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Beyond Bundles, HAI Prevention “Plus Measures” Toolkit Updated 2018

Ventilator Associated Pneumonia (VAP) Prevention Chapter

© 2016 Sue Barnes, RN, CIC, FAPIC

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Document posted here:

Overview: This toolkit was designed for IPs (Infection Prevention professionals) and other clinicians as a resource/reference to support efforts to amplify/enhance infection prevention and control bundles. In the absence of sustained zero preventable infections of any type, and in the absence of risk to patients, products and practices supported by less than category 1 level evidence (i.e. “Plus Measures”) are often employed to amplify/enhance IP bundles. The “Plus Measures” contained within this toolkit are most commonly supported by what CDC considers category II level evidence (see page 3 for evidence categories). Within this toolkit evidence summaries are provided for each plus measure, in order to reduce the time required for literature searching by IPs, and are updated every two years. These “Plus Measures” including products, have been identified by the author during review of peer reviewed journals, attendance of professional conferences, continuing education courses, networking with clinical experts and industry partners. Consequently, the set of plus measures (including products), represented in this document is not all inclusive or exhaustive. I welcome any suggested additions from colleagues and industry partners (sueabarnes@).

This document was developed by Sue Barnes. Please feel free to use and reproduce this document in the spirit of patient safety, and please retain this note for appropriate recognition.

CDC Evidence Categories ():

• Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

• Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.

• Category IC. Required by state or federal regulations, rules, or standards.

• Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

• Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.

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Ventilator Associated Pneumonia (VAP) Prevention

The following standard VAP prevention measures are recommended in:

SHEA/APIC Compendium:

1. Avoid gastric over distention

2. Closed suctioning

3. Daily “sedation vacation” and assessment of readiness to extubate

4. Elevation of the head of the bed to between 30 and 45 degrees

5. Frequent hand hygiene

6. Heat and moisture exchanger change Q 5-7 days

7. Minimize intubation

8. Oral care

9. Periodically remove condensate from circuits while keeping circuit closed. and condensate away from patient’s airway

10. Use orotracheal vs. nasotracheal intubation

11. Ventilator circuit change only if damaged or soiled

If zero preventable infections have not been achieved and/or sustained, consideration might be given to adding one or more of the following “PLUS” prevention measures to your VAP prevention bundle:

DOUBLE CLICK ON ICONS IN TABLE BELOW TO OPEN EMBEDDED DOCUMENTS – COPY & PASTE LINKS INTO BROWSER

|Plus Measures |References |Product order info |Tools |

| | | | |

|Cilostazol (antiplatelet drug) for patients receiving tube feeding. |[pic] |N/A |N/A |

VAP Prevention continued:

|Plus Measures |References |Product order info |Tools |

|Endotracheal tube innovations and approaches including: continuous |[pic] |ETT with subglottic suctioning: |N/A |

|automated cuff pressure monitoring, continuous intermittent | |Hi Lo Vac | |

|subglottic suction ETT, micro cuff with continuous subglottic | |[pic] | |

|suctioning. | | | |

|3. Immunizations |Influenza vaccine |N/A |N/A |

|Flu vaccine for all employees, MDs and patients | | |

|Annual flu and scheduled pneumococcal immunization for patients |/index.htm | | |

| | | | |

| |Pneumonia vaccine | | |

| | | |

| |mo/hcp/index.html | | |

|Mobility |[pic] |N/A |N/A |

|Nutrition and prevention of aspiration |[pic] |N/A |Guidelines enteral feeding: |

|Early enteral feedings | | |

|Feeding tube placement second portion of the duodenum or beyond | | |linical_Resources/Clinical_Guidelines/ |

|Oral hygiene: |[pic] |Oral care kit: |N/A |

|CHG mouth rinse | | |

|Tooth swabs plus brushing | |ne/ | |

|Suction wand holster to reduce contamination between suctioning | | | |

| | |Suction wand holster: | |

| | | | |

VAP Prevention continued:

|Plus Measures |References |Product order info |Tools |

| | | | |

|Patient bathing |[pic] |Coloplast CHG liquid and bathing wipes: |Decision Algorithm CHG Liquid vs Cloths |

|Wipe tubes, lines, devices, groin cleansing | |[pic] |

|Use a sufficient number of CHG cloths (5-6) and use both sides of the| |h-1-en-us.aspx#section=product-description_3 |Instructions for use Sage CHG cloths |

|cloth. | |Hibiclens: 2% CHG liquid or foam |(patients/staff) |

|6 CHG cloths are equal to 4 ounces of the 4% CHG formulation.  | | |[pic] |

| | |Sage: 2% CHG cloths (rinse free): |Instructions for use Coloplast: |

| | | |[pic] |

| | |Sage: MCare (rinse free non- antiseptic cleaner): | |

| | | | |

| | |Theraworx multi-ingredient colloidal silver skin | |

| | |cleanser | |

|Peptic ulcer prophylaxis: consider Sucralfate instead of H2 blockers |[pic] |N/A |N/A |

|or PPI for PUD prophylaxis (in the absence of history of GI bleed) | | | |

|Probiotics |[pic] |N/A |N/A |

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