At the end of this session, participants will be able to:
1) Define Interventional Patient Hygiene (IPH)
2) List the components of an IPH Program
3) Develop a strategy for implementing IPH
4) Understand the importance of skin antisepsis in SSI prevention
5) VAP prevention progress update

Non-Clinical: Providing patient care practices that will reduce the choices of a healthcare-acquired infection
Clinical: IPH is a comprehensive evidenced based intervention and measurement model for reducing the bioburden of both the patient and healthcare worker.

Evidence Based
Practice Intervention
 Oral Care
Responsibility
HCW VAP
Measurable Outcome
 Catheter Care
 Skin Care
HCW BSI
 Hand Hygiene
HCW & Patient SSI, UTI, Reduction of
Resistant Organism Infections,
PU and Skin Breakdown
HCW & Patient All of above

VAP
UTI
Pressure
Ulcers
SSI
BSI

C
C

C’
 Caregiver Knowledge
 Consumer Public Disclosure
 Costs
 Court
HAI’s
Malpractice
 Control IPH

 ICP
 CCRN
 CCRN Mgr/Specialist
 RN
30.9%
22.8%
15.5%
42.2%
48.8% employed >20 years
67.7% Community Hospital
28.3% University/Academic

 Hand Hygiene
 Oral Hygiene
 Early Pre-op Skin Prep
98.7%
94.8%
69.9%
(night before and morning of surgery)
 Bathing/Skin Assessment 93.5%
 Incontinence Care 92.4%

VAP
Pressure Ulcer
67%
43%

 Pressure Ulcer
 SSI
 VAP
 UTI
 LOS
 MRSA/VRE
72%
66%
86%
75%
74%
77%

 Education about IPH Components (within last 2 years)
Hand Hygiene
Oral Hygiene
Early Pre-op Skin Prep
(night before/morning)
Bathing/Skin Assessment
Incontinence Care
98.6%
76.4%
49.1%
40.5%
31.8%

 ICP Involvement in Development IPH Protocol
YES:
NO:
37.6%
63.3%
 Policy for IPH in your Institution
YES:
NO:
Don’t Know:
39.3%
45.3%
15.2%

 Policy for IPH in Your Institution:
YES: 48.4%
NO: 34.7%
Don’t Know 16.8%

Written Policy for:
Oral Care
Bathing/
Skin Assessment
77%
68%
Incontinence Care 54%
Documentation Forms for:
81%
86%
60%

Yes: 42.2%
No: 40.4%
Don’t Remember: 17.3%
Skipped Question: 17%

Very Important
Adequate/Appropriate
Supplies
Adequate Time
94%
90%
Standardization of Protocol 86%
Documentation forms for monitoring 73%
Somewhat Important
4%
7%
11%
25%

VAP
UTI
Pressure
Ulcers
SSI
BSI

 2005 - National Telephone Survey*:
Will Consumers Use Public Disclosure
Data When Choosing a Hospital?
 93% of respondents (9 in 10) said knowing a hospital infection rate would influence their selection of a hospital
*McGuckin M. American Journal of Medical Quality 2006 - In press

Factors Considered in Choosing A Hospital
Very
Important
Somewhat
Important
Not
Important
Don’t
Know
Low infection rates
Previous experience with hospital
High staff-to-patient ratio
Friendly staff
Clean
Close to home
Good reputation
Whether they accept your insurance
*Less than one-half of one percent
85%
54%
64%
68%
94%
49%
79%
88%
8
33
28
27
5
41
18
7
4
10
*
9
5
4
2
3
2
3
*
1
3
*
1
1

Factors Considered in Choosing to Avoid A Hospital
Very
Important
Somewhat
Important
Not
Important
Don’t
Know
42% 45 10 2 The staff is knowledgeable, but not friendly
They are understaffed
They are the best hospital in your area, but do not accept your insurance
You or someone you know had an unpleasant experience there
They have higher-thanaverage infection rates
You have seen or heard it is not clean
74%
63%
60%
87%
79%
20
25
30
7
15
4
10
9
4
5
2
1
1
3
1

