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This document discusses ventilator-associated pneumonia (VAP) and strategies to prevent it called ventilator bundles. It notes that VAP occurs in 8-20% of ICU patients on ventilation and increases mortality by 30%. The ventilator bundle includes elevating the head of the bed, oral care with chlorhexidine, DVT prophylaxis, stress ulcer prophylaxis, and sedation vacation. Adhering to these bundles can reduce the incidence of VAP and healthcare costs. More research is still needed on optimal oral care and gastric residual monitoring.
This document discusses ventilator-associated pneumonia (VAP) and strategies to prevent it called ventilator bundles. It notes that VAP occurs in 8-20% of ICU patients on ventilation and increases mortality by 30%. The ventilator bundle includes elevating the head of the bed, oral care with chlorhexidine, DVT prophylaxis, stress ulcer prophylaxis, and sedation vacation. Adhering to these bundles can reduce the incidence of VAP and healthcare costs. More research is still needed on optimal oral care and gastric residual monitoring.
This document discusses ventilator-associated pneumonia (VAP) and strategies to prevent it called ventilator bundles. It notes that VAP occurs in 8-20% of ICU patients on ventilation and increases mortality by 30%. The ventilator bundle includes elevating the head of the bed, oral care with chlorhexidine, DVT prophylaxis, stress ulcer prophylaxis, and sedation vacation. Adhering to these bundles can reduce the incidence of VAP and healthcare costs. More research is still needed on optimal oral care and gastric residual monitoring.
Bagian Kardiologi dan Kedokteran Vaskular UNPAD Ventilator-associated pneumonia (VAP) is a sub-type of hospital aquired pneumonia (HAP) which occurs in people who are on mechanical ventilation through an endotracheal or tracheostomy tube for at least 48 hours Ventilator-associated pneumonia (VAP) is common in the intensive care unit (ICU), affecting 8 to 20% of ICU patients and up to 27% of mechanically ventilated patients Mortality rates in patients with VAP range from 20 to 50% and may reach more than 70% when the infection is caused by multi-resistant and invasive pathogens VAP is thought to increase the mortality of the underlying disease by about 30%
VAP is also associated with considerable
morbidity, including prolonged ICU length of stay, prolonged mechanical ventilation, and increased costs of hospitalization Delayed diagnosis and subsequent delay in initiating appropriate therapy may be associated with worse outcomes in patients with VAP ,
on the other hand, an
incorrect diagnosis may lead to unnecessary treatment and subsequent complications related to therapy The American Association of Critical- Care Nurses (AACN) VENTILATOR BUNDLE recommended steps for reducing the incidence of VAP these steps incorporate the following guidelines from the Centers for Disease Control and Prevention (CDC) for preventing nosocomial pneumonia elevation of the head of the bed (HOB) to 30º to 45º unless medically contraindicated,
continuous removal of subglottic secretions,
change of ventilator circuit no
more often than every 48 hours, and
washing of hands before and
after contact with each patient. HOB elevation Appropriate DVT prophylaxis Appropriate PUD prophylaxis Appropriate sedation Assessment of readiness to extubate
Institute for Healthcare ImprovementBoston, Massachusetts USA
HOB elevated greater than 30 degrees Reduces frequency and risk of nosocomial pneumonia Simple, no-cost intervention Incidence of aspirations reduced 30% Thromboprophylaxis effective in preventing DVT Multiple methods of thromboprophylaxis • Unfractionated heparin • Heparin • Mechanical prophylaxis Baseline incidence of DVT at 30% In critically ill patients thromboprophylaxis is effective for preventing deep venousthrombosis (DVT). there is agreement that patients who are critically ill or mechanically ventilated are at high risk for DVT and should receive thromboprophylaxis Reduces risk of upper GI bleeding Risk increased in: • Mechanical ventilation greater than 48 hours • Coagulopathy No specific therapy Daily interruption decreases vent LOS Hold sedation daily until patient can • Vent LOS reduced by 33% follow commands • ICU LOS reduced by 35 % Reduce vent LOS, complications, and ICU costs • Daily screening of respiratory function • Spontaneous breathing trials Vent LOS reduced by 1.5 days Reduced self extubation, reintubation, trach, prolonged mechanical ventilation No baseline data The CDC has not offered any recommendations about oral care or about how often to check the residual volume in nasogastric tubes MORE RESEACH IS STILL NEEDED Current Evidence About the Ventilator Bundle and VAP Most published studies have focused on the relationship between HOB elevation and the incidence of VAP. regular hand washing with an alcohol-based solution and limited wearing ofrings are directly related to a decreased rate of VAP. Although the CDC has not recommended strategies for oral care, a literature search revealed that the use of chlorhexidine oral rinse is directly associated with reduced rates of respiratory infection (3% with chlorhexidine vs 10% with placebo; P<.05) Studieshave addressed the use of chlorhexidine before intubation, in patients scheduled for elective cardiac surgery and in patients with respiratory infections such as tracheobronchitis and pneumonia Tracheobronchial colonization causing VAP occurred less often in patients whose mouths had been decontaminated with topical antibiotics than in those who were given a placebo (P < .001 to .04).
Oralaspiration could be a factor that
contributesto VAP. Current recommendations for general practice in tube-fed patients include routine checking of gastric residual volume every 4 to 6 hours and withholding of feeding for 1 hour if gastric residual volume is more than 1 to 1.5 times the amount provided in an hour, or more than 150 mL before bolus feeding These practices, however, have not been specifically studied in relation to VAP.
Elevated gastric residual volume and
vomiting were associated with an increased incidence of VAP.
The supine position and the length of time
the patient stayed in that position were risk factors for gastric aspiration. What we can accomplish? • To achieve greater than 95% on the ventilator bundle.
How will we know that a change is an
improvement? • Monitor percent of ventilator patients receiving all five bundle elements What changes can we make that will result in improvement? • Improve education by distributing a FACT SHEET • Hold in-services for bedside providers • Improve communication among providers by using the DAILY GOALS SHEET during rounds in the ICU. QUALITY MEASURE ADVERSE COSTS EVENTS Elevate HOB xx deaths $xx xx hospital days DVT prophylaxis xx deaths $xx xx hospital days PUD prophylaxis xx deaths $xx xx ICU Appropriate sedation Xx ICU days $xx Appropriate Glucose Control • Intensive insulin therapy • Maintain blood glucose less than 110 mg/deciliter • Decrease morbidity and morality Gastric Decontamination • Reduce colonization with resistant gram negative aerobic bacteria • Reduce ICU and hospital mortality Ventilator bundles and performance improvement Elements of a ventilator bundle Systems of independent redundancy Fact Sheet Additional elements for future implementation