Objectives

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(No Transcript)
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Objectives

• At the end of this session, participants will
  beable to
• Define Interventional Patient Hygiene (IPH)
• List the components of an IPH Program
• Develop a strategy for implementing IPH
• Understand the importance of skin antisepsis in
  SSI prevention
• VAP prevention progress update

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What Is IPH?
4
Non-Clinical Providing patient care practices
that will reduce the choices of a
healthcare-acquired infectionClinical IPH is
a comprehensive evidenced based intervention and
measurement model for reducing the bioburden of
both the patient and healthcare worker.
Definitions
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IPH Practices/Prevention Outcomes
Evidence Based Practice Intervention Responsibility Measurable Outcome
Oral Care HCW VAP
Catheter Care HCW BSI
Skin Care HCW Patient SSI, UTI, Reduction of Resistant Organism Infections, PU and Skin Breakdown
Hand Hygiene HCW Patient All of above
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ICP Opportunity.?
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PressureUlcers
SSI
VAP
BSI
UTI
8
A Convincing Strategy for IPHThe Five Cs
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The Five Cs

• Caregiver Knowledge
• Consumer Public Disclosure
• Costs HAIs
• Court Malpractice
• Control IPH

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Interventional Patient Hygiene Surveyn453

• ICP 30.9
• CCRN 22.8
• CCRN Mgr/Specialist 15.5
• RN 42.2
• 48.8 employed gt20 years
• 67.7 Community Hospital
• 28.3 University/Academic

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Identify Components of IPH

• Hand Hygiene 98.7
• Oral Hygiene 94.8
• Early Pre-op Skin Prep 69.9
• (night before and morning of surgery)
• Bathing/Skin Assessment 93.5
• Incontinence Care 92.4

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Healthcare-Acquired Infection Rates
VAP 67 Pressure Ulcer 43
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Scientific Evidence/ IPH

• Pressure Ulcer 72
• SSI 66
• VAP 86
• UTI 75
• LOS 74
• MRSA/VRE 77

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ICPs Questions

• Education about IPH Components (within last 2
  years)
• Hand Hygiene 98.6
• Oral Hygiene 76.4
• Early Pre-op Skin Prep 49.1(night
  before/morning)
• Bathing/Skin Assessment 40.5
• Incontinence Care 31.8

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ICPs (cont)

• ICP Involvement in Development IPH Protocol
• YES 37.6
• NO 63.3
• Policy for IPH in your Institution
• YES 39.3
• NO 45.3
• Dont Know 15.2

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CCRN/RN Questions

• Policy for IPH in Your Institution
• YES 48.4
• NO 34.7
• Dont Know 16.8

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CCRN/RN (cont)

• Written Policy for Documentation Forms
  for
• Oral Care 77 81
• Bathing/Skin Assessment 68 86
• Incontinence Care 54 60

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IPH Discussed at Orientation/In-Service
Yes 42.2 No 40.4 Dont
Remember 17.3 Skipped Question 17
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Ranking of Factors Relating to IPH
Very Important Somewhat Important Adequate/Appro
priateSupplies 94 4 Adequate Time
90 7 Standardization of Protocol
86 11 Documentation forms for
monitoring 73 25
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How Do We Increase HCWs Knowledge of IPH ? How
Do We Develop and Implement a Strategy for
IPH??Ownership and Back to Basics
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PressureUlcers
SSI
VAP
BSI
UTI
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2. Consumer

• 2005 - National Telephone Survey Will
  Consumers Use Public Disclosure Data When
  Choosing a Hospital?
• 93 of respondents (9 in 10) said knowing a
  hospital infection rate would influence their
  selection of a hospital