SSI VAP UTI
“Hospital Infection data low; too low?”
“Underreporting hurts patients”
Philadelphia Inquirer - May 22, 2006

HAIs
Catheter-related
BSIs (ICU)
CABG SSIs
VAP(ICU)
Hip SSIs
Totals
Number
Occurring
Excess
Patient days
Excess
Hospital Costs
38
33
16
5
92
304
300
96
104
804
$209,000
$373,585
$152,000
$95,022
$829,607
Ref: Am J Infec Control 2005;33:542-7

Health
Care
Spending
Traditional
Cost Controls Modern Cost
Controls
Time
Traditional cost controls
Negotiate prices and service fees
Offer fewer benefits to employees
Shift some costs to patients
Reference: Am J Infec Control 2005;33:542-7
Modern cost controls
Stop doing things that don’t work
Use cost-effective products
Improve procedures

Luke 11-46-47

Am J Infect Control 2005;33:310-2.

Services
Orthopedics:
General Surgery:
Cardio-thoracic:
Medical:
MRSA
Organisms
S. Epidermidis
Pseudomonas
MSSA, Enterococcus,
Enterobacter, Klebsiella
ICU/Surgery/Hand Hygiene





Good Medical Care? It’s a coin flip
The Philadelphia Inquirer - March 16, 2006
U.S. patients receive proper medical care from doctors and nurses 55% of time
N.E.J.M. - Vol 354, No 11, 2006

VAP
UTI
Pressure
Ulcers
SSI
BSI

UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY05
20
18
16
14
12
10
4
2
0
8
6
50th percentile
QTR 1
FY05
QTR 2
FY05
QTR 3
FY05
QTR 4
FY05
QTR 1
FY06
QTR 2
FY06
QTR 3
FY06

 High colony count found in bath water is similar to the number of bacteria found in urine from patients with UTIs.
R. Shannon et al, Journal of HealthCare Safety, Compliance & Infection
Control, April 1999; Vol. 3, No. 4, pg. 180-184
 Bath water could serve as a high magnitude microbial reservoir of potentially antibiotic resistant organisms.
R. Shannon et al, Journal of HealthCare Safety, Compliance & Infection
Control, April 1999; Vol. 3, No. 4, pg. 180-184
 Prepackaged bathing showed lower microbial counts than basins
M. Vernon, DrPH; et al, Archives of Internal Medicine, February 2006;
 Disposable Bed Baths are a desirable form of bathing Critically Ill patients.
E. Larson, RN, PhD. et. al, AJCC, May 2004; Vol. 13, No. 3

1. Can urinary catheter be removed?
2. What was insertion date?
3. Is the patient having any signs or symptoms? (ie, urine cloudy or sediment noted)
4. Change catheter if patient is having signs or symptoms.
Insert silver-coated catheter.

5. If the patient comes to the unit with catheter in place and signs and symptoms are noted, remove old catheter, get a urine specimen and send it to the laboratory, and insert the silver-coated catheter.
6. Drainage bag must be kept lower than the patient’s bladder at all times, including during transport and patient activity. Clamp catheter with rubber-coated hemostats for transport or during off-unit procedure to prevent reflex. Unclamp as soon as possible; do not leave clamped for more than 2 hours.

7. All urinary catheters must be secured to decrease movement of catheter. Use Stat Lock device.
8. Strict handwashing must be used before and after approaching urinary catheter.
9. Perform good pericare daily and after each bowel movement using aseptic technique. Use Clean and
Shield product that has odor-neutralizing wipes to cleanse the area and zinc-coated wipes to protect the area.
10. Sterile technique must be strictly adhered to during insertion of urinary catheter.

