Ventilator Associated Pneumonia (VAP) Prevention Bundle
Policy No. ________
This Sample Protocol or Bundle for VAP Prevention is provided as an educational service of Hawaii Medical. We have prepared two versions, one with and one without references and notes of explanation. This is the version with explanations and footnotes. The reference free version is available as a separate document. The document is in Microsoft Word format for easy editing. Hospitals are encouraged to modify sections to better meet the needs or policies of your institution. Hospitals assume full responsibility for the content, accuracy, and implementation of any aspect of the suggested policy and procedure. This Sample VAP Bundle for the NICU/PICU has been adapted from successful bundles provided by The University of Cincinnati Children’s Hospital, Vanderbilt Children’s Hospital, Dayton Children’s Hospital, Children’s Memorial Hospital at Central DuPage Hospital and recommendations from The Center for Disease Control. The format was copied from Vanderbilt’s standard protocol format. We are very interested in your comments and modifications to the Sample Bundle. We expect to issue future editions based upon feedback from clinicians like you. Please send your questions, comments or modified vap bundles to: Read McCarty, President Hawaii Medical, LLC Telephone 1-800-596-1555 rmccarty@hawaiimedcial.com Thank you.
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April 16, 2007 Sample VAP Bundle 506003053A
Ventilator Associated Pneumonia (VAP) Prevention Bundle
Policy No. ________
Manual: Subject: Policy Number: Approved By: Approved By: Generated By: Effective (Issued) date: Last revised date: Team members performing: Guidelines applicable to: Specific education requirements: Physician Order requirements:
Nursing Policy Manual VAP Prevention
RN, LPN, RT, Care Partner, Nurse Extern, Nurse Intern NICU, PICU
Ventilator Associated Pneumonia (VAP) Prevention Bundle I. Outcome Goal To reduce incidences of ventilator associated pneumonia (VAP). II. Background Ventilator associated pneumonia (VAP) is a nosocomial infection occurring in patients receiving mechanical ventilatory support that is not present at the time of intubation and that develops more than 48 hours after the initiation of that support. VAP is the leading cause of death among hospital-acquired infections. VAP prolongs the time spent on the ventilator and overall length of stay, with an estimated additional cost of $40,000 to a typical hospital stay. In the NICU the cost can be in excess of $200,000 per case. VAP is considered a medical error and not a side effect of ventilation.
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April 16, 2007 Sample VAP Bundle 506003053A
Ventilator Associated Pneumonia (VAP) Prevention Bundle
Policy No. ________
III. Policy All intubated patients will be cared for in accordance with these procedures. IV. Protocol: General Guidelines 1. Educate health care workers regarding the epidemiology and infection control measures for preventing VAP. (CDC)
Education, motivation and rewarding staff has been shown to be a crucial part of VAP prevention bundles. Continuous long term vigilance is required.
2. Strict adherence to NICU Hand Hygiene Policy and gloving with all patient contact is maintained. (CDC)
Reduce cross-contamination especially with multidrug resistant pathogens.
3. Continuous care monitoring to extubate as soon as possible. The extubation readiness test can be used to identify patients who are ready to resume unassisted breathing. (CDC)
Goal is to limit the length of intubation and mechanical ventilation to reduce possibility of infection. The risk of VAP increases with duration of intubation. Early tube removal has been shown to reduce VAP; however, re-intubation should be avoided.
4. Report all changes in the amount and color of ETT secretions to care team. (CDC)
Change in secretions is one sign of VAP.
5. Disinfect high-touch surfaces of equipment with Saniwipe™ each shift. Wear gloves while disinfecting.
All surfaces are a potential source of contamination and should be regularly disinfected. 6.
Single patient resuscitation bags should be replaced once per week. Cleaning and high-level disinfection of reusable equipment are required.
To reduce the possibility of contamination and bacteria growth.
7. Resuscitation bags are never to be placed in the bed or on the counter. They are hung outside of the incubator or radiant warming bed.
This is to reduce possibility of contamination. 8.
Elevate head of bed 15 degrees, neonatal and 30-45 degrees, pediatric, unless contraindicated and accompanied by a written order from the physician. (CDC)
Head of bed elevation has been shown to reduce the risk for aspiration of oropharyngeal or nasopharyngeal secretions or gastrointestinal contents.
9. When feasible, in older children, use an endotracheal tube with a dorsal lumen above the cuff. Maintain correct cuff pressure. (CDC)
This keeps suction secretions from accumulating above the cuff. Correct cuff pressure prevents pooled secretions from entering the air way.
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April 16, 2007 Sample VAP Bundle 506003053A
Ventilator Associated Pneumonia (VAP) Prevention Bundle V.
