Ventilator Associated Pneumonia (VAP) — Improving Practice With An Audited Oral Care Intervention

Kate Gray, Sarah Jarvis, Jamie Bomford, Paul Hayden, Nandita Divekar Medway Maritime Hospital, NHS Foundation Trust, Intensive Care Unit (ICU), Gillingham, Kent, UK

Kate.Gray@medway.nhs.uk

BAckground

oBjectiVes

methods

conclusions

resultsVAP is one of the most common hospital-acquired infections, associated with increased morbidity, mortality, and costs.1 Although definitions vary, VAP typically refers to pneumonia that arises ≥48 hours after intubation and mechanical ventilation.1, 2 While there are non-modifiable risk factors for VAP, risk factors such as supine position, dental plaque, and oropharyngeal colonization are amenable to intervention.3-5 Our nine-bed, level 3 intensive care unit (ICU) cares for patients requiring ventilation, haemofiltration, and other complex therapies. We average 2200 ventilation days per year and have a patient-to-nurse ratio of one-to-one or one-to-two; a doctor is available at all times. Excellent mouth care is an essential element of VAP prevention and integral to our ventilator care bundle, but formal daily audits have not been recorded for mouth care, suctioning, 30°-45° head-up position, or sedation holds.

We hypothesized that our standard mouth care practices could be improved by implementing a new oral care kit. The objective of this study was to audit ventilator care bundle compliance for three months after instituting a new ventilator mouth care protocol and then revert to our unit’s standard oral care practice for an additional three months of auditing. Staff satisfaction with both oral care methods was surveyed. The number of VAP cases was recorded.

The CDC (2012) VAP definition was adapted (Fig. 1).6 Q•Care™ Rx Oral Cleansing and Suctioning System with 3M™ Peridex™ (Chlorhexidine Gluconate 0.12%) Oral Rinse (Sage Products, Cary, IL, USA) oral care system was used for three months, beginning in September, 2012 (Fig. 2). The cost of the system was to be fully reimbursed if the VAP rate was the same or worse than our standard practice. In November 2012, we reverted to our standard oral care practice, which was to perform mouth care using a small toothbrush every 3 hours, and toothpaste at least twice a day; lip moisturisers and any other solutions were used as necessary. A senior nurse audited the ventilator care bundles daily for a further three months (Fig. 3). VAP rates, bundle compliance, nurse satisfaction, and antifungal (Nystatin) use were monitored.

Medway VAP criteria

Patient ventilated 48 hrs

Radiological criteria CXR with new/ progressive and persistent infiltrates/ consolidation/ cavitation

Signs/ symptoms/ laboratory criteria At least one of the following: • fever > 38C •WCC <4 or 12 •PCT > 1.5 (or significant rise)

AND at least two of the following: • new onset purulent sputum •Change in character of sputum •Increased respiratory secretions •New onset cough/ dyspnoea •New abnormal breath sounds on auscultation •Worsening gas exchange

Based on 2012 CDC definition

To diagnose VAP, all boxes must be ticked:

Figure. 1. Medway VAP criteria. Figure. 2a. The Q•Care™ oral care system is part of the ventilator care bundle.

Figure 2b. The Q•Care™ oral care system hangs by the bedside.

Ventilation does not inevitably result in VAP, but VAP is a quality indicator. The European VAP benchmark for ICUs is a rate of 5% to 15% while the US benchmark is 3 to 20 cases per 1,000 ventilator¬ days.7 Use of advanced tools, a comprehensive oral care protocol, and staff compliance with the protocol is associated with significantly reduced rates of ventilator-associated pneumonia.8 A cost-effective analysis found that oropharyngeal decontamination led to VAP prevention and was cost saving for ICU patients.9

It was previously thought that VAP was not a particular problem in our ICU, and that oral care practices were sufficient, but we now see room for improvement. Mouth care and nursing staff satisfaction with the Q•Care™ system were much better than with our standard practice. Nursing staff reported anecdotally that patient mouths were cleaner. Only one case of VAP was noted during the entire study period, suggesting good compliance with the ventilator bundle. Nystatin has not been required for any patient using Q•Care™.

In conclusion, the Q•Care™ system provided better staff compliance and satisfaction with the ventilator care bundle. Instituting this system has the potential to prevent VAP and result in better patient outcomes and less healthcare resource use. As we implement this new, comprehensive oral care system, we will continue to monitor the results.

