VAP Vigilance


Vol. 18 • Issue 3 • Page 14

We were Charles’ last hope. The 75-year-old arrived in Lake Katrine, N.Y., at the Northeast Center for Special Care after a month-long hospitalization. He had acquired severe ventilator-associated pneumonia and influenza, and the hospital physicians warned that his chance of recovery was slim.

As one of the country’s largest residential rehabilitation facilities specializing in ventilator care and weaning, we frequently admit medically complex patients like Charles from local hospitals.

Research suggests alternate health care environments are better prepared to prevent VAP and better equipped to manage it in its early stages.

Intubated patients may be more susceptible to the virus in hospitals because there are simply more people carrying more germs in this setting. Alternate health care environments have an advantage in being able to limit the number of people and departments that staff encounter. At Northeast Center, we assign each staff member to one floor only. This simple practice dramatically cuts down on the spread of germs, and ultimately, on morbidity.

Also, compared to ICUs and hospitals, alternate health care environments have more time and resources to devote to monitoring an intubated patient. Our VAP strategy hinges on a team process to maximize patient care. We have a primary care physician dedicated to the ventilator unit five days a week, supported by 24 respiratory therapists and a team of nurses, licensed practitioner nurses, and certified nursing assistants around the clock.

Although there is little data to document the actual incidence of VAP in long-term care settings, it is an ever-present danger. Avoiding and preventing VAP remains a top priority at our facility, and we take specific precautions with patients (whom we call resident neighbors) to avoid infection.

Protocol for prevention

Studies show that VAP occurs in about 27 percent of all intubated patients.1Mortality rates for those patients can range from 20 percent to 70 percent, and is typically higher in ICU patients and those with bacteremia or multidrug-resistant pathogens.2

In addition to being a life-threatening condition, VAP is an expensive complication. On average, it lengthens a patient’s hospital stay anywhere from seven to 14 days, depending on the severity of infection, and it can cost tens of thousands of dollars to treat.3Because it is a common complication associated with high mortality rates and high costs, many professional organizations and government health care agencies have published guidelines with evidence-based strategies to combat VAP. At Northeast Center,

we adapted the VAP health care practices in the Institute for Healthcare Improvement’s 100,000 Lives Campaign to address our facility’s needs:

•Patient positioning: We elevate intubated residents’ heads between 30 degrees and

45 degrees as recommended in the guidelines. This blocks bodily fluids, specifically acid reflux, from flowing upward into the tube, which can cause bacterial build-up. This incline also prevents aspiration, a known cause of VAP.

•Oral hygiene: While a daily sedation vacation is the second key practice in the guidelines, we do not sedate residents to ventilate them. Instead, our second line of combat is to follow a rigorous oral care regimen. This minimizes bacteria build-up in the mouth, reducing the number of VAP cases.

•Readiness to extubate: We assess each resident’s readiness to extubate daily. Our staff closely monitors each resident’s vital signs and breathing progress so they can remove the ventilator at the earliest valid signs of respiratory independence.

•Clot reduction: We also administer blood thinners to reduce the body’s ability to make blood clots, another major risk factor for VAP.

Sometimes even the best preventative care cannot ensure complete avoidance of VAP. If and when our residents contract VAP, we assess their response to antibiotics, and if effective, we keep them at the center and treat them with heightened care.

Seeing results

By following these best practices, our ventilator staff treated Charles’ infection aggressively and arrested his VAP and flu within weeks. Charles returned home off the ventilator and decannulated after a few months of physical, occupational, and nutritional therapy.

We treat similar cases every day, and our experience shows that an attentive health care regimen provided by skillful, caring health care professionals in a clean environment can combat VAP.

Ironically, hospitals receive some government funding to treat VAP, but long-term treatment centers receive no reimbursement because VAP is viewed as a preventative illness. Although we can bill for beds and some of the equipment used in VAP prevention and treatment, we cannot bill for respiratory therapists at all.

While respiratory staffing cuts into our budget, our facility and chief executive officer have seen the investment pay off. We have found a direct link between specialized staff at the bedside and better outcomes. In addition, our dedication to proactive VAP protocols has been lucrative in building our referrals and our reputation.

References

1. Garpestad E. Vanquishing VAP. [PowerPoint presentation]. Newton, Mass.: 10th Annual Conference on Mechanical Ventilation;2008.

2. Craven DE. Preventing ventilator-associated pneumonia in adults: sowing seeds of change. Chest. 2006;130(1)251-60.

3. Porzecanski I, Bowton DL. Diagnosis and treatment of ventilator-associated pneumonia. Chest. 2006;130(2):597-604.

Thomas R. Harvie, RRT, is the ventilator program director and director of respiratory care at Northeast Center for Special Care, Lake Katrine, N.Y.

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