Ventilator Care Bundle Guidelines-Lancsandsouthcumbria

Cheshire and Merseyside Critical Care Network
VENTILATOR CARE BUNDLE
Ventilator Care Bundle
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THE CARE BUNDLES CONCEPT
The theory behind care bundles is that when several evidence-based interventions/guidelines are grouped together and applied in a single protocol, it will improve patient outcome1
It is a simple method of monitoring adherence/existence of local guidelines, and as such is a valid assessment of quality. It will provide rapid easily interpreted and easily analysed information. It is a form of auditing process only. It can identify areas for improvement. It can result in reducing costs, length of stay, complications and outcomes. It is NOT research. It is NOT about dictating uniformity of local practice across the Network. It will NOT audit the effectiveness of each element comprised within the bundle independently. It is NOT prescriptive. Each unit can identify their own criteria for each element.
1. Fulbrook,P and Mooney, S (2003) Care Bundles in Critical Care: a practical approach
to evidence based practice. Nursing in Critical Care Vol 8 no 6.
Guidelines for the use of Care Bundles in Critical Care
Introduction The concept of care bundles was introduced by the NHS Modernisation Agency following an Intensive Care quality improvement Conference in Chicago USA. The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome1. For example in the Ventilation Care Bundle four elements of care were identified as improving patient outcome. These elements are: Nursing the patient head up to an angle of 30 or greater, Daily review & stopping sedative infusions once a day,
Deep Vein Thrombosis prophylaxis Peptic Ulcer prophylaxis.
Another element of care that has been shown to improve outcome in critically ill patients is Intensive Insulin Therapy. This element can be combined with the ventilation care bundle to produce a five-element care bundle, but is not compulsary. Application of these elements together should be considered for each patient every day. Evidence shows that compliance with this model improves quality of care and patient outcomes. The following guidelines describe agreed criteria for each element. Guideline Element 1 Element 2 Element 3 Element 4 Element 5 Aim The aim of implementing the ventilation care bundle is to demonstrate an impact on ventilator days. The hypothesis we are making is that application of the bundle will contribute to a reduction in ventilator days. The agreed definition of a ventilator day/period for the purpose of future audit is Any artificial airway support (mechanical assistance with pressure support) given in a 12/24hour period to maintain respiratory function delivered via an endotracheal tube (ICS definition of level 3) For example ventilation for 30mins will be classed as one ventilator day/period the same as ventilation for 12/24 hours. DVT Prophylaxis Gastric Ulcer Prophylaxis Head Elevation Daily review & interruption of Sedation Infusions Intensive Insulin Therapy Page 4 6 8 9 12
Ventilation Care Bundle Element 1

Prophylaxis for Venous Thromboembolism Purpose of guideline To reduce the incidence of venous thromboembolism occurring in patients admitted to the critical care unit. Background Information There are a number of recognised risk factors for patients developing venous thromboembolism (VTE). These include major trauma, major surgery, acute medical illness, age, obesity, varicose veins, previous VTE, cancer, heart failure, recent MI or stroke, oestrogen, pregnancy, puerperium, immobility, inflammatory bowel disease and dehydration. This would place all Level III and Level II patients and most Level I patients at being of increased risk of VTE. There are many prospective randomised controlled studies on different patient populations using different methods of VTE prophylaxis that show a positive benefit to prophylactic treatment to patients who have an increased risk of VTE. This has resulted a large number of guidelines both national and local for prophylaxis for VTE in different patient groups. These guidelines vary between different hospitals and between different specialties within the same hospital. A good general guide to VTE prophylaxis in different patient populations can be found on the SIGN website2. There is some evidence to support the use of VTE prophylaxis in critical care patients3,4. However this is not enough to justify another guideline for VTE prophylaxis specific to Critical Care Units. Criteria One or more of the following groups of treatment: 1) 2) 3) TED stockings Mechanical foot/leg pumps Anticoagulants aspirin and related drugs unfractionated heparin low molecular weight heparin warfarin
Inclusion: Patients in the Critical Care Unit.

Exclusion: o Patients who have abnormal coagulation should not receive anticoagulants. o Heparin should be avoided in patients with HITS (heparin induced thrombocytopaenia).
