Transcript presentation (?)

Objectives
At the end of this session, participants will be
able to:
1)
2)
3)
4)
Define Interventional Patient Hygiene (IPH)
List the components of an IPH Program
Develop a strategy for implementing IPH
Understand the importance of skin
antisepsis in SSI prevention
5) VAP prevention progress update
What Is IPH?
Definitions
Non-Clinical: Providing patient care
practices that will reduce the choices of a
healthcare-acquired infection
Clinical: IPH is a comprehensive
evidenced based intervention and
measurement model for reducing the
bioburden of both the patient and
healthcare worker.
IPH Practices/Prevention
Outcomes
Evidence Based
Practice Intervention
Responsibility
Measurable Outcome
 Oral Care
HCW
VAP
 Catheter Care
HCW
BSI
 Skin Care
HCW & Patient
SSI, UTI, Reduction of
Resistant Organism Infections,
PU and Skin Breakdown
 Hand Hygiene
HCW & Patient
All of above
ICP Opportunity….?
Pressure
Ulcers
SSI
VAP
BSI
UTI
A Convincing Strategy
for IPH
The Five C’s
The Five C’s:





Caregiver
Consumer
Costs
Court
Control
Knowledge
Public Disclosure
HAI’s
Malpractice
IPH
Interventional Patient Hygiene Survey
n=453




ICP
CCRN
CCRN Mgr/Specialist
RN
48.8% employed >20 years
67.7% Community Hospital
28.3% University/Academic
30.9%
22.8%
15.5%
42.2%
Identify Components of IPH
 Hand Hygiene
 Oral Hygiene
 Early Pre-op Skin Prep
98.7%
94.8%
69.9%
(night before and morning of surgery)
 Bathing/Skin Assessment
 Incontinence Care
93.5%
92.4%
Healthcare-Acquired Infection
Rates
VAP
67%
Pressure Ulcer
43%
Scientific Evidence/ IPH






Pressure Ulcer
SSI
VAP
UTI
LOS
MRSA/VRE
72%
66%
86%
75%
74%
77%
ICP’s Questions
 Education about IPH Components (within
last 2 years)
Hand Hygiene
Oral Hygiene
Early Pre-op Skin Prep
(night before/morning)
Bathing/Skin Assessment
Incontinence Care
98.6%
76.4%
49.1%
40.5%
31.8%
ICP’s (con’t)
 ICP Involvement in Development IPH Protocol
YES:
37.6%
NO:
63.3%
 Policy for IPH in your Institution
YES:
39.3%
NO:
45.3%
Don’t Know:
15.2%
CCRN/RN Questions
 Policy for IPH in Your Institution:
YES:
NO:
Don’t Know
48.4%
34.7%
16.8%
CCRN/RN (con’t)
Written Policy for:
Documentation Forms for:
Oral Care
77%
81%
Bathing/
Skin Assessment
68%
86%
Incontinence Care
54%
60%
IPH Discussed at Orientation/In-Service
Yes:
42.2%
No:
40.4%
Don’t Remember:
17.3%
Skipped Question: 17%
Ranking of Factors Relating to IPH
Very Important
Somewhat Important
Adequate/Appropriate
Supplies
94%
4%
Adequate Time
90%
7%
Standardization of Protocol 86%
11%
Documentation forms for
monitoring
25%
73%
How Do We Increase HCWs
Knowledge of IPH ?
&
How Do We Develop and
Implement a Strategy for IPH?
˙Ownership and Back to Basics
Pressure
Ulcers
SSI
VAP
BSI
UTI
2. Consumer
 2005 - National Telephone Survey*:
Will Consumers Use Public Disclosure
Data When Choosing a Hospital?
 93% of respondents (9 in 10) said
knowing a hospital infection rate would
influence their selection of a hospital
*McGuckin M. American Journal of Medical Quality 2006 - In press
Factors Considered in Choosing A Hospital
Very
Important
Somewhat
Important
Not
Important
Don’t
Know
Low infection rates
85%
8
4
2
Previous experience with
hospital
54%
33
10
3
High staff-to-patient ratio
64%
28
5
3
Friendly staff
68%
27
4
*
Clean
94%
5
*
*
Close to home
49%
41
9
1
Good reputation
79%
18
2
1
Whether they accept your
insurance
88%
7
3
1
*Less than one-half of one percent
Factors Considered in Choosing to Avoid A Hospital
Very
Somewhat
Not
Important Important Important
Don’t
Know
The staff is knowledgeable,
but not friendly
42%
45
10
2
They are understaffed
74%
20
4
1
They are the best hospital in
your area, but do not accept
your insurance
63%
25
10
3
You or someone you know
had an unpleasant
experience there
60%
30
9
1
They have higher-thanaverage infection rates
87%
7
4
2
You have seen or heard it is
not clean
79%
15
5
1
Does IPH Play a Role in State
Reporting/Public Disclosure?
