CUSP for VAP Factsheet - Maryland Hospital Association

Policy Driven or Structural Measures
1. Use a closed ETT suctioning system.
SHEA1 Pro‐ Recommends the use a cuffed endotracheal tube with in‐line or subglottic suctioning. ZAP2 Pro‐ Recommends the use of closed endotracheal suctioning system. 3
ATS CDC4 Makes No Recommendations
Makes No Recommendations
2. Change closed suctioning catheters only as needed.
All Guidelines AARC Evidence ‐ Based Guidelines (Hess, 2003 )5 Makes No Recommendations Pro‐ Recommends that ventilator circuits should not be changed routinely for infection control purposes. Also, notes that the use of closed suction catheters should be considered part of a VAP prevention strategy. When closed suction catheters are used, they do not need to be changed daily for infection control purposes. 3. Change ventilator circuits only if circuits become damaged or soiled.
Pro‐ Recommends the change of ventilator circuit only when visibly SHEA soiled or malfunctioning. Pro‐Recommends the use of new circuits for each patient, and changes if ZAP the circuits become soiled or damaged, but no scheduled ventilator circuit changes. ATS Makes No Recommendations Pro‐ Recommends the change of circuit when it is visibly soiled or CDC mechanically malfunctioning. 4. Change HME every 5-7 days and as clinically indicated.
Pro‐Recommend the change of humidifier circuit when it is visibly soiled SHEA or mechanically malfunctioning humidifier, not on the basis of duration of use. Pro‐Recommend changes of HMEs every 5 to 7 days or as clinically ZAP indicated. ATS Makes No Recommendations Pro‐ Recommend the change of HME when it malfunctions mechanically CDC or becomes visibly soiled, but not more frequently than every 48 hours. 1
5. Provide easy access to NIVV equipment and institute protocols to promote use.
SHEA Pro‐Recommends the use of noninvasive ventilation whenever possible. ZAP Makes No Recommendations Pro‐Recommends that noninvasive ventilation should be used whenever possible in selected patients with respiratory failure. Makes No Recommendations ATS CDC 6. Periodically remove condensate from circuits, keeping the circuit closed during the
removal, taking precautions not to allow condensate to drain toward patient.
Pro‐ Recommends the removal of condensate from ventilator circuits SHEA while keeping the ventilator circuit closed during condensate removal. ZAP Makes No Recommendation Pro – Recommends that contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented ATS from entering either the endotracheal tube or inline medication nebulizers. CDC Makes No Recommendation 7. Use early mobility protocol.
All Guidelines Makes No Recommendations Pro‐ Findings of this study showed that mechanically ventilated acute Early ICU Mobility Therapy respiratory failure patients who underwent early intensive mobility (Morris, 2008) 6 therapy had a shorter ICU and hospital stay than similar patients who received standard physical therapy. Pro‐The aim of this study was to determine the post hospital outcomes Receiving Early Mobility in ICU of implementing early mobility protocol. This study finding showed that patients who received early ICU mobility therapy had fewer hospital (Morris, 2011) 7 readmissions and deaths in 12 months post discharge period. Early Physical Medicine and Pro‐ This quality improvement program found that the incorporation of Rehabilitation early mobility into the daily care of ICU patients substantially reduced 8
(Needham, 2010) length of stay. 8. Perform hand hygiene.
ATS Pro‐ Recommends the adherence to hand‐hygiene guidelines published by the Centers for Disease Control and Prevention / World Health Organization. Makes No Recommendations
Pro‐ Recommends the use of effective infection control measures: staff education, compliance with alcohol‐based hand disinfection, and isolation to reduce cross‐infection with MDR pathogens. 2
CDC Pro‐ Recommends the decontamination of hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water or by using an alcohol‐based waterless antiseptic agent. 9. Avoid supine position.
SHEA ZAP ATS CDC Pro‐ Recommends the maintenance of patients in the semirecumbent position (30‐45 degrees) unless medically contraindicated. Makes No Recommendation Pro – Recommends that patients should be kept in the semirecumbent position 30‐45degrees rather than supine. Pro‐ Recommends the elevation of head of the bed to an angle of 30‐45 degrees. 10. Use standard precautions while suctioning respiratory tract secretions.
Pro ‐ Recommends appropriate infection prevention and control SHEA practices are used at all times, including aseptic techniques when suctioning secretions and handling respiratory therapy equipment. ZAP Makes No Recommendations ATS CDC Makes No Recommendations Makes No Recommendations 11. Use orotracheal intubation instead of nasotracheal.
Pro‐ Recommends orotracheal intubation over nasotracheal intubation SHEA based on the increased risk of sinusitis. Pro‐ Recommends the use of the orotracheal route for intubation when ZAP intubation is necessary. Pro‐ Recommends orotracheal intubation over nasotracheal intubation ATS based on a trend toward reduction in VAP rates and sinusitis. Pro‐ Recommends the use of orotracheal intubation over nasotracheal CDC intubation unless contraindicated. 12. Avoid the use of prophylactic systemic antimicrobials.
Pro‐ Recommends prophylactic aerosolized or systemic antimicrobials SHEA should not be used for routine VAP prevention. ZAP Makes No Recommendations ATS Makes No Recommendations CDC Makes No Recommendations 13. Avoid non-essential tracheal suctioning.
All Guidelines Make No Recommendations 3
New South Wales Statewide Pro – Recommends that tracheal tube suctioning should not be carried Guideline for Intensive Care out on a routine basis, but rather out of clinical need to maintain the (Rolls, 2009) 9 patency of the tracheobronchial tree. 14. Avoid gastric over-distention.
SHEA Pro‐ Recommends the avoidance of over distention. ZAP Makes No Recommendations ATS Makes No Recommendations CDC Makes No Recommendations Bibliography
1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals . Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31‐S40. 2. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence‐based clinical practice guidelines for ventilator‐associated pneumonia: Diagnosis and treatment. J Crit Care. 2008;23(1):138‐147. 3. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital‐acquired, ventilator‐
associated, and healthcare‐associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388‐416. 4. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidleines for preventing healthcare‐associated pneumonia, 2003: Recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep. 2004;53:1‐36. 5. Hess DR, Kallstrom TJ, Mottram CD, et al. Care of the ventilator circuit and its relation to ventilator associated pneumonia. Respiratory Care. 2003;9(48):869‐79. 6. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238‐2243. 7. Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011;341(5):373‐377. 8. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil. 2010;91(4):536‐542. 9. Rolls K, Smith K, Jones P, et al. Suctioning an adult with a tracheal tube. NSW Health Statewide Guidelines for Intensive Care. 2007. 4