early recognition and management of sepsis: meeting 3...
TRANSCRIPT
Early Recognition and Management of Sepsis: PneumoniaMeeting 3
Angela Craig APN,MS,CCNSCRMC Clinical Nurse Specialist for ICU
Early Recognition and Management of Sepsis• Welcome• Review of Program Objectives
– Develop and implement an early recognition of sepsis process
– Standardize processes for treatment of patients with early sepsis
– Standardize processes for infection prevention of PNA, CAUTI and CLABSI
– Decrease rate of transfer to a higher level facility – Decrease sepsis mortality rates
• Orientation to training materials
Roles and Responsibilities
• Each facility must have a team identified to do this work– Should include: medical director, director of nursing,
infection prevention nurse at a minimum• Team work through action plan provided in specified
timeframe • Implement screening process• Implement early management of sepsis process• Educate staff on screening and management processes• Collect defined process and outcome data
What we did last meeting
• Sepsis screening education plan• Reviewed screening audit and audit expectation• Reviewed patient and family education
Agenda
• Review PNA prevention strategies– Discuss assessing current practices at your facility– Identify one prevention strategy to implement
• Define next steps: CAUTI prevention
Pneumonia
Pneumonia Objectives
• Define Pneumonia (PNA)• Identify risk factors of PNA• Identify signs and symptoms of PNA• Review PNA prevention strategies
Pneumonia Statistics• Leading cause of death due to infectious disease in
the USA, sixth leading cause of death overall >65, leading cause for NH
• >900,000 CAP cases in population over 65• Mortality rate in USA about 5%• Estimated 33-114 HCAP per 1000 NH residents• 1st or 2nd most common infection in NH (13-48%)• Mortality rate 13-41% if NH resident• Medicare paid 17.4 billion in 2004 for readmissions
(about 17%)
Statistics….
Out of 12 million fee-for-service Medicare beneficiaries:
• 20% readmitted within 30 days• 34% readmitted within 90 days• 54% readmitted within one year• 68.9% discharged with medical condition died
within a year• 53% discharged with surgical condition died within
one year
Pneumonia
• Infection of one or both lungs, lobar, segmental, or bronchial
• More than 30 different causes• Can be serious, even fatal, especially for very
young/very old• Pneumococcal vaccine, influenza vaccine, and
ACE inhibitors may have protective effect
Risk Factors for Pneumonia
• Inadequate oral hygiene• Immobility/Poor functional status• Aspiration• Difficulties in swallowing• Altered Mental Status• Co-morbidities• Lack of immunization• Smoking
The Older Adult At Risk• Cognitively impaired• Diminished swallow and
cough reflex • Functionally dependant• Dry mouth• Multiple medications• High rate tooth decay• Behavioral problems
during oral hygieneResearch Dissemination Core. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 2002 Nov. 48 p.Marik PE. et al. Chest; 2003; 124:328–336
Epidemiological & Risk Factor Categories for Institutional Pneumonia
Residents >75 years old at 6x higher risk 33 out of 1000 nursing home residents require
hospitalization for pneumonia per year vs. 1.14 out of 1000 elderly living in the community per year
Leading cause of death in nursing home residents
Annual cost of nursing home acquired pneumonia exceeds $8 billion dollars
Factors that increase bacterial burden or colonization
Factors that increase risk of aspirationTerpenning M. et al. JAGS 2002;50:584-585Murder RR. Am J Med 1998;105:319-330
Significant Independent Predictors of Aspiration Pneumonia
Dependent for feedingDependent for oral careNumber of decayed teethTube feedingMultiple medical diagnosesNumber of medicationsDry mouthSmoking
Langmore SE. et al. Dysphagia 1998;13:69-81
Pathogenesis Prevention
Germs in Mouth
• Dental plaque provides microhabitat• Bacteria replicate 5x/24 hrs
Aspirated into Lungs
• Most common route• 50% of healthy adults micro-aspirate
in sleep
Weak Defenses
• Poor cough• Immunosuppressed• Multiple co-morbidities
Pathogenesis Prevention
Germs in Mouth
• Comprehensive oral care• Oral care protocol that includes all
patients
Aspirated into Lungs
• Swallow screens• Tube feeding protocols• Head of bed elevated
Weak Defenses
• Lung expansion/mobilize• Adequate nutrition• Serum glucose target range• Immunization
Risk Factor Categories for Health Care Acquired Pneumonia
• Factors that increase bacterial burden or colonization
• Factors that increase risk of aspiration
Factors that Increase Bacterial Burden or Colonization
• Extreme age, severe underlying condition/ immunosuppression
• Administration of antibiotics
• Agents which raise the gastric pH
• Withholding gastric feeding
• Mechanical ventilation
• Immobility/Microaspiration• Lack of oral care• Poor infection control
practices• Contaminated respiratory
equipment/contaminated condensate
• Saline administration
Oropharyngeal ColonizationMethodology:• 49 elderly nursing home residents admitted to the
hospital• Examined baseline dental plaque scores &
microorganism within dental plaque • Used pulse field gel electrophoresis to compare
chromosomal DNA
Results:• 14/49 adults developed pneumonia• 10 of 14 pneumonias, the causative organism was
identical via DNA analysisEl-Solh AA. Chest. 2004;126:1575-1582
Practices in Oral Care
• Culture cup, ½ H2O2, ½ sterileH2O…little bit of mouthwash
• Lemon glycerin swabs• Toothette with water &/or
mouthwash• No oral care
That’s not the way we do it here!!!