SSI
VAP
UTI
“Hospital Infection data low; too low?”
“Underreporting hurts patients”
Philadelphia Inquirer - May 22, 2006
3. Costs
Number
Occurring
Excess
Patient days
Catheter-related
BSIs (ICU)
38
304
$209,000
CABG SSIs
33
300
$373,585
VAP(ICU)
16
96
$152,000
Hip SSIs
5
104
$95,022
Totals
92
804
$829,607
HAIs
Ref: Am J Infec Control 2005;33:542-7
Excess
Hospital Costs
Does IPH Play a Role in Costs of HAI’s
Health
Care
Spending
Traditional
Cost Controls
Modern Cost
Controls
Time
Traditional cost controls
Negotiate prices and service fees
Offer fewer benefits to employees
Shift some costs to patients
Reference: Am J Infec Control 2005;33:542-7
Modern cost controls
Stop doing things that don’t work
Use cost-effective products
Improve procedures
4. Court
If Science or Evidence Based
Medicine Does Not Increase
Hand Hygiene Compliance
Then
“Woe to you lawyers also! You lay
impossible burdens on men but will
not lift a finger to lighten them.”
Luke 11-46-47
Guinan J, McGuckin M, et al,
A descriptive review of malpractice
claims for healthcare-acquired
infections in Philadelphia.
Am J Infect Control 2005;33:310-2.
HAI’S Cases (Most Frequent)
Services
Orthopedics:
General Surgery:
Cardio-thoracic:
Medical:
Organisms
MRSA
S. Epidermidis
Pseudomonas
MSSA, Enterococcus,
Enterobacter, Klebsiella
ICU/Surgery/Hand Hygiene
Can IPH Reduce Malpractice
Claims
 C. difficile
 MRSA
 Pre-op Prep
5. Control
Good Medical Care? It’s a coin flip
The Philadelphia Inquirer - March 16, 2006
U.S. patients receive proper medical care
from doctors and nurses 55% of time
N.E.J.M. - Vol 354, No 11, 2006
Pressure
Ulcers
SSI
VAP
BSI
UTI
Control Through IPH
UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY05
20
Rate/1000 Device Days
18
16
14
12
10
8
50th percentile
6
4
2
0
QTR 1
FY05
QTR 2
FY05
QTR 3
FY05
QTR 4
FY05
QTR 1
FY06
QTR 2
FY06
QTR 3
FY06
Is There Evidence to Support
This Trend?
 High colony count found in bath water is similar to the number of
bacteria found in urine from patients with UTIs.
R. Shannon et al, Journal of HealthCare Safety, Compliance & Infection
Control, April 1999; Vol. 3, No. 4, pg. 180-184
 Bath water could serve as a high magnitude microbial reservoir of
potentially antibiotic resistant organisms.
R. Shannon et al, Journal of HealthCare Safety, Compliance & Infection
Control, April 1999; Vol. 3, No. 4, pg. 180-184
 Prepackaged bathing showed lower microbial counts than basins
M. Vernon, DrPH; et al, Archives of Internal Medicine, February 2006;
 Disposable Bed Baths are a desirable form of bathing Critically Ill
patients.
E. Larson, RN, PhD. et. al, AJCC, May 2004; Vol. 13, No. 3
Clinical Process Improvement UTI Bundle
Miller Success Story
1. Can urinary catheter be removed?
2. What was insertion date?
3. Is the patient having any signs or symptoms? (ie, urine
cloudy or sediment noted)
4. Change catheter if patient is having signs or symptoms.
Insert silver-coated catheter.
Urinary Tract Infection Bundle (con’t)
5. If the patient comes to the unit with catheter in place
and signs and symptoms are noted, remove old
catheter, get a urine specimen and send it to the
laboratory, and insert the silver-coated catheter.
6. Drainage bag must be kept lower than the patient’s
bladder at all times, including during transport and
patient activity. Clamp catheter with rubber-coated
hemostats for transport or during off-unit procedure to
prevent reflex. Unclamp as soon as possible; do not
leave clamped for more than 2 hours.
Urinary Tract Infection Bundle (con’t)
7. All urinary catheters must be secured to decrease
movement of catheter. Use Stat Lock device.
8. Strict handwashing must be used before and after
approaching urinary catheter.
9. Perform good pericare daily and after each bowel
movement using aseptic technique. Use Clean and
Shield product that has odor-neutralizing wipes to
cleanse the area and zinc-coated wipes to protect the area.
