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