Disclosures. Learning Outcomes: 5/7/2011. Pulmonary vs. Skin Outcomes: Do We Really Need to Select. Ventilator-Associated Pneumonia(VAP)

Size: px

Start display at page:

Download "Disclosures. Learning Outcomes: 5/7/2011. Pulmonary vs. Skin Outcomes: Do We Really Need to Select. Ventilator-Associated Pneumonia(VAP)"

Darrell McKinney
5 years ago
Views:

1 Disclosures Pulmonary vs. Skin Outcomes: Do We Really Need to Select Just One? Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING Northville, Michigan Vollman 2011 Sage Products Speaker Bureau & Consultant Hill-Rom consultant E.L. Lilly Eloquest Healthcare Learning Outcomes: Ventilator-Associated Pneumonia(VAP) Determine the significance of negative pulmonary & skin outcomes Understand the various evidence based mobility strategies that impact pulmonary outcomes and skin issues. Compare and contrast challenges that may arise when mobility strategies are used to achieve singular outcomes. Outline care practices around mobility interventions that promote achievement of both pulmonary and skin outcomes. VAP crude mortality approximately 10-40%. Pooled mean ranges.5 (RICU) to 10.7 (Burn ICU) per 1000 ventilator days Est cost $30,000-$40,000 per VAP Calculated loss for VAP against matched controls=$12,780 Increase LOS up to 4-14 days Annual cost $2 billion dollars. Edwards JR, et al. Am J of Infect Control, 2007;35: Kollef MH, et al. Chest, 2005:128: Collard HR. Ann Intern Med. 2003;138: Restrepo MI, et al. Infect Control Hosp Epidemiol, 2010;31: Rello J. Chest. 2002;12: ATS Guidelines for HealthCare Acquired Pneumonia 2006 Coffin SE, et al. Infect Control & Hosp Epidemiol, 2008;29(1):S31-S40 Rosenthal VD, et al. Am J of Infect Control, 2008;36: Pressure Ulcer Facts Preventable Events: Pressure Ulcers 4 th leading preventable medical error in the United States 2.5 million patients are treated annually in Acute Care NDNQI data base: critical care 5-14% ~ ~ 22% Incidence in acute care 7% 60,000 persons die from pressure ulcer complications each yr LOS ~ 3x longer PU related hospitalizations 80% from 1993 to 2006 Cost to treat PU $43,000 as a secondary dx National health care cost $ billon dollars for 2010 Dorner, B., Posthauer, M.E., Thomas, D. (2009), Whittington K, Briones R. Advances in Skin & Wound Care. 2004;17: Reddy, M,et al. JAMA, 2006; 296(8): Pressure ulcers (PUs) can be identified, measured, and reported Usually preventable (Long term care divides pressure ulcer reimbursement into avoidable & unavoidable) Significant body of scientific evidence is available to guide practice and prevent Pus CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnosis October, 2008: Stage III and IV PUs acquired after admission will not be reimbursed Documented POA by a provider (a physician or any qualified practitioner legally accountable for establishing a patients diagnosis & must sign the comprehensive initial skin assessment

Atelectasis Decreased Respiratory Motion Abdomen influence on diaphragm motion Atelectasis Increased Risk of

Fortney SM, et al. Physiology of bedrest (Vol 2). New York: Oxford University Press. 1996.

The Effects of Immobility/Supine Position on Respiratory Function Decreased Movement of Secretions Impaired

2 accessed 08/25/2010 The Effects of Immobility/Supine Position on Respiratory Function Basilar Atelectasis Decreased Respiratory Motion Abdomen influence on diaphragm motion Atelectasis Increased Risk of Pulmonary Embolism Increased Dependent Edema Fluid accumulation in the dependant regions Compression atelectasis Fortney SM, et al. Physiology of bedrest (Vol 2). New York: Oxford University Press Greenleaf JE, Kozlowski S. Exerc Sport Sci Rev, 1982;;10: The Effects of Immobility/Supine Position on Respiratory Function Decreased Movement of Secretions Impaired ability to clear tracheobronchial secretions Normal mechanism dysfunctional in supine position Mucocillary escalator Gravity drainage Cough reflex Increased Risk of Atelectasis & the Development of a Ventilator Associated Pneumonia EVIDENCE BASED INTERVENTIONS TO IMPROVE PULMONARY OUTCOMES 2

Head Elevation Research for Prevention of Ventilator-Associated Pneumonia HOB elevation vs. supine significantly reduces the incidence of VAP (Drakulovic MB. et. al. Lancet.