10. Sterile technique must be strictly adhered to during
insertion of urinary catheter.
VAP Rate vs. VAP Care Bundle
25
150-180 Vent Days
70-80 Vent Days
23
90
% COMPLIANCE
80
70
20
18
17
15
60
14
50
10
12
40
30
5
20
7
10
6
0
0
0
Jul
Aug
Sep
Oct
Oral Care Usage
Nov
HOB 30*
Dec
Jan
Feb
Monthly VAP Rate
Mar
0
VAP RATE/1000 DEVICE DAYS
100
Role of ICP in IPH
 Partnership with nursing
 Protocols/policies that include patient
 Product evaluations
 Prospective evaluations
“GOT CLEAN PATIENTS?”
Don’t slide
into
bad habits,
Remember…
Hand Hygiene
Oral Care
Catheter
Site Care
Skin care
Prevention of Surgical Site
Infections
Robert Garcia, BS, MMT(ASCP), CIC
Infection Control Professional &
Consultant
Pressure
Ulcers
SSI
VAP
BSI
UTI
SSIs: Magnitude of the Problem
 1996: 28.4 million ambulatory surgery procedures in the U.S.
(CDC, National Center for Health Statistics)
 2003: 30.8 million inpatient surgical procedures and 9.7
million (37%) of those performed on patients 65 yrs and older
(CDC, National Center for Health Statistics)
 NNIS: SSIs occur in 2.6%1 of all surgeries =
1.5 million SSIs annually2
 SSIs are the 3rd most common HAI1
 Attributable cost: $25,546 (range $1,783 - $134,602)3
1. Mangram AJ, et al., Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention, Hospital Infection Control Practices
Advisory Committee, Atlanta GA. 2. SSI total calculated by multiplying SSI rate from ref. #3 by surgical procedure numbers from ref. #1 and 2.
3. Stone PW, et al., Am J Infect Control. Nov 2005;33(9):501-9.
Relative Costs of HAIs
Rate per
100
admits
Proportion
of all HAIs
Excess
Hospital
Days
Proportion
of costs of
all HAIs
UTI
2.5
35%
1-2
15%
SSI
1.5
20%
7
50%
Pneumonia
1.0
15%
10
30%
BSI
1.0
15%
10-12
5%
Risk Factors for SSI:
The Patient









Age
Nutritional status
Diabetes
How effectively can
Nicotine use
we control these
Obesity
risk factors?
Coexistent infection
Colonization
Altered immune response
Long preoperative stay
Risk Factors for SSI:
Pre- and Intraoperative










Inappropriate use of antimicrobial prophylaxis
Infection at remote site not treated prior to surgery
Shaving the site vs. clipping
Long duration of surgery
Improper skin preparation
Improper surgical team hand antisepsis
Environment of the room (ventilation, sterilization)
Surgical attire and drapes
Asepsis
Surgical technique: hemostasis, sterile field
To a great extent, this is what we can control!
Goal Zero
 The All-or-None Measurement
 An option for calculating performance
 Denominator = No. of pts. eligible to receive
at least 1 or more discrete elements of care
 Numerator = No. of pts. who actually
received care
 No partial credit is given
 The Centers for Medicare & Medicaid (CMS)
has moved to the “all-or-none” approach
Nolan T, Berwick D. All-or-none measurement raises the bar on performance. JAMA 2006;295:1168-70.
Defining Appropriate Care in Surgery
Appropriate use of antibiotics
Appropriate hair removal
Normothermia
Post-op glucose control
Elevation of head of the bed
Orders for weaning program
Patients diagnosed with VAP
DVT and SUD prophylaxis
SIP/SCIP
(CMS)








IHI




Advantages of All-or-None
Measurement
 “….all-or-none measurements more closely reflects the
interests and likely desires of patients. This is especially
true when process components interact with each other
synergistically….violation of a single step in the sterile
technique in surgery may vitiate the benefits of proper
execution of all other steps…”1
 The Take Away Message: in SSI prevention, it makes
little sense to assure that the surgeon has washed his
hands properly if the patient’s skin has not had optimal
prepping
1. Nolan T, Berwick D. JAMA 2005.
Why Should Hospitals Place
Greater Emphasis on How Skin is Prepped?
