ICU
© 2008 TMIT 47

BSI Initiative
Safe Critical Initiative 2006

BSIs revisited
• CL checklist developed
• Staff education through HealthStream
• CL discussed in daily rounds
• Improved culturing technique
• MD accountability for compliance and
documentation

© 2008 TMIT 48

24
 Central Line Checklist
Intensive Care Unit
Central Venous Catheter Insertion
Date:____________ • Checklist downloaded
Time:___________
from BSI web cast and
modified for our unit.
Insertion Site(where catheter was ultimately placed):
◊ Internal Jugular
◊ Subclavian
◊ Femoral
◊ Other (specify):______________
• Checklist attached to every
Consent obtained?
Guidewire exchange?
Pt/Family teaching done?
◊ Yes
◊ Yes
◊ Yes
◊ No
◊ No
◊ No
central line insertion kit.
Pre-insertion skin prep (check any used): • When BSI identified
◊ Alcohol ◊ Betadine (povidone-iodine) ◊ Chlorhexidine ◊ Other (specify):____________

Barrier precautions (check any used): checklist reviewed.

◊ Sterile gloves ◊ Sterile gown ◊ Mask ◊ Cap ◊ Body drape

Washed hands immediately prior to procedure? ◊ Yes ◊ No

Had to break the sterile field during the procedure? ◊ Yes ◊ No

List all sited where insertion was attempted (check all that apply).
◊ RIJ ◊ LIJ ◊ RSC ◊ LSC ◊ RF ◊ LF ◊ Other specify):_____________________

How many different needle sticks did the patient receive (number of skin breaks)?
◊1 ◊2 ◊3 ◊4 ◊5 ◊ 6+ ◊ Unknown

Was ultrasound-guidance used? ◊ Yes ◊ No

Describe the circumstances under which this line was placed: ◊ Non-emergent
◊ Emergent (life-threatening)

© 2008 TMIT 49

Central Line Checklist

• CL Added to Daily Rounds

© 2008 TMIT 50

25
 How this has helped

• Increased Physician compliance with maximal

barrier precautions, site selection and early
discontinuation of femoral lines or lines placed
emergently.
• Increase staff awareness and identification of
lines that need to be removed.
• Better identification of BSIs through proper
culturing.

© 2008 TMIT 51

Bloodstream Infection Rate

3

2.5

1.5
BSI Rate
1

0.5

0
2005 2006 2007 2008

© 2008 TMIT 52

26
 Obstacles that Remain

• RNs remain uncomfortable requesting that

physicians comply with maximal barrier
precautions.
• Utilization of checklist outside the ICU is low.
• Continued resistance to discontinuing PICC lines
by staff.
• Hardwiring the prevention bundle.

© 2008 TMIT 53

Consumer Advocate

Mary E. Foley, MS, RN

Associate Director
Center for Research and Nursing Innovation
University of California, San Francisco (UCSF)
National Patient Safety Foundation Board of Directors
Advisory member, Partnership for Patient Safety (p4ps)
Vice-President, ANA/California state association

© 2008 TMIT 54

27
 Opportunities for Patient and
Family Involvement
• Teach patients and families the proper care of the central
venous catheter as well as precautions for preventing infection.
• Teach patients and families to recognize signs and symptoms
of infection.
• Encourage patients to report changes in their catheter site or
any new discomfort.
• Encourage patients and family members to make sure that
doctors and nurses check the line every day for signs of
infection.
• Invite patients to ask staff if they have washed their hands prior
to treatment.
• Encourage patients and family members to ask questions
before a central line is placed.
WHO CVC-BSI recommendation document. Field review by
The Joint Commission.
© 2008 TMIT 55

Ventilator-Associated Pneumonia (VAP)

Prevention Strategies

Richard J. Wall, MD MPH

Pulmonary, Critical Care, & Sleep Disorders Medicine
Southlake Clinic, Valley Medical Center, Renton, WA
University of Washington, Seattle, WA

© 2008 TMIT 56

28
© 2008 TMIT 57

Overview

• CDC changed the definition for VAP in 2007

– VAP no longer needs the “48 hour” criterion
• Discuss various VAP preventive strategies
– Review the evidence
– Acknowledge that some data are conflicting &
uncertainty still exists for strategies
• Algorithms for diagnosing and treating VAP

© 2008 TMIT 58

29
 VAP Definition

• Most recent studies defined VAP as an infection

occurring > 48 hours after hospital admission in a
mechanically ventilated patient with a
tracheostomy or endotracheal tube.
• In 2007, CDC revised their VAP definition:
– The new criteria state there is no minimum period of time
the ventilator must be in place in order to diagnose VAP.
– This important change must be kept in mind when
examining future studies.

