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VENTILATOR ASSOCIATED PNEUMONIA
DO BUNDLE MAKE A DIFFERENCE? Anis Siham Zainal Abidin
Faculty of Medicine UiTM
ASMIC 2016
INTRODUCTION - Burden of VAP
VENTILATOR BUNDLE CARE
INTERNATIONAL DATA
LOCAL DATA
OUTLINE
VENTILATOR ASSOCIATED PNEUMONIA
ASMIC 2016
US VAP 2.9/1000MV days
Germany VAP 5.1/1000 MV days
Malaysia VAP 12.9/1000 MV days
INCREASE BED DAYS IN ICU INCREASE MORBIDITY &
MORTALITY
$$$$$$ INCREASE COST
VENTILATOR BUNDLE CARE
WHAT IS
ASMIC 2016
INSTITUTE OF HEALTHCARE IMPROVEMENT
▸ Started with ‘100 000 lives campaign’ 2004-2006
▸ Ventilated patients : top priority - morbidity/ mortality
▸ Serious complications for ventilated patients:
▸ Ventilator associated pneumonia (VAP)
▸ Venous thromboembolism (VTE)
▸ Stress-induced gastrointestinal bleed
ASMIC 2016
HEAD ELEVATION 30-50O
DEEP VENOUS THROMBOSIS PROPHYLAXIS
SEDATION VACATION
PEPTIC ULCER DISEASE
PROPHYLAXIS
ORAL HYGIENE
ALL OR NOTHING
ASMIC 2016
FINDINGS : ADULTS
45%
ICU collaborative improvement project IHI
ASMIC 2016
HEAD ELEVATION 30-500
86 MV PATIENTS ASSIGNED TO SUPINE VS SEMI RECUMBENT : SUSPECTED VAP CASES - RATE 34% VS 8% (P:0.003), CONFIRMED CASES - 23% VS 5% (P:0.018)
Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in
mechanically ventilated patients: A randomised trial. Lancet. Nov 27 1999;354(9193):1851-1858.
ASMIC 2016
HEAD ELEVATION 30-500
86 MV PATIENTS ASSIGNED TO SUPINE VS SEMI RECUMBENT : SUSPECTED VAP CASES - RATE 34% VS 8% (P:0.003), CONFIRMED CASES - 23% VS 5% (P:0.018)
Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in
mechanically ventilated patients: A randomised trial. Lancet. Nov 27 1999;354(9193):1851-1858.
FEASIBILITY OF KEEPING THE HEAD ELEVATED: 30O VS 10O
MORE POSITION CHANGES IN SEMI RECUMBENT GROUP NO DIFFERENCE IN VAP RATE
van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-
associated pneumonia: A randomized study. Crit Care Med. 2006 Feb;34(2):396-402.
ASMIC 2016
HEAD ELEVATION 30-50O
DEEP VENOUS THROMBOSIS PROPHYLAXIS
SEDATION VACATION
PEPTIC ULCER DISEASE
PROPHYLAXIS
ORAL HYGIENE
ALL OR NOTHING
ASMIC 2016
SEDATION VACATION
▸ Kress et al. 128 MV patients: daily sedative interruptions vs
clinician discretion. Duration MV 7.2days to 4.9days
(p:0.004)
DAILY SEDATIVE INTERRUPTIONS
READINESS TO EXTUBATE
Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical
ventilation. N Engl J Med. 2000;342(20):1471-1477.
Thomas Strøm, Torben Martinussen, Palle Toft. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a
randomised trial. Lancet 2010; 375: 475–80.
Schweickert WD, Gehlbach BK, Pohlman AS, Hall JB, Kress JP. Daily interruption of sedative infusions and complications of critical illness
mechanically ventilated patients. Crit Care Med. 2004 Jun;32(6):1272-1276.
Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically
ill patients. Am J Respir Crit Care Med. 2003 Dec 15;168(12):1457-1461. Epub 2003 Oct 2.