 When we consider pathogenesis of SSI,
it has been accepted for decades that
most SSI are endogenous in nature
 Surgical Infections1
 Surgical Infections Including Burns2
 Surgical Site Infections3
 Surgical Antisepsis4
1. Dellinger EP, Ehrenkranz. In: Hospital Infections, Bennett & Brachman, 1998 2. Kluymans J. In: Prevention and Control of Nosocomial Infections, Wensel
RP, 1997.3.Wong ES. In: Hospital Epidemiology and Infection Control, Mayhall CG, 1999. 4.Crabtree TD, Pelletier SJ, Pruett TL. In: Disinfection,
Sterilization, an Preservation, Block SS, 2001.
Infection Rates by Wound
Classes
1960-1962
1967-1977
1975-1976
1977-1986
1987-1990
No. of patients
15,613
62,939
59,352
25,919
84,691
Author, year
Howard
1964
Cruse,
1980
Haley
1985
Olson,
1990
Culver
1991
Clean
5.1
1.5
2.9
1.4
2.1
Cleancontaminated
10.8
7.7
3.9
2.8
3.3
Contaminated
16.3
15.2
8.5
8.4
6.4
Dirty
28.0
40.0
12.6
_
_
Years
Wound Class
Dellinger EP, Ehrenkranz NJ. Surgical Infections. In: Hospital Infections. Bennett JV & Brachman PS, eds., 1998
Sources of S. aureus Infection in
Cardiac Surgery
 Prospective study of 376 patients undergoing CABG
 Pre-op nasal cultures, intra-op wound cultures of
patients
 Nasal cultures of all CV surgery/OR personnel
 DNA subtyping of patient’s colonizing/infecting
strains and personnel strains
 38 SSIs (10.1%), 14 deep infections (3.3%), 5
mediastinitis (1.3%)
 Of >30 wound infections, all except 1 from
patient (= endogenously-derived infections)
Jakob et al. Eur J Cardiothorac Surg 2000;17:154-60. Slide courtesy of D. Maki
CDC on Skin Preparation
 Require patients to shower or bathe with an antiseptic
agent on at least the night before the operative day.
Cat IB
 Thoroughly wash and clean at and around the incision
site to remove gross contamination before performing
antiseptic skin preparation. Cat IB
 Use an appropriate antiseptic agent for skin
preparation. Cat IB
 Apply preoperative antiseptic skin preparation in
concentric circles moving toward the periphery. The
prepared area must be large enough to extend the
incision or create new incisions or drain sites, if
necessary. Cat II
Guideline for Prevention of Surgical Site Infection, 1999. HICPAC, Centers for Disease Control.
AORN on Skin Preparation
 The surgical site and surrounding areas should be
clean.
 The skin around the surgical site should be free of soil and
debris. Removal of superficial soil, debris, and transient
microbes before applying antiseptic agent(s) reduces the
risk of wound contamination by decreasing the organic
debris on the skin.
 Cleansing should be accomplished by any of the following
methods before surgical skin preparation:
 Patient showering and/or shampooing before arrival in the practice
setting
 Washing the surgical site before arrival in the practice setting, or
 Washing the surgical site immediately before applying the antiseptic
agent in the practice setting
Standards, Recommended Practices, and Guidelines, 2005 Edition. AORN, Denver, CO.
AORN on Skin Preparation (cont’d)
 When indicated, the surgical site and
surrounding area should be prepared with
an antiseptic agent
 Antiseptic agents should be….used in
accordance with the manufacturer’s written
instructions. Antiseptic agent(s) should have a
broad range of germicidal action.
Skin Prep Protocols: Example I
Package directions: “Use sponge to prep desired area”
Skin Prep Protocols: Example II
2% CHG Cloth Skin Prep
Instructions
 Use first cloth to prepare the skin area indicated for a moist
or dry site, making certain to keep the second cloth where it
will not be contaminated. Use second cloth to prepare larger
areas.
 Dry surgical sites (such as abdomen or arm): use one
cloth to cleanse each 161 cm2 area (approx 5 x 5 inches) of
skin to be prepared. Vigorously scrub skin back and forth for
3 minutes, completely wetting treatment area, then discard.
Allow area to air dry for one (1) minute. Do not rinse.
 Moist surgical sites (such as inguinal fold): use one cloth
to cleanse each 65 cm2 area (2 x 5 inches) of skin to be
prepared. Vigorously rub skin back and forth for 3 minutes
completely wetting treatment area, then discard. Allow to
air dry for one (1) minute. Do not rinse.
Antiseptic Agent Characteristics
 Significantly reduce microbial counts on intact
skin
 Contain a non-irritating, safe antimicrobial
preparation that maintains the skin’s integrity
 Be broad-spectrum
 Be fast-acting and/or have residual effect
 Clearly define time of application and time of
drying
 Be cost effective
Crowded and Confusing Market
Variance in protocols and practice
Chlorhexidine & SSIs
 Why are there no studies that link use of CHG and SSI
prevention?