McGuckin M. American Journal of Medical Quality
2006 - In press
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Factors Considered in Choosing A Hospital Factors Considered in Choosing A Hospital Factors Considered in Choosing A Hospital Factors Considered in Choosing A Hospital Factors Considered in Choosing A Hospital
VeryImportant Somewhat Important Not Important Dont Know
Low infection rates 85 8 4 2
Previous experience with hospital 54 33 10 3
High staff-to-patient ratio 64 28 5 3
Friendly staff 68 27 4
Clean 94 5
Close to home 49 41 9 1
Good reputation 79 18 2 1
Whether they accept your insurance 88 7 3 1
Less than one-half of one percent
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Factors Considered in Choosing to Avoid A Hospital Factors Considered in Choosing to Avoid A Hospital Factors Considered in Choosing to Avoid A Hospital Factors Considered in Choosing to Avoid A Hospital Factors Considered in Choosing to Avoid A Hospital
Very Important Somewhat Important Not Important Dont Know
The staff is knowledgeable, but not friendly 42 45 10 2
They are understaffed 74 20 4 1
They are the best hospital in your area, but do not accept your insurance 63 25 10 3
You or someone you know had an unpleasant experience there 60 30 9 1
They have higher-than-average infection rates 87 7 4 2
You have seen or heard it is not clean 79 15 5 1
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Does IPH Play a Role in State Reporting/Public
Disclosure?
SSI VAP UTI Hospital
Infection data low too low? Underreporting
hurts patients
Philadelphia Inquirer - May 22, 2006
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3. Costs
HAIs Number Occurring Excess Patient days Excess Hospital Costs
Catheter-related BSIs (ICU) 38 304 209,000
CABG SSIs 33 300 373,585
VAP(ICU) 16 96 152,000
Hip SSIs 5 104 95,022
Totals 92 804 829,607
Ref Am J Infec Control 200533542-7
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Does IPH Play a Role in Costs of HAIs
Traditional Health Cost Controls
Modern Cost Care Controls Spending
Time Traditional cost controls Modern
cost controls Negotiate prices and service
fees Stop doing things that dont work Offer
fewer benefits to employees Use cost-effective
products Shift some costs to patients Improve
procedures
Reference Am J Infec Control 200533542-7
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4. Court
If Science or Evidence Based Medicine Does Not
Increase Hand Hygiene Compliance Then Woe to
you lawyers also! You lay impossible burdens on
men but will not lift a finger to lighten
them.Luke 11-46-47
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Guinan J, McGuckin M, et al, A descriptive
review of malpractice claims for
healthcare-acquired infections in Philadelphia.
Am J Infect Control 200533310-2.
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HAIS Cases (Most Frequent)
Services Organisms
Orthopedics MRSA
General Surgery S. Epidermidis
Cardio-thoracic Pseudomonas
Medical MSSA, Enterococcus, Enterobacter, Klebsiella
ICU/Surgery/Hand Hygiene ICU/Surgery/Hand Hygiene
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Can IPH Reduce Malpractice Claims

• C. difficile
• MRSA
• Pre-op Prep

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5. Control

• Good Medical Care? Its a coin flipThe
  Philadelphia Inquirer - March 16, 2006
• U.S. patients receive proper medical care from
  doctors and nurses 55 of timeN.E.J.M. - Vol
  354, No 11, 2006

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PressureUlcers
SSI
VAP
BSI
UTI
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Control Through IPH
UTI Rate- Removal of Prepackaged Bath Product QTR
3 FY05
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Is There Evidence to Support This Trend?

• High colony count found in bath water is similar
  to the number of bacteria found in urine from
  patients with UTIs. R. Shannon et al,
  Journal of HealthCare Safety, Compliance
  Infection Control, April 1999 Vol. 3, No. 4, pg.
  180-184
• Bath water could serve as a high magnitude
  microbial reservoir of potentially antibiotic
  resistant organisms. R. Shannon et al, Journal
  of HealthCare Safety, Compliance Infection
  Control, April 1999 Vol. 3, No. 4, pg. 180-184
• Prepackaged bathing showed lower microbial counts
  than basins
• M. Vernon, DrPH et al, Archives of Internal
  Medicine, February 2006
• Disposable Bed Baths are a desirable form of
  bathing Critically Ill patients.
• E. Larson, RN, PhD. et. al, AJCC, May 2004 Vol.
  13, No. 3

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Clinical Process Improvement UTI BundleMiller
Success Story
1. Can urinary catheter be removed?
2. What was insertion date?
3. Is the patient having any signs or symptoms? (ie, urinecloudy or sediment noted)
4. Change catheter if patient is having signs or symptoms. Insert silver-coated catheter.
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Urinary Tract Infection Bundle (cont)
5. If the patient comes to the unit with catheter in place and signs and symptoms are noted, remove old catheter, get a urine specimen and send it to the laboratory, and insert the silver-coated catheter.
6. Drainage bag must be kept lower than the patients bladder at all times, including during transport and patient activity. Clamp catheter with rubber-coated hemostats for transport or during off-unit procedure to prevent reflex. Unclamp as soon as possible do not leave clamped for more than 2 hours.
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Urinary Tract Infection Bundle (cont)
7. All urinary catheters must be secured to decrease movement of catheter. Use Stat Lock device.
8. Strict handwashing must be used before and after approaching urinary catheter.
9. Perform good pericare daily and after each bowel movement using aseptic technique. Use Clean and Shield product that has odor-neutralizing wipes to cleanse the area and zinc-coated wipes to protect the area.
10. Sterile technique must be strictly adhered to during insertion of urinary catheter.
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VAP Rate vs. VAP Care Bundle
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Role of ICP in IPH