100
90
80
70
60
50
40
30
20
10
0
17
Jul
23
150-180 Vent Days
18
14
70-80 Vent Days
12
25
20
15
10
5
7
Aug
0
Sep
6
Oct Nov Dec Jan Feb
Oral Care Usage HOB 30* Monthly VAP Rate
0
Mar
0






Don’t slide into bad habits,
Remember…
Hand Hygiene
Oral Care
Catheter
Site Care
Skin care

Robert Garcia, BS, MMT(ASCP), CIC
Infection Control Professional &
Consultant

VAP
UTI
Pressure
Ulcers
SSI
BSI

 1996: 28.4 million ambulatory surgery procedures in the U.S.
(CDC, National Center for Health Statistics)
 2003: 30.8 million inpatient surgical procedures and 9.7 million (37%) of those performed on patients 65 yrs and older
(CDC, National Center for Health Statistics)
 NNIS: SSIs occur in 2.6% 1 of all surgeries =
1.5 million SSIs annually 2
 SSIs are the 3rd most common HAI 1
 Attributable cost: $25,546 (range $1,783 - $134,602) 3
1. Mangram AJ, et al., Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention, Hospital Infection Control Practices
Advisory Committee, Atlanta GA. 2. SSI total calculated by multiplying SSI rate from ref. #3 by surgical procedure numbers from ref. #1 and 2.
3. Stone PW, et al., Am J Infect Control. Nov 2005;33(9):501-9.

UTI
SSI
Pneumonia
Rate per
100 admits
Proportion of all HAIs
Excess
Hospital
Days
Proportion of costs of all HAIs
2.5
35% 1-2 15%
1.5
1.0
20%
15%
7
10
50%
30%
BSI 1.0
15% 10-12 5%

 Age
 Nutritional status
 Diabetes
 Nicotine use
 Obesity
 Coexistent infection
 Colonization
How effectively can we control these risk factors?
 Altered immune response
 Long preoperative stay

 Inappropriate use of antimicrobial prophylaxis
 Infection at remote site not treated prior to surgery
 Shaving the site vs. clipping
 Long duration of surgery
 Improper skin preparation
 Improper surgical team hand antisepsis
 Environment of the room (ventilation, sterilization)
 Surgical attire and drapes
 Asepsis
 Surgical technique: hemostasis, sterile field
To a great extent, this is what we can control!

 The All-or-None Measurement
 An option for calculating performance
 Denominator = No. of pts. eligible to receive at least 1 or more discrete elements of care
 Numerator = No. of pts. who actually received care
 No partial credit is given
 The Centers for Medicare & Medicaid (CMS) has moved to the “all-or-none” approach
Nolan T, Berwick D. All-or-none measurement raises the bar on performance. JAMA 2006;295:1168-70.

IHI
Appropriate use of antibiotics
Appropriate hair removal
Normothermia
Post-op glucose control
Elevation of head of the bed
Orders for weaning program
Patients diagnosed with VAP
DVT and SUD prophylaxis
SIP/SCIP
(CMS)













 “….all-or-none measurements more closely reflects the interests and likely desires of patients. This is especially true when process components interact with each other synergistically….violation of a single step in the sterile technique in surgery may vitiate the benefits of proper execution of all other steps…” 1
 The Take Away Message: in SSI prevention, it makes little sense to assure that the surgeon has washed his hands properly if the patient’s skin has not had optimal prepping
1. Nolan T, Berwick D. JAMA 2005.

Why Should Hospitals Place
Greater Emphasis on How Skin is Prepped?
 When we consider pathogenesis of SSI, it has been accepted for decades that most SSI are endogenous in nature
 Surgical Infections 1
 Surgical Infections Including Burns 2
 Surgical Site Infections 3
 Surgical Antisepsis 4
1. Dellinger EP, Ehrenkranz. In: Hospital Infections, Bennett & Brachman, 1998 2. Kluymans J. In: Prevention and Control of Nosocomial Infections, Wensel
RP, 1997.3.Wong ES. In: Hospital Epidemiology and Infection Control, Mayhall CG, 1999. 4.Crabtree TD, Pelletier SJ, Pruett TL. In: Disinfection,
Sterilization, an Preservation, Block SS, 2001.