CDC. MMWR Rec Rep 2004;53(RR-3):1-36.

CDC. NHSN Manual, May 2007. (see references)
© 2008 TMIT 59

Epidemiology of VAP

• Common & serious problem in the ICU

– 2nd most common nosocomial infection
• 15% of all hospital acquired infections
– Attributable mortality may approach 20%
– Estimated cost of $5,000-20,000 per episode
• Increased ICU & hospital length of stay

ATS. Am J Respir Crit Care Med 2005;171:388-416.

Warren DK et al. Crit Care Med 2003;31:1312-7.
© 2008 TMIT 60

30
 Shifting Views on VAP

• No longer an unfortunate occurrence

• Viewed as a preventable medical error by:
– Institute of Medicine
– Leapfrog
– JCAHO
– Centers for Medicare & Medicaid Services (CMS)
• Starting in 2009, CMS will limit reimbursements for
conditions not present at admission (e.g., VAP).

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf
© 2008 TMIT 61

© 2008 TMIT 62

31
 Adult Ventilator Bundle

VAP prevention measures

1. Hand hygiene
2. Patient positioning
3. Daily “Sedation Vacation”
4. Daily assessment of readiness to extubate
5. Oral care
6. Management of secretions

General measures to improve care

⇒ Peptic ulcer prophylaxis
⇒ Deep vein thrombosis (DVT) prophylaxis

© 2008 TMIT 63

Hand Hygiene

• Strict hand hygiene before and after handling

patient or patient’s equipment or supplies

© 2008 TMIT 64

32
 Patient Positioning

• RCT of 86 adult intubated patients

• Semi-recumbent (45o) vs. supine position

Semi-recumbent Supine
Suspected VAP 8% 34%
(90% CI for difference 10-42%; p=0.003)

Confirmed VAP 5% 23%

(90% CI for difference 4-32%; p=0.018)

Drakulovic MB. Lancet.1999;354:1851-1858.

© 2008 TMIT 65

Patient Positioning

• Elevate head of bed 30-45o

– Flex bed or reverse Trendelenberg
– Reduces chance of gastric reflux & aspiration

• Proper position in bed

– minimize abdominal compression
– keep joints in neutral, semi-flexed position

Drakulovic MB. Lancet.1999;354:1851-1858.

© 2008 TMIT 66

33
 Patient Positioning

• Precautions
– Hypovolemia - possible hypotension
– Transporting patients
– Spine precautions
• Consider reverse trendelenberg

Drakulovic MB. Lancet.1999;354:1851-1858.

© 2008 TMIT 67

Positioning DO’s and DON’Ts

Do: Don’t:
• Maintain HOB > 30 • Leave patient in
degrees unless supine position for
contraindicated. prolonged periods.

• Forget to turn off

tube feedings if
placing patient in
supine position.

• Continue Q 2 hour
turning schedule.

© 2008 TMIT 68

34
 Sedation Vacation

• Daily discontinuation of sedation until patient is

responsive (i.e., awake)
• RCT of 128 adults on MV randomized to daily
sedation vacation or usual care (controls).
• Duration of MV:
Sedation vacation 4.9 days
Controls 7.3 days
(p=0.004)
• Complication rates:
Sedation vacation 2.8%
Controls 6.2%
(p=0.04)
Kress JP et al. N Engl J Med 2000;342:1471-7.
Schweickert WD et al. Crit Care Med 2004;32:1272-6.
© 2008 TMIT 69

