# Preventing VAP in your patients?



## KingCountyMedic (Feb 22, 2013)

We are starting to look hard at our rates of VAP in our patients, both pre hospital intubations and in house. Currently the rates of pneumonia are fairly even if you compare hospital to pre hospital. We are probably going to do a study where we prep the mouth with Chlorhexidine prior to RSI. Anyone else doing anything? We have to fill out an airway form on every patient we intubate otherwise we do not get credit for the tube. Much of the form is answering questions about aspiration risks. Was there a risk? Blood or emesis or both? Confirmed in the tube? etc. etc. As you would imagine patients that get extensive BVM use prior to ETT are more prone to aspiration and developing VAP.


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## NomadicMedic (Feb 22, 2013)

Interesting idea. We also complete an extensive airway form on each intubation and while I know VAP is an issue, I haven't heard any connection with field tubes vs ED tubes. 

Of course, you guys intubate more CHF/COPD patients than we do, patients that stay on a vent. For us, CPAP has made most of those tubes vanish. 

I'd be curious to see if there's any correlation.


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## Carlos Danger (Feb 22, 2013)

Have you come across any evidence that cleaning the mouth prior to intubation reduces the risk of VAP? I've never even heard of the practice.

A few years ago I was involved in a research project in the SICU that I was working in at the time. We saw a big reduction in VAP rates by instituting certain nursing and RT practices. We know that VAP is a multi-factorial process with well-defined risk factors, and IIRC, VAP is uncommon in patients who are intubated for less than 48 hours. Given those things, I would be inclined to think that VAP has little or nothing to do with the intubation itself. _(that is as long as you don't drop the ETT on the ground, step on it, pick it up, shake off the small rocks and pieces of grass that are stuck to it, and intubate with it.....as I saw done on a youtube video a while ago)_

It's an interesting thought and probably a good idea for a study, but I think it sounds like a study that would much more appropriately be done in the hospital than the streets. 

Quite frankly, I think during a pre-hospital RSI you have much more pressing things to worry about than VAP.


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## Dwindlin (Feb 22, 2013)

old school said:


> Quite frankly, I think during a pre-hospital RSI you have much more pressing things to worry about than VAP.



This was my first though reading this.  If you have time to muck around with cleaning the mouth with clorhexidine does the patient really need tubed? Or can you just get them to the ED. . .


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## STXmedic (Feb 22, 2013)

old school said:


> Quite frankly, I think during a pre-hospital RSI you have much more pressing things to worry about than VAP.




If you're causing or failing to prevent VAP, and ensuring longer ICU stays and poorer outcomes, I think prevention would be something you'd want to look in to. 

I don't think adequate preparation for a procedure is something to shortcut to try and save time. An intubation or RSI doesn't need to be "Oh my god drop the tube quick!!!". Have you ever seen an EMP cut into the pleural space and shove an ET tube in because the patient had a hemothorax and needed a chest tube ASAP? No. They prep the site, assemble their equipment, and perform the procedure in a way that isn't going to provide future, unneeded harm to the patient. Emergent =/= shortcuts and sacrifices.

I'd be interested to see the results of this study.


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## Hunter (Feb 22, 2013)

old school said:


> Quite frankly, I think during a pre-hospital RSI you have much more pressing things to worry about than VAP.



Do you wipe down a persons arm before an IV or say screw it because you wanna save the few seconds?

This attitude I think is a problem, we don't think enough about how our treatments affect a persons outcome after we drop em off at the ER. It's the classic "Yes it's a save because we got pulses! After working a code for an hour. Oh the patients a vegetable? Doesn't matter we got pulses." I think cleaning the mouth before putting down an ET tube could definitely apply to prehospital, you know if it actually turns out to do something and shorten length of stay.


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## usalsfyre (Feb 22, 2013)

PoeticInjustice said:


> Have you ever seen an EMP cut into the pleural space and shove an ET tube in because the patient had a hemothorax and needed a chest tube ASAP?



Actually, this or even the "finger thoracostomy" are not terribly uncommon where physicians are utilized in the prehospital environment.

I'm actually inclined to agree with old school on this one. While we don't need to use the ETT to scoop vomit out of the mouth, the fact is the ICU should probably be replacing the tube within 48 hours anyway. VAP is a lot more about nonsocomial stuff floating around the ICU than anything they're exposed to in the field. If it's already in the mouth than it's got a conduit to the lungs anyway right?