Years
1960-1962 1967-1977 1975-1976 1977-1986 1987-1990
15,613 62,939 59,352 25,919 84,691
No. of patients
Author, year
Howard
1964
Cruse,
1980
Haley
1985
Olson,
1990
Culver
1991
Wound Class
5.1
1.5
2.9
1.4
2.1
Clean
Cleancontaminated
10.8
7.7
3.9
2.8
3.3
16.3
15.2
8.5
8.4
6.4
Contaminated
28.0
40.0
12.6
_ _
Dirty
Dellinger EP, Ehrenkranz NJ. Surgical Infections. In: Hospital Infections. Bennett JV & Brachman PS, eds., 1998

 Prospective study of 376 patients undergoing CABG
 Pre-op nasal cultures, intra-op wound cultures of patients

Nasal cultures of all CV surgery/OR personnel
 DNA subtyping of patient’s colonizing/infecting strains and personnel strains
 38 SSIs (10.1%), 14 deep infections (3.3%), 5 mediastinitis (1.3%)
 Of >30 wound infections, all except 1 from patient (= endogenously-derived infections)
Jakob et al. Eur J Cardiothorac Surg 2000;17:154-60. Slide courtesy of D. Maki

 Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day.
Cat IB
 Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. Cat IB
 Use an appropriate antiseptic agent for skin preparation. Cat IB
 Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. The prepared area must be large enough to extend the incision or create new incisions or drain sites, if necessary. Cat II
Guideline for Prevention of Surgical Site Infection, 1999. HICPAC, Centers for Disease Control.

 The surgical site and surrounding areas should be clean.
 The skin around the surgical site should be free of soil and debris. Removal of superficial soil, debris, and transient microbes before applying antiseptic agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin.
 Cleansing should be accomplished by any of the following methods before surgical skin preparation:
 Patient showering and/or shampooing before arrival in the practice setting
 Washing the surgical site before arrival in the practice setting, or
 Washing the surgical site immediately before applying the antiseptic agent in the practice setting
Standards, Recommended Practices, and Guidelines, 2005 Edition. AORN, Denver, CO.

 When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent
 Antiseptic agents should be….used in accordance with the manufacturer’s written instructions. Antiseptic agent(s) should have a broad range of germicidal action.

Package directions: “Use sponge to prep desired area”

 Use first cloth to prepare the skin area indicated for a moist or dry site, making certain to keep the second cloth where it will not be contaminated. Use second cloth to prepare larger areas.
 Dry surgical sites (such as abdomen or arm): use one cloth to cleanse each 161 cm2 area (approx 5 x 5 inches) of skin to be prepared. Vigorously scrub skin back and forth for
3 minutes, completely wetting treatment area, then discard.
Allow area to air dry for one (1) minute. Do not rinse.
 Moist surgical sites (such as inguinal fold): use one cloth to cleanse each 65 cm2 area (2 x 5 inches) of skin to be prepared. Vigorously rub skin back and forth for 3 minutes completely wetting treatment area, then discard. Allow to air dry for one (1) minute. Do not rinse.

 Significantly reduce microbial counts on intact skin
 Contain a non-irritating, safe antimicrobial preparation that maintains the skin’s integrity
 Be broad-spectrum
 Be fast-acting and/or have residual effect
 Clearly define time of application and time of drying
 Be cost effective

 Why are there no studies that link use of CHG and SSI prevention?
 Lack of good study design
 Inclusion of surgery types other than clean
 Inadequate application of agent (bathing with agent followed by rinsing)
 New study comparing three commercially available skin prep products (with CHG, iodine, triclosan) provides evidence that pre-op skin prepping with a CHGimpregnated cloth without rinsing or showering at 12 hrs. and 3 hrs. prior to OR skin prepping significantly lowers microbial colonization
Maki DG, Paulson DS. [abstract] Evaluation of 6 preoperative cutaneous antiseptic regimens for prevention of surgical site infection. SHEA Conference, 2006.

