VENTILATOR ASSOCIATED PNEUMONIA
DO BUNDLE MAKE A
DIFFERENCE? Anis Siham Zainal Abidin
Faculty of Medicine UiTM
ASMIC 2016
OUTLINE
INTRODUCTION - Burden of VAP
VENTILATOR BUNDLE CARE
INTERNATIONAL DATA
LOCAL DATA
VENTILATOR
ASSOCIATED
PNEUMONIA
ASMIC 2016
Germany VAP 5.1/1000 MV days
INCREASE BED DAYS IN ICU
INCREASE MORBIDITY &
MORTALITY
$$$$$$ INCREASE
US VAP 2.9/1000MV days
COST
Malaysia VAP 12.9/1000 MV days
WHAT IS
VENTILATOR
BUNDLE
CARE
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
SEDATION
VACATION
PEPTIC ULCER
DISEASE
PROPHYLAXIS
HEAD ELEVATION
30-50O
DEEP VENOUS
THROMBOSIS
ORAL HYGIENE PROPHYLAXIS
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
SEDATION
VACATION
PEPTIC ULCER
DISEASE
PROPHYLAXIS
HEAD ELEVATION
30-50O
DEEP VENOUS
THROMBOSIS
ORAL HYGIENE PROPHYLAXIS
ALL OR NOTHING
ASMIC 2016
SEDATION VACATION
DAILY SEDATIVE READINESS
INTERRUPTIONS TO EXTUBATE
▸ Kress et al. 128 MV patients: daily sedative interruptions vs
clinician discretion. Duration MV 7.2days to 4.9days
(p:0.004)
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
SEDATION
VACATION
PEPTIC ULCER
DISEASE
PROPHYLAXIS
HEAD ELEVATION
30-50O
DEEP VENOUS
THROMBOSIS
ORAL HYGIENE PROPHYLAXIS
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
SEDATION
VACATION
PEPTIC ULCER
DISEASE
PROPHYLAXIS
HEAD ELEVATION
30-50O
DEEP VENOUS
THROMBOSIS
ORAL HYGIENE PROPHYLAXIS
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
SEDATION
VACATION
PEPTIC ULCER
DISEASE
PROPHYLAXIS
HEAD ELEVATION
30-50O
DEEP VENOUS
THROMBOSIS
ORAL HYGIENE PROPHYLAXIS
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.
ASMIC 2016
PAEDIATRIC
MODIFICATION?
ASMIC 2016
SPECIFIC
POPULATION IN A
SPECIFIC LOCATION
COMPRISES OF
SIMPLE MEASURES
CONCEPT COMPLIANCE
FOCUS ON BEST
CARE
ALL OR NONE
ASMIC 2016
PAEDIATRIC VENTILATOR BUNDLE CARE
EXAMPLES OF MONITORING
ELEMENTS
PREVENT BACTERIAL COLONIZATION
HAND HYGIENE
ORAL HYGIENE HIGH INCOME COUNTRIES
CARE OF THE VENTILATOR & SUCTION
TUBING CDC/ NHNS (US), KISS
DAILY SEDATION BREAK (GERMANY), ECDPC, JAPAN
DAILY ASSESSMENT OF READINESS
FOR EXTUBATION
PREVENT ASPIRATION OF LOW TO MIDDLE INCOME
CONTAMINATED SECRETIONS COUNTRIES
MINIMISING RISK OF ASPIRATION
ELEVATION HEAD (15-30O)(30-45O) INICC (ARGENTINA)
SUBGLOTTIC ASPIRATION
ETT CUFF PRESSURE
ASMIC 2016
CDC/NHNS VS INICC
▸ 4 decades ago ▸ 15 years ago
▸ 3000 hospitals US ▸ 703 ICUs, 50 countries
▸ comparison among high ▸ comparison among limited
income countries resources countries
▸ online platform ▸ online platform
▸ benchmark ▸ 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
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 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.
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 PICU UMMC
DATA
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 PRISM score 18
▸ Med days to VAP: 15 ▸ Med LOS: 39.2 days
▸ Crude mortality rate : 28.6%
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
