Presentation title
SUB TITLE HERE Kaiser Permanente Fresno
Kaiser Permanente Fresno
Ventilator Associated Pneumonia
(VAP)
Kaiser Permanente Fresno Learning Objectives
• Discuss current VAP data and components • Review past and current practice to prevent VAP • Define and discuss current strategies for VAP
prevention including SAT, SBT and mobility • Describe the planned culture change in the CCU
Kaiser Permanente Fresno
Mission We seek to satisfy the health care needs of
our members by providing accessible, affordable, comprehensive services of high quality.
Vision We will be the model for health care delivery
by setting the standard for quality, service and affordability within the communities we serve.
Kaiser Permanente Fresno (membership numbers)
Age
Ethnicity
Gender
Kaiser Permanente Fresno Scope of Care Provided
PROVIDED ONSITE General Acute Care
Intensive Care Perinatal Services
Intensive Care Nursery Basic Emergency Nuclear Medicine
Outpatient Services Physical and Respiratory Therapy
Social Services
Kaiser Permanente Fresno Care Delivery Statistics
169 Licensed Beds 2011
Average Daily Census 90 Hospital Admissions 9,079 Births 1,132 Inpatient Surgeries 1,844 Outpatient Surgeries 6,354 ED Visits 28,123 Average Length of Stay 3.6
Kaiser Permanente Fresno VAP data
1.4 0.7
0 0 0 0 1 2 3 4 5 6 7 8 9
10
2008 2009 2010 2011 YTD 2012
Ventilator Associate Pneumonia in CCU
CCU VAP NHSN Benchmark (Pooled Mean)
Rate
of In
fectio
n
Kaiser Permanente Fresno Components to rule out VAP • Chest x-ray: Worsening from prior 2 days • Lab values: WBC greater than 12,000 • Patient temperature greater than 38 C • Stable or decreasing FI02 or Peep, then an
increased level for >2 days. • Positive culture after 48 hours on ventilator
Kaiser Permanente Fresno Definition of VAP from the Centers of Disease Control (CDC)
Definition of VAP is specifically as a PNEU event that occurs at the time a ventilator is in place, or within 48 hours after a ventilator has been in place. There is currently no required duration that the ventilator must be/have been in place for a PNEU to qualify as a VAP.
PNEU event is made up of three components, X-ray, Signs
and Symptoms, and lab work.
Kaiser Permanente Fresno VAP Team
Infection Prevention & Control Team Intensive Care Physicians Respiratory Therapists Critical Care Nursing Staff Critical Care Management Team
Kaiser Permanente Fresno Where we started
2007 we started educating the Critical Care staff in their Annual skills on VAP. We discussed all the four key components of Ventilator Bundle.
Elevation of HOB
30 – 45 degrees
Aspiration Risk (GI contents,
Oropharyngeal & Nasopharyngeal
Secretions)
Improve Patients’ Ventilation (aid
ventilatory efforts, atelectasis)
“Sedation
Vacations” (“Wake-up Assessments”)
Lightening sedation amount of time
on ventilator
Weaning off the Ventilator is easier when patients are able to assist at extubation with
coughing & control of secretions
Prophylaxis: Peptic Ulcers
May protect
against a greater pulmonary
inflammatory response to
aspiration of GI contents
Critically-ill
intubated patients lack ability to defend airway
Prophylaxis: DVT
Appropriate for all sedentary patients (especially CCU)
When implemented
with other 3 Key Components –
rate of Ventilator- Associated Pneumonia significantly
Kaiser Permanente Fresno Oral Care Bundle ABCs of Oral Care Bundle: A = Assess oral cavity and lips every shift. B = Brush patient’s teeth every 12 hours (0600 – 1800) and as needed to prevent formation of dental plaque. In addition we use Chlorahexidine every 12 hours. C = Cleanse oral cavity of unconscious or intubated patients every 4 hours (even hours). S = Suction oral cavity and pharynx every 6 hours (06-12-18-24) to manage oral secretions and minimize the risk of aspiration. Change yankauer every 24 hours. Implement Oral Care Bundle with Ventilator Bundle.
Kaiser Permanente Fresno Sage Oral Care Kits Used
Kaiser Permanente Fresno What we have been doing!
Our focus has been a multidisciplinary approach
from all the team members. Outstanding teamwork and
communication produce optimal outcomes.