• Partnership with nursing
• Protocols/policies that include patient
• Product evaluations
• Prospective evaluations

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GOT CLEAN PATIENTS?
Dont slide into bad habits, Remember
Hand Hygiene Oral Care Catheter Site
Care Skin care
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Prevention of Surgical Site Infections

• Robert Garcia, BS, MMT(ASCP), CIC
• Infection Control Professional Consultant

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PressureUlcers
SSI
VAP
BSI
UTI
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SSIs Magnitude of the Problem

• 1996 28.4 million ambulatory surgery procedures
  in the U.S. (CDC, National Center for Health
  Statistics)
• 2003 30.8 million inpatient surgical procedures
  and 9.7 million (37) of those performed on
  patients 65 yrs and older (CDC, National Center
  for Health Statistics)
• NNIS SSIs occur in 2.61 of all surgeries
• 1.5 million SSIs annually2
• SSIs are the 3rd most common HAI1
• Attributable cost 25,546 (range 1,783 -
  134,602)3

1. Mangram AJ, et al., Guideline for prevention
of surgical site infection, 1999. Centers for
Disease Control and Prevention, Hospital
Infection Control Practices Advisory Committee,
Atlanta GA. 2. SSI total calculated by
multiplying SSI rate from ref. 3 by surgical
procedure numbers from ref. 1 and 2. 3. Stone
PW, et al., Am J Infect Control. Nov
200533(9)501-9.
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Relative Costs of HAIs
Rate per 100 admits Proportion of all HAIs Excess Hospital Days Proportion of costs of all HAIs
UTI 2.5 35 1-2 15
SSI 1.5 20 7 50
Pneumonia 1.0 15 10 30
BSI 1.0 15 10-12 5
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Risk Factors for SSI The Patient

• Age
• Nutritional status
• Diabetes
• Nicotine use
• Obesity
• Coexistent infection
• Colonization
• Altered immune response
• Long preoperative stay

How effectively can we control these risk factors?
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Risk Factors for SSI Pre- and Intraoperative

• Inappropriate use of antimicrobial prophylaxis
• Infection at remote site not treated prior to
  surgery
• Shaving the site vs. clipping
• Long duration of surgery
• Improper skin preparation
• Improper surgical team hand antisepsis
• Environment of the room (ventilation,
  sterilization)
• Surgical attire and drapes
• Asepsis
• Surgical technique hemostasis, sterile field

To a great extent, this is what we can control!
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Goal Zero

• The All-or-None Measurement
• An option for calculating performance
• Denominator No. of pts. eligible to receive at
  least 1 or more discrete elements of care
• Numerator No. of pts. who actually received
  care
• No partial credit is given
• The Centers for Medicare Medicaid (CMS) has
  moved to the all-or-none approach

Nolan T, Berwick D. All-or-none measurement
raises the bar on performance. JAMA
20062951168-70.
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Defining Appropriate Care in Surgery
SIP/SCIP (CMS) IHI
Appropriate use of antibiotics ? ?
Appropriate hair removal ? ?
Normothermia ? ?
Post-op glucose control ? ?
Elevation of head of the bed ?
Orders for weaning program ?
Patients diagnosed with VAP ?
DVT and SUD prophylaxis ?
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Advantages of All-or-None Measurement

• .all-or-none measurements more closely reflects
  the interests and likely desires of patients.
  This is especially true when process components
  interact with each other synergistically.violatio
  n of a single step in the sterile technique in
  surgery may vitiate the benefits of proper
  execution of all other steps1
• The Take Away Message in SSI prevention, it
  makes little sense to assure that the surgeon has
  washed his hands properly if the patients skin
  has not had optimal prepping

1. Nolan T, Berwick D. JAMA 2005.
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Why Should Hospitals Place Greater Emphasis on
How Skin is Prepped?