Esteban A. A comparison of four methods of weaning patients from mechanical ventilation. N Eng J Med. 1995;332:345-350.
Ely EW. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med.
1996;335:1864-1869
ASMIC 2016
HEAD ELEVATION 30-50O
DEEP VENOUS THROMBOSIS PROPHYLAXIS
SEDATION VACATION
PEPTIC ULCER DISEASE
PROPHYLAXIS
ORAL HYGIENE
ALL OR NOTHING
ASMIC 2016
ORAL HYGIENE
▸ Dental plaque biofilms
▸ Saliva production
▸ Reservoir for bacterial
▸ DeRiso et al - 0.12% Chlorhexidine as oral rinse
▸ Chan et al - meta analysis showed oral decontamination with
chlorhexidine reduces VAP
DeRiso AJ, Ladowski JS, DillonTA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial
respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109:1556-1561.
Chan EY, Ruest A, O’Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review
and meta-analysis. BMJ. 2007; 334(7599):889. Epub 2007 Mar 26.
Munro CL, Grap MJ, Jones DI, McClish DK, Sessler CN. Chlorhexidine, tooth brushing and preventing ventilator-associated pneumonia in critically
ill adults. Am J Crit Care. 2009 Sep;18(5):428-437.
ASMIC 2016
HEAD ELEVATION 30-50O
DEEP VENOUS THROMBOSIS PROPHYLAXIS
SEDATION VACATION
PEPTIC ULCER DISEASE
PROPHYLAXIS
ORAL HYGIENE
ALL OR NOTHING
ASMIC 2016
PEPTIC ULCER DISEASE PROPHYLAXIS ▸ Stress ulcer is the most common cause of GI bleed
▸ Increasing gastric pH - promote bacterial overgrowth
▸ Cook et al. Meta analysis: no increase in hospital-acquired
pneumonia, reduced rate of pneumonia with sucralfate.
▸ IDSA conclude H2 antagonist better control of bleed, hence
suggested H2 antagonist or PPI
RISK OF C.DIFFICILE
Cook DJ, Laine LA, Guyatt GH, Raffin TA. Nosocomial pneumonia and the role of gastric pH: A meta-analysis. Chest.1991;100(1):7-13.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital- acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
ASMIC 2016
HEAD ELEVATION 30-50O
DEEP VENOUS THROMBOSIS PROPHYLAXIS
SEDATION VACATION
PEPTIC ULCER DISEASE
PROPHYLAXIS
ORAL HYGIENE
ALL OR NOTHING
ASMIC 2016
DEEP VEIN THROMBOSIS PROPHYLAXIS
▸ Higher incidence in critically ill patient due to immobility
▸ 7th ACCP recommends for ICU patients based on several
RCTs
▸ Collectively used in bundles, VAP rates decreased
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic
and ThrombolyticTherapy. Chest. 2004;126(3 Suppl):338S-400S.
PAEDIATRIC MODIFICATION?
ASMIC 2016
ASMIC 2016
CONCEPT
SPECIFIC POPULATION IN A
SPECIFIC LOCATION
COMPRISES OF SIMPLE MEASURES
FOCUS ON BEST CARE
ALL OR NONE
COMPLIANCE
ASMIC 2016
PAEDIATRIC VENTILATOR BUNDLE CARE
EXAMPLES OF ELEMENTS
MONITORING
PREVENT BACTERIAL COLONIZATION HAND HYGIENE ORAL HYGIENE
CARE OF THE VENTILATOR & SUCTION TUBING
DAILY SEDATION BREAK
DAILY ASSESSMENT OF READINESS FOR EXTUBATION
PREVENT ASPIRATION OF
CONTAMINATED SECRETIONS MINIMISING RISK OF ASPIRATION ELEVATION HEAD (15-30O)(30-45O)
SUBGLOTTIC ASPIRATION ETT CUFF PRESSURE
CDC/ NHNS (US), KISS (GERMANY), ECDPC, JAPAN
INICC (ARGENTINA)
HIGH INCOME COUNTRIES
LOW TO MIDDLE INCOME COUNTRIES
ASMIC 2016
CDC/NHNS VS INICC
▸ 4 decades ago
▸ 3000 hospitals US
▸ comparison among high
income countries
▸ online platform
▸ benchmark
▸ 15 years ago
▸ 703 ICUs, 50 countries
▸ comparison among limited
resources countries
▸ online platform
▸ complementary benchmark
ASMIC 2016
INICC REPORT 2010-2016. AJIC 2016
ASMIC 2016
INICC REPORT 2010-2016. AJIC 2016
ASMIC 2016 PAEDIATRIC DATA - INTERNATIONAL
Brilli et al : reduced VAP infections markedly in the PICU,
from 24 cases in 2005, to 9 cases in 2006, to 2 cases in 2007. Hospital
days fell by 400, and hospital costs by $2,353,222 during this interval.
