PREVENTION OF VENTILATOR- ASSOCIATED PNEUMONIA (VAP) IN ADULTS August 2008

Transcription

1 Chicago, Illinois PAGE: 1 of 5 PREVENTION OF VENTILATOR- ASSOCIATED PNEUMONIA (VAP) IN ADULTS August 2008 Key Content Expert: Dr. Marcella McGuinn, Medical Director, Infection Control These systematically developed statements have been created to assist practitioners in documentation within the Electronic Medical Record. They are not to be construed as an inflexible set of correct procedures. Guidelines are based upon recommendations of multi-disciplinary committees. Variation from these guidelines does not, in itself, constitute improper care or improper professional judgment. Evaluation of these variations requires detailed analysis of the facts and circumstances surrounding the individual practitioner s documentation.

2 Chicago, Illinois PAGE: 2 of 5 NO: G-20.5 DATE: August 2008 SUBJECT: Prevention of Ventilator-Associated Pneumonia OBJECTIVE To guide practices and interventions which promote the reduction of ventilator-associated pneumonia (VAP) in patients in the Medical Center. POSITION STATEMENTS VAP is the leading cause of death among patients with acquired hospital infections. Invasive mechanical ventilation via endotracheal tube has become a common practice in the modern hospital setting. Endotracheal intubation contributes to VAP and sepsis. Implementation of these processes has been proven to decrease the occurrence of VAP resulting in better patient outcomes. Use of antimicrobial coated endotracheal tubes in select patient populations (see addendum) can supplement these practices. Noninvasive positive-pressure ventilation can be used as an alternative ventilation mode when clinically indicated. PROCEDURE 1. Hand hygiene should be done immediately before and after any patient contact or manipulation of ventilator, ventilator tubing, or endotracheal tube. 2. Patients admitted from long-term skilled nursing facilities with mechanical ventilation should have baseline cultures of respiratory secretions obtained on admission to assess colonization and/or infection status. 3. Oral Intubation is preferred over nasal intubation. Aspiration of infected sinus secretions can result in the development of VAP. 4. The duration of mechanical ventilation when clinically indicated should include: daily assessment for readiness to extubate, and weaning from the ventilator as soon as clinically indicated. In addition, measures should be taken to minimize the use of sedation whenever clinically possible as well as taking measures to avoid self-extubation, minimize pain and desaturation (refer to Respiratory Care Department ventilator weaning guidelines). 5. Ventilator circuits are changed: PRN when soiled, or every 30 days. In-line suction catheters are changed once per week or when soiled, and the HME is changed daily or when soiled. 6. Always drain ventilator circuit condensate away from the patient and discard properly. Remember to drain condensate before repositioning the patient. Procedure for draining ventilator circuit: a. Wash hands, and use standard precautions b. Drain fluid away from the patient allowing it to collect in the trap jar. c. Open the ventilator circuit/trap jar carefully as to avoid spillage.

3 Chicago, Illinois PAGE: 3 of 5 d. Drain fluid into a wide-mouthed canister for immediate disposal into an appropriate receptacle. Do not drain/dispose of fluid directly from the ventilator circuit into a trash can or sink. e. Secure trap jar/ventilator tubing appropriately to avoid contamination. f. Remove gloves and perform hand hygiene. 7. Prior to extubation perform subglottic suctioning. 8. Head of bed should be elevated between: , this includes during patient transport; unless medically contraindicated. 9. Gastric tubes should be inserted orally unless contraindicated and removed as soon as possible. Administer continuous enteral feedings to avoid gastric over distention. Placement of small bore feeding tubes into the small bowel instead of the stomach is recommended. Monitor gastric residual volumes per nursing policy (Nursing Policy G-1.1) 10. Endotracheal tubes should be secured to prevent accidental extubation. Perform subglottic suctioning prior to endotracheal tube manipulation. 11. Frequency of suctioning is based on respiratory assessment and need. 12. Use single dose saline vials for clearing of the suction catheter/tubing. Catheter/tubing should NEVER be rinsed with tap water. 13. Wall suction canister liners and suction tubing are discarded between patients or when canister/tubing are visibly soiled or full. (Nursing Policy S-3) 14. Use clean gloves for in-line suctioning and sterile gloves for single use suction catheters. 15. Oral suction catheters should be stored in the respiratory bin in a non-sealed plastic bag. The suction catheter should be kept in non-sealed plastic bag when not in use, and should not be stored on the ventilator or under the patient s bed or pillow. 16. Saline lavage is NOT recommended. 17. Manual resuscitation bag should be stored in the respiratory bin and the patient end should be covered. 18. Oral Hygiene to be performed as follows: a. Subglottic suctioning at least q12h or as needed. b. Toothbrush twice in a 24hr period c. Oralpharyngeal (supraglottic) suctioning at least q12h d. Mucosal moistening at least q4h e. Lip balm application as needed 19. Stress Ulcer Prophylaxis as indicated by patient risk assessment. 20. Cuff pressures of the patient s endotracheal tube/tracheostomy tube will be measured Q12 and minimal leak technique checked an additional 2 times inbetween each of the Q12 hour cuff pressure measurements.

4 Chicago, Illinois PAGE: 4 of 5 Janet M. Spunt, RN, MS Chief Nursing Officer William H. Chamberlin, MD Chief Medical Officer John DeNardo CEO, Healthcare System Addendum Patients who may be considered for use of the Agento Silver Coated E.T. Tube: TM References University of Illinois Medical Center at Chicago Nursing Policies and Procedure Manual G-1.1 Tube Feeding S-3.0 Suctioning Respiratory Care Guideline Manual Ventilator Weaning Guideline Center for Disease Control Guidelines for Prevention of Health-Care Associated Pneumonia, March BJC HealthCare, Prevention of Ventilator-Associated Pneumonia Kollef, M. (2004). Prevention of hospital-associated pneumonia and ventilator-associated Pneumonia. Critical Care Medicine, 32,6. Respiratory Care Policy Procedure Manual; Section III, XI Equipment Care (under each ventilator type

5 Chicago, Illinois PAGE: 5 of 5 Patients who may be considered for use of the Agento Silver Coated E.T. Tube: TM ARDS/Septic/Shock Patients High Risk Cardiothoracic or Vascular surgery patients such as TAA, AAA, Esophagectomy, Lobectomy/lung resection. Patients with neurological impairment who may require prolonged intubation Patients requiring reintubation within 24 hours