Prehospital RSI SHOULD be a last resort. Proper prep is vital but in most cases I want to get the airway taken care of and move on to working on the underlying cause (which may very well be getting to the hospital...I don't do tubes underway if I can avoid it).

Interested to see the result, gut feeling it won't show a CLINICALLY significant reduction.


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## Clipper1 (Feb 22, 2013)

Interesting topic which I think there is alot of research being done especially with all the new developments in ETTs and adjuncts to assist intubation. Companies don't put that much money into R&D of ETTs nor do hospitals pay for expensive tubes unless there is a good reason.  VAP is serious and CMS will not reimburse so all precautions must be taken to prevent it. 

The act of intubation itself is also part of the many factors concerning VAP. That should include being properly prepared with the right equipment including suction and the proper skill level including use of BVM.   If you don't care about how well you do the act of intubation you probably don't care if the patient dies later from complications associated with it as long as they live long enough to be considered an EMS save.

Prehospital tubes are cheap and lack the appropriate cuff design. The cuff itself will often develop a leak after a day or two requiring the cuff to be changed.  They also lack the ability to perform suctioning above the cuff. They also are not silver lined which some hospitals like.  So alot of prehospital tubes will have to be changed if the patient is going to be intubated for more than a day or two.

Most EDs now stock the better ETTs. 

Aspiration is a big risk and I think there was a large variation in protocols for the use of an OG/NG tube. NG tubes are also out of favor because of VAP. The same goes for NTI. 

I think I read someplace where Paramedics use the patient's blood or some other questionable things instead of lubricant for lube. Causing tissue damage and bleeding without using lube is not good either and aspiration of blood can cause serious infections.

Prehospital CPAP can also be controversial because of inappropriate use and failure to clear the airway before application.  Patients may need to be intubated at the hospital not because of the initial complaint but because of aspiration. Usually these situations occur when suction is often forgotten and not ready.


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## Veneficus (Feb 22, 2013)

usalsfyre said:


> I'm actually inclined to agree with old school on this one.



I think this is very reasonable.



usalsfyre said:


> VAP is a lot more about nonsocomial stuff floating around the ICU than anything they're exposed to in the field. If it's already in the mouth than it's got a conduit to the lungs anyway right?



Sort of.

I agree with the nosocomial stuff, particularly the really resistant things that a simple ab regiment will not take care of.

However, I would just like to add that an ET does bypass the physiologic defense mechanisms and being plastic, is a conduit for infection. 

I think that issue with VAP isn't an acute introduction of bacteria so much as it is a migration by one method or another in a patient population that generally doesn't complain verbally and many clinical signs of infection are late signs.



usalsfyre said:


> Interested to see the result, gut feeling it won't show a CLINICALLY significant reduction.



I would be more interested in seeing the culture results for the VAP population and how long they were in the ICU before infection was Dx. 

I think that would be more telling of the source.


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## KingCountyMedic (Feb 22, 2013)

It's something being looked at here, very early stages but we are always looking at improving what we do in the field and hospital. Our work in the field is very much intertwined with our main hospital (Harborview Medical Center)

Currently the intubated patient at the hospital does get their mouth cleaned on a regular basis by an RT in an attempt to cut down on VAP and other problems and they have seen some success so the thinking is what can we do better, prior to intubation? Early study using airway manikins and Paramedic Students and Residents is showing that full mouth prep with Chlorhexidine can be done very quickly prior passing the tube. Of course if you go that far what about the tube? What about the blade? It'd something I never really gave much though until we had a lecture from one of our Docs the other day. I try to keep my tube and gear clean as much as the next guy. It sounds as if a lot of the "bugs" found in the lung of a VAP patient are common in the mouth. Again this is totally new stuff for us to hear about here where I work, just wondered if anyone else is doing anything to clean prior to putting in the tube? I think VAP is seen more in blunt trauma cases, I could be wrong though. A lot of this is way above my pay grade


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## Veneficus (Feb 22, 2013)

KingCountyMedic said:


> It's something being looked at here, very early stages but we are always looking at improving what we do in the field and hospital. Our work in the field is very much intertwined with our main hospital (Harborview Medical Center)
> 
> Currently the intubated patient at the hospital does get their mouth cleaned on a regular basis by an RT in an attempt to cut down on VAP and other problems and they have seen some success so the thinking is what can we do better, prior to intubation? Early study using airway manikins and Paramedic Students and Residents is showing that full mouth prep with Chlorhexidine can be done very quickly prior passing the tube. Of course if you go that far what about the tube? What about the blade? It'd something I never really gave much though until we had a lecture from one of our Docs the other day. I try to keep my tube and gear clean as much as the next guy. It sounds as if a lot of the "bugs" found in the lung of a VAP patient are common in the mouth. Again this is totally new stuff for us to hear about here where I work, just wondered if anyone else is doing anything to clean prior to putting in the tube? I think VAP is seen more in blunt trauma cases, I could be wrong though. A lot of this is way above my pay grade



I think if the study is done well, even if outcomes are not affected, a lot of good information can be had.


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## Dwindlin (Feb 22, 2013)

usalsfyre said:


> Interested to see the result, gut feeling it won't show a CLINICALLY significant reduction.



I actually think you may see a benefit based on the work already done with daily clorhexidine baths.

http://www.ncbi.nlm.nih.gov/pubmed/19751155
http://www.ncbi.nlm.nih.gov/pubmed/19712033
http://www.ncbi.nlm.nih.gov/pubmed/22527065

Having said that, my feelings above still hold true, if you think you have sufficient time to properly cleanse the mouth, maybe you should re-think that tube. . .


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## Veneficus (Feb 22, 2013)

Dwindlin said:


> I actually think you may see a benefit based on the work already done with daily clorhexidine baths.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/19751155
> http://www.ncbi.nlm.nih.gov/pubmed/19712033
> ...



I have read a lot of studies today, could you just tell me if any of these compared a cloro bath with brushing the pts teeth?


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## KingCountyMedic (Feb 22, 2013)

Dwindlin said:


> I actually think you may see a benefit based on the work already done with daily clorhexidine baths.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/19751155
> http://www.ncbi.nlm.nih.gov/pubmed/19712033
> ...



Not at all. A little extra time prior to passing a tube is not a big deal, especially if it can improve the outcome in the patient. Obviously if you have a patient dead or dying, with blood or emesis present it's a different story. If you are taking the time to use some versed and etomidate prior to using anectine on an elective intubation you should have plenty of time to pass a swab around the mouth.


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## Clipper1 (Feb 22, 2013)

There are mountains of studies already done and some do include where the intubation is done which includes the ED and prehospital. Below is just a small sampling of what is known about VAP.  This data is referenced on the CDC and IHI websites.

This is of particular interest.
_Staphylococcus aureus are responsible for 26–35% of VAP in ED and inpatient intubated trauma patients, but account for only 0–13% of VAP in trauma patients intubated in the field._

The source is:
12.Eckert MJ, Davis KA, Reed RL, et al. Ventilator-associated pneumonia, like real estate: location really matters. J Trauma 2006;60: 104–10.

Some of the other studies demonstrate the types of ETT and intubation skill. Any time an inferior ETT must be changed, risks are involved. Other factors will include where the tube is changed. Usually the ED is more questionable than in the ICU. The same will go for central lines placed by ED physicians. 




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Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilatorassociated pneumonia: a meta-analysis. Am J Med 2005;118:11–8.


Grap MJ, Munro CL, Hummel RS III, Elswick RK Jr., McKinney JL, Sessler CN. Effect of backrest elevation on the development of ventilator-associated pneumonia. Am J Crit Care 2005;14:325–32.


Evans D. The use of position during critical illness: current practice and review of the literature. Aust Crit Care 1994;7:16–21.

Grap MJ, Munro CL, Bryant S, Ashtiani B. Predictors of backrest elevation in critical care. Intensive Crit Care Nurs 2003;19:68–74.

van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006;34:396–402.

Cook DJ, Meade MO, Hand LE, McMullin JP. Toward understanding evidence uptake: semirecumbency for pneumonia prevention. Crit Care Med 2002;30:1472–7.

Institute for Healthcare Improvement. Implement the ventilator bundle. Cambridge, MA: Institute for Healthcare Improvement; 2006.

Helman DL Jr., Sherner JH III, Fitzpatrick TM, Callender ME, Shorr AF Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. Crit Care Med 2003;31:2285–90.

Joiner GA, Salisbury D, Bollin GE. Utilizing quality assurance as a tool for reducing the risk of nosocomial ventilatorassociated pneumonia. Am J Med Qual 1996;11:100–3.

Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 2002;30:2407–12.  

Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005;31:243–8.

