Vol. 18 •Issue 23 • Page 30
Provena Saint Joseph Medical Center RTs Currently Winning War Against VAP
RTs at Provena Saint Joseph Medical Center in Joliet, Ill., do not pay mere lip service to providing quality patient care. For staff there, the quality reflects in excellent patient outcomes.
Bill Heidel, BS, RRT, CRT, CPFT, manager of the respiratory care department, is proud of his staff, saying some advances in care at Provena virtually eliminated ventilator-associated pneumonia (VAP) in the critical care units.
“We’re very proud of the fact that we had no cases of VAP in the first quarter of 2005 and had only nine cases in all of 2004,” he explained. “With an average of 31 patients placed on ventilators in our adult ICUs every month, that’s a record to be proud of.”
Heidel is well aware that VAP is currently a national issue. “You have to have your head in the sand right now if you don’t know the importance of fighting VAP,” he said. Agencies like the Centers for Disease Control (CDC) and JCAHO are on the lookout especially.
The Institute for Healthcare Improvement (IHI) has launched an ambitious 100K Lives Campaign with a goal of saving 100,000 lives annually through implementation of specific interventions for preventing avoidable deaths in American hospitals.
One of the interventions of most concern to respiratory therapists is a bundle of recommendations aimed at reducing VAP in the nation’s ICUs.
Common Hospital Foe
VAP typically is found in about 25 percent of all intubated patients and is, in fact, the most common infection in ventilated patients. As such, VAP is a significant issue in any hospital’s morbidity and mortality statistics.
Before gathering baseline data on VAP, Heidel and his colleagues agreed on a common definition for the hospital-acquired infection. “Here at Provena Saint Joseph Medical Center, we’ve set a 48-hour window after someone has been placed on mechanical ventilation,” he explained. “In those first two days, there’s a good possibility that the individual actually contracted the infection before being placed on the vent. But when we start to see microbes and organisms associated with pneumonia in someone who has been on a ventilator more than 48 hours, we call that ventilator-associated pneumonia.”
VAP is a complex problem with multiple contributing factors, and it takes a committed team of health care professionals to tackle the issue, Heidel acknowledged. “Everybody wins if we can get the VAP rate down to essentially nothing. That’s why we’re going after it so aggressively.”
There are no simple interventions to curb the problem. “It really is a complicated issue that requires a multi-disciplinary team approach with a lot of knowledgeable, experienced health care professionals attacking it from various angles,” he said.
One of the keys to the effective management of VAP is early detection. “As respiratory care practitioners, we’re constantly watching for even small changes in the viscosity, quantity and color of the patient’s secretions,” said Heidel. “We alert the physician right away, obtain the cultures as ordered and then look for the common organisms associated with VAP.” Pseudomonas, Klebsiella, Pseudobacter and Enterobacter are the common gram-negative bacteria associated with VAP, and S. aureus is the leading gram-positive organism.
“I don’t envy the doctors who have to pick broad spectrum antibiotics to start the empirical, shot-gun approach against VAP,” said Heidel. “Once the cultures come in, the treatment can be tailored to the results, but it’s still a difficult balancing act. They want to treat the VAP aggressively and effectively but not over-treat or have the patient on antibiotics too long. And, of course, it’s important not to encourage the growth of drug-resistant strains of these organisms.”
One of the key IHI recommendations regarding VAP prevention is to elevate the head of the bed 30 to 40 degrees. “That’s our standard position for ventilated patients,” Heidel said. “If the physician wants the patient supine or in some other position, he has to write a specific order for that position.”
ICU nurses carry out regular oral care on patients who are on ventilators, using a customized kit that contains a toothbrush, oral swabs and mouthwash. With everything readily available in one kit, nurses can easily complete oral care every two to four hours on the patients and document the care in the medical record.
“I really think oral care has significantly reduced the oropharyngeal bacterial population and contributed to our low incidence of VAP,” said Heidel.
“VAP is insidious and can creep up without much warning at times,” Heidel remarked. At Provena, RTs go to the bedside every two hours around the clock to monitor the patient’s secretions and measure the plateau pressure, tidal volume and important oxygen ratios. “These things are telling us if there’s an active VAP coming this way for the patient, and we can start aggressive treatment right away,” he added.
“For our patients on PEEP, we want to make sure oxygen is moving into the hemoglobin properly without causing any unnecessary barotrauma,” he said. “When we divide the patient’s PaO2 by the FiO2 being administered, we want a number that is more than 200 but not necessarily too far over.”
Historically, ventilated patients have been placed on a tidal volume of 10-12 ml/kg of body weight, but practitioners at Provena have changed their way of thinking on this issue. “In our adult ICUs, we use a tidal volume somewhere around 6 ml/kg, and that reduces the risk of barotrauma,” said Heidel.
Watching Patient Closely
Close monitoring of the plateau pressure in order to detect VAP very early on in the disease process is important, he emphasized. If the plateau pressure starts to creep up to about 35 cm of water, staff notify the hospital’s medical director, John Walsh, MD. He, in turn, intructs the physician responsible for the patient, talking about aggressive treatment options to prevent VAP.
