Prevention of Ventilator-Associated Pneumonia. National Call & Webinar October 7, 2008

Transcription

1 Prevention of Ventilator-Associated Pneumonia National Call & Webinar October 7, 2008

2 Purpose By the end of this call, participants will have: Understanding of SHN results related to VAP An overview of emerging issues from the clinical literature Understanding of additional elements for VAP prevention Understanding of how to adapt the bundle to a pediatric population Questions answered October 7,

3 Teams Continue to Enroll Total at July, Safer Healthcare Now! Overview Total # Enrolled Teams September 2005 to July Total # of Enrolled Teams Sep-05 Nov-05 Jun-06 Nov-06 Jan-07 Mar-07 Jun-07 Aug-07 Oct-07 Jan-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 October 7,

4 Safer Healthcare Now! Enrollment by Intervention Intervention Deploy Rapid Response Teams Improve Care for Acute Myocardial Infarction Prevent Adverse Drug Events through Medication Reconciliation Prevent Central Line-Associated Bloodstream Infection Prevent Surgical Site Infection Prevent Ventilator-Associated Pneumonia Antibiotic Resistant Organisms (AROs)/MRSA MedRec (Long Term Care) Venous Thromboembolism National Collaborative on Falls in Long-Term Care Number of Teams *Total Total at August 29, ,021* October 7,

5 Teams Working on Each Intervention RRT AMI Med Rec Central line SSI VAP ARO/MRSA MedRec (LTC) VTE Falls Total *Total at August 29, 2008 Nov / Jul / * October 7,

6 October 7,

7 Review of SHN Results Rosmin Esmail

8 VAP Rate per 1,000 Vent Days INTERVENTION - VAP MEASURE: 1.0 VAP Rate in ICU per 1000 Ventilator Days Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Nov-05 Dec-05 Jan-06 Month Local Team National Goal October 7, Ventilator-Associated Pneumonia Rate per 1000 days

9 VAP Rate per 1,000 Vent Days October 7,

10 VAP Rate per 1,000 Vent Days October 7,

11 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Compliance VAP Bundle INTERVENTION - VAP MEASURE: 2.0 VAP Bundle Compliance Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Month Local Team National Goal October 7, Nov-05 Dec-05 Jan-06 Percent Compliance

12 Compliance VAP Bundle October 7,

13 New Research Dr. Denny Laporta

14 Outline Updated Canadian VAP Prevention guidelines Recent clinical studies: how did they succeed? Decreasing ventilator-days ETTube factors Weaning is in WHAP October 7,

15 Comprehensive evidence-based clinical practice guidelines for VAP Prevention Muscedere J, Dodek P et al. Jnl Crit Care (2008) 23, RECOMMEND 1. orotracheal route for ETT 2. ventilator circuit: new for each patient change only if circuit soiled/damaged 3. HME: Change q5-7d or as clinically indicated 4. Endotracheal suctioning system: closed changed for each patient and as clinically indicated 5. Subglottic secretion drainage: in patients expected to be mechanically ventilated > 72 hrs (consider as near to 45 as possible). 7. Consider: rotating beds oral antiseptic rinses. October 7,

16 Comprehensive EB-CPG for VAP Prevention Jnl Crit Care (2008) 23, DO NOT RECOMMEND: 1. bacterial filters 2. Iseganan (protegrin) NO RECOMMENDATIONS : 1. systematic search for sinusitis 2. type of airway humidification 3. timing of tracheostomy 4. prone positioning 5. aerosolized antibiotics 6. intranasal mupirocin 7. topical and/or intravenous antibiotics. October 7,

17 How did the clinical studies decrease the incidence of VAP? 1. Ventilator-days (device exposure) 2. Endotracheal tube factors Leakage around ETT Subglottic suction (EVAC) cuff barrier (polyurethane vs PVC) Interaction with PEEP «mucus slurper» Biofilm Antiseptic (Silver) Endotracheal «mucus shaver» 3. WHAP Wean the Patient as soon as possible Hand Hygiene Aspiration Precautions Prevent Contamination Workload: : the Human Factor October 7,

18 Early- and late-onset VAP: Comparison of risk factors. Giard M, Lepape A, et al. Jnl Crit Care (2008) 23, Key Points: Interventions that decrease vent-days: more likely to decrease Early- onset VAP for most patients But 2/3 VAPs were of Late-onset. Despite a lower daily HR, these sicker pts (Lepape, Valles) have a prolonged cumulative device (ETTcircuit vent) exposure October 7,

