Can nurses Compliance to Ventilator Care Bundle Help to Prevent Ventilator Associated Pneumonia in ICU? Mok Chi Man, RN (SP) ICU, PYNEH, HKEC 1
Introduction Ventilator-associated pneumonia (VAP): Lung parenchyma inflammations caused by infections of patients with invasive mechanical ventilation use. Second most hospital acquired infection in the US. Early onset <48 hours. Late onset >96 hours. Center for Disease Control & Prevention (CDC) 2011: The overall ventilator use in various hospital unit types: 0.01 to 0.47 patient days VAP rate : 0.0 to 4.4 per 1000 ventilator days. 2 (Barie, 2007; Cianferoni, 2010; Hedrick et.al, 2008;Torpy, 2008; Valencia & Torres, 2009 )
CDC Pneumonia Criteria Before 2015: Indicated the specific type of VAP: PNU1-Clinically defined pneumonia. PNU2-Pneumonia with common bacteria pathogens. PNU3-Pneumonia in immunocompromised patients. In 2015: CDC new definition Ventilator associated event (VAE). VAP defining criteria: more objective using clinical patient data Go to search CDC- VAE http://www.cdc.gov/nhsn/pdfs/vae/draft- Ventilator-Associate-Event-Protocol_v6.pdf. 3
VAP Risk Factor: >60 yrs. Malnutrition, Pre-existing pulmonary disease, Multi organ failure, Coma, Burns/trauma, Prolong MV use. Re-intubation. Contamination. Supine position. Not adequate Endo-tracheal tube (ETT) cuff pressure. 4
Epidemiology Mortality rate: 3%-17%. While 52 % of VAP was preventable. Mortality rate exceeds 75% for patients infected with multi-drug resistance organisms. Increase ICU length of stay. Increase charges. 5 (Barie, 2007; Cianferoni, 2010; Hedrick et.al, 2008; Lau et al, 2015;Torpy, 2008; Valencia & Torres, 2009; )
Revisit the VAP Process Pathogenesis of VAP Bacteria enter the lower respiratory tract via two pathways: Aspiration of organisms from the oropharynx and gastro-intestinal tract (most common cause) Via ventilator circuit & tracheal tube 6
Background Causes of VAP are a multifactorial: studies support that good compliance of ventilator care bundle (VCB) helps to prevent VAP. Start from 2010; VAP rate at PYNEH ICU varies from : 20-70 / 1000 ventilator days. Ventilator care bundle (VCB) performed. No systemic checklist. No structured audit to assess staff compliance. 7
Institute for Healthcare Improvement (IHI) Ventilator Care Bundle (VCB) Ventilator bundle become the core VAP prevention: (1) Elevation of head of the bed (HOB) between 30 o to 45 o. (2) Daily sedation interruption and daily assessment of readiness to be extubate. (3) Peptic ulcer disease prophylaxis. (4) Deep venous thrombosis prophylaxis (unless contraindicated). (5) Daily oral care with chlorhexidine. Its the practice of whole bundle not just an individual component. 8
A Cluster Based Team Quality Improvement Project in Critical Care Areas 1. Setting up a team.(rhcicu, PYNEH ICU) 2. To advocate staff compliance to VCB. 9
Ventilator Care Bundle (HKEC) Elevate Head Of Bed 30 o -45o. Perform oral care with antiseptic oral rinse twice per day. Perform hand hygiene before and after each respiratory care. Review sedation target daily. Assess readiness to wean and to extubate daily. Drain condensate of the ventilator circuit before patient repositioning. Carry out disinfection of respiratory consumables and equipment a/c to protocol. Check and maintain ETT cuff pressure (24-30 cm H2O). Verify correct placement of the feeding tube at regular interval. Assess patient s tolerance of NG feeding regularly. 10
Ventilator Care Bundle (VCB) Compliance Audit Objectives: To study nurses compliance on VCB to prevent VAP. To provide feedback to nurses. To recommend follow-up actions for improvement if needed. Methodology: Design an audit form with 10 criteria. A delicate audit team to collect data by: Clinical observation. Checking documentation. Sample Design: A convenient sampling method: target 80 samples. (RH 20 + PYNEH 80). 11
PYNEH ICU Team Members 12
PYNEH VCB Compliance Rate 100 90 80 70 60 50 40 30 20 10 0 95% Aug- 13 13
PYNEH ICU Improvement Measures 1. Teaching with video: demonstration on proper ways to remove ventilator circuit condensate. 2. Reinforce documentation for changing ventilator assembly regularly. 3. Peer reminder on hand hygiene. 4. Clinical reminder on sedation target.
PYNEH VCB Compliance Rate 100 90 80 70 60 50 40 30 20 10 0 95% Aug-13 Dec-14 15
RH Cardiac and Intensive Care Unit Team Members 16
RH VCB Compliance Rate 100 90 80 70 60 50 40 30 20 10 0 95% Aug-13 17
RH CICU Enhancement Practice 1. Handmade label at the bedside to facilitate HOB over 30o 2. Oral care: schedule oral hygiene to 4 times a day with chlorhexidine rinsing and tooth brushing. 18
RH CICU Enhancement Practice 3. Cuff pressure: add a label on the cuff inflator to signal the desired cuff pressure to be maintained at 30 cm H2O. 4. Reinforce draining condensate of the ventilator tubing before patient repositioning. 19
RH VCB Compliance Rate 100 90 80 70 60 50 40 30 20 10 0 95% Aug-13 Dec-14 20
Significant Improvements (80 samples) Full compliance to VCB 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 51% 2013 2014 89% 2013 2014 Full compliance to VCB = number of samples with all Yes & + NA items to all 10 audit items total number of samples (80)
8.02 0 10 20 30 40 50 60 70 80 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 PYNEH ICU VAP Rate 1st compliance audit 2 nd compliance audit
VAP Rate Hospital PYNEH RH Yearly mean VAP Rate (per 1000 ventilator days) 2012 : 19.1 2013: 9.6 2014: 6.8 2013: 6.3 2014: 13.8 ( Jan to Apr) Proper Reporting. Newly implement the VCB measures. Outcomes: 6.4 in the rest of the year after full promulgation of VCB. 23
Nursing ACTION in FUTURE Protocols: Continuous review & compliance audit Proper reporting: Set VAP as regular item in department meeting & promulgate VAP rate to all staff. Ventilator Care Bundle Education: Be target : new comers Multi-discipline: Liaison with other department/ team
Bring Home Message Does VCB useful? Yes. It need continuous monitor compliance. How to prevent VAP is most the best? Teamwork. Strict compliance to VCB. Disseminate & Share results of audit findings. Disseminate & Share updated guidelines. What can we do? Department collaboration & support. Look for additional control measures for VAP. 25
Acknowledgment Special thanks to our team members: PYNEH: Dr. CW Lau (AC PYICU), Dr. G Lam (AC, PYICU), Ms. HM So (NC, HKEC), Ms. L Lau (WM, PYICU ), Ms.MC Chiu (APN, PYICU); Ms. SC Li (APN, PYICU ). Ms. PM Wong (RN, PYICU). RH: Ms. Patricia Chan (NO, RH CICU), Dr. A. Yeung (AC, RH CICU). Ms. Tang SL (RH CICU WM). Senior Management support: Dr. WW Yan (COS, PYICU). Dr. YK Lau (Consultant, RH). Dr. Raymond Liu (SMO, RH). Ms. Angela Lee (DOM RH CICU). Ms. Nora Kwok (DOM, PYNEH). 26