Experts continue to debate the pros and cons of manipulating the ventilator circuit during routine changes, Heidel noted. “The ventilator circuit remains a controversial topic today, but the majority of the literature shows that manipulation of the circuit does make patients more susceptible to pneumonia. We’ve taken those research findings and applied them to our practice, so we change the circuit only once a month unless gross contamination occurs in the interim.”
Heat moisture exchangers (HMEs) have largely replaced standard heated humidifiers for patients on ventilators at the hospital, Heidel said. “We know from earlier studies that regular humidifiers put out a lot of condensate that can travel back to the airway and inoculate the patient with pneumonia-causing organisms. The HME, on the other hand, traps body heat and exhaled moisture and then gives that back to the patient with the next inhalation without any condensate to serve as a reservoir for inoculating and growing organisms.”
Provena RTs use dry circuits as part of their respiratory care standards to ensure evidence-based practice. “If we do use a heated humidifier, we incorporate a heated wire circuit to reduce the possibility of condensate formation,” Heidel explained.
Currently, respiratory therapists are changing out HMEs daily. “But we’re watching the literature closely and see some indicators that say we should be doing it every 48 hours or even less often,” said Heidel. “We haven’t yet decided to change our practice, but we’ll keep monitoring the research in the field.”
Focus on Weaning
Patients weaned by RTs are weaned faster than patients weaned by physicians, and Heidel said literature backs that up. “That research was the springboard for our weaning protocol and for the prominent role RT plays in weaning here in the ICU. Our philosophy here is, ‘the day you go on the ventilator is the day you start weaning.'” Night staff RTs make weaning rounds at 5 a.m. every day, following the protocol.
Early weaning is one of the best defenses against VAP, according to the director. “I call this protocol our ‘hole card,’ because it’s our ace against VAP.” Provena RTs use a weaning protocol that is a combination of recommendations from Duke University and from Loyola University Health System, tailored to the hospital by the medical director. (See Sidebar on Weaning Protocol)
ET tubes are the source of infection, rather than the ventilator, Heidel pointed. “It’s that darn ET tube inserted below the cords that’s bringing in the biofilm that causes the pneumonias. Currently, Provena is getting ready to trial test an ET tube that provides continuous suctioning above the cuff to remove sub-glottic secretions before they can travel down into the sterile airway.
Heidel will evaluate the impact of the new ET tubes on patient outcomes, especially in light of the higher cost of the new tubes. “Is it just a frill or will it have real clinical benefit?” he asked.
If there is a silver lining from all of the current focus on ventilator-associated pneumonia, it centers on that fact that it has forced various hospital departments to work closely together, said Heidel.
It is for those reasons the respiratory care department was recently given the AARC Quality Respiratory Care Recognition Award for the second year in a row.
Sandy Keefe is a California practitioner.
Provena Saint Joseph Medical Center’s Weaning Protocol
Every day at 5 a.m., RTs at Provena Saint Joseph Medical Center in Joliet, Ill., make the rounds of ventilator-dependent patients in the adult ICUs. Each patient is evaluated against the following set of established criteria that determine eligibility for weaning:
• Heart rate less than 120 beats/minute.
• Systolic BP less than 180 and greater than 90 (patients on any neo-synephrine, levophed or dopamine greater than 5 mcg/kg/min are not eligible).
• Respiratory rate less than 35 breaths/minute.
• Sedation Scale score of 3, 2, 1, or S (3=awake and alert, 2=slight drowsy, easy to arouse; 1=frequently drowsy, arousable, S=sleep). Somnolent patients or those with minimal or no response to physical stimulation are rated as a 4 and are not eligible for weaning.
• O2 saturation greater than or equal to 90 percent.
• Adequate cough reflexÐyes or no?
Patients who meet these criteria are then placed on CPAP +5cm and maintained on their current FiO2 setting for 5 minutes before being evaluated against the following criteria:
• Respiratory rate less than 35 breaths/minute.
• Rapid shallow breathing index (RSBI) less than 100 (RR/Vt).
• O2 saturation greater than or equal to 90 percent.
• If all of the above conditions are met, the RT then implements weaning by leaving the patient on CPAP +5cm, adding PS+5cm, and continuing the current FiO2 for two hours if tolerated. The RT notifies the physician of the weaning trial and then places the patient back on initial setting after two hours if no extubation order has been received.
The trial is terminated and the patient is placed back on previous ventilator settings if any of the following conditions occur:
• Respiratory rate increases more than 15 breaths per minutes, or exceeds 35 breaths per minute.
• O2 saturation goes below 90 percent.
• Heart rate increases more than 20 beats/minute.
• Systolic BP goes over 180 or drops below 90.
• Increased anxiety, diaphoresis or any significant dysrhythmia is detected.
• The ventilator weaning protocol is clearly outlined in a one-page, fill-in-the-blank format that makes it quick and simple for RTs to document their clinical practice.