Ventilation Care Bundle Element 1

o
Patients with specific clinical instructions from a consultant
Level of evidence Level I B and Level II A evidence Grade A recommendation for the guideline Authors Dr Mike Swart, Torbay Hospital., Peninsula Critical Care Network Adapted by Lancashire and South Cumbria Critical Care Network Implementation date April 04 Review date April 05
Stress Ulcer Prophylaxis Purpose of guideline To minimise the risk of ulceration of the gastric mucosa in patients who are critically ill. Background information Critically ill patients are at risk of stress ulcers, which may lead to upper GI haemorrhage. Although the incidence appears to be declining, significant risk factors include burns, sepsis, shock, head injury, hepatic or renal failure, coagulopathy, ARDS and corticosteroid therapy. The incidence of overt bleeding is 9.0%, but clinically important bleeding (hypotension and requiring transfusion) is unusual, with an incidence of 2%5. Measures that reduce the incidence and severity of stress ulceration are clearly welcome, but studies to date have shown conflicting results and there may be an increased risk of nosocomial pneumonia in patients receiving acid suppressing drugs. There is a lack of consensus on the optimal therapy to treat and prevent stress ulcers6, reflecting discordant results from a variety of trials and meta-analyses that have attempted to address this problem. Aside from drug therapy, the role of enteral nutrition in gastric protection is established 12. Many units now follow protocols that include the discontinuation of stress ulcer prophylaxis once enteral nutrition has been established. Criteria These will include one of the following groups of treatment:
1)
2)
H2 receptor antagonists. E.g. Ranitidine and Sucralfate Proton Pump inhibitors E.g. Omeprazole (should be reserved for patients with a known current or past history of peptic ulcer disease, used for treatment only, not for prophylaxis.)
Inclusions: Patients in the Critical Care Unit Exclusion: o Patients established on enteral feeding o Known sensitivity to the drug o Porphyria o Patients with specific clinical instructions from a consultant Cautions o Hepatic impairment o Renal impairment o Pregnancy and breast-feeding
Level of evidence Level 1 A evidence Grade A recommendation for the guideline Author Dr Jonathan Paddle, Peninsula Critical Care Network Adapted by Lancashire and South Cumbria Critical Care Network Implementation date April 04 Review date April 2005
Semi recumbent Positioning Purpose of the Guideline To reduce risk of ventilator associated pneumonia and aspiration. Background Information Ventilator-associated pneumonia accounts for up to half of all infections in the intensive care unit 13. Pneumonia prolongs the duration of mechanical ventilation and the subsequent stay in the Critical Care Area and increases the risk of mortality14,15. Kollef 16 identified that the supine body position is an important independent risk factor for ventilator associated pneumonia. Following a randomised trial, Drakulovic17 concluded that mechanically ventilated patients cared for in the semi recumbent position had lower rates of clinically suspected and microbiologically confirmed pneumonia than in the supine position. Despite the strong evidence to support this prevention strategy, it is clear that these principles are under utilised in practice. The definition of semi recumbent has been agreed by the Network in line with National recommendations to be an angle of 30o, however this does not imply that patients should not be sat at angles greater than 30o. As practitioners it is clear that this simple but effective practice has a direct impact on infection rates and the quality of the care that our patients will receive. Criteria 1) 2) 3) All patients should have a minimum resting height of around 30. This should be established in whatever resting position the patient is placed e.g. tilted to the side for pressure relieve or on their back. The position of the patient is charted hourly on the patients observation chart in the space made available for position. Physiotherapy treatment may require the patient to be fully recumbent. This should be for a maximum period of 30 minutes and then the patient will be repositioned to an angle of 30. Inclusion: Patients in the Critical Care Unit Exclusions: o 15o head up elevation for the acute head injured patient o Suspected or actual spinal or spinal cord injury o Diagnosed unstable pelvis o Haemodynamic instability confirmed daily with Anaesthetic Consultant o Patients requiring prone positioning o Patients with specific clinical instructions from Consultant eg hip surgery
Daily Review & Interruption of Sedation Infusions Purpose of guideline To reduce the duration of mechanical ventilation and the length of stay of patients in the critical care unit. Background Information Sedative drugs are given to patients in the critical care unit by infusions to reduce distress and suffering and ensure comfort through necessary delivery of treatment. Over sedation may occur when sedative drugs are given by an infusion. This may then prolong the duration of mechanical ventilation and the length of stay of patients in the critical 1 care unit 8. This may result in an increase in a patients distress and suffering. It may also lead to an increase in morbidity and mortality. Continuous sedation also makes it harder for medical staff to assess a patient neurologically20 The Society of Critical Care Medicine in the USA has published an evidence based clinical guideline on the use of sedatives and analgesics in critically ill adults19. This review is a valuable contribution to the evidence base for the use of sedation in critical care patients. In a prospective randomised study on 128 mechanically ventilated critical care patients sedation infusions were either stopped on a daily basis or at the discretion of the critical care team. Sedation was restarted when the patients became awake or agitated. In the group of patients that had their sedation stopped on a daily basis there was a reduction in the duration of mechanical ventilation by more than 2 days and a reduction in critical care length of stay by 3.5 days20. To assess adequacy of sedation in a consistent and uniform way you need to use a sedation score. One of the most well known sedation scores is the Ramsay Sedation Scale21. This has the advantage of simplicity, however it has never been objectively validated22. A sedation score that has been validated on adult critically ill patients has been published by Riker and Picard23. This is shown below in a modified form. The modification is a change in the numerical scale and a prcis of the sedation description.
