Decreasing VAE Through a Customized Oral Care Practice

2 5 T H A N N UA L T R AU M A A N D C R I T I C A L C A R E S Y M P O S I U M

O C TO B E R 2 6 , 2 0 1 9

L AU R E N C OX B S N , R N , C C R N

DisclosuresI have no disclosures.

Objectives▪Gain understanding for the importance of Healthcare-associated pneumonia prevention

▪Discuss definitions of VAP, VAE, HAP and NIMs

▪Learn about pathophysiology of changes in the oral mucosa

▪Learn about prevention strategies

Introduction▪ Pneumonia is 2nd most common Healthcare Associated Infection (HAI) worldwide (Kaneoka et al., 2015)

▪ Pneumonia accounts for 15% of all HAIs (Tablan, Anderson, Besser, Bridges & Hajjeh, 2003)

▪ Ventilator Associated Pneumonia (VAP) is the number one cause of death in critically ill patients (Warren, Medej, Wood, & Schutte, 2019)

▪ Recent studies estimate mortality rate secondary to VAP are around 10-13% (Jenson, Maddux and Waldo, 2018; Kalil, Metersky, Klompas, & Muscedere et al. 2016)

▪ All cause mortality related to VAP can range from 20-50% (Kalil et al., 2016)

▪ Hospital Associated Pneumonia (HAP) has an attributable 20-33% mortality rate according to some studies (Tablan et al., 2003)

Why is this important you ask?▪People are dying

▪Healthcare Associated Pneumonia (HAP) substantially increases healthcare costs, length of stay, patient morbidity, and mortality (Kaneokaet al., 2015)

▪One study reports▪ It is estimated that each VAP costs an additional $40,000 per patient

▪ Mechanical ventilation (MV) is prolonged by 7.6-11.5 days

▪ Hospitalization is prolonged by 11.5-13.1 days

▪ 50% of patients with HAP will develop complications (Kalil et al., 2016)

▪Nearly 300,000 patients receive MV each year in the US▪ This is a life-saving therapy for some patients with critical illness or respiratory failure

▪ MV is frequently associated with additional complications and poor outcomes

▪ Some of these complications: VAP, sepsis, Acute Respiratory Distress Syndrome (ARDS), and pulmonary edema

▪MV costs from $600-1500 per day (Wunsch et al., 2010)

▪HAP can have serious complications (Kalil et al., 2016)

▪HAP increases likelihood that patient will discharge to skilled nursing facility (SNF) instead of home (Quinn et al., 2014)

▪In 2011, there were approximately 157,000 HAIs– 39% were VAPs (National Healthcare Safety Network (NHSN) Patient Safety Component Manual 2019)

Who is at risk for HAP/VAP?▪Burns/trauma

▪Neurological disease

▪Decreased level of consciousness

▪Thoraco-abdominal surgery

▪Aspiration

▪Age 70 years or >

▪Presence of nasogastric tube

▪Recent bronchoscopy

▪Supine position

▪Immobilization due to illness/trauma

▪Contact with healthcare personnel with contaminated hands

▪Malnutrition

▪Immunosuppression

▪Repeat endotracheal intubation

▪General anesthesia

▪Postoperative patients

▪ Dependent functional status

▪ Chronic steroid use

▪ Recent alcohol use

▪ COPD

▪ Smoking within 1 year of surgery

▪ CVA history with existing deficit

▪ Sensorium impairment

▪ Transfusion of >4 units of blood prior to surgery (Tablan et al., 2003)

Who is at risk for HAP/VAP?▪Admitted to ICU

▪Poor oral care

▪Intubation (Landgraf, Reinheimer, Merlin, & Couto et al., 2017)

▪Mechanical Ventilation (NHSN, 2019)

▪Nasal or oropharyngeal colonization (Messika, Combe, & Ricard, 2018)

▪Elderly patients with low BMI

▪Malnourished

▪Low albumin

▪Taking Central Nervous System (CNS) active drugs

▪Acid reduction therapy

▪Presence of poorly controlled pain

▪Periodontal disease

▪Dental caries

▪Problems with feeding/swallowing (Quinn et al., 2014)