 Protocol should consider the following aspects:
1) An antiseptic should be selected based on certain characteristics as addressed by the FDA
2) How and when is the antiseptic dispensed to the patient?
3) How often should the patient use the antiseptic product – once or twice?
4) When are the best times to accomplish preoperative antiseptic shower/bath?
Nancy B. Bjerke. Preoperative skin preparation: a system approach. Infection Control Today.
http://www.infectioncontroltoday.com/articles/1a1topics.html?wts=200605100734198&hc=39&req=bjerke

5) Is the whole body cleansed or just the incisional site?
6) What kind of educational materials are available or does the facility need to create their own?
7) Is the surgeon’s support necessary for this initiative, or does it involve only nursing?
8) Who verifies completion of this patient responsibility and where is this documented?
Nancy B. Bjerke. Preoperative skin preparation: a system approach. Infection Control Today.
http://www.infectioncontroltoday.com/articles/1a1topics.html?wts=200605100734198&hc=39&req=bjerke

 Work Outward.
Begin at the incision site and move out in concentric circles. Discard the sponge applicator when periphery is reached and do not return a sponge/applicator to the incision site once it has been applied to that area. Extend prep beyond the anticipated drape borders.
 Prep problem areas last.
Certain areas within the incision site with the potential to house excess bacteria need particular attention during the prepping process. The umbilicus typically has a high microbial count and needs to be cleaned with a Q-tip prior to prepping. Open wound, and perineal areas should be prepped last.
 Be careful with drapes.
When applying a drape, it is critical you follow the drape’s individual product instructions. Certain preps need to remain in contact with the skin for a specified amount of time to be fully effective.
Placing a drape before the solution dries could interfere with this time requirement, so check the product’s package label for special instructions.
Cynthia Spry. Outpatient Surgery Magazine. http://www.outpatientsurgery.net/infection_control/2005/brush_up_skin_prep_protocol.php

 Avoid pooling.
Applying excess amounts will cause the prep solution to pool under the patient. Pooled prep solution in contact with the skin can cause irritation or burn and can compromise the adhesive of a dispersive electrode. Be especially careful to prevent pooling under a tourniquet cuff. If a flammable agent, such as alcohol, is used, allow the solution to dry to reduce the possibility of fire. Use of an active electrode in the presence of a flammable agent could result in fire.
 Document action.
Performing a skin assessment, documenting the assessment, prepping and observing the condition of the skin after surgery are other key components of a successful infection control strategy. Look at the condition of the skin before the prep. Is there a rash? Do you notice a break in skin integrity? Written documentation of your assessment will create a baseline record and will let staff in the recovery unit determine if a later skin reaction was the result of the prep.
Spry C, Outpatient Surgery Magazine. May 2005. http://www.outpatientsurgery.net/infection_control/2005/brush_up_skin_prep_protocol.php

VAP
UTI
Pressure
Ulcers
SSI
BSI

 Third most common HAI and most common among
ICU patients
 Second most costly HAI
 Between 10% and 20% of patients receiving >48 hours of mechanical ventilation will develop VAP 1
 Critically ill patient who develop VAP appear to be twice as likely to die compared to those without VAP
 Patients with VAP have significantly longer lengths of stay in the ICU (mean = 6.10 days) 2
1. Sole ML, et al., Am J Crit Care. March 2002;11(2):141-9
2. Rello J, et al., Chest. Dec 2002;122(6):2115-21

Component
 Head of bed elevation
 Daily “sedation vacation” and daily assessment of readiness to extubate
 Peptic ulcer disease (PUD) prophylaxis
 Deep vein thrombosis (DVT) prophylaxis
 Cleaning of equipment
 Do not routinely replace ventilator circuits
 Hand hygiene
 Subglottic secretion drainage
 Prevention of oropharyngeal colonization
UI = unresolved issue; NA = not addressed
IHI CDC


 (II)
 (IB)


 (UI)
NA
 (IA)
 (IA)
 (IA)
 (II)
 (II)
IHI 100K Lives Campaign. Getting Started Kit: VAP How-to Guide; CDC Guideline for Preventing Healthcare-Associated
Pneumonia, 2002.