 Lack of good study design
 Inclusion of surgery types other than clean
 Inadequate application of agent (bathing with agent followed by
rinsing)
 New study comparing three commercially available skin
prep products (with CHG, iodine, triclosan) provides
evidence that pre-op skin prepping with a CHGimpregnated cloth without rinsing or showering at 12
hrs. and 3 hrs. prior to OR skin prepping significantly
lowers microbial colonization
Maki DG, Paulson DS. [abstract] Evaluation of 6 preoperative cutaneous antiseptic regimens for prevention of surgical
site infection. SHEA Conference, 2006.
What we commonly see in the
medical record:
“The patients skin was
prepped in the usual sterile
manner”
Pre-operative Shower/Bath Protocol

Protocol should consider the following aspects:
1) An antiseptic should be selected based on
certain characteristics as addressed by the FDA
2) How and when is the antiseptic dispensed to
the patient?
3) How often should the patient use the antiseptic
product – once or twice?
4) When are the best times to accomplish
preoperative antiseptic shower/bath?
Nancy B. Bjerke. Preoperative skin preparation: a system approach. Infection Control Today.
http://www.infectioncontroltoday.com/articles/1a1topics.html?wts=200605100734198&hc=39&req=bjerke
Pre-operative Shower/Bath Protocol
5) Is the whole body cleansed or just the incisional
site?
6) What kind of educational materials are available
or does the facility need to create their own?
7) Is the surgeon’s support necessary for this
initiative, or does it involve only nursing?
8) Who verifies completion of this patient
responsibility and where is this documented?
Nancy B. Bjerke. Preoperative skin preparation: a system approach. Infection Control Today.
http://www.infectioncontroltoday.com/articles/1a1topics.html?wts=200605100734198&hc=39&req=bjerke
Surgical Skin Prep Protocol
 Work Outward. Begin at the incision site and move out in concentric
circles. Discard the sponge applicator when periphery is reached and do not
return a sponge/applicator to the incision site once it has been applied to
that area. Extend prep beyond the anticipated drape borders.
 Prep problem areas last. Certain areas within the incision site with the
potential to house excess bacteria need particular attention during the
prepping process. The umbilicus typically has a high microbial count and
needs to be cleaned with a Q-tip prior to prepping. Open wound, and
perineal areas should be prepped last.
 Be careful with drapes. When applying a drape, it is critical you follow
the drape’s individual product instructions. Certain preps need to remain in
contact with the skin for a specified amount of time to be fully effective.
Placing a drape before the solution dries could interfere with this time
requirement, so check the product’s package label for special instructions.
Cynthia Spry. Outpatient Surgery Magazine.
http://www.outpatientsurgery.net/infection_control/2005/brush_up_skin_prep_protocol.php
Skin Prep Protocol
 Avoid pooling. Applying excess amounts will cause the prep solution to
pool under the patient. Pooled prep solution in contact with the skin can
cause irritation or burn and can compromise the adhesive of a dispersive
electrode. Be especially careful to prevent pooling under a tourniquet cuff. If
a flammable agent, such as alcohol, is used, allow the solution to dry to
reduce the possibility of fire. Use of an active electrode in the presence of a
flammable agent could result in fire.
 Document action. Performing a skin assessment, documenting the
assessment, prepping and observing the condition of the skin after surgery
are other key components of a successful infection control strategy. Look at
the condition of the skin before the prep. Is there a rash? Do you notice a
break in skin integrity? Written documentation of your assessment will
create a baseline record and will let staff in the recovery unit determine if a
later skin reaction was the result of the prep.
Spry C, Outpatient Surgery Magazine. May 2005.
http://www.outpatientsurgery.net/infection_control/2005/brush_up_skin_prep_protocol.php
Prevention of VentilatorAssociated Pneumonia
Pressure
Ulcers
SSI
VAP
BSI
UTI
VAP Facts
 Third most common HAI and most common among
ICU patients
 Second most costly HAI
 Between 10% and 20% of patients receiving >48
hours of mechanical ventilation will develop VAP1
 Critically ill patient who develop VAP appear to be
twice as likely to die compared to those without VAP
 Patients with VAP have significantly longer lengths
of stay in the ICU (mean = 6.10 days)2
1. Sole ML, et al., Am J Crit Care. March 2002;11(2):141-9
2. Rello J, et al., Chest. Dec 2002;122(6):2115-21
Current Recommendations
Component
IHI
CDC
Head of bed elevation

(II)
Daily “sedation vacation” and daily
assessment of readiness to extubate

(IB)
Peptic ulcer disease (PUD) prophylaxis

(UI)
Deep vein thrombosis (DVT) prophylaxis

NA
Cleaning of equipment
(IA)
Do not routinely replace ventilator circuits
(IA)
Hand hygiene
(IA)
Subglottic secretion drainage
(II)
Prevention of oropharyngeal colonization
(II)
UI = unresolved issue; NA = not addressed
IHI 100K Lives Campaign. Getting Started Kit: VAP How-to Guide; CDC Guideline for Preventing Healthcare-Associated
Pneumonia, 2002.