Wake-up AND Breathe

• “Wake-up & Breathe” Trial

• RCT of 336 MV patients at 4 hospitals
– n = 168 received a spontaneous breathing trial (SBT)
– n = 168 received 1st a sedation vacation and 2nd a SBT
• Intervention group:
– 3.1 fewer ventilator-days (p=0.02)
– 3.8 fewer ICU days (p=0.01)
– 4.3 fewer hospital days (p=0.04)
• Patients in the intervention group were also less
likely to die in the next 12 months: HR 0.68
(p=0.01) Girard TD et al. Lancet 2008 12;371:126-34.
Ely EW et al. NEJM 1996;335:1864-9
© 2008 TMIT 70

35
 Oral Care

• Rationale: oral pathogens contaminate secretions

that eventually migrate into the lungs.
• 2 recent meta-analyses demonstrated a lower risk
of VAP with oral chlorhexidine
– RR 0.74 (0.56-0.96)
– RR 0.61 (0.45-0.82)
• Safe, feasible, & cheap.

REC: Consider oral antisepsis with chlorhexidine.

Chlebicki MP. Crit Care Med 2007;35:595-602.
Chan EY et al. BMJ 2007;334:889.
© 2008 TMIT 71

Oral Care

• Method of chlorhexidine (CHX) application

matters!
– Completely clean mouth & oropharynx prior to CHX
– Avoid brushing/mouthwashes for 2 hours after CHX
– Caveat: may cause tooth discoloration
• Can be removed at next dental cleaning = reversible
• Explain rationale to families
• No need to use expensive commercial oral care
products

© 2008 TMIT 72

36
 Oral Care Protocols

• Numerous protocols are published in the literature

& online
• Practice patterns vary considerably between ICUs
• Pick one, develop a guideline for your ICU, &
implement it!
– Oral care is more likely to be performed if you make a protocol
– Consider making it a part of routine ventilator care

© 2008 TMIT 73

Management of Secretions

• Proper management of secretions is essential

• To prevent aspiration of pooled secretions,
perform hypopharyngeal suctioning before:
– suctioning ETT
– repositioning ETT
– deflating the cuff
– repositioning patient

© 2008 TMIT 74

37
 Management of Secretions

• Type of suctioning system (open vs. closed)

does not affect VAP.
– Closed system is likely safer for providers.
• Scheduling changes of the closed suctioning
systems does not affect VAP incidence.
– Cost considerations favor less frequent changes.

REC: Use a closed suctioning system & change

system as clinically indicated.

Rabitsch W et al. Anesth Analg 2004;99:886-92.

Topeli A et al. J Hosp Infect 2004;58:14-9.
© 2008 TMIT 75

Suctioning Equipment Issues

• Keep ETT cuff pressure at desired level

(~20 cm H2O)
• Keep end of vent circuit, suction
catheter/Yankauer, & manual ventilation bag off
the bed. Hang them up or place them on a
sterile paper.
• Keep vent circuit free from accumulated water
by draining away from the patient.
• Change suction canister and mouth care kit
every 24h.

© 2008 TMIT 76

38
 PUD Prophylaxis

• Reduces acid production in stomach & the

consequent risk of bleeding.
• Some studies suggest increased rates of VAP in
patients on prophylactic treatments, with a trend
toward lower VAP with sucralfate (vs. H2
blockers).
• Proton pump inhibitors may be more efficacious
than H2 blockers and sucralfate, but there is a
paucity of data comparing the various regimens.

© 2008 TMIT 77

PUD Prophylaxis
2008 Surviving Sepsis Campaign Guidelines:
“We recommend that stress ulcer prophylaxis using a
H2 blocker (grade 1A) or proton pump inhibitor (grade 1B)
be given to patients with severe sepsis to prevent upper
gastrointestinal (GI) bleed.
The benefit of prevention of upper GI bleed must be
weighed against the potential effect of an increased
stomach pH on development of ventilator-associated
pneumonia.”

Dellinger RP. Crit Care Med 2008; 36:296–327

© 2008 TMIT 78

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 DVT Prophylaxis
Systematic review of risks of venous
thromboembolism and its prevention:
“We recommend, on admission to the intensive care
unit, all patients be assessed for their risk of VTE.
Accordingly, most patients should receive
thromboprophylaxis (Grade 1A).”

Geerts WH. Chest 2004;126:338S-400S.