Changing ventilator circuits only when soiled, draining circuit
condensate every 2-4 hours, storing oral suction devices in
nonsealed plastic bags at the bedside, performing mouth care every
4 hours, elevating the HOB, and draining ventilator circuits before
moving patients
This PICU experienced a 7.5-month period without a single case of
VAP
Brennan et al: reduction in VAP followed implementation of a bundle of
interventions in the NICU.
Bundle included a focus on endotracheal tube care and preventing extubation,
careful oral hygiene, maintaining cleanliness of respiratory equipment, and use
of noninvasive ventilation, such as bubble continuous positive airway pressure.
Brilli RJ, Sparling KW, Lake MR, et al. The business case for preventing ventilator-associated pneumonia in pediatric intensive
care unit patients. Jt Comm J Qual Patient Saf. 2008;34:629-638.
Brennan R, Loughead J, DeJulio P, Leston S, Sosin J. Creating and implementing a bundle to reduce VAP in the NICU.
Improvement Report. Institute for Healthcare Improvement; 2006.
LOCAL DATA
PICU UMMC
ASMIC 2016
PICU UMMC : INICC + PEDICARE
‣ PEDICARE - Aug 2008 till current (Dec ’15 : 3909 patients)
‣ INICC - November 2013 till current (Dec ’15: 1047patients)
‣ Pre intervention baseline check:
‣ 1 Nov 2013 - 31 Jan 2014 (3 months)
‣ Intervention period:
‣ 12 monthly till Jan 2016
* Unpublished data
ASMIC
VENTILATOR BUNDLE AS PER INICC
GENERAL STRATEGIES HAND HYGIENE, LIMIT USE MV MULTDIMENSIONAL APPROACH BUNDLE, EDUCATION, OUTCOME, PROCESS, FEEDBACK VAP RATES, FEEDBACK PRACTISES
CORE STRATEGIES
PREVENT ASPIRATION SEMI RECUMBENT, AVOID GASTRIC OVER DISTENSION,
AVOID UNPLANNED EXTUBATION, CUFFED ETT WITH SUBGLOTTIC SUCTION, CUFF PRESSURE
REDUCE COLONIZATION ORAL ETT, ORAL CARE
MINIMISE EQUIPMENT CONTAMINATION REMOVE CONDENSATE CHANGE TUBING WHEN VISIBLY SOILED STORE & DISINFECT RESPIRATORY THERAPY
ASMIC 2016
PICU UMMC VAP DATA (NOV 2013-31/01/2016) N=1047
▸ VAP: 46
▸ Med days to VAP: 15
▸ Crude mortality rate : 28.6%
▸ Med PRISM score 18
▸ Med LOS: 39.2 days
ASMIC 2016
INTERVENTION
ASMIC 2016
ASMIC 2016
ASMIC 2016
COMPLIANCE
SUMMARY HAI in developing
countries Reasons:
infrastructure, resources,
understaffing, overcrowding,
scarcities of local guidelines and
policies
Importance of
monitoring to improve
outcomes
THANK YOU