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Implementation of Ventilator Bundle Approach in Prevention of Ventilator Associated Pneumonia in Geriatric ICU patients

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aiatalla salama

on 3 October 2012

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Transcript of Implementation of Ventilator Bundle Approach in Prevention of Ventilator Associated Pneumonia in Geriatric ICU patients

by Aiatalla Salama A bundle of intervention according to CDC & IHI Implementation of Ventilator Bundle Approach in Prevention of Ventilator Associated Pneumonia in Geriatric ICU patients Treatment Diagnosis Risk factors Device related Staff related General factors The rates of VAP vary from 10 to 41.7 per 1000 ventilator-day in developing countries. Nasogastric tube placement Presence of invasive devices Improper hand washing Not wearing personal protective equipment Supine position Increased duration of mechanical ventilation Diagnosis of VAP established according to CDC,2004 which depend on clinical,radiological criteria and confirmed with microbiological techniques (optional). Initially adequate antibiotic therapy is so important in reducing the mortality of VAP, when patients are at risk for MDR organisms, initial therapy should be broad and known to be effective against MDR pathogens, especially Pseudomonas aeruginosa and MRSA, and tailored to the local antibiogram. Prevention Empiric antimicrobial coverage should account for the resistance patterns of common pathogenic isolates in any particular unit. Once microbiologic results including sensitivities are known, “de-escalation” of antimicrobial coverage to fit the culture results is indicated, using the most narrowly focused antibiotics appropriate 1.Elevation of the head of the bed to 30–45 It is an integral portion of the VAP Care bundle. It has been decreased the VAP rates by reduction of the gastroesophageal reflux and subsequent aspiration of secretions,Alexiou et al. (2009) found that a 45º position significantly lowers the incidence of the clinically diagnosed VAP compared with the supine position. 2.Daily ‘sedation vacation’ and daily assessment of readiness to extubate It is an integral component of the VAP bundle and can have major implications in that,patients who are extubated early are at decreased risk of VAP. 3.Peptic ulcer disease prophylaxis It is not a specific strategy for VAP prevention. It was included in the Ventilator Bundle as a strategy to prevent stress related mucosal disease, as mechanical ventilation is a significant risk factor. 4.Deep Venous Thrombosis (DVT) prophylaxis Sedated ventilated patients are at significantly increased risk for DVT. So, DVT prophylaxis is an important component of standard care of those patients. 5. Chlorhexidine antiseptic The use of the oral antiseptic chlorhexidine gluconate has been definitively demonstrated to be an effective VAP prevention strategy, and its use has been advocated in the most recent evidence-based VAP prevention clinical practice guidelines. Furthermore, safety, feasibility, and cost considerations for this intervention are all very favorable. 6.Subglottic secretion drainage Agencies such as the AACN and CDC support the use of continuous subglottic suction; 7. Hand washing Decontamination of hands before and after contact with patients along with wearing gloves is a corner stone in the prevention of VAP as stated by CDC, 2003.Also it recommends using antimicrobial soap and water if hands are visibly soiled. To diagnose VAP among mechanically ventilated patients in Geriatric ICU.
To estimate the incidence denisty of VAP per 1000 ventilation days.
To evaluate the role of implementation of VAP care bundle approach in prevention of VAP.
To evaluate the role of colonization in development of VAP. Aim Of Work PATIENTS AND METHODS Results Introduction Ventilator-associated pneumonia (VAP) is pneumonia in a patient on mechanical ventilatory support for more than 48 hours,The onset of VAP can be divided into 2 types: early and late onset VAP. Definition Incidence Pathogenesis Association between the score VAP care bundle elements between the two groups. Comparison between the two studied groups as regard VAP care bundle score. Association between the oral colonization and occurrence of VAP. Association between oral colonization density and occurrence of VAP. Odds ratio of VAP in relation to oral colonization and occurrence of VAP. Calculation of VAP rates among two groups. Acknowledgment Conclusion & Recommendations Oral colonization had a signficant major role in the development of VAP by 6 time Thank
You However the ATS,2007 criteria for diagnosis of VAP depend mainly on clinical ,microbiological criteria,while radiological techniques are optional which includes
•Purulent tracheal secretions In addition, one or more of the following criteria :