© 2008 TMIT 79

Other Preventive Strategies

© 2008 TMIT 80

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 Route of Intubation

• 2 routes of intubation: oral & nasal

• Orotracheal route is associated with reduced
VAP (vs. nasotracheal route)
– Also, orotracheal route has less sinusitis
– VAP incidence higher if patient develops sinusitis

REC: Orotracheal route of intubation should be

used whenever possible.

Holzapfel L et al. Crit Care Med 1993;21:1132-8.

© 2008 TMIT 81

Ventilator Circuit Changes

• The frequency of ventilator circuit changes does

not affect VAP
• 2 trials show no benefit
• Cost considerations favor less frequent changes

REC: Do not schedule ventilator circuit changes.

– However, do provide a new circuit for each patient and
any time the circuit becomes soiled or damaged.

Kollef JH et al. Ann Intern Med 1995;123:168-74.

Lorente L et al. Inf Cont Hosp Epidemiol 2004;25:1077-82.
© 2008 TMIT 82

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 Airway Humidification

• No VAP difference between heat and moisture

exchanger (HME) vs. heated humdifier
• However, if using HME, less frequent changes
may lead to slightly less VAP, and it is cheaper.

REC: If using HME, change every 5-7 days, or as

clinically indicated.

Davis K et al. Crit Care Med 2000;28:1412-8.

Thomachot L et al. Crit Care Med 2002;30:232-7.
© 2008 TMIT 83

Subglottic Suctioning

© 2008 TMIT 84

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© 2008 TMIT 85

Subglottic Suctioning

• Several trials show reduced VAP with use of a

tube that drains subglottic secretions.
– Most cost-effective when used in patients who are anticipated
to require prolonged MV.
• Caveat: animal studies suggest possible
tracheal injury from certain tubes (due to
erosion by the suction port).

REC: Consider a tube with subglottic secretion

drainage if the patient is expected to be
intubated > 3 days.
Smulders K et al. Chest 2002;121:858-62.
Lorente L et al. Am J Resp Crit Care Med 2007;176:1079-83.
© 2008 TMIT 86

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 Early Tracheostomy

• Early (vs. late) tracheostomy does not affect

incidence of VAP.
– The few positive studies had methodological issues.
• Even if a small benefit is demonstrated, the risk &
cost of tracheostomy need to be justified.

REC: Do not perform early tracheostomy if the only

reason is VAP prevention.

© 2008 TMIT 87

Kinetic Beds

• Immobility is associated with increased VAP.

– Kinetic beds employ rotational therapy to prevent and
treat respiratory complications.
• Meta-analysis of kinetic beds Æ decreased VAP.
– No effect on ventilator days, ICU days, or mortality.

REC: Consider use of kinetic beds to reduce VAP.

Goldhill DR et al. Am J Crit Care 2007;16:50-61.

© 2008 TMIT 88

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 Prophylactic Antibiotics

• Some studies suggest prophylactic antibiotics may

decrease VAP:
– Intranasal mupirocin (Staph aureus)
– Aerosolized
– Intravenous
• No effect on MV days, ICU days, or mortality.
– Potential for emergence of antibiotic resistance.

REC: Do not use prophylactic antibiotics.

© 2008 TMIT 89

Tips For Success

• Set an Aim: “Improve the health & well-being of

ventilated patients by reducing the VAP rate.”
• Set goal: “Reduce VAP rate by 50% by August
2008.” “Implement use of ventilator bundle with
> 95% reliability.”
• Plan Well: Adopt a change methodology that
accelerates improvement.
• Benchmark: Use a national benchmark (e.g.,
National Healthcare Safety Network)
Nelson EC, Batalden PB, Ryer JC. Clinical Improvement Action Guide. JCAHO, Oakbrook, IL, 1998
© 2008 TMIT 90

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 5 VAP Algorithms

• Diagnosis of VAP in 4 populations:

1) Adults
2) Immunocompromised
3) Children (1-13yo)
4) Neonates (<1yo)
• Initial empiric treatment of VAP
Source: Wall RJ, Ely EW, Talbot TR, et al. Evidence-based
algorithms for diagnosing and treating ventilator-associated
pneumonia. Journal of Hospital Medicine 2008 (in press).