Crunden E, Boyce C, Woodman H, Bray B. An evaluation of the impact of the ventilator care bundle. Nurs Crit Care 2005;10: 242–6.

Cocanour CS, Peninger M, Domonoske BD, et al. Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 2006; 61:122–9.


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## Clipper1 (Feb 22, 2013)

KingCountyMedic said:


> Not at all. A little extra time prior to passing a tube is not a big deal, especially if it can improve the outcome in the patient. Obviously if you have a patient dead or dying, with blood or emesis present it's a different story. If you are taking the time to use some versed and etomidate prior to using anectine on an elective intubation you should have plenty of time to pass a swab around the mouth.



If you are from King County, Washington you might look up the research articles from U of Washington. 

I think what sets that area apart is the education and skill level obtained during Paramedic training.


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## KingCountyMedic (Feb 22, 2013)

Clipper1 said:


> If you are from King County, Washington you might look up the research articles from U of Washington.
> 
> I think what sets that area apart is the education and skill level obtained during Paramedic training.



Agree 100% 

Most of the writers of those UW research articles lecture us and ride with us on a regular basis. The newest research on this issue is now being talked about as a possible field study. It sounds like Seattle will kick it off and then they will look at expanding the study from there.


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## Clipper1 (Feb 22, 2013)

KingCountyMedic said:


> Agree 100%
> 
> Most of the writers of those UW research articles lecture us and ride with us on a regular basis. The newest research on this issue is now being talked about as a possible field study. It sounds like Seattle will kick it off and then they will look at expanding the study from there.



The results from your area may not be indicative of all EMS since there is such a discrepancy in skills, education and continued competency. 

I think those who believe what happens in the field has not bearing on results in the hospital are the ones who have the most to learn.


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## Dwindlin (Feb 22, 2013)

KingCountyMedic said:


> Not at all. A little extra time prior to passing a tube is not a big deal, especially if it can improve the outcome in the patient. Obviously if you have a patient dead or dying, with blood or emesis present it's a different story. If you are taking the time to use some versed and etomidate prior to using anectine on an *elective* intubation you should have plenty of time to pass a swab around the mouth.



There should be no such thing in the pre-hospital realm.  Don't get me wrong, I'm glad there is a large group of providers out there who aren't just about following the protocol and want more education and understanding.  However, I am still a minimalist in both my view and practice.  The words elective should never be in front of ANYTHING we do.


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## Wheel (Feb 22, 2013)

Dwindlin said:


> There should be no such thing in the pre-hospital realm.  Don't get me wrong, I'm glad there is a large group of providers out there who aren't just about following the protocol and want more education and understanding.  However, I am still a minimalist in both my view and practice.  The words elective should never be in front of ANYTHING we do.



I wouldn't say never. Pain management is elective. Rarely is it necessary. Should we not do that? That being said I do agree that less is more and you should be able to justify your treatments.


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## usalsfyre (Feb 22, 2013)

There's emergent intubations and then there's *EMERGENT* intubations. My guess is they're trying to capture the former group.


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## KingCountyMedic (Feb 22, 2013)

usalsfyre said:


> There's emergent intubations and then there's *EMERGENT* intubations. My guess is they're trying to capture the former group.



Yes exactly, a extra step if time and the situation allows for it might not be a bad idea.

And when I say elective intubation, I mean making the decision to intubate before the the patient crashes requiring an emergent intubation.

:beerchug:


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## Carlos Danger (Feb 22, 2013)

PoeticInjustice said:


> If you're causing or failing to prevent VAP, and ensuring longer ICU stays and poorer outcomes, I think prevention would be something you'd want to look in to.
> 
> I don't think adequate preparation for a procedure is something to shortcut to try and save time. An intubation or RSI doesn't need to be "Oh my god drop the tube quick!!!". Have you ever seen an EMP cut into the pleural space and shove an ET tube in because the patient had a hemothorax and needed a chest tube ASAP? No. They prep the site, assemble their equipment, and perform the procedure in a way that isn't going to provide future, unneeded harm to the patient. Emergent =/= shortcuts and sacrifices.
> 
> I'd be interested to see the results of this study.



I've done more than a few RSI's, so I'm pretty pretty familiar with how they should be done......if you've never seen a chest tube placed in 10 seconds with little concern for prep, then you haven't been involved in many emergent CT placements. In a true emergency, the A-B-C's really do trump concerns for infection.