19 Subglottic Secretion Drainage SSD. A Literature Review. DePew CL et al. AACN Advanced Critical Care18(4): ;2007. UPSIDE It decreases VAP mostly early-onset Endorsed by AACN*, ATS/IDSA**, Canadian guidelines CHALLENGE Maintaining subglottic suction line patency Tracheal herniation, pinched in bite block Hissing noise from the subglottic suction line orifice during aspiration QUESTIONS 1. Does subglottic suctioning cause clinically relevant mucosal injury? 2005: manufacturer redesigned EVAC ( suction line diameter, orifice position to the cuff-ett junction) 2. Does the use of EVAC decrease ventilator days? length of stay? 3. What is the influence of CASS on VAP when all other VAP bundle elements are practiced? 4. Other 1. What level of suction pressure achieves efficient aspiration and patency without causing harm? 2. Could elucidating the safest, most efficient, and effective suction method impact VAP incidence? 3. Is there a difference in volumes aspirated and patency between low-continuous and high-intermittent suction? October 7,

20 Influence of an Endotracheal Tube with Polyurethane Cuff and Subglottic Secretion Drainage on Pneumonia Lorente L et al. Am J Respir Crit Care Med Vol 176. pp , 2007 October 7,

21 Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an ICU Lucangelo U et al. Crit Care Med 2008; 36: PEEP = 5 cm H2O was effective in delaying the passage of fluid around the cuffs of tracheal tubes both in vivo and in vitro. The SealGuard tube proved to be more resistant to leakage than Hi-Lo. October 7,

22 Silver - Coated Endotracheal Tubes and Incidence of VAP The NASCENT Randomized Trial Kollef MH et al. JAMA. 2008;300(7): October 7,

23 Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial):a randomised controlled trial TD Girard, JP Kress, JB Hall,, GR Bernard, EW Ely. Lancet 2008; 371: October 7,

24 Awakening and Breathing Controlled trial. Girard. Lancet 2008 October 7,

25 Awakening and Breathing Controlled trial. Girard. Lancet 2008 October 7,

26 Other references Prevention measures for VAP: a new focus on the Endotracheal tube Ramirez P, Ferrerb W, Torres A. Curr Opin Infect Dis (2007) 20: Excess ICU mortality attributable to VAP: the role of early vs late onset Valles J et al. Intens Care Med AACN PracticeAlert. VAP. http//: ATS/IDSA: Guidelines for the management of adults with hospital-acquired, ventilatorassociated & healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171: Investigating the Failure to Aspirate Subglottic Secretions with the EVAC Endotracheal Tube. Dragoumanis CK, et al. Anesth Analg 2007;105: Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: A randomized trial. Valencia M et al. Crit Care Med 2007; 35: Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in Randomized multiple-center feasibility study. Rello J, Kollef M, Diaz E, et al. Crit Care Med 2006;34: Effect of a nurse-implemented sedation protocol on the incidence of VAP. Quenot J-P, Ladoire S, et al. Crit Care Med 2007 Vol. 35, No. 9 October 7,

27 Additional Elements for VAP Prevention Paule Bernier

28 Nutrition Oral decontamination Hand hygiene October 7,

29 Nutrition

30 October 7,

31 www. criticalcarenutrition.com October 7,

32 Enteral vs Parenteral Infections Costs LOS, mortality: no data Strong Conditional October 7,

33 60-70% of energy requirements (enteral) in the 1st week LOS ventilation days infection rate Fair imperative October 7,

34 When to feed? Within 24-48h if adequate intravascular volume infectious complications ICU LOS Mortality: not enough data Strong Conditionnal October 7,

35 Successful Nutritional support Timely initiation Safest, most effective route Best metabolic milieu Adequate substrate, appropriate formula selection Safe and adequate quantity Active Presence of dietitian (7 / 7) Protocole: at least to initiate evaluation October 7,

36 Oral decontamination

37 Lower VAP rates with Chlorhexidine, Oral rinse,gel,paste 0.12%, 0.2%, 2 %... Pre-op and bid, tid until extubation,21 days, 28 days, discharge October 7,

38 LA Pineda, RG Saliba, AA El Solh. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a metaanalysis. Critical Care 2006, 10:R35 Siempos I Falagas ME. Oral decontamination with chlorhexidine reduces the incidence of nosocomial pneumonia. Letter. Critical Care 2007, 11:402 E Y Chan, A Ruest, M O Meade DJ Cook. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334;889. A. Kola, P. Gastmeier. Efficacy of oral chlorhexidine in preventing lower respiratory tract infections.meta-analysis of randomized controlled trials. Journal of Hospital Infection (2007) 66, 207e216. H Tantipong, C Morkchareonpong, S Jaiyindee, V Thamlikitkul. Randomized Controlled Trial and Meta-analysis of Oral Decontamination with 2% Chlorhexidine Solution for the Prevention of Ventilator-Associated Pneumonia. Infect Control Hosp Epidemiol 2008; 29: October 7,

