Preventing Ventilator-Associated Pneumonia
Monday January 12, 2004
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basics help keep down the rate of infection.
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection acquired in the ICU, occurring in 21% of intensive care patients anytime after 48 hours of intubation.1,2 Among ventilator-dependent patients, VAP is the leading cause of death from hospital-acquired infection and is quite often caused by highly resistant gram-negative organisms, including Pseudomonas aeruginosa and methicillin-resistant staphylococci (MRSA).1 VAP-related death occurs between 24% and 76% of the time, depending on contributing factors.3
VAP accounts for a tremendous expense in antibiotic consumption in the ICU and delayed extubation or weaning from mechanical ventilation. Further, excessive antibiotic use promotes antimicrobial resistance and a drastic change in the bacterial flora in oropharyngeal secretions that occurs within the first 48 hours after intubation, with gram-positive organisms replaced by stronger, more resistant gram-negative bacteria.2
VAP is diagnosed by a combination of physical examination and x-ray assessment. Sampling endotracheal secretions via suctioning or lower-respiratory secretions obtained through broncheoalveolar lavage helps confirm the diagnosis and identify causative organisms.
Patients who smoke or have substance abuse disorders and those with diabetes, renal failure, and a history of lung disease or use of steroid medications have a greater incidence of VAP, thus making the nursing history and assessment a crucial component in planning VAP prophylaxis. Some 28% to 40% of patients experiencing traumatic brain injury develop VAP.4
Historically, VAP was attributed to suspected contamination of ventilator tubing; however, further investigation reveals other more likely causes. VAP often results from aspirated secretions from the upper airway during intubation or from secretions and gastric aspirate leaking below the inflated endotracheal tube cuff. Patients are more likely to develop VAP because of aspirated secretions than through what is inhaled through the tubing.1,5
Measures to Reduce Risk
The impact of prophylactic use of aerosolized antibiotics on VAP incidence was tracked in one study of 40 critically ill trauma patients. Ceftazidime aerosol treatments were given to the treatment group and normal saline (placebo) treatments to the control group. The patients receiving ceftazidime were 73% less likely to develop VAP by day 14 and 54% less likely to develop VAP during the entire course of their stay.6
Another prophylactic option available is selectively decontaminating the subglottic area with an antibiotic suspension. Research among a sample of 79 multiple trauma patients requiring ventilation for more than five days showed this approach cut the incidence of VAP by 35%.7 While proven by research to be effective, however, the procedure can damage tracheal mucosa and has yet to become a standard part of bedside care.1,8
Research among 150 patients undergoing mechanical ventilation for more than three days supports the impact of basic care measures to reduce VAP. Even when decontamination with antibiotic solution was not carried out but staff performed intermittent subglottic secretion drainage, the incidence of VAP decreased by 12%.9
Bedside Nursing and VAP
Diane Pagano, RN, MSN, CCRN, director of critical care services at JFK Medical Center, Atlantis, says initiatives that have made a dramatic difference in VAP incidence include ventilator rounds and focusing on nursing care basics - since ventilator rounds began in July 2002, she says, VAP has become relatively rare. Patients are usually considered for vent rounds if they're on a ventilator for more than a week or if they have underlying conditions or factors that the nurse believes places them at greater risk for VAP.
JFK's interdisciplinary rounds include nursing staff, physicians, respiratory and physical therapists, nurse practitioners, pharmacists, case managers, the nurse educator, and dietary staff. Jessica Nelson, RN, describes the rounds as a means of streamlining communication between the disciplines. The nurse, she adds, is central to coordinating care: "We watch [patients] much closer and pay attention to the subtle changes in their lab values and physical assessments."
Nurses at JFK are taught to suspect VAP when patients are on ventilator for five or more days. Patients at a greater risk for VAP include those with multiple trauma, those underlying medical conditions or compromised immune systems, and those with poor underlying health or nutritional status.
Hill-Rom beds that convert into chairs at JFK assist in using gravity and positioning to promote a more natural pulmonary toilet. The semirecumbent positioning has proved effective in reducing VAP8, and bed positioning capabilities are especially important when patients receive enteral feedings. "Ventilator patients receiving tube feedings must be positioned with the head of their bed upright," says Nelson. "Carefully monitoring residuals is especially important in preventing aspiration." Nurses may believe that the endotracheal tube protects against aspiration, but this is simply not true.
