ZAP VAP YVONNE SENTNER WAYNESBURG UNIVERSITY NUR589: EVIDENCE-BASED NURSING PRACTICE NANCY STYNCHULA, BSN, RN OCTOBER 6, 2010 INTRODUCTION Ventilator Associated Pneumonia (VAP) is the second most common infection that patients develop while in the hospital and the leading cause of death due to hospital acquired infections (Augustyn, 2007). Hospital acquired infections are also known as nosocomial infections. VAP usually happens when patients are on mechanical ventilation (the ventilator) for over 48 hours.
VAP is costly because it increases the hospital length of stay, often times in the Intensive Care Units (ICU). Patients are often on the ventilator and are receiving antibiotics to treat the pneumonia. This paper will show that by doing something as simple as swishing a drug known as Chlorhexidine around in your mouth (or for those who are ventilated, having their mouth swabbed with it) can decrease the number of VAPs and patients, hospitals and insurance companies money. PICOT QUESTION
In patients requiring mechanical ventilation for over 48 hours, is the usage of oral Chlorhexidine solution twice daily effective in reducing Ventilator Associated Pneumonia (VAP)? Population Any patients that are on the ventilator for over 48 hours, regardless of age, sex, or past and current medical history. Intervention Patients on the ventilator for over 48 hours will be given Chlorhexidine to “swish and spit” to help kill bacteria present in the mouth. For patients that are extubated, the Chlorhexidine will be treated like a mouthwash.
For those who are on the ventilator, the Registered Nurses (RNs) will swab out their mouth with the Chlorhexidine liquid. Comparison There is no comparison because all patients will be given Chlorhexidine twice a day. Outcome The outcome will prove that there will be a lower number of VAPs due to the use of Chlorhexidine treatments on all patients. Time One year will be needed to complete this study. KEY WORDS Ventilator, Chlorhexidine, Ventilator Associated Pneumonia, Pneumonia, Intensive Care Unit, Prevention, Patients INTRODUCTION
Pneumonia is the second most common hospital acquired infection (also known as nosocomial infections) in the United States. It is also the leading cause of death in comparison to other nosocomial infections. Ventilator Associated Pneumonia (VAP) can occur when a patient has been mechanically ventilated for over 48 hours. It is a costly infection. The cost of VAP is estimated to be an additional $40,000 per hospital admission per patient and an estimated $1. 2 billion per year. Education is the number one way to reduce the transmission of VAP to patients.
Interventions should start before a patient is intubated. Nurses need to educate patients and other staff about the importance of good mouth care, proper suctioning (both orally and via the endotracheal tube (ETT), the importance of inserting a nasogastric or orogastric tube, having the patient’s head of bed (HOB) at 30 degrees (or higher) and finally the importance of using chlorhexidine twice daily which will be discussed in this paper. Pneumonia is the 2nd most common hospital acquired (nosocomial) infection that can lead to death of many hospitalized patients.
Ventilator associated pneumonia (VAP) is a form of nosocomial pneumonia that can occur to patients that are intubated for over 48 hours. Since there is a high ratio of patients who get VAP, it is to the hospital’s advantage to learn ways to decrease the incidence of contracting it. By decreasing the number of VAP patients, the hospital can save money because the patients will spend less time in the Intensive Care Units (ICU) and the additional cost of care (such as antibiotics, salaries, and equipment needed to treat patients). The cost of VAP is estimated to be $40,000 per hospital admission per patient.
By using chlorhexidine, which is relatively inexpensive, hospitals will save billions of dollars a year. Interventions to prevent VAP begin at the time of intubation and should be continued until the patient is extubated. Due to the higher nurse / patient ratios, education is essential to preventing VAP. Nosocomial infections relate directly to nursing care so nurses should understand the pathophysiology, risk factors, and prevention strategies for VAP. Augustyn (2007) explains there are two types of VAP, early onset and late onset.
Early onset occurs 48-96 hours after intubation and is associated with antibiotic-susceptible organisms. Late-onset VAP occurs more than 96 hours after intubation and is associated with antibiotic-resistant organisms. The pathophysiology of VAP involves two main processes: colonization of the respiratory and digestive tracts and microaspiration of secretions in the airway. If the patient has preexisting conditions such as immunosuppression, chronic obstructive pulmonary disease (COPD) or another respiratory disease, the chance of getting VAP increases.