39 Hand Hygiene

40 5 components of success staff education monitoring of practices and performance feedback, reminders in the workplace, adoption of an institutional safety climate and, last but not least, a system change the preferential recourse to the use of alcohol-based hand rub as the new standard for patient care. Pittet D, October 2008 October 7,

41 World alliance for patient safety WHO guidelines on hand hygiene in health care (advanced draft): a summary. Clean hands are safer hands Stop! Clean your hands October 7,

42 October 7,

43 Adapting VAP Bundle for Pediatric Population Gordon Krahn

44 What is the problem! Second most common infection in PICU Suspected VAP accounts for 50% of empiric antibiotic use. NNIS rate for pediatric patients is 2.9 cases per 1000 ventilator days. Wide range of 0 to 8.1 If a patient develops VAP 3.7 additional days of ventilation 8% go on to develop multi organ failure or death. October 7,

45 Definition of VAP in Children Lack of Gold Standard CDC definition mocriteriav1.pdf 3 age categories o Infant to < 1 year of age o 1 12 years of age o > 12 years of age Recommend enlisting the help of your Infection Control department Apply the definition consistently October 7,

46 The Evidence Few pediatric studies Adaptation of the Adult bundle to Pediatrics What is appropriate? What is safe? What is practical? October 7,

47 The Bundle October 7,

48 Hand Washing Hand Washing Hand washing o Hand washing Hand washing» Hand washing Hand washing Hand washing o Hand washing Hand washing» Hand washing October 7,

49 HOBITTT (HOB) Head of Bed Elevated to at least 30 degrees (I for instill) Eliminate the routine use of instill when suctioning (T for tubing) Place the ventilator tubing in a dependant position to prevent condensate for draining into patient (T for teeth) routine oral care at least q4h (T for tummy) gastric tube in proper position October 7,

50 For Consideration EVAC tubes where size appropriate Avoid use of muscle relaxants Extubate as soon as possible Only change ventilator and manual resuscitator bag circuit when visibly soiled Take extra care when moving the patient to ensure condensation from circuit doesn t flow into patient. October 7,

51 10 9 Ventilator Associated Pneumonia British Columbia Children's Hospital Fiscal Year Incidence of VAP Monthly Rate Compound Rate Incidence and Monthly Rate Period 8 Period 9 Period 10 Period 11 Period 12 Period 13 Period 1 Period 2 Period 3 Period 4 Fiscal Year Fiscal Year June 27 to July 24, 2008 VAP rate/1000 Vent Days October 7,

52 Your Questions Facilitated by Leanne Couves

53 Resources VAP Getting Started Kit & Worksheets to be updated in Fall 2008 Communities of Practice Canadian ICU Collaborative Improvement Guide available when enrolled October 7,

54 About the Canadian ICU Collaborative Dr. Claudio Martin

55 Benefits of Participating Faster learning and quicker gains October 7,

56 Benefits of Participating (continued) Face-to-face Learning Sessions Evidence-based changes, ready to test and implement Coaching from experienced Faculty on application of changes Education and training on tools for improvement and measurement Advice on targeted strategies to overcome resistance and address barriers Monthly feedback on progress from the Collaborative Faculty Monthly conference calls specific to challenges your team is facing A List-Serve that provides real-time sharing of information, direct to your Inbox A website for storing and sharing your documents with others A comprehensive Improvement Guide with examples, checklists, tools No cost to join! October 7,

57 Expectations for Participating Teams Commitment of a team sponsor Full participation of a multidisciplinary team Development of measures Regular reporting of progress to the Faculty Willingness and commitment to implement rapid and widespread changes Desire to innovate Regular access to and Internet October 7,

58 Timelines for VAP & CLI Series Fall 2008 watch for details on SHN website and CoP Nov Informational Calls Dec Enrolment Deadline Jan 2009 Learning Session 1 April Learning Session 2 October Learning Session 3 December Collaborative Series ends October 7,

59 Planning Team Contacts Dr. Claudio Martin, Collaborative Chair Bruce Harries, Collaborative Director Leanne Couves, Improvement Advisor Ardis Eliason October 7,

60 VAP Faculty Contacts Paule Bernier Rosmin Esmail Gordon Krahn Dr. Denny Laporta October 7,