Practice Plan
Establish and consistently implement VAP prevention guidelines that focus on surveillance, minimization of ventilator patient days, prevention of aspiration and gastric distention, equipment cleansing, oral hygiene and avoidance of unintended extubation and reintubation \cite{18840087}. An example of an evidence-based bundle is the Institute for Healthcare Improvement’s How-to Guide: Prevent Ventilator Associated Pneumonia. This Guide can be accessed online through the Institute for Healthcare Improvement (IHI)\cite{00007}. In addition the Armstrong Institute for Patient Safety and Quality at John Hopkins University has published a Toolkit to Improve Safety of Mechanically Ventilated Patients that includes recommendations on preventing, measuring and tracking outcomes related to VAP. This Toolkit can be accessed online through the John Hopkins Medicine website \cite{institute}.
We have also listed the key components here:
- If tolerated by patient, elevate the Head of the Bed to between 30 and 45 degrees
- Daily Sedation Interruption and Daily Assessment of Readiness to Extubate
- Peptic Ulcer Disease (PUD) Prophylaxis
- Deep Venous Thrombosis (DVT) Prophylaxis
- Daily Oral Care with Chlorhexidine
- Check the patient’s ability to breathe on his/her own every day so the patient can be taken off the ventilator as soon as possible \cite{00008}.
- Before and after touching the patient, ensure that healthcare providers are following hand hygiene procedures.
- Consider implementing Electronic Hand Hygiene Compliance technology to ensure accurate and reliable measurement, feedback and improvement of this essential performance indicator. See APSS 2A for detailed information on the evidence in support of electronic solutions to measure hand hygiene behavior and a list of technology suppliers.
Technology Plan
Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org - Implement endotracheal tubes designed to drain subglottic secretions
- Such as Kimberly-Clark® KIMVENT MICROCUFF Subglottic Suctioning Endotracheal Tube, Teleflex® ISIS HVT, Smiths Medical Portex SACETT Suction Above Cuff Endotracheal Tube or Mallinckrodt® SealGuard Evac Endotracheal Tube
- If endotracheal tubes designed to drain subglottic secretions are not available, consider use of the Vyaire Medical Tri-Flo Subglottic Suction System
- Implement oral hygiene including the use of Chlorhexidine
- Such as SAGE Q-Care Rx Oral Cleansing and Suctioning Systems or HALYARD or Medline Oral Care Kits with CHG
- Implement electronic surveillance technologies that support antimicrobial stewardship (in late onset cases of VAP bacteria is often multi-drug resistant, and can have great clinical and economic challenges)
- Considering implementation of Electronic Measurement of hand hygiene compliance. See APSS 2A for details.
Metrics
Topic:
Ventilator-associated Pneumonia Rate (VAP)
Rate of patients on a ventilator for more than 48 hours who develop pneumonia while on the ventilator or within 1day of ventilator removal per 1,000 ventilator-days
Outcome Measure Formula:
Numerator: Ventilator-associated Pneumonia infections based on CDC NHSN definitions for all inpatient units \cite{00009}
Denominator: Total number of ventilator-days for all patients on a ventilator in all tracked units
* Rate is typically displayed as VAP/1000 ventilator days
Metric Recommendations:
Indirect Impact:
All patients with conditions that lead to temporary or permanent ventilation
Direct Impact:
All patients that require invasive ventilation