• When we consider pathogenesis of SSI, it has been
  accepted for decades that most SSI are endogenous
  in nature
• Surgical Infections1
• Surgical Infections Including Burns2
• Surgical Site Infections3
• Surgical Antisepsis4

1. Dellinger EP, Ehrenkranz. In Hospital
Infections, Bennett Brachman, 1998 2. Kluymans
J. In Prevention and Control of Nosocomial
Infections, Wensel RP, 1997.3.Wong ES. In
Hospital Epidemiology and Infection Control,
Mayhall CG, 1999. 4.Crabtree TD, Pelletier SJ,
Pruett TL. In Disinfection, Sterilization, an
Preservation, Block SS, 2001.
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Infection Rates by Wound Classes
Years 1960-1962 1967-1977 1975-1976 1977-1986 1987-1990
No. of patients 15,613 62,939 59,352 25,919 84,691
Author, year Howard 1964 Cruse, 1980 Haley 1985 Olson, 1990 Culver 1991
Wound Class
Clean 5.1 1.5 2.9 1.4 2.1
Clean- contaminated 10.8 7.7 3.9 2.8 3.3
Contaminated 16.3 15.2 8.5 8.4 6.4
Dirty 28.0 40.0 12.6 _ _
Dellinger EP, Ehrenkranz NJ. Surgical Infections.
In Hospital Infections. Bennett JV Brachman
PS, eds., 1998
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Sources of S. aureus Infection in Cardiac Surgery

• Prospective study of 376 patients undergoing CABG
• Pre-op nasal cultures, intra-op wound cultures of
  patients
• Nasal cultures of all CV surgery/OR personnel
• DNA subtyping of patients colonizing/infecting
  strains and personnel strains
• 38 SSIs (10.1), 14 deep infections (3.3), 5
  mediastinitis (1.3)
• Of gt30 wound infections, all except 1 from
  patient ( endogenously-derived infections)

Jakob et al. Eur J Cardiothorac Surg
200017154-60. Slide courtesy of D. Maki
54
CDC on Skin Preparation

• Require patients to shower or bathe with an
  antiseptic agent on at least the night before the
  operative day. Cat IB
• Thoroughly wash and clean at and around the
  incision site to remove gross contamination
  before performing antiseptic skin preparation.
  Cat IB
• Use an appropriate antiseptic agent for skin
  preparation. Cat IB
• Apply preoperative antiseptic skin preparation in
  concentric circles moving toward the periphery.
  The prepared area must be large enough to extend
  the incision or create new incisions or drain
  sites, if necessary. Cat II

Guideline for Prevention of Surgical Site
Infection, 1999. HICPAC, Centers for Disease
Control.
55
AORN on Skin Preparation

• The surgical site and surrounding areas should be
  clean.
• The skin around the surgical site should be free
  of soil and debris. Removal of superficial soil,
  debris, and transient microbes before applying
  antiseptic agent(s) reduces the risk of wound
  contamination by decreasing the organic debris on
  the skin.
• Cleansing should be accomplished by any of the
  following methods before surgical skin
  preparation
• Patient showering and/or shampooing before
  arrival in the practice setting
• Washing the surgical site before arrival in the
  practice setting, or
• Washing the surgical site immediately before
  applying the antiseptic agent in the practice
  setting

Standards, Recommended Practices, and Guidelines,
2005 Edition. AORN, Denver, CO.
56
AORN on Skin Preparation (contd)

• When indicated, the surgical site and surrounding
  area should be prepared with an antiseptic agent
• Antiseptic agents should be.used in accordance
  with the manufacturers written instructions.
  Antiseptic agent(s) should have a broad range of
  germicidal action.

57
Skin Prep Protocols Example I
Package directions Use sponge to prep desired
area
58
Skin Prep Protocols Example II
59
2 CHG Cloth Skin Prep Instructions

• Use first cloth to prepare the skin area
  indicated for a moist or dry site, making certain
  to keep the second cloth where it will not be
  contaminated. Use second cloth to prepare larger
  areas.
• Dry surgical sites (such as abdomen or arm) use
  one cloth to cleanse each 161 cm2 area (approx 5
  x 5 inches) of skin to be prepared. Vigorously
  scrub skin back and forth for 3 minutes,
  completely wetting treatment area, then discard.
  Allow area to air dry for one (1) minute. Do not
  rinse.
• Moist surgical sites (such as inguinal fold) use
  one cloth to cleanse each 65 cm2 area (2 x 5
  inches) of skin to be prepared. Vigorously rub
  skin back and forth for 3 minutes completely
  wetting treatment area, then discard. Allow to
  air dry for one (1) minute. Do not rinse.