Elevation of the Head of the Bed
 Recent randomized controlled study that disputes study
referenced by CDC to recommend use of semirecumbent
positioning to prevent VAP
 Study is unique in three aspects:
 Patient positioning was continuously monitored in first week
 The semirecumbent position was compared to the standard of care
 Data analyzed according to the intention-to-treat principle
 Results:
 Patients in supine position (control) reached only 9.8 to 14.8
degrees (i.e., standard of care)
 Mean backrest position in study group was 30 degrees
 No difference in VAP rates between the groups
 Pressure ulcers: 30% in supine group, 28% in semirecumbent group
van Nieuwenhoven CA, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated
pneumonia: A randomized study. Crit Care med 2006;34:396-402.
Stress Ulcer Prophylaxis
Flanders SA, Collard HP, Saint S. Nosocomial pneumonia: State of the
Science. Am J Infect Control 2006;36:84-93
 7 meta-analyses, >20 studies
 4 showed significant VAP reductions
 3 showed similar but non-significant VAP reductions
Cook D, et al. A comparison of sucralfate and rantidine for the prevention of upper
gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian
Critical Care Trials Group. N Eng J Med 1998;338:781-97.
 Large randomized trial showed no benefit in either sucralfate or H2
antagonists
Kantorova I, et al. Stress ulcer prophylaxis in clinically ill patients: a randomized
controlled trial. Hepatogastroenterology, 2004;2004:51:757-61.
 randomized, placebo-controlled trial, 287 pts.
 studied omeprazole (PPI), famotidine (H2 antagonist), sucralfate
 No significant differences in bleeding or pneumonia rates among the 4 groups
Subglottic Secretion Drainage
 Meta-analysis of randomized trials
 5 trials met inclusion criteria (patients >72
hrs. of mechanical ventilation)
 Results:
 shortened duration of ventilation by 2 days
 shortened length of stay by 3 days
 delayed onset of pneumonia by 6.8 days
Dezfulian C, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia:
a meta-analysis. Am J Med 2005;118:11-18.
Pathogenesis & Interventions
“Strategies to prevent VAP are likely to be successful
only if based upon a sound understanding of pathogenesis
and epidemiology. The major route for acquiring endemic
VAP is oropharyngeal colonization by endogenous flora
or by pathogens acquired exogenously from the intensive
care unit environment, especially the hands or apparel of
health-care workers, contaminated equipment, hospital
water, or air. The stomach represents a potential site of
secondary colonization and reservoir of nosocomial
gram-negative bacilli.”
Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective
strategies for prevention. Respir Care 2005;50:725-39.
Linking Oral and Dental Colonization
with Respiratory Infection
 A review of the published evidence linking
oropharyngeal colonization and respiratory infection,
including VAP (20 studies)
 Provides suggested oral and dental interventions, some
beyond the scope of current guidelines
Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associated
pneumonia: Underappreciated risk and a call for interventions. Am J Infect Control 2005;33:527-41.
Suggested Oral & Dental Care
Interventions
Suggested Intervention
Reasoning
Conduct a daily assessment of the lips, oral
tissue, tongue, teeth, and saliva of each patient
on a mechanical ventilator
Assessment allows for for initial identification of oral
hygiene problems and for continued observation of
oral health
Use separate connection tubing for oral and
tracheal suction
Opening a “closed” system may allow for the
dissemination of respiratory pathogens into the
environment surrounding the patient
Use a toothbrush as opposed to foam swabs or
gauze to remove dental plaque
Dental plaque has been identified as a source of
pathogenic bacteria associated with respiratory
infection
Protocols should be implemented that assist
patients at risk in maintaining adequate salivary
production and tissue health
Saliva provides both mechanical and immunological
effects which act to remove pathogens colonizing
the oropharynx
Care should be taken when using oral care
solutions: Use an alcohol-free, antiseptic rinse
to prevent bacterial colonization of the
oropharyngeal tract
Mouthwashes with alcohol cause excessive drying
of oral tissues. Hydrogen peroxide has been shown
to assist in clearing debris buildup and provide
antibacterial properties
Avoid using lemon-glycerin swabs for oral care
Lemon-glycerin compounds are acidic and cause
drying of oral tissues
Suggested Intervention
Reasoning
Toothpaste should contain additives which assist
in the breakdown of mucous in the mouth
Additives such as sodium bicarbonate have been
shown to assist in removing debris accumulations on
oral tissues and teeth
Use a water-soluble moisturizer to assist in the
maintenance of healthy lips and gums
Dryness and cracking of oral tissues and lips provides
regions for bacterial proliferation. A water-soluble
moisturizer allows tissue absorption and added
hydration.