© 2008 TMIT 91

Wall RJ et al. J Hospital Medicine 2008 (in press).

© 2008 TMIT 92

46
 Wall RJ et al. J Hospital Medicine 2008 (in press).
© 2008 TMIT 93

Wall RJ et al. J Hospital Medicine 2008 (in press).

© 2008 TMIT 94

47
 Wall RJ et al. J Hospital Medicine 2008 (in press).
© 2008 TMIT 95

Wall RJ et al. J Hospital Medicine 2008 (in press).

© 2008 TMIT 96

48
 Selected References
1. ATS. Guidelines for the management of adults with hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388-416.
2. CDC. Guidelines for preventing health-care--associated pneumonia, 2003: Recommendations
of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR
2004;53(RR-3):1-36.
3. CDC. The National healthcare safety network (NHSN) manual: Patient safety component
protocol (updated May 2007).
www.cdc.gov/ncidod/dhqp/pdf/nhsn/NHSN_Manual_Patient_Safety_Protocol052407.pdf
4. Cook D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill
patients. Ann Intern Med 1998 Sep 15;129(6):433-40.
5. Kollef M. Epidemiology and outcomes of healthcare-associated pneumonia: results from a large
US database of culture-positive pneumonia. Chest 2005;128:3854-62.
6. Langley JM, Bradley JS. Defining pneumonia in critically ill infants and children. Pediatr Crit
Care Med 2005;6[supp]:S9-S13.
7. Muscedere J and the Canadian Critical Care Trials Group. Comprehensive evidence-based
practice guidelines for ventilator-associated pneumonia: Prevention. J Crit Care 2008;23:126-37.
8. Muscedere J and the Canadian Critical Care Trials Group. Comprehensive evidence-based
practice guidelines for ventilator-associated pneumonia: Diagnosis & treatment. J Crit Care
2008;23:141-50.
9. Wall RJ et al. Evidence-based algorithms for diagnosing and treating ventilator-associated
pneumonia. J Hospital Medicine 2008 (in press).

© 2008 TMIT 97

Implementing VAP
Prevention
Bundle

Joan Reischel, RN, BSN, CCRN

Clinical Coordinator, Critical Care
The Medical Center of Aurora

© 2008 TMIT 98

49
 VAP Initiative

• VAP identified as high priority for IHI initiative

• Team Goal: Zero VAPs
• Team included
RT
Nursing
Physical Therapy
Pharmacy
Quality

© 2008 TMIT 99

VAP Rate 2005-2007

30

The Medical Center of Aurora

Number Of VAPs per 1000 ventilator days

Control Chart for

Ventilator Associated Pneumonia
Lower is better

20

10

8.51 8.77

6.97 6.93
5.80 5.85 6.08 5.85

3.44 3.06
2.79 2.90
2.31 2.46

0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
5

6
5

05

06

7
05

06

06

06

07

07
5

6
5

6
05

06
l-0

l-0
-0

p -0

-0

-0

-0

-0
n-0

n-0

-0

n-0

n-0

-0

n-0
g -0

g -0

p-
-

-
b-

b-

b-

-
r-

r-
ov

ec

ov

ec
ay

ay
ar

ar

ar
ct

ct
Ju

Ju
Ja

Ju

Ja

Ju

Ja
Fe

Ap

Se

Fe

Ap

Se

Fe
Au

Au
O

O
M

M
N

D
M

Time in Month/Year

© 2008 TMIT 100

50
 VAP Initiative

• Education provided to staff regarding ventilator

bundle
• Reminders created and posted at the HOB
• RT Documentation revised to include bundle
• Ventilator bundle added to daily rounds
• Hi/Lo Evac endotrtacheal tubes added
• Oral Care protocol to Q 2 Hrs
• Chlorhexidine oral rinse bid
• Data provided to providers monthly
© 2008 TMIT 101

Laminated Signs for Rooms

ZAP VENTILATOR-ASSOCIATED PNEUMONIA

REMEMBER:

Elevation of the HOB to between 30 & 45o

Oral Care

Daily “sedation vacation” and daily assessment of readiness to extubate

Peptic ulcer disease (PUD) prophylaxis

Deep venous thrombosis (DVT) prophylaxis (unless contraindicated)

© 2008 TMIT 102

51
 Daily Rounds Ventilator
Information
• Daily Rounds form

© 2008 TMIT 103

Accomplishments

• 224 days without a VAP

• VAP Team awarded First Prize at TMCA Quality
Days for PI Project
• Ready for Phase II

© 2008 TMIT 104

52
 Safe Critical Care Initiative

• Utilization of Algorithm
• Development of chart audit tool
• Physician involvement of case review
• Focus on safety culture

© 2008 TMIT 105

VAP Algorithm

© 2008 TMIT 106

53
 Use of Algorithm

• Algorithm shown to the Critical Care Division in

the fall of 2006.
• To be used for the diagnosis of VAP.
• At that time we had gone 6 months without a
VAP.

© 2008 TMIT 107

VAP Audit Tool

Ventilator Associated Pneumonia Review Sheet

Initial Review Final Review Comments

Admission Date
On Mech v ent >48hr?
Date first on Vent
Sputum sent within 48 hr of intubation?
Type of culture: BAL or trach
Result of culture:
Date of repeat culture
Type of culture: BAL or Trach Asp
Result of culture:
Aspiration suspected?
Immuno comp pt? (neutropenia; leukemia; lymphona; HIV;
splenectomy; organ tx on immunosupp therapy, High dose steroids;
cytotoxic chemo)

If YES Immunocompromised Pt., Use Algorithm 2

Pt. Age >= 13 Yes No If yes, continue:
IF THE FOLLOWING FOUR ARE NO, NOT A VAP
Fev er (38C or 100.4F) w/o other cause?
Leukopenia (<4000 WBC/m3)
Leukocytosis ( >12000 WBC/m3)
Altered Mental Status with no other cause

IF ANY TWO of the FOLLOWING ARE YES, THEN COMPLETE THE ALGORITHM: IF NO, THEN NOT A VAP
Change in the character of the sputum? (new onset purulent,
incr. secretions, incr. suction)
New or worsening cough, dyspnea or tachypnea?
Crackles or bronchial breath sounds?

© 2008 TMIT 108

54
 VAP Audit Tool
Worsening Gas exchange (O2 desat, increased Vent
requirements)
Laboratory criteria that support the diagnosis of VAP

One Positive chest radiograph? (shows new or progressive

infiltrate, consolidation, or cavitation)
Date first positive chest radiograph:
Does this case meet CDC VAP guidelines for VAP dx?

VAP ABX Algorithm if YES for presumptive VAP:

ABX Therapy? (w/n 4 hr. of presumptive VAP dx)
Risk Factors? (Prior ABX w/n 3 mo; current hosp. >=5 days; known resis tance; immunosupp; recent NH; hemodialysis;
home wound care or infusion therapy, family member known infection)
If Risk Factors NO, Appropriate Drug Therapy:
Single Drug Therapy
If Risk Factors YES , Appropriate Drug Therapy:
Triple Drug Therapy
Pt. has underlying Cardiopulmonary Disease? (Resp. distress;
pulm edema; bronchopulmonary dysplasia; COPD)

Second (serial) positive chest radiograph? (persistence of

findings on prior film(s)

Compliance with VAP Bundle. If no, please comment

HOB > 30o
Hi Lo ET Tube to suction
Sedation Vacation
Weaning Protocol? Tolerating weans?
PUD/DVT
Oral Care
Chlorhexidine Rinse BID

Outcomes: Pt Sticker:

© 2008 TMIT 109

Going Forward

• Hardwire Bundle Compliance

• Reinforce staff’s leadership role in this initiative
• Encourage staff to drive change in the future
• Find another Collaborative

© 2008 TMIT 110

55
 Consumer Advocate

Mary E. Foley, MS, RN

Associate Director
Center for Research and Nursing Innovation
University of California, San Francisco (UCSF)
National Patient Safety Foundation Board of Directors
Advisory member, Partnership for Patient Safety (p4ps)
Vice-President, ANA/California state association

© 2008 TMIT 111

Q&A

© 2008 TMIT 112

56