Crit Care Med, 2006;34:396-402) Joint Commission has HOB at 30 degrees in ventilator patients as a core measure for the reduction of VAP Manual Turning: Impact on Pneumonia Effect of Post Op

3 Head Elevation Research for Prevention of Ventilator-Associated Pneumonia HOB elevation vs. supine significantly reduces the incidence of VAP (Drakulovic MB. et. al. Lancet. 1999;354: ) Continuous measurement of HOB confirmed that some amount of elevation is critical to reduce VAP (Van Nieuwenhoven CA, et al. Crit Care Med, 2006;34: ) Joint Commission has HOB at 30 degrees in ventilator patients as a core measure for the reduction of VAP Manual Turning: Impact on Pneumonia Effect of Post Op Immobilization (Chulay MA et al, CCM, 1982) RCT: 35 post op CABG patient, Compared q 2 turning/supine in 1st 24 hrs Results: Patient turned has less fever & 3 day in ICU LOS Freq of Turning on Pneumonia (Schallom et. al. 2005) Observation: 284 ICU pts for 16/hrs/day x3 days Mean # of observed turns 9.64 vs. 23 possible turns/48 hrs) Results: Day 4 patients with pneumonia turned average 8.6 x vs without pneumonia Cushion Based Rotation Bed CLRT to Prevent VAP Goldhill DR et al. Amer J Crit Care, 2007;16:50-62 Methodology Prospective randomized controlled trial, 3 medical ICUs at a single center Eligible if ventilated < 48 hours & free from pneumonia, ALI or in ARDS 150 patients with 75 in each group 35 CLRT patients t allocated to undergo percussion before suctioning Measures to prevent VAP were standardized for both groups including HOB Results: CLRT vs. Control VAP: 11% vs. 23% p =.048 Ventilation duration: days vs days, p =.02 LOS: vs days, p =.01 Mortality: no difference Staudinger t, et al. Crit Care Med, 2010;38. 3

Rotation Therapy Outcome Studies Progressive Mobility Programs Stanford Univ MC 1994: MICU Cape Fear Valley MC 1994: Sarasota Memorial 2001 Medical Center of Georgia 2002 ICU LOS by 5.

20% decrease of SMR [standard mortality ratio] Vent Days, Hospital LOS, ICU LOS by 5-6 days.

4 Rotation Therapy Outcome Studies Progressive Mobility Programs Stanford Univ MC 1994: MICU Cape Fear Valley MC 1994: Sarasota Memorial 2001 Medical Center of Georgia 2002 ICU LOS by 5.2 days Days of Pneumonia by 52% H & ICU LOS, Vent Days 48 fewer VAP year of the 6 month bed study Lag time effect: decreased days on therapy LAG time resulted in 14% decrease in HLOS, Vent Days, & 20% decrease of SMR [standard mortality ratio] Vent Days, Hospital LOS, ICU LOS by 5-6 days. Journey to tolerating upright position, tilt, sitting, standing and walking can occur quicker through the use of technology Early Physical and Occupational Therapy in Mechanically Ventilated Patients Early Physical and Occupational Therapy in Mechanically Ventilated Patients Prospective randomized controlled trial from screen, 104 patients mechanically ventilated < 72hrs, functionally independent at baseline met criteria Randomized to early exercise of mobilization during periods of daily interruption ti of sedation (49 pts) or two daily interruption of sedation with therapy as ordered by the primary care team (55 pts) Primary endpoint: number of patients returning to independent functional status at hospital discharge ( able to perform activities of daily living and walk independently) Schweickert WD, et al. Lancet, 373(9678): Schweickert WD, et al. Lancet, 373(9678): Early Physical and Occupational Therapy in Mechanically Ventilated Patients Safe Well tolerated functional outcome duration of delirium VFD EVIDENCE BASED INTERVENTIONS TO PREVENT SKIN INJURY CAUSED BY PRESSURE & MOISTURE Schweickert WD, et al. Lancet, 373(9678):

5 Pressure Ulcers Impact of Moisture Shear A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Moisture increases the friction coefficient Urinary and fecal incontinence are common in the acute care setting, occurring in more than one-third of hospitalized adults. Humidity/Moisture: Strain at which the skin breaks is 4x greater with excess moisture than dry skin Moisture increases the risk of shear & friction damage Friction MOISTURE Adapted from Barb Bates-Jensen Nicolopoulos CS, et al. Arch Dermatol Res. 1998;290: Bliss DZ, et al. Nurs Res.2000;49: Gray M, et al. Adv Skin Wound Care. 2002;15(4): EBP Recommendations to Achieve Offloading & Reduce Pressure Turn & reposition every 2 hours (avoid positioning patients on a pressure ulcer) Repositioning should be undertaken to reduce the duration & magnitude of pressure over vulnerable areas Cushioning devices to maintain alignment /30 sidelying & prevent pressure on boney prominences Use lifting device or other aids to reposition & make it easy to achieve & sustain the turn Assess whether actual offloading has occurred Reger SI et al, OWM, 2007;53(10):50-58, National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; EBP Recommendations to Achieve Offloading & Reduce Pressure Turn & reposition every 2 hours (avoid positioning patients on a pressure ulcer) Use active support surfaces for patients at higher risk of development where frequent manual turning may be difficult Turning is still required on surfaces designed to redistribute pressure Heal-protection devices should elevate the heel completely (offload) in such a way as to distribute weight along the calf Uses pillows to offload if expected immobility < 8hrs Uses device is expected to be immobile > 8hrs Progressive mobility program 2 clinical trials currently underway to examine turning regimes on pressure ulcers & other outcomes in acute & ICU patients (2011) Reger SI et al, OWM, 2007;53(10):50-58, National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; / EBP Recommendations to Reduce Injury From Incontinence Clean the skin as soon as it becomes soiled. Use a protective cream or ointment on the skin to protect it from wetness. Disposable barrier cloth prevents unprotected episodes ( 5 Million Lives Campaign) Use an incontinence pad and/or briefs to absorb/wick away wetness from the skin. Consideration of pouching device or a bowel management system Ensure an appropriate microclimate & breathability < 4 layers of linen National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom MOBILITY Shear Pressure SACRAL Pressure Ulcers Friction MOISTURE 5