I'm not suggesting shortcuts, though....quite the opposite, in fact. RSI is by far the riskiest procedure that we do in the field, and the airway deserves to be the sole focus of the intubator. He or she does not need to be worrying about anything other than assessing and then securing the airway. The bottom line is that a field RSI is a truly critical procedure which should preclude all other concerns that are not directly related to the success of securing the airway.

If there were any reason to think that this would *significantly* improve outcomes, then OK, maybe then it'd be worth finding a way to work it into the sequence. But I think that should be shown pretty decisively before we bring it into the field and add another step to an already task-saturated situation.

In the ICU's chlorexidine rinses are actually pretty time consuming. We didn't see much improvement in our VAP rate until we were up to 2 minutes every 2 hours with teeth brushing every 8 hours. I just do not see it being practical or wise to try to do a proper mouth rinse in the middle of an emergent intubation.


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## Action942Jackson (Feb 22, 2013)

Dwindlin said:


> Having said that, my feelings above still hold true, if you think you have sufficient time to properly cleanse the mouth, maybe you should re-think that tube. . .



Actually, given any situation, you have ample time.  If you pre-oxygenate correctly allowing sufficient BVM ventilations with a nasal cannula cranked at 6 lpm in place providing additional oxygenation.  When you build that oxygenation toilet up, you stop BVM ventilations and the oxygen delivered through a nasal cannula can replace what the body would use in that time frame.  Giving additional minutes to drop the tube.  

It's a trick the was taught by our medical director and during a statewide EMS conference.  It truly does allow the time to take a deep breath, ensure proper preparations (suction, c-collar, additional tubes, blades, etc) and fully grasp the task at hand, instead of the "oh :censored::censored::censored::censored: I've gotta drop that tube now because their sats are dropping after 15 seconds."  It's not about how fast you can drop the tube, but why your tubing, how your tubing, what benefit will the patient receive, what will their clinical course in ICU be, and what are some possible risks associated with it.  

I love to see places actively evaluating what can change vs throwing stuff to the wall and seeing if it sticks.


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## Clipper1 (Feb 22, 2013)

old school said:


> I'm not suggesting shortcuts, though....quite the opposite, in fact. RSI is by far the riskiest procedure that we do in the field, and the airway deserves to be the sole focus of the intubator. He or she does not need to be worrying about anything other than assessing and then securing the airway. The bottom line is that a field RSI is a truly critical procedure which should preclude all other concerns that are not directly related to the success of securing the airway.



The other factors are important. There is alot more to successful intubation than just putting the tube through the cords.  

If you are truly educated and trained in RSI, then you should be in control of the airway which may allow for a few seconds to properly have all the necessary equipment in place along with being in a good position to prevent further damage to the patient.  

If EMS can not improve the overall survival of the patient, then what is the point? Intubation should be alot more than just a one dimensional skill. It should be viewed as a multifactorial asset to survival.  The timing of that skill is also part of that step. With the current studies  on intubation and cardiac arrest, when and where intubation should be done must be considered.  

EM doctors probably don't like to have their intubations and lines questioned by CM doctors but they understand the reasons behind the concerns.  They know their emergently placed lines might increase a risk for infection with associated death and must be honest in their own assessment and communication to those assuming continued care for the patient.  This is difficult when egos are involved but medicine is changing that as more evidence is revealed forcing changes in practice.


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## Dwindlin (Feb 22, 2013)

Veneficus said:


> I have read a lot of studies today, could you just tell me if any of these compared a cloro bath with brushing the pts teeth?



None of these looked at cleansing the mouth with clorhexidine.  I just posted them to show proof of concept that these measure can reduce hospital acquired infections.  These mainly looked at line infections.


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## Dwindlin (Feb 22, 2013)

Action942Jackson said:


> Actually, given any situation, you have ample time.  If you pre-oxygenate correctly allowing sufficient BVM ventilations with a nasal cannula cranked at 6 lpm in place providing additional oxygenation.  When you build that oxygenation toilet up, you stop BVM ventilations and the oxygen delivered through a nasal cannula can replace what the body would use in that time frame.  Giving additional minutes to drop the tube.



Don't disagree with you here, only to say if I go to "pre-oxygenate" and the sat's are hanging in there and I'm effectively ventilating I'm done.  If I can maintain the patient without having to do an invasive procedure in less than ideal conditions that's what I'm doing.