 Recent randomized controlled study that disputes study referenced by CDC to recommend use of semirecumbent positioning to prevent VAP
 Study is unique in three aspects:
 Patient positioning was continuously monitored in first week
 The semirecumbent position was compared to the standard of care
 Data analyzed according to the intention-to-treat principle
 Results:
 Patients in supine position (control) reached only 9.8 to 14.8 degrees (i.e., standard of care)
 Mean backrest position in study group was 30 degrees
 No difference in VAP rates between the groups
 Pressure ulcers: 30% in supine group, 28% in semirecumbent group van Nieuwenhoven CA, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: A randomized study. Crit Care med 2006;34:396-402.

Flanders SA, Collard HP, Saint S. Nosocomial pneumonia: State of the
Science. Am J Infect Control 2006;36:84-93
 7 meta-analyses, >20 studies
 4 showed significant VAP reductions
 3 showed similar but non-significant VAP reductions
Cook D, et al. A comparison of sucralfate and rantidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian
Critical Care Trials Group. N Eng J Med 1998;338:781-97.
 Large randomized trial showed no benefit in either sucralfate or H2 antagonists
Kantorova I, et al. Stress ulcer prophylaxis in clinically ill patients: a randomized controlled trial. Hepatogastroenterology, 2004;2004:51:757-61.
 randomized, placebo-controlled trial, 287 pts.
 studied omeprazole (PPI), famotidine (H2 antagonist), sucralfate
 No significant differences in bleeding or pneumonia rates among the 4 groups

 Meta-analysis of randomized trials
 5 trials met inclusion criteria (patients >72 hrs. of mechanical ventilation)
 Results:
 shortened duration of ventilation by 2 days
 shortened length of stay by 3 days
 delayed onset of pneumonia by 6.8 days
Dezfulian C, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005;118:11-18.

“Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic
VAP is oropharyngeal colonization by endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial gram-negative bacilli.”
Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Respir Care 2005;50:725-39.

 A review of the published evidence linking oropharyngeal colonization and respiratory infection, including VAP (20 studies)
 Provides suggested oral and dental interventions, some beyond the scope of current guidelines
Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: Underappreciated risk and a call for interventions. Am J Infect Control 2005;33:527-41.

Suggested Intervention Reasoning
Conduct a daily assessment of the lips, oral tissue, tongue, teeth, and saliva of each patient on a mechanical ventilator
Use separate connection tubing for oral and tracheal suction
Assessment allows for for initial identification of oral hygiene problems and for continued observation of oral health
Opening a “closed” system may allow for the dissemination of respiratory pathogens into the environment surrounding the patient
Use a toothbrush as opposed to foam swabs or gauze to remove dental plaque
Dental plaque has been identified as a source of pathogenic bacteria associated with respiratory infection
Protocols should be implemented that assist patients at risk in maintaining adequate salivary production and tissue health
Care should be taken when using oral care solutions: Use an alcohol-free, antiseptic rinse to prevent bacterial colonization of the oropharyngeal tract
Saliva provides both mechanical and immunological effects which act to remove pathogens colonizing the oropharynx
Mouthwashes with alcohol cause excessive drying of oral tissues. Hydrogen peroxide has been shown to assist in clearing debris buildup and provide antibacterial properties
Avoid using lemon-glycerin swabs for oral care Lemon-glycerin compounds are acidic and cause drying of oral tissues