▪Mandatory ventilator modes

▪Increased net fluid balance

▪Use of paralytics, sedatives and benzodiazepines (Lewis, Li, Murphy, & Klompas, 2014)

▪Poor health status

▪Diabetes mellitus

▪Length of hospitalization (Chao, Chen, Wang, Lee, & Tsai, 2009)

▪Male sex

▪Tracheostomy

▪ARDS

▪Multi-system Organ Failure (MOSF) (Parisi et al., 2016)

Burn patients are at increased risk▪According to Magill et al. (2016), the critical care units with the highest incidence of VAE are:

▪ Trauma critical care units

▪ Surgery critical care units

▪ Neurology/Neurosurgery critical care units

▪ Medical critical care units

▪ And Burn critical care units

▪Injured patients are at highest risk of contracting VAP than any other group (Mosier & Pham, 2009)

▪The lung is the initial organ to succumb in the dying burn patient

▪Inhalation injury leads to pathological changes that favor pneumonia

▪Respiratory sequelae of inhalation injury is primary cause for mortality in patients with additional thermal injury

▪Respiratory tract infections are most significant complication for burn-injured patients

▪Burn patients with 20% or greater Total Body Surface Area (TBSA) are more likely to get pneumonia (Edelman, Khan, Kempf, & White, 2007)

Basic Definitions▪Pneumonia is inflammation of lung

▪Healthcare-Associated Infection is attributed to any infection that occurs when the Date of Event is on or after 3 days of hospital admission

▪Healthcare-Associated Pneumonia is classified as “PNEU” according to the CDC and NHSN definitions

▪PNEU is pneumonia identified with clinical, radiologic and laboratory criteria

▪Nosocomial Infection Marker (NIM)- An alternate marker for presence of an HAI based on microbiology data (pathogen >105) and patient census data

▪Ventilator-associated Pneumonia (VAP) is a new pneumonia occurring 48 Hours or greater after endotracheal intubation that is characterized by new infiltrates, new onset fever, leukocytosis and purulent sputum (Mogyordi, Dunai, Gal, & Ivanyi, 2016)

▪Ventilator Associated Events (VAE) are acknowledged when after a period of stability there is a subsequent period of instability where the patient requires increased PEEP or FIO2 and show some signs of infection or inflammation

▪VAE is broken down into VAC, IVAC and PVAP

▪Old VAP definitions are no more!

Definitions

Definitions▪ What’s the difference?

▪ The old Pnu1 definition relied on radiographic confirmation

▪ Had subjective content like character of sputum

▪ New VAE definitions are more specific

Pathophysiology of HAP/VAP▪ Colonization of oral-pharyngeal (OP) mucosa

(caries or plaques) or stomach

▪ Natural or forced (MV) aspiration of contents of OP mucosa (Cutler and Sluman, 2013)

▪ Up to 45% of healthy adults micro-aspirate in their sleep (Tablan et al., 2003)

▪ MV helps push infectious material past cuff or potentially through the tube into lower airways

▪ Colonization of trachea can lead to pneumonia

▪ Can also occur and Secondary Blood Stream Infection (BSI)

Pathophysiology of HAP/VAP▪Poor oral hygiene and subsequent colonization is independent risk factor for VAP

▪Any disruption to the health of the OP mucosa can increase colonization▪ Decrease in saliva

▪ Xerostomia

▪ Dental caries

▪ Biofilm

▪ Dental abscess (Yildiz, Durna, & Akin, 2013)

▪Anything that inhibits normal protective mechanisms (Cough, glottis closure, mucociliary clearance) increases risk of aspiration/VAP/HAP

Pathophysiology of HAP/VAP▪ Poor oral hygiene can result in increase in

pathogenicity of microorganisms over time (Jenson et al., 2018)

▪ Routine oral care can help offset pathological changes of the OP mucosa during hospitalization