Policy No. ________
Protocol: Mouth / Oral care Provide developmentally supportive mouth care every four hours. (CDC) a. Follow manufacturer’s instructions for oral care product. b. Pay attention to infant’s cues – if infant becomes distressed, contain and comfort until stability is reestablished. c. Encourage rooting reflex in older infants d. Follow infants tongue movements with swab – do not force swab. e. Encourage parents to perform oral care when parents are deemed competent and comfortable with procedure
Routine oral decontamination is an effective method for reducing VAP by decreasing the microbial load in the oropharyngeal cavity. It has been found that the incorporation of routine oral hygiene into standard practice reduced VAP by 67%.
VI.
Protocol: Suctioning Guidelines 1. The ETT suction set-up should remain closed as much as possible.
Data supports the concept of ETT set-ups being closed as much as possible and connections remaining sterile similar to an IV line to decrease exposure to organisms.
(CDC) 2. Suction only as clinically indicated. Clinical conditions include but are not limited to: visible secretions, unexplained drop in SaO2 and/or vent airway graphics reveal evidence of secretions.
Suctioning is not a benign procedure and can cause lose of FRC and suctioning can create atelectasis. Secretions and bacteria can migrate down the tube and settle in the lungs.
3. Mouth should be suctioned prior to the nose in all instances.
Reduces risk of cross contamination.
4. Oral suctioning should occur before ETT suctioning, repositioning ETT tube, extubation or significant patient repositioning.
Helps prevents aspiration of contaminated secretions residing in the rear of the oral cavity.
5. When not in use, oral suction devices are stored in a non-sealed plastic bag.
This is to help lower the risk of contamination.
6. Oral suction devices are changed daily.
This is to prevent growth of bacteria. Suction equipment used for oral and endotracheal suctioning becomes colonized with pathogens within 2- 24 hours.
7. The ventilator circuit end is not contaminated during patient suctioning procedure. Therefore do not to lay the circuit end directly on the bed linen.
This is to reduce possibility of contamination as it should be assumed the bed linen and most surfaces are contaminated.
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April 16, 2007 Sample VAP Bundle 506003053A
Ventilator Associated Pneumonia (VAP) Prevention Bundle 8. Suction line is rinsed with sterile water after each use.
Policy No. ________
This is to prevent growth of bacteria. Suction equipment used for oral and endotracheal suctioning becomes colonized with pathogens within 24 hours. Tap water may be contaminated.
9. Suction canisters are changed every Monday and/or as needed when visibly soiled. Date the canister when changed.
This is to prevent growth of bacteria. Suction equipment used for oral and endotracheal suctioning becomes colonized with pathogens within 2- 24 hours.
10. Use separate suction set-up for ETT & oral suction systems. This includes canisters / tubing, etc.
The risk of cross contamination between oral & ETT is high.
11. Do not use saline lavage for suctioning, unless ordered by physician, or ETT appears plugged.
The use of NS for lavage has been shown to lead to VAP because it can introduce organisms into lungs as it travels down the ETT. Studies have shown the practice of saline lavage may be detrimental to the patient as bacteria may be dislodged from the catheter and ETT into the lung while simultaneously causing oxygen desaturation. (CDC)
VII.
Protocol: Ventilator Management
This keeps the line closed and reduces air contaminates from entering.
1. Change ventilator circuits only when visibly soiled, not routinely. (CDC) 2. Drain condensate from the ventilator circuit every 2-4 hours. Avoid draining condensate toward patient.
Warm expired air condenses in ventilator tubing and microbial growth can occur rapidly in the pooled condensate.
3. Always drain ventilator circuit before repositioning patient.
Helps prevents aspiration of potentially contaminated secretions.
4. Consider closed condensation trap systems. (CDC)
Closed systems help maintain system integrity. 5.
Oxygen therapy equipment should be cleaned, rinsed and allowed to completely air dry. (CDC)
Prevent bacteria growth.
6. CPAP systems can remain on standby for no longer than 12 hours with flow and heater remaining on.
Longer standby increases the risk of contamination.
7. Consider using circuits and heaters that reduce or eliminate water in the tubing.
Discourages bacteria growth.
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April 16, 2007 Sample VAP Bundle 506003053A
Ventilator Associated Pneumonia (VAP) Prevention Bundle
Policy No. ________
8. To reduce “rain-out,” keep circuits out of drafts or shield with towel / blanket (do not lay towel or blanket on circuit or heater).
Condensation can become contaminated.
VIII. Parent / Family Education 1. Inform parents and family about the VAP protocol, importance of hand washing, and risk of micro-aspiration due to tube or patient movement. 2. Assess parent’s desire and ability to participate in or carry out oral care. IX. Documentation 1. Protocol interventions are documented on the nursing flowsheet. Cross References 1. CDC “Guideline for Hand Hygiene in Health-Care Settings” Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Excerpt published MMRW October 25, 2002 / 51 (RR16); 1-44 2. CDC “Guidelines for Preventing Health-Care Associated Pneumonia”, 2003 Recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Excerpt published MMRW March 26, 2004 / 53 (RR03); 1-36
X.
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April 16, 2007 Sample VAP Bundle 506003053A