Suggested Intervention Reasoning
Toothpaste should contain additives which assist in the breakdown of mucous in the mouth
Additives such as sodium bicarbonate have been shown to assist in removing debris accumulations on oral tissues and teeth
Use a water-soluble moisturizer to assist in the maintenance of healthy lips and gums
Dryness and cracking of oral tissues and lips provides regions for bacterial proliferation. A water-soluble moisturizer allows tissue absorption and added hydration.
Yankauer catheters should be covered between uses on a patient
Remove secretions that accumulate in the subglottic area (above the endotracheal tube cuff) routinely and prior to removal of the endotracheal tube
Yankauers used on a patient and left uncovered on the bed or other surface pose the risk of contaminating the patient’s environment with pathogens from the oropharyngeal tract
Secretions forming in the subglottic area are rapidly colonized with pathogenic bacteria; aspiration of this colonized secretion has been shown to cause ventilator-associated pneumonia
Check for adequate endotracheal tube cuff pressure at least once per day
Inadequate cuff pressure is associated with aspiration of bacteria-laden secretions located above the cuff
Check the positioning of the endotracheal tube at least once per day
Over time, endotracheal tubes may begin to move up the trachea, leading to a possible unplanned extubation and concurrent aspiration of contaminated subglottic secretions

 Rochester Medical center, Rochester, NY
 At least 220 days without a VAP case http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/UniversityofRoche sterStrongMemorialHealthWorkingtoReduceComplicationsfromVentilatorsandPreventVAPint.ht
m
 Overlake Hospital, Bellevue, WA
 Reduced VAP by 80% in one year http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/DoingBetterSpend ingLess.htm
 Consortium of 127 ICUs in 70 hospitals
 68/127 ICUs eliminated VAP for at least six months
 Along with CLAB bundle, estimates are that 1,500 lives were saved,
81,000 hospital days, and $165 million http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/DoingBetterSpend ingLess.htm
 Owenboro Medical Health System, Owensboro, KY
 Reduced VAP by 72% in 18 months http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVentilato rAssociatedPneumoniaOwensboro.htm

http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/EliminateVentilatorAssociatedPneumonia.htm

 Used HMO Acronym:
 Head of Bed: keep at least 30 degrees or greater unless contraindicated
 Mobility: Each even hour, complete or assist the patient in performing mobility

Oral Care: Perform oral care every even hour on intubated and trached patients. Suction brush at 0800 and 2000. Suction catheters at extubation, position changes, and every 6 hours or as needed.
Preimplementation
10.8 per 1000 vent days
Postimplementation
3.6 per 1000 vent days
Percent change
67% reduction
SICU VAP rate
(NNIS criteria)
Housewide adult
ICU and intermediate ICU
VAP rate
5.1 per 1000 vent days
2.7 per 1000 vent days
48% reduction
Simmons-Trau D. ZAP VAP with a back-to-basics approach. Nurs 2006 Crit Care;1:28-36.

 Baptist Memorial DeSoto
 Baptist Memorial Hospital
Golden Triangle
 Bay Regional Medical Center
 McLeod Regional Medical
Center
 OSF Saint Francis Medical
Center
 Overlake Hospital Medical
Center
 Palmetto Health Baptist
 Upper Chesapeake Medical
Center

Brookdale University Hospital Medical Center, NY
 Objective: to determine the effect of a comprehensive oral care program on rates of VAP, mortality, cost
 MICU patients on mechanical ventilation >48 hrs.
 Pre-intervention: 1/1/0112/31/02, “standard” oral care
 Intervention: 1/1/03-12/31/04, education and use of a novel oral-dental care system designed to reduce bacterial colonization of the oropharyngeal tract and teeth
 Standards of care during the entire 48-month study included 7d vent circuit replacement, 24-hour HME filter replacement, 24-hour closed suction catheter replacement, semirecumbent position unless contraindicated, administration of stress ulcer prophylaxis, and use of a weaning protocol.
Garcia R, Jendresky L, Colbert L, Bailey A. 48-month study on reducing VAP using advanced oral-dental care: protocol compliance, rates, mortality, and cost. Abstract presented at the 2006 APIC Conference, Tampa, FL. [publication pending, Crit Care Med]