▪ Patients with acidosis, alcoholism, azotemia, coma, diabetes mellitus, hypotension, leukocytosis, leukopenia, pulmonary disease, or endotracheal or nasogastric tubes in place are at increased risk of colonization (Tablan et al., 2003)

▪ Frequent oral care can help decrease bacterial burden and therefore lead to decrease in risk for HAP/VAP (Quinn et al., 2014; Messika et al., 2018)

Prevention- What do we have control of?▪In 2003, the CDC recommended all hospitals develop an oral care protocol (Warren, Medei, Wood, & Schutte, 2019)

▪In 2004, the Institute for Healthcare Improvement recommended a treatment bundle for VAP prevention1. Head of Bed (HOB) > 30°

2. Peptic Ulcer Disease prophylaxis

3. Deep Vein Thrombosis prophylaxis

4. Daily sedation vacations (Zuckerman, 2016)

• In 2010, the IHI added a 5th component

5. Daily oral care with Chlorhexidine (Pileggi, Mascaro, Bianco, Nombile, & Pavia, 2018)

▪Oral care has been shown to decrease respiratory infections VAP and HAP (Landgraf et al., 2017; Jenson et al., 2018; Kaneoka et al., 2015)

▪Even most basic aspects of infection prevention should be used: alcohol-based hand disinfection, use of microbial surveillance, and aggressive attempts at early device removal

Current Prevention Efforts

Current Prevention Efforts

Tube Necessity▪Noninvasive Positive Pressure Ventilation (NPPV) has been presented as a way to decrease the need for intubation as well as reduction of MV days

▪Several studies show that patients that receive NPPH for acute hypercapnic respiratory failure secondary to COPD have improved survival rates

▪Decrease in pneumonia rate noted in patients that received NPPV instead of MV

▪Spontaneous breathing trials (SBTs) and spontaneous awakening trials (SATs) have been shown to improve patient outcomes (Lewis et al., 2014)

▪Daily SBTs and SATs decrease VAE rates (Klompas et al., 2015; Magill et al., 2016)

▪SATs and SBTs are associated with shorter episodes of MV (Klompas, Li, Kleinman, Szumita & Massaro, 2016; Kallet, 2019; Ottosen & Evans, 2014)

Current Prevention Efforts

Insertion▪Subglottic suction has been included in several VAE Prevention bundles (Zuckerman, 2016; Schleder, Stott, &Lloyd, 2002; Enwere, Elofson, Forbes, & Gerlach, 2016; Ottosen & Evans, 2014)

▪Subglottic suction decreases VAE risk (Bergmans et al., 2017)

▪Subglottic suction decreases VAP (Kallet, 2019; Jackson & Owens, 2019; Magill et al., 2016; Mosier & Pham, 2009; Chao et al., 2009; Klompas, 2015)

Current Prevention Efforts

Documentation▪Evidence-based oral care programs/bundles should include routine assessment of the mouth (Warren et al., 2019; Cutler & Sluman, 2014;

▪Oral assessment tools can help determine oral care needs as well as monitor effectiveness (Ames et al., 2011)

▪Oral care tools can help nurses customize oral care for each individual patient in order to preserve good oral hygiene (Yildiz et al., 2013)

Current Prevention Efforts

Environment▪Use of closed-circuit suction catheters should be a part of MV bundles

▪Endotracheal tube cuff pressures should be monitored and adjusted to prevent aspiration of contents into the lower airways (Kallet, 2019)

▪Head-of-bed elevation is an important prevention measure and is part of the MV bundle (Mogyordi et al., 2016; Lewis et al., 2014; Zuckerman, 2016; Kallet, 2019; Cutler & Sluman, 2014; Klompas et al., 2015)

▪Head-of-bed elevation may decrease MV days (Klompas et al., 2016)

▪Utilize the arm of ventilator to hold the tubing in order to prevent condensate from entering the patient’s lungs (Cutler & Sluman, 2014; Mosier & Pham, 2009; Zuckerman, 2016)

Current Prevention Efforts

Prevention▪Toothbrushing should be part of MV bundle (Kallet, 2019)

