Ventilator Associated Pneumonia Prevention Bundle

Appendix I: Policy Driven Structural Measures

Ventilator Associated Pneumonia Prevention Bundle

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.
ATS3 / Makes No Recommendations
CDC4 / Makes No Recommendations
2. Change closed suctioning catheters only as needed.
All Guidelines / Makes No Recommendations
AARC
Evidence - Based Guidelines
(Hess, 2003 )5 / 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.
SHEA / Pro- Recommends the change of ventilator circuit only when visibly soiled or malfunctioning.
ZAP / Pro-Recommends the use of new circuits for each patient, and changes if the circuits become soiled or damaged, but no scheduled ventilator circuit changes.
ATS / Makes No Recommendations
CDC / Pro- Recommends the change of circuit when it is visibly soiled or mechanically malfunctioning.
4. Change HME every 5-7 days and as clinically indicated.
SHEA / Pro-Recommend the change of humidifier circuit when it is visibly soiled or mechanically malfunctioning humidifier, not on the basis of duration of use.
ZAP / Pro-Recommend changes of HMEs every 5 to 7 days or as clinically indicated.
ATS / Makes No Recommendations
CDC / Pro- Recommend the change of HME when it malfunctions mechanically or becomes visibly soiled, but not more frequently than every 48 hours.
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
ATS / Pro-Recommends that noninvasive ventilation should be used whenever possible in selected patients with respiratory failure.
CDC / Makes No Recommendations
6. Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient.
SHEA / Pro- Recommends the removal of condensate from ventilator circuits while keeping the ventilator circuit closed during condensate removal.
ZAP / Makes No Recommendation
ATS / Pro – Recommends that contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers.
CDC / Makes No Recommendation

7. Use early mobility protocol.
All Guidelines / Makes No Recommendations
Early ICU Mobility Therapy
(Morris, 2008)6 / Pro- Findings of this study showed that mechanically ventilated acute respiratory failure patients who underwent early intensive mobility therapy had a shorter ICU and hospital stay than similar patients who received standard physical therapy.
Receiving Early Mobility in ICU
(Morris, 2011)7 / Pro-The aim of this study was to determine the post hospital outcomes of implementing early mobility protocol. This study finding showed that patients who received early ICU mobility therapy had fewer hospital readmissions and deaths in 12 months post discharge period.
Early Physical Medicine and Rehabilitation
(Needham, 2010)8 / Pro- This quality improvement program found that the incorporation of early mobility into the daily care of ICU patients substantially reduced length of stay.
8. Perform hand hygiene.
SHEA / Pro- Recommends the adherence to hand-hygiene guidelines published by the Centers for Disease Control and Prevention / World Health Organization.
ZAP / Makes No Recommendations
ATS / 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.
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 / Pro- Recommends the maintenance of patients in the semirecumbent position (30-45 degrees) unless medically contraindicated.
ZAP / Makes No Recommendation
ATS / Pro – Recommends that patients should be kept in the semirecumbent position 30-45degrees rather than supine.
CDC / 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.
SHEA / Pro - Recommends appropriate infection prevention and control practices are used at all times, including aseptic techniques when suctioning secretions and handling respiratory therapy equipment.
ZAP / Makes No Recommendations
ATS / Makes No Recommendations
CDC / Makes No Recommendations
11. Use orotracheal intubation instead of nasotracheal.
SHEA / Pro- Recommends orotracheal intubation over nasotracheal intubation based on the increased risk of sinusitis.
ZAP / Pro- Recommends the use of the orotracheal route for intubation when intubation is necessary.
ATS / Pro- Recommends orotracheal intubation over nasotracheal intubation based on a trend toward reduction in VAP rates and sinusitis.
CDC / Pro- Recommends the use of orotracheal intubation over nasotracheal intubation unless contraindicated.
12. Avoid the use of prophylactic systemic antimicrobials.
SHEA / Pro- Recommends prophylactic aerosolized or systemic antimicrobials 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
New South Wales Statewide
Guideline for Intensive Care
(Rolls, 2009) 9 / Pro – Recommends that tracheal tube suctioning should not be carried out on a routine basis, but rather out of clinical need to maintain the 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 RespirCrit 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.