Clipper1 said:


> If EMS can not improve the overall survival of the patient, then what is the point?



Very little of what we do has any impact on overall mortality.  Sorry to burst anyone's bubble. . .


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## Clipper1 (Feb 22, 2013)

Dwindlin said:


> None of these looked at cleansing the mouth with clorhexidine.  I just posted them to show proof of concept that these measure can reduce hospital acquired infections.  These mainly looked at line infections.



_Although tooth brushing is effective for mechanical removal of dental plaque, there is no convincing evidence that tooth brushing reduces VAP risk. Most studies of the effectiveness of mechanical oral care have been anecdotal or used a non-experimental design, and many studies included oral care along with other interventions with proven efficacy (e.g., head of bed elevation), and tested all the interventions together as a bundle. _

That is from this article:
Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004;13:25–33

This may or may not have a place in prehospital medicine but should be examined in the ED and trauma centers.  At least oral care should be initiated in the ED following intubation rather then just considering it an ICU nurse task. Ventilators are now being held in the ED for several hours due to lack of ICU beds. 

http://www.sageproducts.com/lit/20939c.pdf


You can find the abstracts to these articles on Medscape or Pubmed.



DeRiso AJ, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Am J Respir Crit Care Med 1996;109:1556–61.

Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 2002;11:567–70.


Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005;33:1728–35.

Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilatorassociated pneumonia. Am J 
Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006; 296:2460–6.


Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334:889.


Chlebicki MP, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2007;35:595–602.


Munro CL, Grap MJ, McClish D, Sessler CN. Chlorhexidine reduces ventilator associated pneumonia (VAP) in mechanically ventilated ICU adults. Crit Care 
Grap MJ, Munro CL, Elswick RK, Sessler CN, Ward KR, Higgins SM. Early, single chlorhexidine application to reduce oral flora and VAP in trauma victims. Am J Crit Care 2009;18:200.


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## Clipper1 (Feb 22, 2013)

Dwindlin said:


> Very little of what we do has any impact on overall mortality.  Sorry to burst anyone's bubble. . .



You must be talking solely about cardiac arrest. 

If you need to intubate a 20 y/o asthma or OD patient, there is no reason to give up on them.  Weekend college drunk binges are nasty but they can survive.  COPD and CHF exacerbations which are beyond CPAP can also survive with short term intubation. So can many sepsis patients but might require a few days on a ventilator in ICU. Trauma is another area which can be survived.  Sometimes intubation is needed for pain and seizure control. That does not mean it is a death sentence.


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## WTEngel (Feb 22, 2013)

Anyone heard of ET tube lubricant with selenium added? A friend of mine is the PI on a study they are doing in Lubbock where they are using selenium coated airways and selenium added lubricant in their procedures.

Supposedly it has significantly reduced the biofilm build up along with the VAP rate.

Not sure about the commercial availability, but it peaked my interest.


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## Clipper1 (Feb 22, 2013)

WTEngel said:


> Anyone heard of ET tube lubricant with selenium added? A friend of mine is the PI on a study they are doing in Lubbock where they are using selenium coated airways and selenium added lubricant in their procedures.
> 
> Supposedly it has significantly reduced the biofilm build up along with the VAP rate.
> 
> Not sure about the commercial availability, but it peaked my interest.



The ICUs here are looking at antimicrobial coating as an alternative to silver for a more cost effective method if they produce the same results. 

There are several studies available online which have taken place over the past decade.


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## KingCountyMedic (Feb 22, 2013)

Dwindlin said:


> Don't disagree with you here, only to say if I go to "pre-oxygenate" and the sat's are hanging in there and I'm effectively ventilating I'm done.  If I can maintain the patient without having to do an invasive procedure in less than ideal conditions that's what I'm doing.
> 
> 
> 
> Very little of what we do has any impact on overall mortality.  Sorry to burst anyone's bubble. . .




Maybe this is the case where you work. Not so in many other progressive parts of the world, mine included. Please tell me you don't rely on a patients O2 Sats to determine your course of treatment?


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## jwk (Feb 22, 2013)

Have y'all looked through these studies and the dates on them?  Some of them are 20 years old.  I can't bear to look through the whole laundry list of pointless and inapplicable studies.  Did any of them deal with chlorhexidine rinse prior to ETT?  If not, they're absolutely worthless in proving the point you're trying to prove.  If you have such a study, please post it, by itself, instead of a list of unrelated chlorhexidine skin prep and nosocomial infection articles.  (one was from _Nursing Economics_ for god's sake!)  Evidence based medicine - and there is no evidence for this.