Criteria 1) The sedation score should be recorded on every sedated patient every two hours. 2) The medical staff on the morning ward round should set the desired sedation score. This score will usually be 0. 3) Patients who require a deeper level of sedation for one of the exclusions should have this documented in the medical notes. 4) If the sedation score is less than 0 then all sedative infusions should be stopped until a 0 score is achieved. When stopping these infusions check that the appropriate sedation and analgesia is prescribed and available should the patient require sedation or analgesia in the future. Sedation Score +3: Agitated and restless +2: Awake and uncomfortable +1: Aware but calm 0: Roused by voice -1: Roused by touch -2: Roused by painful stimuli -3: Unrousable A: Natural sleep P: Paralysed by muscle relaxants Intensive Care Society (2004)
Inclusion: Patients in the Critical Care Unit who are receiving an intravenous infusion of a sedative drug. These drugs include benzodiazepines, opiates and propofol. Exclusion: o Patients who are receiving infusions of muscle relaxants. o Patients whose ventilator requirements require reversed I:E ratios o Patients who require prone positioning. o Patients who have raised intra cranial pressure. o Patients with specific clinical instructions from a consultant o If patients sedation score is already within desired range o Patients who are ventilated but require NO sedation
Level of evidence Level II B evidence Grade B recommendation for the guideline One prospective randomised double blind study. This was not classed as Level I A because of the size of the study (128 patients) and the patient population, which was a critical care unit in the USA. Authors Dr Mike Swart, Torbay Hospital Peninsula Critical Care Network Adapted by Lancashire and South Cumbria Critical Care Network Implementation date April 2004 Review date April 2005
Intensive Insulin Therapy
Purpose of guideline To maintain blood glucose levels within optimal parameters in acutely ill patients, ultimately reducing mortality and improving critical care outcomes. Background Information A study has found that tight control of blood glucose levels reduces mortality among intensive care patients.24 Van den Berghe and colleagues investigated the effect odf intensive insulin therapy and conventional treatment in 1548 patients admitted to ICU. Intensive therapy consisted of an insulin infusion being started if the blood glucose level exceeded 6.1mmols/litre and adjusted to maintain the level between 4.4 and 6.2mmols/litre. In the conventional treament regime, insulin was started if the blood glucose level exceeded 12mmols/litre and adjusted to maintain it between 10.0 and 11.1 mmols/litre. The intensive treatment group, 4.6% of patients died compared with 8% of the conventional treatment group, representing, after adjustment, an unbiased risk reduction of 32%. Intensive treatment also reduced the incidence of complications such as septicaemia, acute renal failure and critical illness polyneuropathy. The researchers comment that hyperglycaemia and insulin resistance are common in critically ill patients even if they have not previously had diabetes. This study demonstrated that hyperglycaemia is not beneficial and should be treated with intensive insulin therapy. Criteria 1) All acutely ill patients should have their blood glucose maintained between 4 8.3 mmols/l 2) Implementation of sliding scale glucose monitoring protocol
Inclusion: Patients on the Critical Care Unit. Exclusions: o Diagnosed Acute Myocardial Infarction o Ketoacidosis & Hyper Osmotic Non-ketoacidosis (HONK).
Level of Evidence Level 1+/- evidence Author Lancashire and South Cumbria Critical Care Network Implementation date April 2004 Review date April 2005
References
2.
Fulbrook,P and Mooney, S (2003) Care Bundles in Critical Care: a practical approach to evidence based practice. Nursing in Critical Care Vol8 no 6.
3. www.sighn.ac.uk
4. 5.
Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 2001;161:12681279 Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxiparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxiparin Study Group. N Eng J Med 1999;341:793-800
6. Cook DJ, Pearl RG, Cook RJ et al. Incidence of clinically important bleeding in
mechanically ventilated patients. J Intensive Care Med 1991;6:167-74.
7. Lam NP, Le P-DT, Crawford SY et al. National survey of stress ulcer prophylaxis. Crit
Care Med 1999;27:98-103.
8. Cook DJ, Witt LG, Cook RJ et al. Stress ulcer prophylaxis in the critically ill: a metaanalysis. Am J Med 1991;91:519-27.
9. Prodhom G, Leuenberger P, Koerfer J et al. Nosocomial pneumonia in mechanically

ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. Ann Intern Med 1994;120:653-62.
10. Messori A, Trippoli S, Vaiani M et al. Bleeding and pneumonia in intensive care
patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials. Br Med J 2000;321:1103-6.
11. Cook D, Guyatt G, Marshall J et al. A comparison of sucralfate and ranitidine for the
prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. New Eng J Med 1998;338:791-7.