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Antiseptic Agent Characteristics

• Significantly reduce microbial counts on intact
  skin
• Contain a non-irritating, safe antimicrobial
  preparation that maintains the skins integrity
• Be broad-spectrum
• Be fast-acting and/or have residual effect
• Clearly define time of application and time of
  drying
• Be cost effective

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Crowded and Confusing Market
Variance in protocols and practice
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(No Transcript)
63
Chlorhexidine SSIs

• Why are there no studies that link use of CHG and
  SSI prevention?
• Lack of good study design
• Inclusion of surgery types other than clean
• Inadequate application of agent (bathing with
  agent followed by rinsing)
• New study comparing three commercially available
  skin prep products (with CHG, iodine, triclosan)
  provides evidence that pre-op skin prepping with
  a CHG-impregnated cloth without rinsing or
  showering at 12 hrs. and 3 hrs. prior to OR skin
  prepping significantly lowers microbial
  colonization

Maki DG, Paulson DS. abstract Evaluation of 6
preoperative cutaneous antiseptic regimens for
prevention of surgical site infection. SHEA
Conference, 2006.
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What we commonly see in the medical record

• The patients skin was prepped in the usual
  sterile manner

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Pre-operative Shower/Bath Protocol

• Protocol should consider the following aspects
• An antiseptic should be selected based on certain
  characteristics as addressed by the FDA
• How and when is the antiseptic dispensed to the
  patient?
• How often should the patient use the antiseptic
  product once or twice?
• When are the best times to accomplish
  preoperative antiseptic shower/bath?

Nancy B. Bjerke. Preoperative skin preparation a
system approach. Infection Control
Today.http//www.infectioncontroltoday.com/articl
es/1a1topics.html?wts200605100734198hc39reqbj
erke
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Pre-operative Shower/Bath Protocol

1. Is the whole body cleansed or just the incisional
   site?
2. What kind of educational materials are available
   or does the facility need to create their own?
3. Is the surgeons support necessary for this
   initiative, or does it involve only nursing?
4. Who verifies completion of this patient
   responsibility and where is this documented?

Nancy B. Bjerke. Preoperative skin preparation a
system approach. Infection Control
Today.http//www.infectioncontroltoday.com/articl
es/1a1topics.html?wts200605100734198hc39reqbj
erke
67
Surgical Skin Prep Protocol

• Work Outward. Begin at the incision site and move
  out in concentric circles. Discard the sponge
  applicator when periphery is reached and do not
  return a sponge/applicator to the incision site
  once it has been applied to that area. Extend
  prep beyond the anticipated drape borders.
• Prep problem areas last. Certain areas within the
  incision site with the potential to house excess
  bacteria need particular attention during the
  prepping process. The umbilicus typically has a
  high microbial count and needs to be cleaned with
  a Q-tip prior to prepping. Open wound, and
  perineal areas should be prepped last.
• Be careful with drapes. When applying a drape, it
  is critical you follow the drapes individual
  product instructions. Certain preps need to
  remain in contact with the skin for a specified
  amount of time to be fully effective. Placing a
  drape before the solution dries could interfere
  with this time requirement, so check the
  products package label for special instructions.

Cynthia Spry. Outpatient Surgery Magazine.
http//www.outpatientsurgery.net/infection_control
/2005/brush_up_skin_prep_protocol.php
68
Skin Prep Protocol

• Avoid pooling. Applying excess amounts will cause
  the prep solution to pool under the patient.
  Pooled prep solution in contact with the skin can
  cause irritation or burn and can compromise the
  adhesive of a dispersive electrode. Be especially
  careful to prevent pooling under a tourniquet
  cuff. If a flammable agent, such as alcohol, is
  used, allow the solution to dry to reduce the
  possibility of fire. Use of an active electrode
  in the presence of a flammable agent could result
  in fire.
• Document action. Performing a skin assessment,
  documenting the assessment, prepping and
  observing the condition of the skin after surgery
  are other key components of a successful
  infection control strategy. Look at the condition
  of the skin before the prep. Is there a rash? Do
  you notice a break in skin integrity? Written
  documentation of your assessment will create a
  baseline record and will let staff in the
  recovery unit determine if a later skin reaction
  was the result of the prep.

Spry C, Outpatient Surgery Magazine. May 2005.
http//www.outpatientsurgery.net/infection_control
/2005/brush_up_skin_prep_protocol.php
69
Prevention of Ventilator-Associated Pneumonia
70
PressureUlcers
SSI
VAP
BSI
UTI
71
VAP Facts

• Third most common HAI and most common among ICU
  patients
• Second most costly HAI
• Between 10 and 20 of patients receiving gt48
  hours of mechanical ventilation will develop VAP1
• Critically ill patient who develop VAP appear to
  be twice as likely to die compared to those
  without VAP
• Patients with VAP have significantly longer
  lengths of stay in the ICU (mean 6.10 days)2

