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

Hospital Associated Pneumonia (HAP) 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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Hospital Acquired Pneumonia (HAP) Prevention (Non-Ventilator Associated)

The following standard prevention measures are recommended in:

CDC Guidelines for Preventing Healthcare Associated Pneumonia:

1. Aspiration prevention: patient teaching coughing, and airway clearance, use incentive spirometry, avoid over sedation, head of bed (HOB) 30 degrees unless contraindicated, ambulation encouraged, speech/swallow evaluation as needed

2. Early ambulation and incentive spirometry post operatively

3. Flu vaccine for patients and employees

4. Hand hygiene healthcare workers and patient

5. Oral hygiene

6. Routine verification of appropriate feeding tube placement

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 HAP 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 HAP prevention |[pic] |N/A |N/A |

|Immunizations – additional considerations |[pic] |N/A |N/A |

|Mandatory annual flu vaccine for all employees and MDs | | | |

|Dual vaccination - flu and pneumococcal immunization for older patients | | | |

|Using multiple communication strategies, providing real-time feedback on rates, providing a | | | |

|greater range of incentives to be vaccinated. | | | |

HAP Prevention continued

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

|Oral care for patients with dysphagia (e.g. stroke) – additional considerations |[pic] |Sage 0.12% CHG oral rinse and moisturizer and |AACN Oral Care |

|Cleanse oral cavity every 4 hours with soft foam swab and suction, and use antiseptic oral| |sodium bicarb toothbrush |[pic] |

|rinse (e.g. chlorhexidine gluconate) to reduce bacterial load in the oral cavity. | | |

|Brush teeth every 12 hours with sodium bicarbonate impregnated suction toothbrush which | |e/ | |

|contains anti-plaque solution to help dissolve mucous and biofilm. | | | |

|Apply a mouth moisturizer to oral mucosa every 2 to 4 hours. | |Medline 0.12% CHG oral rinse: | |

|Antiseptic oral rinse (e.g. chlorhexidine gluconate) the night before and morning of | | |

|surgery to reduce the risk of post op pneumonia for those receiving general anesthesia. | |luconate-CHG-Oral-Rinse/Mouthwash/Floss/Z05-PF0| |

| | |6308 | |

|Patient mobility – additional considerations |[pic] |N/A |N/A |

|Mobility protocol for critical care patients | | | |

|For surgical patients: | | | |

|Operative day: Range of motion, dangling at the bedside, transition to the chair on the | | | |

|operative day, if able | | | |

|Postoperative day one: transferring from the bed to the chair 2 to 3 times and, if | | | |

|feasible, ambulation in the room and hallway | | | |

|Peptic ulcer prophylaxis: Sucralfate instead of H2 blockers or PPI for PUD prophylaxis (in|[pic] |N/A |N/A |

|absence of history of GI bleed) to reduce bacterial overgrowth in GI tract | | | |

HAP Prevention continued

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

|Swallowing evaluation and rehabilitation |[pic] |N/A |Dysphagia assessment tools |

|Early detection of swallowing difficulty | | |[pic] |

|Fiber-endoscopic evaluation of swallowing (FEES) in neurological patients | | | |

|Swallowing therapy | | |RCT - Effectiveness of |

|Tongue acupuncture | | |Swallowing Care Guided by |

|Ultrasound examinations during mealtimes | | |Ultrasound Examination |

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