Kaiser Permanente Fresno Critical care vision Our team provides critically ill patients
and their families expert and compassionate care, guiding them through times of crisis in a way we’d want for our own families.
This means preventing a VAP!
Kaiser Permanente Fresno RT Component
Heat & moisture exchanger/filters Inline closed system suction catheters Inline metered dose inhalers for bronchodilators Routine instillation of saline discouraged Routine cuff pressure maintenance and monitoring Daily surface disinfection Daily change and replacement of airway supplies
Kaiser Permanente Fresno Current components added
Daily Multi Disciplinary Rounds This includes a discussion about VAP bundle
components Order sets with all components included Consistent ventilator weaning process
Kaiser Permanente Fresno Initiation of Mechanical Ventilation Order Set
SAT Safety Screen
Perform SAT
SBT Safety Screen
Perform SBT
Consider Extubation
SAT SAFETY SCREEN • No active seizures • No alcohol withdrawal • No agitation or paralytics • No myocardial ischemia • Normal ICP PASS?
SAT FAILURE • Anxiety, agitation, or pain • RR >35 or SpO2 <88% • Respiratory distress • Acute cardiac arrhythmia Restart Sedatives at 50% of prior rate
SBT SAFETY SCREEN • No agitation • SpO2 > 88% • FiO2 50% • PEEP < 7.5 cm H20 • No myocardial ischemia • No vasopressor use • Inspiratory efforts PASS?
SBT FAILURE • RR > 35 or < 8 • SpO2 < 88% • Respiratory distress • Mental status change • Acute cardiac arrhythmia Resume Full Ventilatory Support
Kaiser Permanente Fresno
Prophylactic Pneumonia vaccines Minimize use of sedation and narcotics Mobilize patients as soon as possible
Kaiser Permanente Fresno Where we are headed!
CULTURE CHANGE Individual Immobility Inconsistent Ventilator Mgmt and Weaning Sedation Long-term deconditioning
Team
Mobility
Daily Weaning Assessments
Sleep/wake cycles
“Back to baseline”
Kaiser Permanente Fresno
22
Delirium
Ventilation Management
Early Mobility
Daily Goals & Care Coordination
Bringing It All Together
Kaiser Permanente Fresno
Neurological
RASS (Richmond Agitation Sedation Scale)
CAM ICU (Confusion Assessment Method)
Promoting sleep
23 2012 National Quality Conference
Kaiser Permanente Fresno
Pulmonary Spontaneous
Awakening Trial Spontaneous
Breathing Trial Lung protective
strategies for Acute Lung Injury, Acute Respiratory Distress Syndrome (ARDS)
Kaiser Permanente Fresno
Musculoskeletal Mobility protocol Mobility goals achieved
daily Number of feet walked Ambulating vented patients
Kaiser Permanente Fresno Mobility Protocol
Kaiser Permanente Fresno Ambulating Ventilated Patient Checklist ACTION If Yes continue to the next
action
Patient HR<120, RR<30 Yes/No
Patient tolerates HOB>45 degrees Yes/No
Patient has Dangles at least once in 24 hrs Yes/No
If patient is on specialty service obtain OK from consulting MD (esp neurosurgery, neurology, cardiology)
Yes/No
Yes to all above Yes/No
Kaiser Permanente Fresno Yes…..then
Contact PT & RT to arrange time for ambulation Yes/No
Prior to time for walk, perform the following: •Obtain monitor & stand •Consolidate IV & tubing if possible •Do not DC BP cuff until after dangle test •Obtain walker •Ambu bag with 90 adapter •Patient slippers, extra gown, diaper if needed
Yes/No
When team present dangle at the side of bed. Take BP: Patient not orthostatic
Yes/No
Patient stands and does several steps at bedside Yes/No
Ambulate patient. Document # feet. Yes/No
Kaiser Permanente Fresno Current Challenges
Consistent use of the Order sets Variation in practice of Physicians Mobility protocol is developing…… not all staff has
bought into the new expectations.
Kaiser Permanente Fresno What are we expecting for the future?
No ventilator associated pneumonia Shorter CCU patient days Decrease in delirium Return of the patient to baseline prior to the admit Reduced mortality in the CCU Increase in teamwork and communication
Kaiser Permanente Fresno References
Centers for disease control & prevention: http://www.cdc.gov/ Institute for health improvement:: http://www.ihi.org/Pages/default.aspx Centers for disease control & prevention: http://www.cdc.gov/ Kaiser Permanente Regional: Oakland, California