As was previously stated, VAP is caused by bacteria. Bacteria can spread to the lungs from different sources. These include nares, dental plaque, gastrointestinal tract, patient-to-patient contact and the ventilator circuit. The endotracheal tube can provide a direct route for bacteria to enter the respiratory tract. The bacteria come from pooled secretions above the endotube’s cuff or in the upper airway and can get disseminated into the lungs by ventilator-induced breaths. Aspiration of gastric contents is another potential cause of VAP because the stomach acts as a reservoir for bacteria.
If the patient has a nasogastric or orogastric tube this can lead to the reflux of bacteria into the airway. Body positioning, level of consciousness, and number of intubations can also increase the likelihood of VAP. Improper hand washing can result in cross contamination. With all the likely sources of VAP, hospitals and nurses must make every effort to prevent its spread. All of the articles reviewed for this paper states that education is the best way to zap vap! Doctors and nurses should encourage patients to get their pneumonia vaccination.
Hand washing is also important for doctors, nurses and visitors. Nurses should give diligent mouth care every few hours and use chlorhexidine twice a day. They should suction the patient’s endotube and mouth every two hours and as needed to prevent the pooling of secretions. Turning the patient every two hours and doing chest physiotherapy (chest percussion) can increase pulmonary drainage. A flutter valve can help break up secretions so the patient is able to cough them up easily. The head of bed should be elevated between 30 and 45 degrees to minimize the risk of reflux and aspiration of bacteria.
Many studies suggest that interventions to reduce VAP should start with intubation and end with extubation. Many doctors feel that the interventions should start with all patients because they never know when a patient will need intubated. Prophylaxis should start at hospital admission. This paper will mainly discuss the importance of using chlorhexidine oral solution. Chlorhexidine is an antimicrobial that decreases the bacteria in the mouth. If the patient is extubated, they take the chlorhexidine solution and rinse it in their mouth for 30 seconds, then spit it out.
If the patient is intubated, the nurse swabs the mouth with the chlorhexidine solution and then suctions out the extra with a yankauer suction catheter. This paper will discuss the mixed reviews on chlorhexidine based on several studies. REVIEW 1 Koeman, et al (2006) discusses a double-blind, multicenter Dutch trial on the effects of chlorhexidine. 385 nonimmunocompromised patients who were on the ventilator for over 48 hours were randomly assigned to one of 2 treatment groups. The first group of patients received chlorhexidine 2% in petroleum jelly FNA (the chlorhexidine group).
The second group was given chlorhexidine 2% plus colistin 2% in petroleum jelly FNA (the CHX/COL group). The third group received the placebo of petroleum jelly FNA alone. All patients were in the semi-recumbent position with the head of bed elevated 30 degrees. 52 out of 385 patients developed VAP, including 13 (10%) in the chlorhexidine group, 16 (13%) in the CHX/COL group, and 23 (18%) assigned placebo (petroleum jelly alone). Koeman, et al (2006) explains that there was no significant difference of VAP contamination between the 3 groups, including mortality and number of days on the ventilator.
The difference was colonization occurring during days 5-8 was lower in the CHX/COL group than the other two groups. Also the chlorhexidine group showed a reduction in oropharangeal colonization with gram positive organisms while the CHX/COL reduced colonization of gram negative organisms. Simply put, the use of oral decontamination with chlorhexidine is a low-cost intervention that doesn’t carry the risk of antibiotic resistance. Evidence shows though that a significant reduction in VAP (and of mortality) with the use of chlorhexidine has not been proven. REVIEW 2
Ganz, et al. (2009) did a study to describe the oral-care practices of Intensive Care Unit (ICU) nurses, compare those practices with current evidence-based practice (EBP), and to determine if the use of evidence based practice (EBP) was associated with personal demographic or professional characteristics. 218 practicing ICU nurses were surveyed about their oral care practices. The survey included questions about demographic and professional characteristics (such as age, gender, nursing education, years of ICU experience, shifts worked and whether they were full or part time. The other questions included a checklist of oral-care practices including equipment, solutions and technique used. The nurses then rated their level of priority of oral care on a scale of 0-100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with current best evidence. Then ANOVA was used to statistically analyze the data to determine differences of EBP based on demographic and professional characteristics. The most commonly used equipment was gauze pads (84%), tongue depressors (55%), and toothbrushes (34%).
Chlorhexidine was the most common used solution at 75%. 44% of the nurses admitted to brushing their patients’ teeth. 71% perform an oral assessment before oral care is done, yet no one could say what assessment tool was used. 57% of the nurses documented their oral care when charting. While many of the nurses ranked oral care a high priority, many didn’t implement EBP into their care. This tells us that there is an importance in encouraging ICU nurses to use evidence-based protocols on oral care. This is why the study was done on VAP.