1. Sole ML, et al., Am J Crit Care. March
200211(2)141-92. Rello J, et al., Chest. Dec
2002122(6)2115-21
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Current Recommendations
Component IHI CDC
Head of bed elevation ? ?(II)
Daily sedation vacation and daily assessment of readiness to extubate ? ?(IB)
Peptic ulcer disease (PUD) prophylaxis ? ?(UI)
Deep vein thrombosis (DVT) prophylaxis ? NA
Cleaning of equipment ?(IA)
Do not routinely replace ventilator circuits ?(IA)
Hand hygiene ?(IA)
Subglottic secretion drainage ?(II)
Prevention of oropharyngeal colonization ?(II)
UI unresolved issue NA not addressed
IHI 100K Lives Campaign. Getting Started Kit VAP
How-to Guide CDC Guideline for Preventing
Healthcare-Associated Pneumonia, 2002.
73
Elevation of the Head of the Bed

• Recent randomized controlled study that disputes
  study referenced by CDC to recommend use of
  semirecumbent positioning to prevent VAP
• Study is unique in three aspects
• Patient positioning was continuously monitored in
  first week
• The semirecumbent position was compared to the
  standard of care
• Data analyzed according to the intention-to-treat
  principle
• Results
• Patients in supine position (control) reached
  only 9.8 to 14.8 degrees (i.e., standard of care)
• Mean backrest position in study group was 30
  degrees
• No difference in VAP rates between the groups
• Pressure ulcers 30 in supine group, 28 in
  semirecumbent group

van Nieuwenhoven CA, et al. Feasibility and
effects of the semirecumbent position to prevent
ventilator-associated pneumonia A randomized
study. Crit Care med 200634396-402.
74
Stress Ulcer Prophylaxis
Flanders SA, Collard HP, Saint S. Nosocomial
pneumonia State of the Science. Am J Infect
Control 20063684-93

• 7 meta-analyses, gt20 studies
• 4 showed significant VAP reductions
• 3 showed similar but non-significant VAP
  reductions

• Cook D, et al. A comparison of sucralfate and
  rantidine for the prevention of upper
  gastrointestinal bleeding in patients requiring
  mechanical ventilation. Canadian Critical Care
  Trials Group. N Eng J Med 1998338781-97.
• Large randomized trial showed no benefit in
  either sucralfate or H2 antagonists
• Kantorova I, et al. Stress ulcer prophylaxis in
  clinically ill patients a randomized controlled
  trial. Hepatogastroenterology, 2004200451757-61
  .
• randomized, placebo-controlled trial, 287 pts.
• studied omeprazole (PPI), famotidine (H2
  antagonist), sucralfate
• No significant differences in bleeding or
  pneumonia rates among the 4 groups

75
Subglottic Secretion Drainage

• Meta-analysis of randomized trials
• 5 trials met inclusion criteria (patients gt72
  hrs. of mechanical ventilation)
• Results
• shortened duration of ventilation by 2 days
• shortened length of stay by 3 days
• delayed onset of pneumonia by 6.8 days

Dezfulian C, et al. Subglottic secretion drainage
for preventing ventilator-associated pneumonia
a meta-analysis. Am J Med 200511811-18.
76
Pathogenesis Interventions

• Strategies to prevent VAP are likely to be
  successful only if based upon a sound
  understanding of pathogenesis and epidemiology.
  The major route for acquiring endemic VAP is
  oropharyngeal colonization by endogenous flora or
  by pathogens acquired exogenously from the
  intensive care unit environment, especially the
  hands or apparel of health-care workers,
  contaminated equipment, hospital water, or air.
  The stomach represents a potential site of
  secondary colonization and reservoir of
  nosocomial gram-negative bacilli.

Safdar N, Crnich CJ, Maki DG. The pathogenesis of
ventilator-associated pneumonia its relevance to
developing effective strategies for prevention.
Respir Care 200550725-39.
77
Linking Oral and Dental Colonization with
Respiratory Infection

• A review of the published evidence linking
  oropharyngeal colonization and respiratory
  infection, including VAP (20 studies)
• Provides suggested oral and dental interventions,
  some beyond the scope of current guidelines