12. Levy MJ, Seelig CB, Robinson NJ et al. Comparison of omeprazole and ranitidine for
stress ulcer prophylaxis. Dig Dis Sci 1997;42:1255-9.
13. Pingleton SK and Hadzima SK. Enteral alimentation and gastrointestinal bleeding in
mechanically ventilated patients. Crit Care Med 1983;11:13-6.
14. Vincent. JL, Bihari. DJ, Suter. PM, et al: The Prevalence of nosocomial pneumonia in
intensive care units in Europe (EPIC). JAMA 1995; 274:639-644
15. Fagon JY, Chastre J, Vuagnat A, et al (1996) Nosocomial pneumonia and mortality
among patients in intensive care units. JAMA 275: 866-869
16. Heyland DK, Cook DJ, Griffith LE, et al (1999) The attributable morbidity and mortality
of ventilator-associated pneumonia in the critically ill patient: The Canadian Critical Care Trials Group. American journal of Critical Care Medicine 159: 1249-1256
17. Kollef. M. ventilator associated pneumonia: A multivariate analysis. JAMA 1993; 270:
1965-1970
18. Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for
nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354:1851-8.
19. Kollef MH, Levy NT, Ahrens TS, et al. The use of continuous IV sedation is
associated with prolongation of mechanical ventilation. Chest 1998;114:541-548
20. 21. 22. 23.
Jacobi J, Fraser GL, Coursin DB, et al: Clinical practice guidelines for the use
of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-141 Kress JP, Pohlman AS, OConnor MF, Hall JB. Daily interruption of sedative
infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471-7 Ramsey MAE, Savage TM, Simpson BRJ, et al: Controlled sedation with
alphalaxone-alphadolone. BMJ 1974;2:256-259 Hansen-Flaschen J, Cowen J, Polomano RC: Beyond the Ramsey scale:
need for a validated measure of sedating drug efficiency in the intensive care unit. Crit Care Med 1994;22:732-733
24. Riker RR, Picard JT, Fraser GL: Prospective evaluation of the Sedation Agitation
Scale for adult critically ill patients. Crit Care Med 1999;27:325-1329
25. Van den Berghe, G. (2001) Intensive Insulin Therapy in Critically ill Patients. New
England Journal of Medicine 345: 1359.
VENTILATION CARE BUNDLE AUDIT FORM HOSPITAL . DATE
Bed PROPHYLAXISDVT Yes No Exclusions
10
11
12
13
14
15
PROPHYLAXISGU
Yes No Exclusions Yes No Exclusions
REVIEWSEDATION
ELEVATIONHEAD
Yes No Exclusions Optional Element Yes
Cheshire and Merseyside Critical Care Network INSULIN THERAPY No
Exclusions
NB. If an exclusion applies then yes may also be ticked.
Element
DVT Prophylaxis
Criteria
One or more of the following: TED Stockings Mechanical foot/leg pumps Anticoagulants
Exclusions
Patients who have abnormal coagulation should not receive anticoagulants Heparin should be avoided in patients with HITS (heparin induced thrombocytopaenia) Patients with specific clinical instructions from Consultant Patients established on enteral feed Known sensitivity to the drug Porphyria Patients with specific clinical instructions from Consultant
GU Prophylaxis
One of the following
Head Elevation
H2 receptor antagonist eg Ranitidine, Sucralfate or other Proton pump inhibitors eg Omeprazole or other
All patients have a resting height of at least 30o The position of the patient is charted hourly Physiotherapy treatment may require the patient to be fully recumbent; this should be for a maximum period of 30 mins.
Sedation Review
Sedation score should be recorded on every sedated patient every hour Medical staff on the morning round should set the desired sedation score, normally 0. Patients who require deeper level of sedation for one of the exclusions should have this documented in the medical notes. If the sedation score is less than the desired score then all sedative infusions should be
15o head up elevation for the acute head injured patient Suspected or actual spinal or spinal cord injury Diagnosed unstable pelvis Haemodynamic instability confirmed daily by Anaesthetic Consultant Patients requiring prone positioning Patients with specific clinical instructions from Consultant eg hip surgery Patient not sedated. Patients who are receiving infusions of muscle relaxants. Patients whose ventilator requirements require reversed I:E ratios Patients who require prone positioning. Patients who have raised intra cranial pressure. Patients with specific clinical instructions from Consultant Aneasthetist If patients sedation score is already within desired range
Cheshire and Merseyside Critical Care Network stopped until this score is achieved. When stopping these infusions check that the appropriate sedation and analgesia is prescribed and available should the patient require sedation or analgesia in the future. Optional Element Intensive Insulin Therapy All acutely ill patients should have their blood glucose maintained between (4 8.3 mmols) (SSC) Implementation of sliding scale glucose monitoring protocol Acute Myocardial Infarction Hyper Osmotic Non-ketoacidosis (HONK) Patients with specific clinical instructions from Consultant

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