Nourish to Heal
Nutrition is crucial in the healing process, but timing and delivery route for feedings also play important roles in VAP incidence. One study compared early vs. late (postintubation) feeding strategies and found patients receiving early feedings had a 19% greater incidence of VAP.10 Feedings given through nasogastric or gastric (PEG or similar) tubes are more likely to contribute to regurgitation and aspiration leading to VAP than those delivered distally to the stomach - feedings delivered into the small bowel through a jejunostomy or similar tube result in a lower incidence of VAP.11 Stress-ulcer prophylaxis through the use of H2 blocking medications like cimetadine (Tagamet) and the use of oscillating beds have also proved important in reducing VAP rates.8
Pagano says that the patient's location in the unit, along with family care issues, is also important. JFK has four units with 52 ICU beds that house cardiac, med/surg, neurological, and open-heart patients.
Recent remodeling has also enhanced care delivery, says Nelson. All of the rooms afford the patient a window view - "We've seen an elevation of patient moods with the opportunity to look outside." She adds that the view also assists with reorientation and more natural sleep patterns.
While JFK has yet to compile data on the effectiveness of its VAP program, initial observations by staff and physicians identify the program as a big-time winner. Pagano is quick to identify the contribution of her staff: "Nurses providing excellent bedside care and taking a more assertive role in communicating with physicians deserve the lion's share of the credit in combating VAP."
The Joint Commission on Accreditation of Healthcare Organizations is equally impressed. During a recent survey, VAP initiatives were commended and the ICU staff recognized for its excellent performance. So pleased were JCAHO surveyors that they not only left behind a rating of 99 without a single Type 1 recommendation, but also invited the facility to take part in implementing and testing practice protocols to combat VAP.
Keeping Tabs on VAP
Rhonda Anderson, RN, MSN, CCRN, clinical nurse specialist in the critical care unit at Sarasota Memorial Hospital, Sarasota, has 20 years of experience with ventilated patients. Her facility benchmarks the incidence of VAP based on VAP criteria from the Centers for Disease Control and Prevention through use of the APACHE III database. The infection control department performs surveillance and monitors appropriate use of antibiotics.
Patients on ventilators, says Anderson, are sedated according to protocols that include periods of lighter sedation to permit nursing assessment and combat oversedation. Respiratory therapy-driven ventilator protocols include daily attempts at weaning.
"Combating VAP is easy when nurses focus on the basics of care, such as adequate nutrition, oral care, reducing or eliminating skin breakdown, and the use of H2 blocking medications," says JFK's Pagano. Basic hygiene, sharp assessment skills, patient positioning, and early identification and treatment of VAP are mandatory.
"Oral care is also a crucial component of VAP prevention at Sarasota Memorial," says Anderson. "Patients are given oral care every two to four hours while they're intubated." VAP can develop when bacterial colonies form in the trachea. Thus, preventing colonization in oral and tracheal secretions is a key factor in reducing or eliminating VAP.
Chest physiotherapy (CPT), another basic intervention, is quite effective in reducing VAP. In one study, 60 adult patients ventilated at least 48 hours were divided into two groups, half receiving therapy and half not. The group receiving CPT was 31% less likely to develop VAP.12 Anderson says that ventilated patients at Sarasota Memorial receive aggressive continuous lateral rotation therapy, combined with percussion and vibration performed by nurses and respiratory therapy staff.
Though technology and equipment are important in reducing infection rates, research reveals that it's not the equipment that makes the greatest difference, but rather how it's used and under what circumstances. In research comparing open vs. closed, in-line suctioning systems, both performed well with very little difference in the rate of VAP.13 At JFK and Sarasota Memorial, protocols require use of the sterile in-line system where communication with potential outside contaminants is substantially reduced.
Results Are Convincing
Pagano and Anderson say that when VAP is reduced or eliminated, the impact is felt throughout the hospital - average length of stay decreases, antibiotic expense is reduced, and most important, patients experience less pain and discomfort associated with prolonged stay and ventilation.
Nelson credits ventilator rounds with enhancing communication with family members: "It promotes communication with family members and helps identify the goals and plans for their ventilated loved one - I can more easily simplify terms to increase understanding."
High-touch may prevail over high-tech, according to Pagano. "Collaboration and common sense," she says, go a long way toward helping nurses combat VAP.
Susanne J. Pavlovich-Danis, RN, MSN, ARNP-C, CDE, maintains a private adult health practice in Plantation. She is also professor and area chair for nursing at the University of Phoenix, Fort Lauderdale.
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