Garcia R. A review of the possible role of oral
and dental colonization on the occurrence of
health care-associated pneumonia
Underappreciated risk and a call for
interventions. Am J Infect Control 200533527-41.
78
Suggested Oral Dental Care Interventions
Suggested Intervention Reasoning
Conduct a daily assessment of the lips, oral tissue, tongue, teeth, and saliva of each patient on a mechanical ventilator Assessment allows for for initial identification of oral hygiene problems and for continued observation of oral health
Use separate connection tubing for oral and tracheal suction Opening a closed system may allow for the dissemination of respiratory pathogens into the environment surrounding the patient
Use a toothbrush as opposed to foam swabs or gauze to remove dental plaque Dental plaque has been identified as a source of pathogenic bacteria associated with respiratory infection
Protocols should be implemented that assist patients at risk in maintaining adequate salivary production and tissue health Saliva provides both mechanical and immunological effects which act to remove pathogens colonizing the oropharynx
Care should be taken when using oral care solutions Use an alcohol-free, antiseptic rinse to prevent bacterial colonization of the oropharyngeal tract Mouthwashes with alcohol cause excessive drying of oral tissues. Hydrogen peroxide has been shown to assist in clearing debris buildup and provide antibacterial properties
Avoid using lemon-glycerin swabs for oral care Lemon-glycerin compounds are acidic and cause drying of oral tissues
79
Suggested Intervention Reasoning
Toothpaste should contain additives which assist in the breakdown of mucous in the mouth Additives such as sodium bicarbonate have been shown to assist in removing debris accumulations on oral tissues and teeth
Use a water-soluble moisturizer to assist in the maintenance of healthy lips and gums Dryness and cracking of oral tissues and lips provides regions for bacterial proliferation. A water-soluble moisturizer allows tissue absorption and added hydration.
Yankauer catheters should be covered between uses on a patient Yankauers used on a patient and left uncovered on the bed or other surface pose the risk of contaminating the patients environment with pathogens from the oropharyngeal tract
Remove secretions that accumulate in the subglottic area (above the endotracheal tube cuff) routinely and prior to removal of the endotracheal tube Secretions forming in the subglottic area are rapidly colonized with pathogenic bacteria aspiration of this colonized secretion has been shown to cause ventilator-associated pneumonia
Check for adequate endotracheal tube cuff pressure at least once per day Inadequate cuff pressure is associated with aspiration of bacteria-laden secretions located above the cuff
Check the positioning of the endotracheal tube at least once per day Over time, endotracheal tubes may begin to move up the trachea, leading to a possible unplanned extubation and concurrent aspiration of contaminated subglottic secretions
80
VAP Bundle Success Stories

• Rochester Medical center, Rochester, NY
• At least 220 days without a VAP case
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/UniversityofRochesterStr
  ongMemorialHealthWorkingtoReduceComplicationsfromV
  entilatorsandPreventVAPint.htm
• Overlake Hospital, Bellevue, WA
• Reduced VAP by 80 in one year
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/DoingBetterSpendingLess.
  htm
• Consortium of 127 ICUs in 70 hospitals
• 68/127 ICUs eliminated VAP for at least six
  months
• Along with CLAB bundle, estimates are that 1,500
  lives were saved, 81,000 hospital days, and 165
  million
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/DoingBetterSpendingLess.
  htm
• Owenboro Medical Health System, Owensboro, KY
• Reduced VAP by 72 in 18 months
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/ReducingVentilatorAssoci
  atedPneumoniaOwensboro.htm

81
Swedish Medical Center Results of VAP Bundle
Intervention
http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
veCare/ImprovementStories/EliminateVentilatorAssoc
iatedPneumonia.htm
82
VAP Bundle Comprehensive Oral Care

• Used HMO Acronym
• Head of Bed keep at least 30 degrees or greater
  unless contraindicated
• Mobility Each even hour, complete or assist the
  patient in performing mobility
• Oral Care Perform oral care every even hour on
  intubated and trached patients. Suction brush at
  0800 and 2000. Suction catheters at extubation,
  position changes, and every 6 hours or as needed.

Pre-implementation Post-implementation Percent change
SICU VAP rate (NNIS criteria) 10.8 per 1000 vent days 3.6 per 1000 vent days 67 reduction
Housewide adult ICU and intermediate ICU VAP rate 5.1 per 1000 vent days 2.7 per 1000 vent days 48 reduction
Simmons-Trau D. ZAP VAP with a back-to-basics
approach. Nurs 2006 Crit Care128-36.
83
Adding Comprehensive Oral Care to the IHI VAP
Bundle Achieving Zero

• Baptist Memorial DeSoto
• Baptist Memorial Hospital Golden Triangle
• Bay Regional Medical Center
• McLeod Regional Medical Center
• OSF Saint Francis Medical Center
• Overlake Hospital Medical Center
• Palmetto Health Baptist
• Upper Chesapeake Medical Center

84
48-month Study on Effect of Oral-Dental Care on
VAP Brookdale University Hospital Medical
Center, NY

• Objective to determine the effect of a
  comprehensive oral care program on rates of VAP,
  mortality, cost
• MICU patients on mechanical ventilation gt48 hrs.
• Pre-intervention 1/1/01-12/31/02, standard
  oral care
• Intervention 1/1/03-12/31/04, education and use
  of a novel oral-dental care system designed to
  reduce bacterial colonization of the
  oropharyngeal tract and teeth
• Standards of care during the entire 48-month
  study included 7d vent circuit replacement,
  24-hour HME filter replacement, 24-hour closed
  suction catheter replacement, semirecumbent
  position unless contraindicated, administration
  of stress ulcer prophylaxis, and use of a weaning
  protocol.