▪Toothbrushing can aid in VAP prevention (Kaneoka et al., 2015; Cutler and Sluman, 2014)

▪Toothbrushing and suctioning are an important preventative measure in the care of the ICU patient (Yildiz et al., 2013)

▪Removal of OP secretions is an important to VAP prevention (Cutler & Sluman, 2014)

▪Oral care for non-ventilated patients should be performed 4x per day or after meals and nightly (Quinn et al., 2014)

▪Oral care for the mechanically ventilated patient should occur at least every 4 hours (Warren et al., 2019

▪Subglottic suctioning should be utilized prior to turning to aid in preventing VAP if continuous subglottic suctioning is unavailable (Chao et al., 2009)

▪Oral chlorhexidine should be used to decrease colonization of the OP mucosa (Klompas et al., 2016; Kaneoka et al., 2015; Cutler & Sluman, 2014; Warren et al., 2019; Kallet, 2019; Landgraf et al., 2017; Ottosen & Evans, 2014; Mosier & Pham, 2009)

Current Prevention Efforts

Education▪Soiled or colonized hands of health professionals can put patients at risk for HAP

▪Alcohol-based hand hygiene should be performed before patient encounter (Ottosen & Evans, 2014)

▪Staff education is necessary when implementing oral care protocols (Warren et al., 2019; Ames et al., 2011)

Current Prevention Efforts

Oral Care Challenges▪Industry standard kits don’t supply enough subglottic suction catheters

▪Many burn patients need oral care every 2 hours

▪Industry standard kit is setup for every 4 hours

▪Hard to tell compliance

▪Jenson et al. (2018), in a similar study said that greatest barriers to nursing for proper oral care are time and prioritization

Burn ICU’s Change Project▪ Our solution to lack of appropriate kit

▪ Customizable oral care kit for all patients, intubated and non-intubated patient

▪ Each pocket was labeled with a time corresponding to an oral care administration time

▪ Night shift loads, all shifts perform

▪ Implemented with Lean Daily Management (LDM)

▪ Education rolled out in April during staff meeting

▪ If stocked/utilized inappropriately nurses should address the proper way the kit should have been utilized during bedside report

▪ The charge nurse would address/educate any non-compliance by nursing

Change project▪To help improve compliance, kit was used to encourage non-intubated, independent or dependent patients and family members to be included in their care by including them in the brushing routine customized for the patient.

▪All staff, nursing and patient care assistants (PCA), were encouraged to perform any oral care that was remaining in the pocket for any hour

▪A chart was created that detailed how to set up each oral care kit according to the needs of different types of patients.

▪We used hospital policy and procedure regarding frequency of oral care, how to perform oral care and type of oral care per patient

▪We increased the frequency of oral care whether due to the condition of their mouth or their current state of illness

▪If the nurse felt there was a need to perform additional oral care for a patient, then this was deemed appropriate

▪Our goal was to see decrease in VAP or respiratory NIMs

Results▪Expected a decrease and instead saw increase

▪Noticed an issue with compliance in August

▪We increased monitoring of compliance, compliance improved

▪In September, still had increase

▪Most likely due to some outside factor

Challenges/Limitations

▪Need a longer study period

▪Pre-intervention was slow time of year

▪Had early issues with compliance

▪Did not achieve desired outcome

Future Work▪ Education of staff in the Burn Center is always an ongoing process

▪ Our hospital is a teaching hospital therefore we constantly have flux of nurses in and out

▪ One of our barriers to practice may be newer nurses in need of education

▪ Patient compliance was often a problem in the non-intubated, independent group

▪ Patient education regarding the importance of frequent oral care may help compliance in the future

▪ Continue to track compliance

▪ We are considering increasing frequency of Chlorhexidine

Conclusions▪VAP/HAP/VAE are significant threat to all hospitalized patients

▪Burn patients are at increased risk of acquiring HAP/VAP/VAE

▪Prevention is key

▪Did not achieve expected outcomes, but our compliance was better than we thought

▪There are many challenges to preventing HAI, need to continue this work in other units

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