Vap

oh boy, do we ever have the proptcols for vap. it's the "boogey of the month" at my facility. the rules are HOB at 30 degrees at all times unless contraindicated, mouth care with special little swabs and biotene mouthwash that attach to suction tubing, special little yankauers with sleeves over them special little Y connectors for the yankauer tubing and in line suction tubing, all this comes in a package with the set up and enough products for q 4 hour oral care for 24 hours the set up needs to be changed q 24 hours. little toothbrushes that attach to the suction tubing as teeth must be brushed q 24 hours. oh yeah, and if the HOB is less than 30 degrees, like say, when you are repositioning your pt you must sub glottal suction with yet another special attachment. the other part of the "bundle" is PUD prophylaxis, DVT prophylaxis, q day wake up unless contraindicated and q day RSBI. i like the packets with the mouthcare products, it keeps everything you need in one self contained, clutter free location and i like the special yankauers, the sleeve on them keeps them clean. PUD and DVT prophylaxis we do anyway and HOB 30 degrees, why not? often contraindicated d/t hemodynamic instability in my pt population though. the only thing i really have a problem with is the subglottal suction every time the HOB is under 30 degrees. think about how many times you reposition a pt in a shift. it's unreal to think you are going to sub glottal suction every time. sorry my vap rant. i tried to find a pic of the products we use, but no luck. hope this is informative.

We do everything that the first poster responding does (except the subglottal suction...I do suction my patients prior to putting their head down but it's not protocol)...and here is a picture of what we use Q 4h for our intubated patients:

Oral Hygiene Products

We used to do it Q shift, but in the last year, found that our incidence of VAP plummeted when we changed to Q 4h. The little kits are about $12 a piece, which compared to the cost of VAP, is nothing. I like the Sage products and although my patients don't necessarily enjoy the toothbrushing WHILE I'm going at it, they seem to feel better afterwards! = )

Melanie = )

The reason why you are hearing so much about it is that it is part of IHI's (Institute for Healthcare Initiatives) 100,000 lives campaign.

Institute for Healthcare Improvement: Implement the Ventilator Bundle

If you are looking for policies to develop a VAP 'bundle', IHI has plenty to say about.

I used to be a fan of IHI's 100,000 lives campaign. I'm getting to the point now where I feel that the IHI is more interested in pushing a political agenda then they are in saving lives. It WAS a good idea, but an idea that TPTB couldn't resist corrupting as a means to press their own agendas.

Instead of encouraging EBP (evidence based practices), the new goals of IHI seems to be to use their credibility to push Ivory Towered fads.

And that's just sad.

~faith,

Timothy.

Here is the evidence-based guideline for prevention of healthcare-associated pneumonia: http://www.cdc.gov/mmwr/PDF/rr/rr5303.pdf

At my facility the protocol is HOB at least at 30 degrees. We suction them and clean their mouths at least every 2 hours. All vent patients get a special kit every 24 hours with mouth swabs, biotene mouthwash, and these special toothbrushes and mouth swabs with suction in them. Also we are now doing only OG tubes if they are vented because inserting an NG introduces whatever bacteria that was in their nose to their ETT. We also do Peptic Ulcer Disease Prophylaxis and DVT prophylaxis unless it is contraindicated.

How can inserting an NGT introduce nasal bacteria to the ETT? The ETT is a closed system, and I sincerely hope the NGT isn't going where the ETT is...?

How can inserting an NGT introduce nasal bacteria to the ETT? The ETT is a closed system, and I sincerely hope the NGT isn't going where the ETT is...?

Honestly I am not entirely sure... that is just the explanation I got. Since they started doing all these things it has cut down on the number of VAPs immensly. We didn't have any at all for a few months.

Ah, I looked it up. It's a twofold issue: the risk of aspiration of feeds, and introducing bacteria to the nasopharynx causing nasopharyngitis - and then intubating.

At my facility the protocol is HOB at least at 30 degrees. We suction them and clean their mouths at least every 2 hours. All vent patients get a special kit every 24 hours with mouth swabs, biotene mouthwash, and these special toothbrushes and mouth swabs with suction in them. Also we are now doing only OG tubes if they are vented because inserting an NG introduces whatever bacteria that was in their nose to their ETT. We also do Peptic Ulcer Disease Prophylaxis and DVT prophylaxis unless it is contraindicated.

I used to work in Ohio and we had that same protocol in the MSICU. HEre in phoenix we do mouth care qshift. We have those green swabbies but we aren't required to use them. Even vented pts. get mouth care qshift. We have these new tube things that hang on the side of the bed that we are supposed to keep our yanker in. We are supposed to change it q24hrs. We keep HOB up 30.

We use the same 24hr kits described above, performing oropharyngeal suctioning at least q 12 hrs and routine oral care at least q 4 hrs. Suctioning with yankaur prior to lowering HOB.

Another part of our VAP bundle is daily sedation vacation and daily weaning attempts. We have cut and dry parameters to perform the sedation vacation, only contraindicated in a few specific circumstances: significant hemodynamic instability (not just 1 low BP reading), PEEP must be less than 10, FiO2 less than 60%, ICP can't be increased. Might not perform if we have a severe trauma requiring multiple surgeries every couple of days and needs to stay on Vec or something. We can either decrease sedation by 50% or turn off. If pt doesn't need it, we discontinue it.

Turning q 2 hrs of course and continuous lateral rotation therapy if not contraindicated.

Our bundle also specifies the need for a speech therapy eval prior to starting liquids/foods/oral meds if pt has been intubated >48 hrs.

All our patients coming directly from surgery to ICU and pts intubated in our hospital all are done with an ETT that has the continous subglottic suction.

Pretty much the same in our Neuro ICU in Edmonton ... HOB @ 30, OG vs NGTs, oral care: cleaning the tongue and teeth (where possible) with a toothbrush + toothpaste Q12h + mouthcare Q2H using toothettes with chlorhexidine mouthwash & suction. We also started using EVAC tubes (which sxn secretions above the cuff) about 5/52 ago. The Q2H mouthcare is also important in maintaining long-term patency of the EVAC tubes.