###  Remember to order daily "sedation vacations" on your patients receiving continuous intravenous sedation so that assessment of readiness to wean from mechanical ventilation can be completed on AM rounds. 

###  Each day, document in your notes your clinical impressions regarding the patients' potential for weaning on that day. 

###  Remember to order any additional testing (labs, blood gases, CXR, weaning parameters) that you feel will assist you in this assessment process on the next morning rounds with your attending physician. 

###  Inform the nurse promptly after placing an order for a spontaneous breathing trial so that it can be initiated promptly.

### 

### [Peptic ulcer disease (PUD) prophylaxis]{.underline}.

###  The IHI (2005) has found that when PUD prophylaxis is applied as part of a set of interventions for ventilator care, the rate of pneumonia decreases precipitously. 

###  [What is your role in the process?]{.underline} Please remember to order PUD prophylaxis on all mechanically ventilated patients.

### 

### [Deep venous thrombosis (DVT) prophylaxis (unless medically contraindicated).]{.underline}

###  The IHI (2005) has found that when DVT prophylaxis is applied as part of a set of interventions for ventilator care, the rate of pneumonia decreases sharply.

###  [What is your role in the process?]{.underline} Please remember to order DVT prophylaxis on all mechanically ventilated patients.

## other mechanisms to reduce vap at the Dayton, VAMC:

Some other interventions that the facility is utilizing to reduce VAP
are:

-   An oral care protocol for all mechanically ventilated patients.

-   A gastric tube management and tube feeding protocol for mechanically
    ventilated patients.

-   A repositioning and head of the bed elevation protocol for
    mechanically ventilated patients

-   A trial of endotrachial tubes that have a dorsal lumen to facilitate
    the removal of subglottic secretions.

## thank you!

### Thank you for your assistance in this process. You will also receive an instruction sheet that will assist you in the ordering of protocols that can make the process easier. {#thank-you-for-your-assistance-in-this-process.-you-will-also-receive-an-instruction-sheet-that-will-assist-you-in-the-ordering-of-protocols-that-can-make-the-process-easier. .Heading-Top-of-Column}

## References:

### 1. Drakulovic, M.B., Torres, A., Bauer, T.T., Nicolas, J.M., Nogue, S., & Ferrer, M. (1999). Supine body position as a risk factor for Nosocomial pneumonia in mechanically ventilated patients: a randomized trial. *Lancet*, 354, 1851 -- 1858.

### 2. Ely, E.W., Baker, A.M., Dunagan, D.P., Burke, H.L., Smith, A.C., Kelly, P.T., et al. (1996). Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. *New England Journal of Medicine*, 335, 1864 -- 1869.

### 3. Institute for Healthcare Improvement. (2005). *Getting started kit: preventing ventilator associated pneumonia*. Boston, MA.

4\. Kress J.P., Pohlman A.S., O\'Connor M.F., & Hall, J. B. (2000).
Daily interruption of sedative infusions in critically ill patients
undergoing mechanical ventilation. *New England Journal of Medicine*,
20, 1471 -- 1477.

### 5. Rello, J., Ollendorf, D.A., Oster, G., Vera-Llonch, M., Bellm, L., Redman, R., & Kollef, M.H. (2002). VAP Outcomes Scientific Advisory Group: Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. *Chest*, 6, 2115 -- 2121.

### 6. Richards, M.J., Edwards, J.R., Culver, D.H., & Gaynes, R.P. (2000). Nosocomial infections in combined medical-surgical intensive care units in the United States. *Infection Control Hospital Epidemiology*, 21, 510 -- 515.

### 7. Tablan, O.C., Anderson, L.J., Besser, R., Bridges, C., & Hajjeh, R. (2004). Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care--associated pneumonia, 2003 recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. *Morbidity and Mortality Weekly Report Recommendations and Reports*, 2004, 53, 1 -- 36.

