Zapping VAP

1
Zapping VAP

• Anne Burton, RN, BSN
• Michelle Farber, RN, CIC
• Pam Madrid, RN, CCNS
• Lynn Nelson, RN, BA, CCRN
• Mercy and Unity Hospitals
• April 6, 2005

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Basic VAP Prevention Elements

• Hand hygiene
• Ventilator bundle
• Oral care

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Hand Hygiene Campaign

• JCAHO Patient Safety Goal
• CDC posters in visitor lounge and in ICU
• http//www.cdc.gov/handhygiene/Education for
  patients and visitors
• Patient and family educational brochures
• How to Prevent Infections During your Hospital
  Stay
• Infection Control info in Visiting Information
  brochure
• Foam-In and Foam-Out Campaign
• Alcohol-based foam usage reports
• Observation audits were impractical
• Signage at entrance to patients room

4
Ventilator Bundle Elements

• HOB elevated gt 30 degrees
• Scheduled readiness to wean assessment
• Sedation vacation/appropriate sedation
• DVT prophylaxis
• Stress ulcer prophylaxis
• If patient condition prohibits intervention it
  is NOT counted against the bundle compliance

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Practical Application HOB

• Collaborate with Respiratory Care
• Add HOB to vent orders and ventilator checks
• HOB signs in room
• Daily compliance monitoring
• Electronic report
• Visual auditing
• Degree indicator
• Marked on the bed frame
• Protractor
• Discussed at daily ICU rounds

6
HOB Education

• Gravity is our friend
• Any elevation is better than none
• Use reverse Trendelenburg if unable to bend at
  hip
• Exclusion criteria
• Femoral line - can use reverse Trendelenburg
• Hypotension, unstable VS
• Head trauma/spine injuries (needs order from
  Neurosurgery)
• Seems easy, but can be hardest to get compliance

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Practical Application Readiness to Wean
Assessment

• KEY CONCEPT This does NOT mean a weaning trial,
  but rather weaning readiness assessment based on
  clinical condition
• Automatic wean per RT is an option on ICU
  ventilator pre-printed orders
• Many weaning protocols available
• Difficult to get physicians to agree
• Pulmonologists and Internal Medicine trust RT
  assessment skills
• Communication has been the key

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Practical Application Readiness to Wean
Assessment

• Compliance at Mercy was already good Unity had
  opportunity for improvement
• Mercy RT had a culture of proactive weaning
• Unity improved over a short amount of time
  through collaboration between nursing and RT
• Timeframe
• Required in last 24 hrs per IHI
• To be completed every shift per pre-printed
  ventilator orders
• Part of ventilator macro for documentation

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Practical Application Daily Sedation Vacation

• Does not replace other assessments and
  appropriate weaning of medication
• Not a true vacation, but a purposeful decrease
• Allows use of minimum dose with effect
• Allows complete neuro assessment at least once
  per day
• Amount of decrease is dependent on the medication
• Ordered for a set time - between 0800 and 1100

10
Practical Application Daily Sedation Vacation

• Included in pre-printed sedation orders
• Exceptions for CLRT, PC ventilation, or
  neuromuscular blockade
• Culture of not overusing infusions
• Daily compliance monitoring
• Electronic report (MAAS score)
• Discussed at daily ICU rounds

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Practical Application DVT Prophylaxis

• Implemented in 1999
• Mechanical or medication
• SCDs/TEDs (automatic when ICU Ventilator
  pre-printed orders are used)
• Aces
• Anticoagulant
• Daily monitoring
• Electronic report
• Discussed in ICU rounds

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Oral Care

• Developed and implemented protocol in end of year
  2002
• Teeth brushing Q 8-12 hours
• Oral care with swabs Q 2-4 hours
• Sub-glottic suctioning Q 6-8 hours
• Reinforced in the ICU Standards of Practice
• Included on pre-printed ventilator orders
• Products
• Non-alcohol based antiseptic solution or
  toothpaste (i.e., Perox-A-Mint)
• Oral suction swabs with mouth moisturizer
• Suction toothbrushes
• Sub-glottic suction catheters
• Covered Yankeur

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What Works!

• Oral care protocol
• Vent bundle
• Collaboration - RN, RT, MD, IC
• Measure current practice vs. evidence-based
  practice
• PDSA Cycles
• Celebrate successes!!

14
What Works!

• Education EVERYWHERE and EVERYONE!
• Department newsletters
• Bulletin boards
• High traffic areas (staff bathroom)
• Formal inservices
• Modified orientation
• Measurement and Feedback