Garcia R, Jendresky L, Colbert L, Bailey A.
48-month study on reducing VAP using advanced
oral-dental care protocol compliance, rates,
mortality, and cost. Abstract presented at the
2006 APIC Conference, Tampa, FL. publication
pending, Crit Care Med
85
Patient Demographics Baseline Measurements
Characteristics Pre-Intervention Period (n 859) Intervention Period (n 755)
Mean age SD 61.3 12.2 63.1 9.8
Males, no. () 523 (61) 483 (64)
APACHE II 26.8 8.8 27.3 7.9
Reason for ICU admission, no. () Reason for ICU admission, no. () Reason for ICU admission, no. ()
Acute respiratory failure 404 (47) 325 (43)
Cardiovascular disease 189 (22) 181 (24)
Gastrointestinal disease 95 (11) 90 (12)
Renal disease 60 (7) 53 (7)
Sepsis 51 (6) 45 (6)
Trauma 26 (3) 15 (2)
Neurological disease 17 (2) 23 (3)
Other 17 (2) 23 (3)
86
Protocol Compliance
87
Outcome Data
Variable Pre-intervention Period (n859) Intervention Period (n755)
Duration of ventilation, mean days 10.3 6.5
Ventilator utilization ratio 0.68 0.63
ICU stay, days 12.7 6.5
VAP per 1000 ventilator days 8.3 4.5 (p lt.05)
VAP, no. () 44 (5.1) 23 (3.0)
Mortality, no. () 163 (18.9) 138 (18.2)
88
VAP Rates, MICU, 2001-2005
Near Zero!
89
Cost of VAP
Study/Year Pts with VAP Measure ICU Type Cost with VAP Cost without VAP Cost per VAP case
Warren 2003 127 Attributable cost (hospital) Med, surg 27,033 15,136 11,897
Rello 2002 842 Charges Med, surg, trauma 104,983 63,689 41,294
Cocanour 2005 70 Attributable cost Trauma 82,195 25,037 57,158
Kollef 2005 499 Charges Various ICUs 150,841 __ 150,841
Warren DK, et al. Outcome and attributable cost
of ventilator-associated pneumonia among
intensive care unit patients in a suburban
medical center. Crit Care Med 2003311312-3. Rell
o J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm
L, Redman R, Kollef MH. Epidemiology and outcomes
of VAP in a large US database. Chest
20021222115-2121. Cocanour et al. Cost of
ventilator-associated pneumonia in a shock trauma
intensive care unit. Surg Inf, 2005665-72. Kolll
ef MN, et al. Epidemiology and outcomes of
health-care-associatedpneumonia Results from a
large US database of culture-positive pneumonia.
Chest 20051283854-62.
90
Cost Avoidance BUMC VAP Project
STUDY PTS WITH VAP MEASURE ICU TYPE REPORTEDVAP COST INFECTION COST (VAP cost x 12avoided casesper year) TOTAL COSTAVOIDED/YR ( Infection cost product cost)
Warren 127 Attributable cost (hospital) Med, Surg 11,897 142,764 83,631
Rello 842 Charges Med, Surg, Trauma 41,294 495,528 436,395
Cocanour 70 Attributable cost Trauma 57,158 685,896 626,763
Kollef 499 Charges Various 150,841 1,810,092 1,750,959
Total product cost 59,133
91

• My thanks to the Brookdale family for their
  dedication and supreme efforts in improving the
  care of our patients

92
Questions Answers

• Dr. Maryanne McGuckin ScEd., MT(ASCP)Senior
  Research InvestigatorAdjunct Associate
  ProfessorSenior Fellow, Leonard Davis Institute
  for Health Economics Senior Fellow, Institute on
  Aging University of Pennsylvania School of
  Medicine

• Robert Garcia BS, MMT(ASCP), CIC
• Asst. Director of Infection ControlBrookdale
  Univ. Hospital Medical Center718.240.5924
  rgarcia_at_brookdale.edu
• President
• Enhanced Epidemiology, LLCP.O. Box 211 Valley
  Stream, NY 11580516.810.3093 rgarciaicp_at_aol.com