Characteristics
Mean age ± SD
Males, no. (%)
APACHE II
Pre-Intervention Period
(n = 859)
61.3 ± 12.2
523 (61)
26.8 ± 8.8
Reason for ICU admission, no. (%)
Acute respiratory failure
Cardiovascular disease
Gastrointestinal disease
Renal disease
Sepsis
Trauma
Neurological disease
Other
404 (47)
189 (22)
95 (11)
60 (7)
51 (6)
26 (3)
17 (2)
17 (2)
Intervention Period
(n = 755)
63.1 ± 9.8
483 (64)
27.3 ± 7.9
325 (43)
181 (24)
90 (12)
53 (7)
45 (6)
15 (2)
23 (3)
23 (3)

50
40
30
20
10
0
100
90
80
70
60
Q1 2003 Q2 2003 Q3 2003
Daily assessment
Oral tissue cleansing q6h
Q4 2003 Q1 2004
Deep suctioning q4h
Kits at bedside
Q2 2004 Q3 2004
Tooth brushing 2xd
2-line connector used
Q4 2004

Variable
Duration of ventilation, mean days
Pre-intervention Period
(n=859)
Intervention Period
(n=755)
10.3
6.5
Ventilator utilization ratio 0.68
0.63
ICU stay, days
VAP per 1000 ventilator days
VAP, no. (%)
Mortality, no. (%)
12.7
8.3
44 (5.1)
163 (18.9)
6.5
4.5 ( p <.05)
23 (3.0)
138 (18.2)

2
0
6
4
10
8
12
14
16
Nea
r
Zer o!
Pre-intervention Period Intervention Period Confirmatory Period
Mean annual rate

Study/Year
Warren 2003
Rello
2002
Cocanour
2005
#Pts with
VAP
127
842
Measure ICU Type
Cost with
VAP
Cost without
VAP
Attributable cost
(hospital)
Med, surg $27,033 $15,136
Charges
Med, surg, trauma
$104,983 $63,689
70
Attributable cost
Trauma $82,195 $25,037
Cost per
VAP case
$11,897
$41,294
$57,158
Kollef
2005
499 Charges
Various
ICUs
$150,841 __ $150,841
Warren DK, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003;31:1312-3.
Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of
VAP in a large US database. Chest 2002;122:2115-2121.
Cocanour et al. Cost of ventilator-associated pneumonia in a shock trauma intensive care unit. Surg Inf,
2005;6:65-72.
Kolllef MN, et al. Epidemiology and outcomes of health-care-associatedpneumonia: Results from a large US database of culture-positive pneumonia. Chest 2005;128:3854-62.

STUDY
Warren
Rello
Cocanour
Kollef
# PTS WITH
VAP
MEASURE ICU TYPE
REPORTED
VAP COST
INFECTION
COST
(=VAP cost x 12 avoided cases per year)
TOTAL COST
AVOIDED/YR
(= Infection cost
— product cost)
127
842
70
Attributable cost
(hospital)
Med, Surg
Charges
Med, Surg,
Trauma
Attributable cost
Trauma
$11,897
$41,294
$57,158
$142,764
$495,528
$685,896
$83,631
$436,395
$626,763
499 Charges Various $150,841 $1,810,092 $1,750,959
Total product cost = $59,133

My thanks to the Brookdale family for their dedication and supreme efforts in improving the care of our patients

Dr. Maryanne McGuckin ScEd., MT(ASCP)
Senior Research Investigator
Adjunct Associate Professor
Senior Fellow, Leonard Davis Institute for Health Economics
Senior Fellow, Institute on Aging
University of Pennsylvania School of Medicine
Robert Garcia BS, MMT(ASCP), CIC
Asst. Director of Infection Control
Brookdale Univ. Hospital Medical Center
718.240.5924 ~ rgarcia@brookdale.edu
President
Enhanced Epidemiology, LLC
P.O. Box 211 ~ Valley Stream, NY 11580
516.810.3093 ~ rgarciaicp@aol.com