Sorry to be blunt - but I put ETT's in for a living, many times, every single working day, both electively and emergently.  Someone would have to come up with absolute solid evidence that this is helpful, and I can tell you, it's nowhere in the anesthesia literature, much less coming close to making a change in clinical practice.  

Nosocomial infections are a serious problem, but they're a problem largely of the environment patients find themselves in.  But if ETT-acquired infections were really a problem, we'd be seeing a lot more of it.  We simply don't.  It's not even a blip on the radar.  Most patients, even critically ill ones, don't keep them that long, because if long-term intubation is anticipated, a trach will come sooner rather than later.  

And BTW - most of those in my profession never lubricate their ETT's.


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## jwk (Feb 22, 2013)

KingCountyMedic said:


> Please tell me you don't rely on a patients O2 Sats to determine your course of treatment?



Well of course you do.  Are you serious?


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## Clipper1 (Feb 22, 2013)

jwk said:


> Have y'all looked through these studies and the dates on them?  Some of them are 20 years old.  I can't bear to look through the whole laundry list of pointless and inapplicable studies.  Did any of them deal with chlorhexidine rinse prior to ETT?  If not, they're absolutely worthless in proving the point you're trying to prove.  If you have such a study, please post it, by itself, instead of a list of unrelated chlorhexidine skin prep and nosocomial infection articles.  (one was from _Nursing Economics_ for god's sake!)  Evidence based medicine - and there is no evidence for this.
> 
> Sorry to be blunt - but I put ETT's in for a living, many times, every single working day, both electively and emergently.  Someone would have to come up with absolute solid evidence that this is helpful, and I can tell you, it's nowhere in the anesthesia literature, much less coming close to making a change in clinical practice.
> 
> ...



If there is not such thing as ETT acquired infections, why have there been so many studies on these infections and why have there been improvements since different tubes have been used along with other bundle considerations? 

VAP has been around and studied for many years.  This is nothing new and it is impossible to post every article on the topic.  The articles just show how long this has been researched. No one just discovered it and much can be learned from past studies to move forward with new studies.  

The point is, care does not stop with just the insertion of the ETT nor is just putting the tube through the cords all there is to the intubation process. 

Hospitals do have a goal of decreasing vent days and not making a trach patient out of everyone who comes into the ICUs. LTC is not the way to go and should not be used as an excuse not prevent poor outcomes.  

The reason VAP is of economic concern is that CMS will not pay for hospital acquired infections. Regardless of whether the actual incident began in the prehospital phase, the hospital will be held accountable and must do what they can.  

Because of the past research and awareness of VAP or VAE, incidences have decreased. After well over 20+ years of research and improving policies, it would be stupid to continue making the same mortality rate occur over and over.   To say not to initiate such things like a oral hygiene or other prophylactic as soon as possible would not be doing the patients any favor for a chance at reducing their vent days or death. 

Check with you local hospital's ICU and see if they have a VAP bundle in place and see if it has oral care to be initiated when the ET tube is present.


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## Veneficus (Feb 23, 2013)

Clipper1 said:


> I think those who believe what happens in the field has not bearing on results in the hospital are the ones who have the most to learn.



You should post this in every thread on the site.


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## Dwindlin (Feb 23, 2013)

KingCountyMedic said:


> Maybe this is the case where you work. Not so in many other progressive parts of the world, mine included. Please tell me you don't rely on a patients O2 Sats to determine your course of treatment?



This should be the case were everyone works.  Again, just because we can do something doesn't mean we should.  

Yes I rely on sats, as well as a host of other things to guide what I do.


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## Dwindlin (Feb 23, 2013)

Clipper1 said:


> _Although tooth brushing is effective for mechanical removal of dental plaque, there is no convincing evidence that tooth brushing reduces VAP risk. Most studies of the effectiveness of mechanical oral care have been anecdotal or used a non-experimental design, and many studies included oral care along with other interventions with proven efficacy (e.g., head of bed elevation), and tested all the interventions together as a bundle. _
> 
> That is from this article:
> Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004;13:25–33
> ...



