Continues -ETT over Standard S-ETT based on the final attributable cost of VAP. Systematic Review (Overend, 2009) 17 Pro- Analyzed 15 RCT and 13 RCO of mechanically ventilated patients. Study showed that new evidence continues to be varied in strength for suctioning practice, but the evidence has improved since 2001 suggesting that members of the health care team should incorporate this evidence into their practice. Literature Review (Depew, 2007) 18 Pro- Review of meta-analysis 2 that looked at 5RCT that compared aspiration of subglottic secretion vs. standard ETT care. Findings conclude that there insufficient outcome evidence to support the use of subglottic technology – aside from the VAP rate reduction.
Appendix F: VAP Prevention – Oral care with Chlorhexidine (CHG) Things you should know! Regular oral care with CHG is associated with decreased colonization of dental plaque, and a decreased incidence of ventilator-associated pneumonia (VAP). Guidelines for VAP prevention, published before 2008, do not address the use of CHG for oral care. Increasing evidence to support this intervention has emerged over the past several years. In 2011, a systematic review and meta-analysis of 12 randomized trials supported the use of oral care with CHG for VAP prevention. Overall, this study found a 38% VAP reduction. Favorable effects were more pronounced in cardiosurgical studies (up to a 59% VAP reduction). guidelines below were written, 11 other peer reviewed publications have been written supporting the effectiveness of the use of CHG for oral care in the prevention of VAP 2008-Society for Healthcare Epidemiology of America A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Perform regular oral care with an antiseptic solution in accordance with product guidelines. Did not specify CHG. All studies demonstrated the effectiveness of oral care with CHG, specifically in the cardiac surgery population. 2004-Canadian VAP Prevention Guidelines: clinical practice guidelines for the prevention of ventilator-associated pneumonia. The use of the oral antiseptic chlorhexidine should be considered. Based on 1 level 1 and 2 level 2 trials, the use of the oral antiseptic CHG may decrease the incidence of VAP. Safety, feasibility, and cost considerations for this intervention are all very favorable. 2004-Guidelines for the Management of adults with Hospital-acquired, Ventilator-associated, and Pneumonia. Recommends regular oral care. States that chlorhexidine has prevented hospital-acquired pneumonia in specific populations such as those undergoing coronary bypass grafting, However, also states that routine use is not recommended until more data is available. 2003-CDC Guidelines for preventing Pneumonia No recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of healthcare–associated pneumonia in all postoperative or critically ill patients and/or other patients at high risk for pneumonia
7. Use early mobility protocol. All Guidelines No Recommendations Early ICU Mobility Therapy (Morris, 2008) 6 Pro- Findings of this study showed that mechanically ventilated acute respiratory failure patients who underwent early intensive mobility therapy had a shorter ICU and hospital stay than similar patients who received standard physical therapy. Receiving Early Mobility in ICU (Morris, 2011) 7 Pro-The aim of this study was to determine the post hospital outcomes of implementing early mobility protocol. This study finding showed that patients who received early ICU mobility therapy had fewer hospital readmissions and deaths in 12 months post discharge period. Early Physical Medicine and Rehabilitation (Needham, 2010) 8 Pro- This quality improvement program found that the incorporation of early mobility into the daily care of ICU patients substantially reduced length of stay. 8. Perform hand hygiene. SHEA Pro- Recommends the adherence to hand-hygiene guidelines published by the Centers for Disease Control and Prevention / World Health Organization. ZAP No Recommendations ATS Pro- Recommends the use of effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with MDR pathogens. CDC Pro- Recommends the decontamination of by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water or by using an alcohol-based waterless antiseptic agent. 9. Avoid supine position. SHEA Pro- Recommends the maintenance of patients in the semirecumbent position (30-45 degrees) unless medically contraindicated. ZAP Makes No Recommendation ATS Pro – Recommends that patients should be kept in the semirecumbent position 30-45degrees rather than supine. CDC Pro- Recommends the elevation of head of the bed to an angle of 30-45 degrees.
