In 2002, we were introduced to the term “ventilator-associated pneumonia” (VAP), a rather subjectively defined state which only captured about 32% of actual preventable incidences of pneumonia. Then, in 2013, the CDC commissioned a special task force to nail down exactly who or what was responsible for poor outcomes – any poor ventilator outcome – ushering in the age of the ventilator-associated event (VAE).
Of all healthcare facility acquired pneumonias, 86% are associated with mechanical ventilation and are described as ventilator-associated pneumonia (VAP). More than 3900 VAPs were reported by hospitals participating in the National Health Safety Network in 2012.
The CDC transitioned from VAP to VAE surveillance in adult inpatient settings in 2013. This new surveillance detects a broader range of conditions and events are classified into three hierarchical tiers: ventilator-associated conditions (VAC), infection-related ventilator-associated complication and possible/probable VAP. It’s obvious they are looking for much higher numbers (search “CDC VAE” and you will be hit with several pages of staggering statistics and resources).
The most current research suggests that most VACs (the broadest of the three tiers) are due to pneumonia, acute respiratory distress syndrome, atelectasis and pulmonary edema. The literature also says that all of those aforementioned states can be prevented. The tightening of VAP guidelines has come to pass just as hospitals and healthcare facilities are being financially penalized for “untoward” outcomes.
SEE ALSO: Reducing Ventilator-Associated Events
The current VAP bundle (head of bed elevation, oral care, DVT prophylaxis and peptic ulcer prophylaxis) is the standard of care for ventilated patients. Depending on where you practice, you may not be responsible for any of these items and yet other departments may participate aggressively.
Let’s review what the respiratory therapist can do to help ward off VAE:
The national average for hand washing compliance in healthcare facilities is only 48%. Take the time to wash your hands, and do it correctly. We all know the “wash with the Happy Birthday song or scrub through three verses of Row, Row, Row Your Boat.”
Head of the Bed Up At Least 30 Degrees
This is paramount, as aspiration is a major concern. Make sure tube feedings are held before you perform any procedure which will agitate the patient. If your patients are ordered a sedation vacation, make the time to be at the bedside. It’s been my experience that vacations are often cut too short or not given at all because the therapist wasn’t at the bedside to assist the nurse. Keep this in mind: patients who successfully participate in routine sedation breaks get extubated quicker, dramatically reducing the potential to get tagged with a VAE.
Maintain the Patient’s Airway
Assist with oral care and do your best to keep the patient’s mouth clean. Imagine how you would feel being intubated for several days and unable to brush your teeth. Suction the oropharynx frequently. Keep the cuff at the minimum pressure necessary to maintain minimal leak, as anything less will allow for microaspiration. Move the endotracheal tube from side-to-side on a routine basis to prevent breakdown of the lips and facilitate a new place to clean while performing oral care.
Maintain Your Equipment
Change bacterial filters on the vents routinely and keep your machine clean by wiping them down frequently. At a minimum, wipe the main controls of your vent at the beginning and of your shift and clean any unsightly spills or splashes off the machine as soon as you identify them.
Use Assessment Skills
Atelectasis, pneumonia and pulmonary edema can all usually be warded off by paying close attention to breathing sounds and reporting changes as soon as you hear them. Take the time to get to know your patients, spending time with the charts to look for potential decline. Is the white count creeping up? Is the blood pressure heading south? Has the pulse ox been stable with FIO2 weaning? How’s the chest X-ray? What are the blood gases doing? How are the lactate levels? The more you study the patient’s chart and understand the data, the better you will get at making early interventions.
Get to know your bugs. Those reading this likely know that E. Coli is normal flora found in the bowel, but what about Acinetobacter or Klebsiella? Where do Staphylococcus aureus or Pseudomonas aeruginosa come from? Knowing how and where these bugs originate can help you to educate other staff and healthcare team members about what potentially could be causing issues with your healthcare acquired infection issues.
It is imperative that we, as a profession, become more involved with the care of our patients. Your job is not to just run in, check the vent and make sure everything is okay. Your job is to take care of the respiratory needs of that patient and to do everything in your power, to the extent to which you are allowed within scope of practice, to keep your patients safe and from harm.
Knowledge is not only power – it is respect.
Edwin C. Frost is an RRT and is president of Aeris Consulting & Management, LLC-Mantua, N.J., and president and chief clinical officer of CPAPAmerica.com.