![](media/image1.jpeg){width="2.4319444444444445in"
height="3.2708333333333335in"}

### Welcome to the critical care units of the dayton, vamc! {#welcome-to-the-critical-care-units-of-the-dayton-vamc .Heading-Top-of-Column}

###  The attending physicians and nurses of the Dayton, VAMC Intensive Care and Coronary Care Units hope that your rotation through our facility will be an enjoyable and sentinel learning experience for you.  {#the-attending-physicians-and-nurses-of-the-dayton-vamc-intensive-care-and-coronary-care-units-hope-that-your-rotation-through-our-facility-will-be-an-enjoyable-and-sentinel-learning-experience-for-you. .Heading-Top-of-Column}

###  Our facility has adopted an assertive approach in the prevention of VAP at our institution and we need your help. [You are a pivotal element of our process.]{.underline}  {#our-facility-has-adopted-an-assertive-approach-in-the-prevention-of-vap-at-our-institution-and-we-need-your-help.-you-are-a-pivotal-element-of-our-process. .Heading-Top-of-Column}

### Why should vap be PREVENTED? {#why-should-vap-be-prevented .Heading-Top-of-Column}

###  The Centers for Disease Control and Prevention (CDC) have found that pneumonia causes 15% of all hospital-acquired infections and is the leading cause of nosocomial infection related death (Tablan, Anderson, Besser, Bridges, and Hajjeh, 2003). The mortality rate of patients with VAP is higher than that of uninfected patients (50% versus 34%) and varies between the populations considered (Warren, et al., 2003). 

###  Rello, et al. (2002) found that VAP increases a patient's length of stay in the ICU by 6.1 days and hospitalization by 10.5 days. This study also found length of stay and the additional need for antibiotics significantly impact health care expenditures by adding an estimated \$16,050 to \$41,294 to the cost of a hospital admission. Additionally, VAP has been reported to be the most common hospital-acquired infection among patients requiring mechanical ventilation in the United States (Richards, Edwards, Culver, and Gaynes, 1999). 

### How Can Vap Be PREVENTED?

###  The Institute for Healthcare Improvement (2005) has developed a system of intervention sets which they term care bundles. Care bundles, in general, are groupings of best evidenced based practices with respect to a disease process that individually improve care. When the groupings are applied together the result is substantially superior improvement. 

###  The ventilator bundle is a group of evidence based practices that, when placed into daily practice for [all patients on mechanical ventilation, result in a dramatic reduction in the incidence of VAP.]{.underline} With this in mind, our facility has adopted the ventilator bundle into the daily care of ventilated patients in the ICU and CCU of our institution

### IHI (2005) program Overview and your role in the process:

The ventilator IHI bundle has four components:

-   **[Elevation of the patients' head of the bed to between 30 and 45
    degrees (unless medically contraindicated).]{.underline}**

In a randomized controlled trial conducted by Drakulovic, et al. (1999)
it was found that when intubated patients on mechanical ventilation were
assigned to semi-recumbent positioning (30 to 45 degrees), there were
18% fewer confirmed cases of VAP.

**[What is your role in the process?]{.underline}** Please order that
the head of the bed be elevated to between 30 and 45 degrees on all of
the ventilated patients that you care for (if not contraindicated). Note
the head of the bed position of your ventilated patient during your
rounds and remind the nursing staff if the height is too low. Remember,
however, that for certain procedures (linen changes, repositioning)
nurses do (briefly) lower the head of the bed to prevent back injuries.

-   **[Daily "sedation vacation" AND daily assessment of readiness to
    extubate (unless medically contraindicated).]{.underline}**

Kress, Pohlman, O'Conner, and Hall (2000) found that when 128 adults on
mechanical ventilation were randomized to daily interruption of sedation
per protocol until the patient was awake or interruption only at the
clinician's discretion, the duration of ventilation was decreased from
7.3 days to 4.9 days in the group randomized to routine awakening per
protocol.

Ely, et al. (1996) found, in a randomized, controlled trial involving
300 adult patients receiving mechanical ventilation in medical and
coronary intensive care units, that daily systematic screening of the
respiratory function of adults receiving mechanical ventilation reduced
the duration of the mechanical ventilation from a median of 6 days to
median of 4.5 days and reduced the hospitalization costs from a median
of \$20,890 to a median of \$15,740.

[What is your role in the process?]{.underline} When utilizing
continuous intravenous sedation, order that the sedation be titrated to
a specific sedation level. The critical care units of our facility
currently utilize a modified Ramsay Scale to monitor intravenous
sedation. We suggest, in most ventilated patients, that a target
sedation level of '4' is a good place to start.