The project was able to describe oral-care practices of the ICU nurse, compare those to the current EBP, and determine whether personal demographic or professional characteristics were related to evidence-based oral care. No significant relationships were found between the two. REVIEW 3 The Centers for Disease Control and Prevention (CDC) recommend diligent oral hygiene care for patients on the ventilator that is at risk for nosocomial pneumonia. It has been suggested that VAP will soon become one of the preventable hospital-acquired illness that will no longer be reimbursed.
Hospitals are stressing the importance of good oral hygiene to prevent the development of VAP. Dental plaque and oropharynx colonization are important factors in the development of nosocomial pneumonia. With patients on the ventilator, changes in the normal flora of the mouth occur within 48 hours of intubation. Endotracheal tubes act as a conduit and are one of the causes of VAP. Halm and Armola’s (2009) article reviewed and summarized current evidence that oral care has on colonization and nosocomial pneumonia in ventilated patients. Seven randomized controlled trials and one meta-analysis were used.
Oral care interventions (such as brushing teeth) or pharmacological (various forms / strengths of chlorhexidine) were used. The frequency of use varied. The outcomes that were measured were dental plaque scales, oral culture scores, bacterial cultures, clinical pulmonary infection scores, and CDC diagnostic criteria for lower respiratory tract infections (such as fever, leukocytosis and pulmonary infiltrates). For dental plaque colonization, tooth brushing reduced plaque colonization but the use of 0. 12% chlorhexidine had no effect. Chlorhexidine gel (0. %) lowered the number of positive cultures on dental plaque on days 5 to 7 and day 10 but not past day 11. It is recommended that more studies comparing 0. 12% and 0. 2% chlorhexidine and how they are applied be done to find the optimal dose with the best benefit. For oropharangyl colonization, 2% chlorhexidine/2% colistin was the most beneficial because it reduced both gram-negative and gram-positive bacteria. 2% chlorhexidine alone only reduced gram-positive bacteria. Another study also showed that chlorhexidine (swab or spray) reduced the number of colonizations or caused no bacterial growth at all.
For most of the studies, chlorhexidine was seen as a favorable intervention to reduce the growth of bacteria in order to prevent VAP. By using chlorhexidine, the patients require less antibiotic use and reduce the risk of antibiotic resistance. Further research is needed to determine the frequency of oral care practices that will result in the best patient outcomes. REVIEW 4 The objective of Munro, et al. (2009) study was to examine the effects of oral care done mechanically, pharmacologically or a combination of both on VAP.
Patients who were ventilated for over 24 hours were enrolled in the study. Patients that were already diagnosed with pneumonia or those who had no teeth were excluded. 547 patients were randomly assigned to receive 1 of 4 treatments. Those treatments were 0. 12% chlorhexidine solution applied twice as day, teeth brushing done three times a day, a combination of both. The final group was the control group which received “usual care”. The patients remained in the study for a maximum of 7 days or until they were extubated. At the end of the study, patients were assigned scores according o the Clinical Pulmonary Infection Score (CPIS). For the CPIS, points were assigned based on the patients’ temperature, white blood cell count, tracheal secretions, oxygenation, chest x-rays, and tracheal secretion cultures. The total for each section was the patients’ scores. To make the study unbiased, each patient and nurse was given instructions on the specific way they were to apply the chlorhexidine solution and brush teeth. The outcome of the study was that Chlorhexidine solution was effective in reducing the number of VAPs, while tooth brushing did not.
The combination of the two showed no additional benefit over each being done separate. It has been shown that tracheal colonization started on the first day of intubation so it is important to start VAP prevention before the intubation occurs. DISCUSSION All of the articles reviewed had one thing in common. Chlorhexidine solution is a great tool to help prevent VAP in ventilated patients. The interesting fact is that while chlorhexidine is effective, there are other things that must be done in addition to the use of chlorhexidine that offers patients the best chance of preventing VAP.
Craven (2006) states that there is an Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign that is recommending hospitals use the “ventilator bundle” in addition to chlorhexidine. The “ventilator bundle” is five simple components that also reduce the progression of VAP. These are elevating the bed to 30 to 45 degrees, a daily “sedation vacation,” daily assessment for readiness of patient to be extubated, and prophylaxis for peptic ulcer disease (PUD) and deep vein thrombosis (DVT). Several hospitals using this approach are reporting zero episodes of VAP over time.
SUMMARY While most articles reviewed state that elevating the head of bed, good oral mouth care and chlorhexidine are all components needed to prevent VAP, Craven (2006) also suggests that other factors must occur to “zap vap. ” Education is a given. It is important to educate staff about the “ventilator bundle” and chlorhexidine. Everyone understands that, but it is also important to reintroduce staff to infection control methods, such as hand washing and using personal protective devices (such as gowns, gloves, masks and glasses) when appropriate.