VAP

� In the Q•Care™ system group, 135 patients were admitted to the ICU, 91 were ventilated, and 14 had a subglottic tube.

� In the standard oral care protocol group, 129 patients were admitted to the ICU, 87 were ventilated, and 31 had a subglottic tube.

� There were no cases of VAP while the Q•Care™ system was in use and one case with the standard oral care protocol (Fig. 4).

� Nystatin was not needed with the Q•Care™ system, but was needed twice with the standard oral protocol.

Figure 6. Oral care compliance was substantially better with the Q•Care™ system than with the standard oral care protocol.

Figure 4. Pneumonias per 1,000 ventilator days.

one case of VAP = 3.19

3.503.002.502.001.501.000.500.00

no cases of VAP = 0

episodes per 1.000 Ventilator days

standard care Q•Care™

100

80

60

40

20

0oral hygiene

Q•Care™oral hygiene

standrard care

compliance

� Similar levels of compliance were observed for the majority of the elements of the ventilator care bundle during both the Q•Care™ system and standard oral care portions of the study (Fig. 5).

Figure 5. Compliance was similar for most parameters of the ventilator care bundle during the Q•Care™ system and the standard oral care portions of the study.*

Personal Protection equipment standard carePersonal Protection Equipment Q•Care™

hand hygiene After standard careHand Hygiene After Q•Care™

hand hygiene Prior standard careHand Hygiene Prior Q•Care™

genitouriary Prophylaxis standard careGenitouriary Prophylaxis Q•Care™

sedation hold standard careSedation Hold Q•Care™head up standard care

Head Up Q•Care™

0 20 40 60 80 100

standard care Q•Care™

� Compliance with the oral hygiene protocol was substantially higher during the Q•Care™ oral care system part of the study than when the standard oral care protocol was used (Fig. 6).

satisfactionNursing staff experience was better with the Sage Q•Care™ system than with the standard oral protocol. Of the 25 staff members surveyed:� 100% strongly agreed that the Q•Care™ system was more convenient to use (Fig. 7).

Figure 7. Nurses agreed that the Q•Care™ system was more convenient to use.

25

20

15

10

5

0Agree disagreestrongly agree strongly disagree

� 76% strongly agreed and 24% agreed that the Q•Care™ system saved nursing time.� 88% strongly agreed and 8% agreed that the protocol was easier to comply with when

using the Q•Care™ system.� 52% strongly agreed and 36% agreed that the Q•Care™ suction toothbrush was effective

at removing plaque. Two staff disagreed and one strongly disagreed.� 80% strongly agreed and 20% agreed that the Yankauer device effectively suctions

whilst avoiding trauma to the oral cavity.� 68% strongly agreed, 20% agreed, and 12% disagreed that using a one-piece instead of a

two-piece tool allows for better compliance with the oral care protocol.

Figure 3. Medway audit criteria.

� Bed Days� Ventilator Days� Head Up 30º– 45º� Sedation Held

� DVT Prophylaxis� GU Prophylaxis� Humidification� Hand Hygiene prior

� PPE� Safe Disposal Of

equipment� Hand Hygiene After

� Oral Hygiene� SG Tube Days� 4-Hourly SG Tube

Aspirations

compliance 98%

100%

0% 0% 0%

compliance 78%

reFerences1 Greene LR, et al. 2009. http://www.apic.org/Resource/EliminationGuideForm/18e326ad-b484-471c-9c35-6822a53ee4a2/File/VAP_09.pdf. Accessed 20 August 2013. 2 American Thoracic Society; Infectious Diseases Society of America. Am J Respir Crit Care Med. 2005;171:388–416. 3 O’Keefe-McCarthy S. Dynamics. 2006;17:8-11. 4 Soh KL, et al. J Infect Dev Ctries. 2012;6:333-9. 5 Somal J, Darby JM. Crit Care. 2006;10:312. 6 Center for Diseases Control Prevention (CDC) Ventilator-associated Pneumonia (2012). http://www.cdc.gov/HAI/vap/vap.html. Accessed 22 August 2013. 7 Morgan P, et al. Crit Care. 2009;13(Suppl 1):P296 (doi: 10.1186/cc7460). 8 Garcia R, et al. American J Critical Care. Nov 2009; 18: 523-32. 9 van Nieuwenhoven CA, et al. Crit Care Med. 2004;32:126-30.

Acknowledgements Thank you to the intensive care staff at Medway maritime Hospital who supported this audit. This work was supported by Sage Products LLC.