Healthcare associated infections are a major cause of poor outcomes for patients. Ventilator associated-pneumonia, a subset of hospital acquired pneumonia, results in increased patient morbidity and mortality, prolonged length of stay and increased healthcare costs. Up to one quarter of patients requiring mechanical ventilation develop ventilator associated pneumonia. Ventilator-associated pneumonia can be caused by the migration of microorganisms from colonised endotracheal and/or tracheostomy tubes, direct inoculation via bronchoscopy or other respiratory procedures or by aspiration. Affected patients may have prior underlying lung disease or immune suppression. Minimising the risk of ventilator associated pneumoniaIntubation and tracheostomy tube insertion should only be undertaken by persons trained and competent in the technique. Key recommendations
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Internet Citation: Head of Bed Elevation or Semirecumbent Positioning Literature Review. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD. 1University of Michigan School of Nursing, Department of Systems, Populations and Leadership, Ann Arbor Michigan Find articles by Emily Boltey 1University of Michigan School of Nursing, Department of Systems, Populations and Leadership, Ann Arbor Michigan 2University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor Michigan 3Institute for Healthcare Policy and Innovation, University of Michigan Ann Arbor Michigan Find articles by Olga Yakusheva 1University of Michigan School of Nursing, Department of Systems, Populations and Leadership, Ann Arbor Michigan 3Institute for Healthcare Policy and Innovation, University of Michigan Ann Arbor Michigan Find articles by Deena Kelly Costa Keywords: critical care nursing, evidence-based practice, VAP prevention, mechanical ventilation Healthcare associated infections (HAI), such as ventilator-associated pneumonia (VAP), are the most common and most preventable complication of a patient’s hospital stay. Their frequency and potential adverse effects increase in critically ill patients because of impaired physiology, including a blunted immune response and multi-organ dysfunction. Traditionally, VAP rates have been measured as an indicator of quality of care. Despite recent initiatives to measure complications of mechanical ventilation and a decrease in incidence over the past few years, VAP remains an issue for critically ill adults, with mortality estimated as high as 10%. This article reviews the top five evidence-based nursing practices for reducing VAP risk in critically ill adults. The most important evidence-based practice for lowering VAP risk is minimizing a patient’s exposure to mechanical ventilation, which can be achieved in two ways. First, you can encourage and advocate for the use of noninvasive ventilation approaches, such as bilevel positive airway pressure or continuous positive airway pressure. The face masks used with these approaches can be uncomfortable for patients, but data from a small randomized clinical trial suggests that similar benefits can be achieved using a helmet instead. In addition to better patient comfort, helmets resulted in a significantly lower intubation rate compared to face masks. Second, when mechanical ventilation can’t be avoided, work to minimize its duration. Ventilator weaning protocols or evidence-based care bundles (for example, the Awakening, Breathing Coordination, Delirium, and Early mobility (ABCDE) bundle) can be effective in shortening mechanical ventilation duration. Nurse-led and respiratory therapist-led ventilator-weaning protocols that include daily interruption of sedation and coordination with a spontaneous breathing trial have been effective in removing patients from mechanical ventilation quickly and appropriately. If a ventilator-weaning protocol doesn’t exist on your unit, take the opportunity to design and develop one. Oral health quickly deteriorates in mechanically ventilated patients. Some patients sustain injuries to the oral mucosa during the intubation procedure, and after intubation, patients are prone to dry mouth. These factors, in addition to a severely compromised immune system, can cause an increase in bacteria colonization in the oral mucosa, with the endotracheal tube serving as a direct route to the lungs. Adequate oral care can reduce bacterial overgrowth and reduce the risk for infection. In a meta-analysis of more than 18 randomized controlled trials (RCTs), routine oral care with chlorhexidine reduced the incidence of VAP. Currently, no guidelines exist for oral hygiene frequency. A recent systematic review of 38 RCTs showed oral care being performed anywhere from one to four times a day. Making oral care a routine part of a patient’s assessment in the ICU is one way to enhance its frequency. Consider developing a unit-specific protocol with clear articulation of roles and responsibilities. Aspiration of secretions that accumulate around the endotracheal tube of mechanically ventilated patients can lead to VAP. Subglottic secretion suctioning can be performed by both the nurse and respiratory therapist and can aid in prevention. A recent meta-analysis of 20 RCTs found that subglottic suctioning reduced the risk for VAP by 45% compared to patients who didn’t receive suctioning. Coordinating subglottic suctioning when conducting oral care may be a good mechanism to cluster care and ensure both of these practices are routinely delivered. Proper positioning (keeping the head of the bed between 30–45 degrees) and encouraging early mobility of mechanically ventilated patients aid in the prevention of VAP. Gastric reflux and aspiration can also lead to VAP in mechanically ventilated patients. Keeping the head of the bed elevated between 30–45 degrees (semi-recumbent position) is recommended to reduce reflux and subsequent risk for VAP. Early mobility can be challenging, but it results in more ventilator-free days. Evidence supports the feasibility of early mobilization for critically ill patients, even shortly after intubation, as long as the patient isn’t sedated. Early mobility protocols include a progressive approach that transitions from dangling at the edge of the bed, to standing at the edge of bed, to marching in place and then, for patients who can tolerate a higher level of activity, ambulating. For the best patient outcomes, coordinate exercise and mobilization with physical and occupational therapists. Adequate nurse staffing in the ICU, especially for mechanically ventilated patients, can help minimize VAP risk. It provides nurses with the time, opportunity, and resources to implement care practices that reduce risk, and it allows them to spend more time with their patients, which may lead to early identification of VAP and prompt treatment. Healthy work environments and interprofessional collaboration also have been associated with lowering the risk for VAP. Two studies found that better nurse work environments, in conjunction with physician staffing, have implications for VAP risk. For example, in open ICUs where patients are managed by general physicians instead of specially trained critical care physicians, having better nurse work environments can reduce VAP rates for mechanically ventilated patients. Similarly, prior work identified that when nurses work in environments that support professional nursing practice (i.e. healthy nurse work environments), nurses are significantly less likely to report frequent VAP. These data provide support for you to work with other nurses to ensure your work environment supports professional nursing practice. Ways to do this include developing shared governance models, engaging in quality improvement activities to enhance high quality care and encouraging positive team interactions. Partnering with ICU physician and the rest of the interprofessional team, especially respiratory therapy, are two key ways to continue to encourage positive team interactions and reduce VAP risk. Nurses are particularly well positioned to lead the healthcare team in VAP prevention. You can help minimize patients’ exposure to mechanical ventilation, work collaboratively to develop a ventilator weaning protocol, and ensure implementation of evidence-based care that minimizes VAP risk. Key points
All of the authors work at the University of Michigan in Ann Arbor. Emily Boltey is a doctoral (PhD) student in the Department of Systems, Populations and Leadership at the School of Nursing; Olga Yakusheva is an Associate Professor in the Department of Systems, Populations and Leadership at the School of Nursing and Department of Health Management & Policy in the School of Public Health, a member of the Institute for Healthcare Policy & Innovation; and Deena Kelly Costa is an Assistant Professor in the Department of Systems, Populations and Leadership at the School of Nursing and a member of the Institute for Healthcare Research and Quality. Funding for this work was provided by the Agency for Healthcare Research & Quality (K08 HS024552, PI Costa).
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Which position is best for the patients to reduce the risk of ventilator-associated pneumonia?
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