Reducing ventilatorassociated pneumonia in ICU

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Reducing ventilator-associated pneumonia in ICU

• Eva Joelsson-Alm, CCRN, MSN
• Department of Anaesthesia and Intensive Care

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Sven Svensson

• 68 yr, COPD, DM, cardiovascular disease
• Endovascular thoracic aortic repair
• Postoperative complications- MI- respiratory
  failure - renal failure
• Intensive care ventilator, dialysis

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After 17 days in ICU
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day 18

• Fever 38,7
• Purulent secretions
• New chest X-ray infiltrates

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VAP?
Bronchoscopy
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VAP!
Bronchoscopy
Pseudomonas aeruginosa
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VAP

• Ventilator-associated pneumonia?

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VAP

• Ventilation-associated pneumonia !
• gt 48 h after intubation
• HAP hospital acquired pneumonia gt 48
  h after hospital admission

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What we do know about VAP

• A common and severe complication of mechanical
  ventilation
• Increases mortality, morbidity and costs

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Pathogenes

• Early VAP
• Staphylococcus aereus
• Streptococcus
• Haemofilus influenzae

• Late VAP
• Pseudomonas
• Klebsiella
• Acinetobacter
• Stenotrophomonas

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Treatment

• Broadspectrum antibiotics
• Multiresitance

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Prevention!
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Strategies for prevention

• Prevention of ventilator-associated pneumonia an
  evidence-based systematic review. Collard H-R,
  Saint S, Matthay M-A. Annals of Internal
  Medicine. 2003 138494-501.
• Impact of a Monitored Program of Care on
  Incidence of Ventilator-Associated Pneumonia
  Results of a Longterm Performance-Improvement
  ProjectWeireter et al.Journal of the American
  College of Surgeons. 2009208(5) 700-704

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The bundle approach

• Using a Bundle Approach to Improve Ventilator
  Care Processes and Reduce Ventilator-Associated
  PneumoniaRoger Resar et al.Journal on Quality
  and Patient Safety. 2005 31(5) 243-248

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Södersjukhuset ICU 2003
We knew all about VAP-prevention but
didnt do it!
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A part of a national project 2004

• Reducing health-care related infections
• The Breakthrough Series Model for Improvement

Our aim
To decrease the incidence of VAP by 40
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Method

• 13 interventions
• A responsible person or group for every
  intervention
• A total of 22 people directly involved in the
  project

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Our interventions

• Reduce the risk for airway colonization
• Avoid aspiration and regurgitation
• Reduce time on ventilator

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Strict hygiene policy

• No rings!
• No watches!
• Short sleeves!
• Plastic aprons!

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Even doctors can
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Reduce the risk for airway colonization

• Oral care with chlorhexidine

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An alternative to chlorhexidine?

• Lactobacillus plantarum 299

Use of the probiotic Lactobacillus plantarum 299
to reduce pathogenic bacteria in the oropharynx
of intubated patients a randomised controlled
open pilot study. Klarin B, Molin G, Jeppsson
B, Larsson A.Crit Care. 200812(6)R136. Epub
2008 Nov 6
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Reduce the risk for airway colonization

• Oral care with chlorhexidine
• Suction of subglottal secretions

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Reduce the risk for airway colonization

• Oral care with chlorhexidine
• Suction of subglottal secretions
• Closed suction system change every 72 h
• Ventilator circuit change every 7 d

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Reduce the risk for airway colonization

• Oral care with chlorhexidine
• Suction of subglottal secretions
• Closed suction system change every 72 h
• Ventilator circuit change every 7 d
• Reduce inhalations

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MDI port inhalation
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MDI port inhalation
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Avoid aspiration and regurgitation

• Elevated head-of bed
• 30

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Reduce time on ventilator

• Non-invasive ventilation
• Sedation protocol
• Weaning protocol

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Results
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VAP-incidence per year
VAP-incidence per year
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Patients with gt 48 h ventilator
Patients treated gt 48 h in ventilator
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Key success factors

• Active involvement of the staff
• Multidisciplinary approach
• Feed-back to staff- show monthly reports!

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Nursing interventions are the most important!
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Thank you!