Lemon & Glycerin Swabs• Harmful• Hastens drying of mucosa by
depleting the saliva reserve caused by over-stimulation of salivary glands by lemon juice
• Citric acid has no moisturizing capabilities
• Irritates oral mucosa & decalcifies teeth
• Glycerin is a trihydric alcohol that absorbs water causing drying
Foss-Durant Am et al. Clin Nurs Res. 1997;6(1):90-104Krishnasamy M. Eur J Cancer Care. 1995;4(4):173-177Regnard C et al. Br Med J. 1997;315(7114):1002-1005Van Drimmelen JR et al. Nurs Res 1969;18:327-332
Oral Care Reduces Pneumonia In Nursing Homes
Methodology• 11 nursing homes in Japan over 2 year period• 417 enrolled / 366 residents analyzed (death from other causes)• 184 received oral care program/182 did not• Tooth brushing after each meal (teeth or dentures) & 1x weekly
review by dentist/or hygienist
Results
No Oral Oral Care p valueFebrile 29% 15% p<.01Pneumonia 19% 11% p<.05Death 16% 7% p<.01MMSE Increase p<.05
Yoneyama et al. JAGS. 2002;50:430-433
Oral Care Reduces Pneumonia In Nursing Homes Residents
• Oral care improves swallowing and cough reflex sensitivities
Watando A. et al. Chest, 2004; 126:1066–1070)
Brush & Swab
• 77% more clean proximal sites with brushing• 44% more clean crevice sites with brushing• Benefit of brushing is directly correlated with
technique • Foam swabs could not remove plaque from
sheltered areas on or between teeth
Pearson LS. et. al. J of Adv Nursing. 2002;39(5):480-489
Toothbrush; grade D, Swabs; unresolved, Use of flexible suction catheter post oral cleansing; Grade D (Berry AM et al. AJCC, 2007;16:552-563)
Brushing Removes Plaque• Methodology:
– 34 volunteers– Double-blind crossover study– Examine the amount and % of
plaque removed with a single brushing with 3 solutions (Sodium Bicarb, Crest, Cologate)
• Results:– Significantly higher % of plaque
removed with one minute brush using Sodium Bicarb
Mankodi et al. J Clin Dent. 1998; 9(3):57-60
Proposed Oral Care PlanIndependent
Weekly assessment,encouragement to perform tooth brushing/denture cleaning minimum x2 daily
Dependent on Oral Care
Ability to expectorate
Assist with brushing teeth/clearing out debris &/or cleaning dentures with CPCafter each meal/night & moisturize following cleaning
Unable to expectorate
Brush teeth (dentures) /clear debris using suction toothbrush am & pm with CPC followed by moisturizingAssist oral cleansing (dentures)/clear debris after lunch & dinner using a suction swab with CPC followed by moisturizing denture cleaning
Oral Care Protocol
Your Role in Preventing Pneumonia
• Proper hand hygiene• Comprehensive Oral Care• Prevention of Aspiration• Swallow screens• Proper positioning during
eating/feeding and sleep• Immunizations• Mobility/ Lung expansion• Adequate nutrition
Current State Assessment related to PNA Prevention Practices
PNA Prevention Action PlanStep Who? When? Status
1. Assess current infection prevention practices for PNA
2. Identify gaps in application of PNA prevention practices and develop plan to implement strategies to close gaps
3. Develop an infection prevention education plan for PNA
4. Audit PNA prevention practices5. Identify facility acquired PNA
rates
Sepsis Early Recognition Action Plan
Homework• Continue with the sepsis screening audits• Do current state assessment for PNA prevention• Review oral care protocol with team and begin to
discuss how to implement it
Questions?
Thank you for your participation in this important work