Bibliography 1. MHA Keystone ICU Group. Oral care checklist. 2003. 2. Scannapieco FA, Yu J, Raghavendran K, et al. A randomized of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care. 2009;13(4):R117. doi: 10.1186/cc7967. 3. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of pneumonia in ICU populations. Intensive Care Med. 2006;32(2):230-236. doi: 4. Hutchins K, Karras G, Erwin J, Sullivan K. Comprehensive oral care program reduces rates of VAP in ICU. Mercy Medical Center, Springfield, MA. (unpublished / poster presented only). 5. American Association of Critical Care Nurses. Oral care in critically ill. AACN Practice Alerts. 2010. 6. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: A randomized controlled JAMA. 2006;296(20):2460-2466. doi: 10.1001/jama.296.20.2460. 7. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care. 2009;18(5):428-37; quiz 438. doi: 10.4037/ajcc2009792. 8. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. 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(2):131-136. doi: 10.1086/526438.
Question#3: Have medications for sedation been held during the past 24hrs (SAT)? If Yes- Enter ‘Y’ in SAT column. If No- Enter ‘N’ in SAT Column If Contraindicated/Not indicated – Enter ‘C/NI’ in SAT column. This patient will not be included in computation of your compliance rate for this measure. SAT Con: What are the contraindications/not indicated conditions for this patient having a Spontaneous Awakening Trial? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘C/NI’ entered in the SAT column) If ‘C/NI’ was entered in the SAT column, answer this question. Enter the number associated with the answer into the box. For example, enter ‘1’ if the patient is currently receiving a sedative infusion for active seizures or alcohol withdrawal. Contraindications listed on the back of the data collection sheet. SBT: Has the patient had a Spontaneous Breathing in the last 24 hours? (Only for patients currently intubated/trached and mechanically ventilated.) SBT definition: To conduct a trial of spontaneous breathing, ventilatory support is removed and the patient is allowed to breathe through either a circuit or a ventilatory circuit with low levels of PS (5–8 cmH2O in adults) with or without 5 cmH2O PEEP. No changes are required in the fraction of inspired oxygen or the level of positive end-expiratory pressure. (Evaluated every 24hrs for patients receiving full vent support.) Enter ‘Y’ if the patient had a SBT. Enter ‘N’ if the patient did not have a SBT. Enter ‘C/NI’ if the use of a SBT is contraindicated/not indicated. SBT Con: What is the contraindication for this patient having an SBT? (Only for patients currently intubated/trached and mechanically ventilated AND with ‘C’ entered in the SAT column) If ‘C/NI’ was entered in the SBT column, answer this question. the number with the answer into the box. Contraindications listed on the back of the data collection sheet. Please enter data from this paper-based data collection form in the CECity web-based reporting system at least once per week.
Contraindications and Locations – Enter the appropriate number (Only enter contraindications if you have marked C or C/NI of ‘0’ (if a numerical column)) Sub-G ETT Contraindications Other Tracheostomy HOB Contraindications Other Hypotension Unstable Physiological Status Low Cardiac Index Cervical, thoracic or lumbar surgery or instability LVAD RVAD aortic balloon pump Open abdomen Patient refusal Oral Care Contraindications Patient refusal No oral care, no contraindication Oral care with CHG Contraindications Other Patient is to have an allergic or hypersensitivity reaction to chlorhexidine Patient is < 2 months of age is a possibility of direct contact of CHG with meninges ALL oral care is contraindicated. (In this case, the answer in the Oral Care column for this patient should also be “C”.) Patient refusal No oral care w/ CHG , no contraindication SAT Contraindications Other Patient is receiving a sedative infusion for active seizures or alcohol withdrawal. Patient is receiving escalating sedative doses due to ongoing agitation. Patient is receiving neuromuscular blockers. Patient has had evidence of active myocardial ischemia in the previous 24 hrs. Patient has had evidence of increased intracranial pressure in the previous 24 hours. Patient is not receiving sedation medications. SBT Contraindications Other Doesn’t have adequate oxygenation [SpO2 < 88% on an FiO2 of ≤ 50% and a PEEP of ≤3 cm H2O] No spontaneous inspiratory effort in a 5-min period. agitation requiring escalating sedative doses. Significant use of vasopressors or inotropes. Patient has had evidence of increased intracranial pressure in the previous 24 hours. Location of Intubation Your ICU/unit Another ICU/unit in your hospital Outside hospital OR Rapid Response Team (RRT) ED Cardiovascular and Interventional Laboratory (CVDL) During a code on the floor Another location not listed