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VentWorld Director
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Picture of GaryMefford
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I recieved a request for info from a nurse educator recently about VAP prevention, particularly related to oral care and decontamination. I offered her some of the info I have, but I wanted some opinions on what interventions are really the most effective or is it just go with the VAP Bundle from IHI. Thanks
 
Posts: 147 | Location: Buckeye Az | Registered: January 27, 2006Reply With QuoteReport This Post
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WE use the sage oral care kits q 6 hrs and a Hi/Lo Evac ETT if the patient requires intubation.No VAP's since going to this plan of care.
 
Posts: 13 | Location: Greenwwood,ar.,united states | Registered: November 09, 2003Reply With QuoteReport This Post
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Here are some more thoughts on this:
There are a few strong, relatively low cost strategies that can be implemented that might make a real difference. You may be using some of them already, but here are the some I might suggest if not already implemented. We have a historically very low VAP rate, but I try to keep up to date with strategies in this area, because it is going to get worse for all of us.

1. The most effective thing I think you can do is educate the staff on effective strategies. VAP rates usually decrease proportionally with VAP related education.

2. Strict hand hygiene. Seems simple, but watch your staff. Their ink pens and stethoscopes will contaminate their hands if touched after hand washing.

3. New info is really condemning the keyboards. I suggest working with your IC nurse to get some sort of disposable keyboard covers we can just throw away routinely in high risk areas.

4. HOB actually @ 30 degrees minimum at all times. Check to see if everyone realizes what 30 degrees is and if the patient is settled to the foot of the bed 30 degrees is not 30 degrees.

5. It must be recognized that all manipulation of the ETT can cause secretions pooled above the cuff to migrate into the airway. Use of a 12 or 14 fr catheter to clear the pooled secretions should be considered before any ETT manipulation, including rotation from L to R corners of the mouth, and particularly deflation of cuff for moving to a new depth, etc. Consider the same before deflation for PMV on trach patients. Above the cuff suction lumens built into tubes are being reported as improving VAP rates, but at increased ETT cost.

6. Be sure you are using an HME with very good filtration ability. I am sold on it. I just saw an inservice while teaching at Kindred Central Tampa by James McGuire PhD on these types of filters. I wasn't but now am sold.

7. PEEP/CPAP baseline levels of 5 minimum on all patients. If you have any docs who use PEEP or CPAP 0 try to convince them to use 5 minimum. I heard Dr. Shapiro speak once many years ago, and he called anything less than 10 "chicken soup, can't hurt, might help" I have no reference on this that I can think of, but it seem logical to me that there will be less secretions sucked down past the cuff if there is a constant positive pressure below it. As I said we have a very low VAP rate, we remove from the vent for all airway clearance, which flies in the face of some recommendations, but we never go less than PEEP/CPAP of 5 on anyone, and this comes to mind as a possible contributing factor to our positive VAP rates.

8. Implement an aggressive vent weaning protocol and monitor daily for compliance to the protocol. This seems to be mentioned in most VAP prevention literature as a strategy and where there are protocols monitoring for adherence really makes them work better. I have one I will post here soon. If you have a good one (that means to me a all rest or all work based protocol that doesn't involve stepwise decrease in SIMV rates and takes into account pt/vent discynchrony), (just an educated opinion, don't want to criticize anyone's effective processes), monitoring for adherence will make it better and the quicker they get off the lower chance of VAP.

The IHI website, at IHI.org has a VAP reduction getting started kit that you can probably print to educate with, I haven't used it, but it looks like it would be a good tool. They recommend implementing the ventilator bundle, and have some good evidence of it's effectiveness.

Have you heard Dr. Yeager from Denver speak on TTAV. He came to the Arlington Kindred facility a few months ago and his info in very compelling. I think we all should be at least considering this technique for weaning. Respironics has a product on the market that facilitates this now. I will try to get more info on this and post soon. Dr. Yeager presented in New Orleans two years ago and in San Antone in December at AARC National Convention. If I remember right he cited lower VAP rates as a benefit of implementation along with much shorter wean times.

Good luck, the bugs are getting tougher to beat every day.

More thought on this please...
 
Posts: 147 | Location: Buckeye Az | Registered: January 27, 2006Reply With QuoteReport This Post
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