VENTILATOR ASSOCIATED PNEUMONIA

DO BUNDLE MAKE A DIFFERENCE? Anis Siham Zainal Abidin

Faculty of Medicine UiTM

ASMIC 2016

INTRODUCTION - Burden of VAP

VENTILATOR BUNDLE CARE

INTERNATIONAL DATA

LOCAL DATA

OUTLINE

VENTILATOR ASSOCIATED PNEUMONIA

ASMIC 2016

US VAP 2.9/1000MV days

Germany VAP 5.1/1000 MV days

Malaysia VAP 12.9/1000 MV days

INCREASE BED DAYS IN ICU INCREASE MORBIDITY &

MORTALITY

$$$$$$ INCREASE COST

VENTILATOR BUNDLE CARE

WHAT IS

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

HEAD ELEVATION 30-50O

DEEP VENOUS THROMBOSIS PROPHYLAXIS

SEDATION VACATION

PEPTIC ULCER DISEASE

PROPHYLAXIS

ORAL HYGIENE

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

HEAD ELEVATION 30-50O

DEEP VENOUS THROMBOSIS PROPHYLAXIS

SEDATION VACATION

PEPTIC ULCER DISEASE

PROPHYLAXIS

ORAL HYGIENE

ALL OR NOTHING

ASMIC 2016

SEDATION VACATION

▸ Kress et al. 128 MV patients: daily sedative interruptions vs

clinician discretion. Duration MV 7.2days to 4.9days

(p:0.004)

DAILY SEDATIVE INTERRUPTIONS

READINESS TO EXTUBATE

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

HEAD ELEVATION 30-50O

DEEP VENOUS THROMBOSIS PROPHYLAXIS

SEDATION VACATION

PEPTIC ULCER DISEASE

PROPHYLAXIS

ORAL HYGIENE

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

HEAD ELEVATION 30-50O

DEEP VENOUS THROMBOSIS PROPHYLAXIS

SEDATION VACATION

PEPTIC ULCER DISEASE

PROPHYLAXIS

ORAL HYGIENE

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

HEAD ELEVATION 30-50O

DEEP VENOUS THROMBOSIS PROPHYLAXIS

SEDATION VACATION

PEPTIC ULCER DISEASE

PROPHYLAXIS

ORAL HYGIENE

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.

PAEDIATRIC MODIFICATION?

ASMIC 2016

ASMIC 2016

CONCEPT

SPECIFIC POPULATION IN A

SPECIFIC LOCATION

COMPRISES OF SIMPLE MEASURES

FOCUS ON BEST CARE

ALL OR NONE

COMPLIANCE

ASMIC 2016

PAEDIATRIC VENTILATOR BUNDLE CARE

EXAMPLES OF ELEMENTS

MONITORING

PREVENT BACTERIAL COLONIZATION HAND HYGIENE ORAL HYGIENE

CARE OF THE VENTILATOR & SUCTION TUBING

DAILY SEDATION BREAK

DAILY ASSESSMENT OF READINESS FOR EXTUBATION

PREVENT ASPIRATION OF

CONTAMINATED SECRETIONS MINIMISING RISK OF ASPIRATION ELEVATION HEAD (15-30O)(30-45O)

SUBGLOTTIC ASPIRATION ETT CUFF PRESSURE

CDC/ NHNS (US), KISS (GERMANY), ECDPC, JAPAN

INICC (ARGENTINA)

HIGH INCOME COUNTRIES

LOW TO MIDDLE INCOME COUNTRIES

ASMIC 2016

CDC/NHNS VS INICC

▸ 4 decades ago

▸ 3000 hospitals US

▸ comparison among high

income countries

▸ online platform

▸ benchmark

▸ 15 years ago

▸ 703 ICUs, 50 countries

▸ comparison among limited

resources countries

▸ online platform

▸ 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

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.

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 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 DATA

PICU UMMC

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 days to VAP: 15

▸ Crude mortality rate : 28.6%

▸ Med PRISM score 18

▸ Med LOS: 39.2 days

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