Yankauer catheters should be covered between
uses on a patient
Yankauers used on a patient and left uncovered on
the bed or other surface pose the risk of
contaminating the patient’s environment with
pathogens from the oropharyngeal tract
Remove secretions that accumulate in the
subglottic area (above the endotracheal tube
cuff) routinely and prior to removal of the
endotracheal tube
Secretions forming in the subglottic area are rapidly
colonized with pathogenic bacteria; aspiration of this
colonized secretion has been shown to cause
ventilator-associated pneumonia
Check for adequate endotracheal tube cuff
pressure at least once per day
Inadequate cuff pressure is associated with aspiration
of bacteria-laden secretions located above the cuff
Check the positioning of the endotracheal tube
at least once per day
Over time, endotracheal tubes may begin to move up
the trachea, leading to a possible unplanned
extubation and concurrent aspiration of contaminated
subglottic secretions
VAP Bundle Success Stories
 Rochester Medical center, Rochester, NY
 At least 220 days without a VAP case
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/UniversityofRoche
sterStrongMemorialHealthWorkingtoReduceComplicationsfromVentilatorsandPreventVAPint.ht
m
 Overlake Hospital, Bellevue, WA
 Reduced VAP by 80% in one year
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/DoingBetterSpend
ingLess.htm
 Consortium of 127 ICUs in 70 hospitals
 68/127 ICUs eliminated VAP for at least six months
 Along with CLAB bundle, estimates are that 1,500 lives were saved,
81,000 hospital days, and $165 million
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/DoingBetterSpend
ingLess.htm
 Owenboro Medical Health System, Owensboro, KY
 Reduced VAP by 72% in 18 months
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVentilato
rAssociatedPneumoniaOwensboro.htm
Swedish Medical Center:
Results of VAP Bundle Intervention
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/EliminateVentilatorAssociatedPneumonia.htm
VAP Bundle & Comprehensive
Oral Care
 Used HMO Acronym:
 Head of Bed: keep at least 30 degrees or greater unless
contraindicated
 Mobility: Each even hour, complete or assist the patient in performing
mobility
 Oral Care: Perform oral care every even hour on intubated and
trached patients. Suction brush at 0800 and 2000. Suction catheters
at extubation, position changes, and every 6 hours or as needed.
Preimplementation
Postimplementation
SICU VAP rate
(NNIS criteria)
10.8 per 1000 vent
days
3.6 per 1000 vent
days
67% reduction
Housewide adult
ICU and
intermediate ICU
VAP rate
5.1 per 1000 vent
days
2.7 per 1000 vent
days
48% reduction
Simmons-Trau D. ZAP VAP with a back-to-basics approach. Nurs 2006 Crit Care;1:28-36.
Percent change
Adding Comprehensive Oral Care to the
IHI VAP Bundle: Achieving Zero
 Baptist Memorial DeSoto
 Baptist Memorial Hospital
Golden Triangle
 Bay Regional Medical Center
 McLeod Regional Medical
Center
 OSF Saint Francis Medical
Center
 Overlake Hospital Medical
Center
 Palmetto Health Baptist
 Upper Chesapeake Medical
Center
48-month Study on Effect of
Oral-Dental Care on VAP:
Brookdale University Hospital Medical Center, NY
 Objective: to determine the effect of a comprehensive oral care
program on rates of VAP, mortality, cost
 MICU patients on mechanical ventilation >48 hrs.
 Pre-intervention: 1/1/01-12/31/02, “standard” oral care
 Intervention: 1/1/03-12/31/04, education and use of a novel oral-dental
care system designed to reduce bacterial colonization of the
oropharyngeal tract and teeth
 Standards of care during the entire 48-month study included 7d vent
circuit replacement, 24-hour HME filter replacement, 24-hour closed
suction catheter replacement, semirecumbent position unless
contraindicated, administration of stress ulcer prophylaxis, and use of
a weaning protocol.