•New or persistent infiltrates on chest radiographs.
•The same microorganism isolated from pleural fluid and tracheal secretions.
•Radiographic cavitation or histopathological demonstration of pneumonia. A meta-analysis, including five studies and 896 patients, confirmed that subglottic secretion drainage was effective in the prevention of early-onset VAP among patients expected to require more than 72-h duration of mechanical ventilation. General measures Conduct active surveillance.
Hand hygiene & personal protective equipment.
Minimize the duration of ventilation.
Care of respiratory equipment. Specific measure According to CDC & IHI Ventilator Care Bundle CDC VAP care bundle includes IHI VAP care bundle includes •Elevation of the head of the bed from 30º to 45º unless medically contraindicated.
•Continuous removal of subglottic secretions.
•Change of ventilator circuit no more often than every 48 hours, and
•Washing of hands before and after contact with each patient. •Elevation of the Head of the Bed.
•Daily "Sedation Vacations" and Assessment of Readiness to Extubate.
•Peptic Ulcer Disease Prophylaxis .
•Deep Venous Thrombosis Prophylaxis . Endo tracheal aspirate (ETA) is a practical simple, non-invasive diagnostic method in clinically suspected VAP cases. Most of the patients had a late onset VAP with multiresistant organisms that indicate an endogenous source of infection that need empirical combination therapy. Implementation of VAP care bundle had reduced the VAP rate among the studied patients with significant improvement of head of bed elevation, oral care and PUD prophylaxis. This study was conducted at the Central Microbiology Unit of Clinical Pathology Department in collaboration with Geriatric ICU. Where? Who? 50 intubated mechanically ventilated patients who were admitted in Geriatric ICU are divided into two groups
group 1:before implementation of VAP care bundle
group 2:after implementation of VAP care bundle When? This study was achieved over a period of 6 months from May to October, 2011. All the studied patients were subjected to :
1. Full history taking
2. Full clinical examination
3. Microbiological assessment of oral colonization using oral swab.
4. Diagnosis of suspected cases of VAP based on clinical criteria according CDC (2004) in association with microbiological examination ETA.
5. Clinical Audit on adoption and compliance with bundle elements before and after implementation of VAP care using VAP checklist.
6.Assessment of the care of respiratory equipments. What? Semiquantitative culture, (Joseph et al., 2010): Procedure:Using the four quadrant technique. Satisfactory ETA
Acceptable ETA samples were containing less than 10 SEC.
Specimen preparation
Endotracheal aspirates were mechanically liquefied and homogenized by vortexing for 1 minute with sterile glass beads, followed by centrifugation at 3000rpm, for 10 minutes (Dennis et al., 1997). Isolation of organisms according to conventional culture technique as the oral swabs were inoculated into plates of blood agar and MacConkey agar which were incubated at 37C. Microbiological examination of oral swab: Diagnosis of VAP cases was done based on clinical, radiological finding according to NNIS and CDC criteria (2004):
One of the following:
Fever ≥ 38°C with no other recognized cause
WBC count ≤ 4,000/µL or 1≥ 2,000 µL
For adults ≥ 70 yr old, altered mental status with no other recognized cause

And at least two of the following:

New-onset purulent sputum or change in character of sputum, or increase in respiratory secretions or suctioning requirements
New-onset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath sounds
Worsening gas exchange, increased oxygen requirements, increased ventilatory support Serial chest radiographs with new or progressive and persistent infiltrate or cavitation. Clinical Radiographic Microbiological examination of ETA of suspected cases VAP bundle checklist according to IHI (2010). •Checklist was applied for each patient with a total score 14 for each patient.
Two methods were applied for evaluation of the performance of VAP care bundle among the studied two groups:
*Calculation of VAP care bundle score in the two studied groups either:
-Per bundle=summation of the patients score/total score x 100
-Per element=element done for every patient x 2 Interpretation Quoted from Arabia et al., 2008. *Calculation of the compliance percent of VAP bundle per element.
Total VAP care bundle element compliance percent=
number of the actual patient were the element had been performed/total number of the patients x100 Quoted from Bouza (2008). Comparison between the two studied groups as regard number of VAP cases. Comparison between results of ETA and oral swabs cultures. What is bundle? Bundles are a method used to implement evidence-based clinical practice guidelines as it is a series of interventions related to ventilator care that when implemented together, will achieve significantly better outcomes than when implemented individually. *0 not done
*1 not done correctly
*2 well done Microbilogical (optional) Using ETA
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