The staff in turn educates visitors which prevent the bacteria being transferred to waiting rooms, cafeterias and restrooms. Craven (2006) states that environmental issues are one area that needs to be improved in order to reduce cross contamination. This is especially true when the VAP is caused by drug resistant bacteria. Studies have been shown to implicate inanimate objects as an indirect contributor to nosocomial infections, including VAP. More aggressive environmental disinfection is needed to reduce the spread of health endangering organisms.
It is also important to have adequate staff in the ICUs so the staff is able to comply with the infection control practices. Currently hospitals may be unable to meet this demand due to financial limitations so the other areas mentioned must be strictly adhered to. When a patient is shown to have drug resistant organisms, it is important to avoid allowing the nurse to take care of immunocompromised patients to avoid cross contamination. This is why it is important to have adequate staffing. VAP prevention is a multidisciplinary agenda. It needs to be fought from many different angles to protect patients.
Figure 1 (copied from Craven, 2006) summarizes the agenda for VAP prevention. Evidence – based VAP Prevention Program Decreased VAP Morbidity ; Mortality Assess Outcomes ; Monitor Compliance Translation of Prevention Strategies into Hospital Practice Regulatory Measures Multidisciplinary Team Financial Incentives Institutional Support S Su Figure 1 IMPLICATIONS FOR PRACTICE As nurses, we never know when patients are going to be intubated. This is why it is important for us to start chlorhexidine upon admission of the patient. All hospitals should have a VAP prevention policy in place.
At Allegheny General Hospital, the policy is number III. A. 70 (see attached). The policy covers everything from hand washing to changing the yankauer every 24 hours. It also states the head of bed (HOB) should be at least 30 degrees unless contraindicated. The newest addition is the order for chlorhexidine and how it should be applied. Section 3 states the outcomes that will happen if everything is done according to policy standard. The attention grabber of using simple things such as chlorhexidine and keeping the HOB elevated 30 degrees is these processes are cheap.
Hospital administration cannot argue about the effectiveness of chlorhexidine. It has been proven in numerous studies that it is effective. It is also not time consuming. Nurses argue when they feel they have one more action to do because they already feel stressed about appropriate care and the time they have to complete it. Swabbing a patient’s mouth takes 30 seconds. Making sure the HOB is elevated to above 30 degrees takes another 30 seconds. These are 2 things that nurses can do in 60 seconds to save a life. Nurses are always looking for evidence-based practices to provide the best care for patients.
This is why chlorhexidine is important to institute in all hospitals. More time needs to be spent on educating nurses about the importance of oral care. Making VAP prevention a policy unites all caregivers (such as nurses, doctors and respiratory therapists) in the fight against VAP. It is something that is highly preventable but has a large impact on morbidity and mortality. Protocols and monitoring tools must be developed to decrease the incidence of VAP. These should not only include the ICUs but the step-down units as well. No one is immune to VAP. IMPLICATIONS FOR RESEARCH
More research needs to be done to help prevent VAP for the contraindicated patients. For the patients that are unable to have the HOB elevated 30 degrees, is chlorhexidine alone enough? Should jejunostomy / gastrostomy tubes be placed to reduce the risk of aspiration which is associated with VAP? What other ways can hospital institutions fight against VAP? There are hospitals that are using subglottic endotubes. These tubes prevent the pooling of secretions in the throat so bacteria cannot colonize there. Should they become the standard of care for patients who may be intubated long-term?
Does performing a tracheotomy on a patient earlier rather than later reduce the risk of VAP? Are silver nitrate lined endotubes really effective in not allowing bacteria to colonize on the endotubes? If so, is the extra cost worth it when hospital administration compare the costs of using those to the cost of VAP? In the studies we reviewed, was the HOB elevated? Did the caretakers follow the “ventilator bundle”? Several studies did not say if patients had been reintubated during this admission (which increases the likelihood of VAP) or if they were already diagnosed with pneumonia?
It was stated that patients had been intubated for over 48 hours but for how long? Research must be done also to reduce the chance of aspiration, since it and VAP go hand in hand. Obviously, there are many avenues that still need to be evaluated to reduce VAP. What is important though is to know that until all avenues have been researched, chlorhexidine is a cheap and effective way to reduce the likelihood of VAP in patients requiring intubation for over 48 hours. REFERENCES Augustyn, B. (2007). Ventilator-Associated Pneumonia.
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