Garcia R, Jendresky L, Colbert L, Bailey A. 48-month study on reducing VAP using advanced oral-dental care: protocol compliance,
rates, mortality, and cost. Abstract presented at the 2006 APIC Conference, Tampa, FL. [publication pending, Crit Care Med]
Patient Demographics & Baseline
Measurements
Pre-Intervention Period
(n = 859)
Intervention Period
(n = 755)
Mean age ± SD
61.3 ± 12.2
63.1 ± 9.8
Males, no. (%)
523 (61)
483 (64)
26.8 ± 8.8
27.3 ± 7.9
Acute respiratory failure
404 (47)
325 (43)
Cardiovascular disease
189 (22)
181 (24)
Gastrointestinal disease
95 (11)
90 (12)
Renal disease
60 (7)
53 (7)
Sepsis
51 (6)
45 (6)
Trauma
26 (3)
15 (2)
Neurological disease
17 (2)
23 (3)
Other
17 (2)
23 (3)
Characteristics
APACHE II
Reason for ICU admission, no. (%)
Protocol Compliance
100
90
80
70
60
50
40
30
20
10
0
Q1 2003
Q2 2003
Q3 2003
Q4 2003
Q1 2004
Q2 2004
Q3 2004
Daily assessment
Deep suctioning q4h
Tooth brushing 2xd
Oral tissue cleansing q6h
Kits at bedside
2-line connector used
Q4 2004
Outcome Data
Pre-intervention Period
(n=859)
Intervention Period
(n=755)
Duration of ventilation,
mean days
10.3
6.5
Ventilator utilization ratio
0.68
0.63
ICU stay, days
12.7
6.5
VAP per 1000 ventilator
days
8.3
4.5 (p <.05)
44 (5.1)
23 (3.0)
163 (18.9)
138 (18.2)
Variable
VAP, no. (%)
Mortality, no. (%)
0
Nov-05
Sep-05
Jul-05
May-05
Mar-05
Intervention Period
Jan-05
Nov-04
Sep-04
Jul-04
May-04
Mar-04
Jan-04
Nov-03
Sep-03
Pre-intervention Period
Jul-03
May-03
Mar-03
Jan-03
Nov-02
Sep-02
Jul-02
May-02
Mar-02
Jan-02
Nov-01
14
Sep-01
16
Jul-01
May-01
Mar-01
Jan-01
VAP cases per 1000 vent days
Nea
r
Zer
o!
VAP Rates, MICU, 2001-2005
Confirmatory Period
Mean annual
rate
12
10
8
6
4
2
Cost of VAP
Study/Year
Warren 2003
ICU Type
Cost with
VAP
Cost
without
VAP
Cost per
VAP case
Attributable
cost
(hospital)
Med, surg
$27,033
$15,136
$11,897
$104,983
$63,689
$41,294
#Pts with
VAP
Measure
127
Rello
2002
842
Charges
Med,
surg,
trauma
Cocanour
2005
70
Attributable
cost
Trauma
$82,195
$25,037
$57,158
Kollef
2005
499
Charges
Various
ICUs
$150,841
__
$150,841
Warren DK, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit
patients in a suburban medical center. Crit Care Med 2003;31:1312-3.
Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of
VAP in a large US database. Chest 2002;122:2115-2121.
Cocanour et al. Cost of ventilator-associated pneumonia in a shock trauma intensive care unit. Surg Inf,
2005;6:65-72.
Kolllef MN, et al. Epidemiology and outcomes of health-care-associatedpneumonia: Results from a large US
database of culture-positive pneumonia. Chest 2005;128:3854-62.
Cost Avoidance: BUMC VAP Project
INFECTION
COST
TOTAL COST
AVOIDED/YR
# PTS WITH
VAP
MEASURE
ICU TYPE
REPORTED
VAP COST
Warren
127
Attributable
cost
(hospital)
Med, Surg
$11,897
$142,764
$83,631
Rello
842
Charges
Med, Surg,
Trauma
$41,294
$495,528
$436,395
Cocanour
70
Attributable
cost
Trauma
$57,158
$685,896
$626,763
Kollef
499
Charges
Various
$150,841
$1,810,092
$1,750,959
STUDY
Total product cost = $59,133
(=VAP cost x 12
avoided cases
per year)
(= Infection cost
— product cost)
My thanks to the Brookdale family for
their dedication and supreme efforts
in improving the care of our patients
Questions & Answers
Dr. Maryanne McGuckin ScEd., MT(ASCP)
Senior Research Investigator
Adjunct Associate Professor
Senior Fellow, Leonard Davis Institute for Health Economics
Senior Fellow, Institute on Aging
University of Pennsylvania School of Medicine
Robert Garcia BS, MMT(ASCP), CIC
Asst. Director of Infection Control
Brookdale Univ. Hospital Medical Center
718.240.5924 ~ [email protected]
President
Enhanced Epidemiology, LLC
P.O. Box 211 ~ Valley Stream, NY 11580
516.810.3093 ~ [email protected]