6 Common Belief CLRT can be used as a prevention therapy for skin to achieve turning in critically ill patients I do not need to manually turn my patient when on CLRT When using CLRT, the therapy should be stopped every 2 hrs followed by offloading of the sacrum for 30 minutes, then resume CLRT I do not need to manually turn a patient on an air pressure support surface to relieve pressure Truth Based on Literature & Experience 30 years of research focus on the use of CLRT as a prevention therapy towards pulmonary outcomes Manual turning for assessment of the lungs and skin should occur at the level of frequency done for patients not on the therapy If CLRT therapy performed correctly with lung & skin assessment completed on a regular basis, offloading is not necessary All patients need to be turned. Some surfaces because of the pressure reducing capabilities allow the patient to remain in a position for a longer period of time INCREASE YOUR UNDERSTANDING OF THE IMPORTANCE OF PERFORMING CLRT CORRECTLY CLRT: Performed Correctly CLRT: Performed Correctly Driven by a protocol with placement criteria & discontinuation of use Placement criteria: Suctioning every 30 minutes and/or secretions > 30cc per 24 hours Areas on consolidation and/or lobar atelectasis per chest x-ray and/or requiring frequent bronchoscopy for secretion removal Difficulty with oxygenation: PaO2 of 60mmHg on > 40% FiO2 and 5 of PEEP (direction of ventilatory support increasing) Patients who are at risk for ARDS. This may include critically ill patients with Septic Shock, Gastric Aspiration, and/or Multiple Trauma. Critically ill patients unable to tolerate a manual turn by displaying a sustained drop (> 5 minutes) in oxygen saturation (< 88%), blood pressure (SBP < 85mmHg), and/or heart rate (< 60 beats per minute) Driven by a protocol with placement criteria & discontinuation of use Discontinuation criteria: Respiratory status improved: 48 hours post clear chest x-ray, 48 hours of a PaO2 > 60mmHg on 40% FiO2 or less and 5 of PEEP (Direction of ventilator support decreasing) and/or secretions < 30cc per 24 hours, or one hour or more time between suction interventions Agitation not therapeutically managed CLRT Performed Correctly The therapy MUST be driven by a protocol Settings & changes in settings are nursing orders and are written and documented Turn frequency and amount: Minimum of 18 hours per day & six cycles per hour (use timed therapy never > 10 mins, if you use pause times never > 3 mins) Usual time 5 minutes or 1 min pause time to achieve research based number of cycles One lung above the other Monitor initial turn cycle to ensure one lung is above the other Automation of turning requires insertion of usual assessment practices (q 2hr for lungs & skin) Evaluate daily to determine continued need or ability to progress to other forms of mobility Potentials Reasons for Why Skin Injury May Occur When Using CLRT CLRT is an advance therapeutic technique Training & monitoring of therapy use is not performed to ensure accuracy & safety Patients are not rotated enough to achieve one lung above the other or frequent enough > 18hrs a day with minimum i of 6 cycles One lung above the other is enough to have sacral offload Q 2 hr assessment of skin & lungs is not performed Most nurses have been educated 1x or maybe 2x on how to use the bed (not enough for a advance therapeutic technique) HOB at 30 degrees causes challenges in maintaining effective rotation 6

7 How to Achieve Pulmonary Outcomes with CLRT without Skin Injury Therapy is only used for pulmonary purposes with a protocol that has direction on frequency & rotation of a turn Education of frontline caregivers initially & then yearly to maintain competence Built into orientation Round to ensure correct utilization of the therapy & documentation Right patient/right reason Rotation Frequency Reinforce the need for q 2 hr assessment of skin & lungs Achieve HOB through 15 degree HOB and 15 degree reverse trendelenburg Jankowski IM. Crit Care Nurse, 2010;30(2): S Culpepper LS. Crit Care Nurse, 2010;30(2):S Vollman KM. Crit Care Nurs Clin of N Amer, 2006;18: Years of CLRT for Pulmonary Prevention Care Zero sacral skin injury while using the therapy Questions? kvollman@comcast.net 7

Minimal Physiologic Mobility Requirement UNDERSTANDING THE IMPACT OF A STATIONARY SUPINE POSITION. Mobility Matters: 1990 s CLRT Research

Mobility Matters: Minimal Physiologic Mobility Requirement Move Every 11 Minutes During Sleep Kathleen M. Vollman MSN, RN, CCNS, FCCM Clinical Nurse Specialist / Educator/Consultant ADVANCING NURSING kvollman@comcast.net