Did you read the articles or just the abstracts.  I just spent too much of my morning going over all of those articles and most of them aren't impressive.  Many of them have pretty significant flaws.  Many of the studies lost more than half their enrolled patients, most are using a diagnostic tool that has been called into question (CPIS), none of them demonstrated any mortality benefit or decreased vent time. And only one showed (a small) dcreased LOS.  And the one that showed decreased LOS was in one subset of patients.


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## Veneficus (Feb 23, 2013)

Dwindlin said:


> I just spent too much of my morning going over all of those articles and most of them aren't impressive.  Many of them have pretty significant flaws.  Many of the studies lost more than half their enrolled patients, most are using a diagnostic tool that has been called into question (CPIS), none of them demonstrated any mortality benefit or decreased vent time. And only one showed (a small) dcreased LOS.  And the one that showed decreased LOS was in one subset of patients.



Welcome to my world


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## Carlos Danger (Feb 23, 2013)

Clipper1 said:


> EMS can not improve the overall survival of the patient, then what is the point?



That is a good question. Has pre-hospital intubation even been shown to improve survival? If we're really worried about contaminating the airway, why not stick to SGA's?

You seem to be assuming that this will improve survival, while there is no proof of that. People once assumed that hard spine boards and intra-cardiac epi would improve survival, too.

As I wrote before, *IF* there were some indication that this might significantly improve outcomes, then I would be all for finding a way to work it into an RSI protocol. But no such indication exists. I do not see a reason to add an additional step to an already critical, task-saturated sequence. 

If you guys were more familiar with how VAP is managed in the ICU's, you would see exactly what I mean. The only things that have been shown to reduce VAP incidence in the ICU's are things that require _consistent_ effort and _frequent_ interventions......so I just don't see why we think a single, quick treatment in the field is going to make any difference at all.

I'm not saying this shouldn't be looked at, I'm just saying I don't think pre-hospital is the appropriate forum for the initial investigations.


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## Dwindlin (Feb 23, 2013)

Veneficus said:


> Welcome to my world



Been in your world for a while now. . .

Just rarely bring it up. <_<


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## Clipper1 (Feb 23, 2013)

Dwindlin said:


> Did you read the articles or just the abstracts.  I just spent too much of my morning going over all of those articles and most of them aren't impressive.  Many of them have pretty significant flaws.  Many of the studies lost more than half their enrolled patients, most are using a diagnostic tool that has been called into question (CPIS), none of them demonstrated any mortality benefit or decreased vent time. And only one showed (a small) dcreased LOS.  And the one that showed decreased LOS was in one subset of patients.



You may need to sign in to Medscape or PubMed to see the full articles. Registration is free.

I have read alot of the studies since many of them have been posted in ICUs and EDs. You might try looking around the hospitals to where they post current news.

Why do you say they are flawed?  PNA is a killer even in young people. That part of it is very real.  CDC and CMS are making adjustments for some flaws with a new VAE algorithm.  

This data is not only in the US but around the world. There is just too much information on it to adequately cover it. But, go to the ICUs and talk to just about anyone working there and ask what their VAP protocols are. As it has been mentioned, there are many factors to consider. But, if you just sit around and wait for a patient to die without doing anything to improve outcome especially when it is very preventable, isn't that rather negligent? Why should CMS pay for something which could have been prevented?

Some of those articles have been cited by the CDC and IHI for the development of guidelines and protocols in the US. 

It is not just the US. Here is the Canadian guidelines.
http://www.zapthevap.com/index.php?option=com_content&task=view&id=15&Itemid=28

Ireland
http://www.hpsc.ie/hpsc/A-Z/Microbi...ionControlandHAI/Guidelines/File,12530,en.pdf

UK
http://www.bjmp.org/content/ventilator-associated-pneumonia-overview

http://www.nice.org.uk/guidance/index.jsp?action=article&o=38047
Here are some more websites for you to look at. The more knowledge you get the less you will be inclined to say this is bull:censored::censored::censored::censored:.  Reducing mortality in a hospital is not a joke. The spread of infection which can be prevented is not a joke.  The numbers are there. Anyone who has ever worked in an ICU or read a patient chart on transport should know about the consequences of an infection. 

http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx

http://www.cdc.gov/hai/vap/vap.html

This article discusses many of the factors with VAP. Full article with references.
http://emedicine.medscape.com/article/304836-overview#aw2aab6b2

Full article with references.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/

Here is a JEMS article discussing a study.
http://m.jems.com/article/patient-care/link-between-intubation-ventilator-acqui

Even one day less on a ventilator or a decreased stay in the ICU is a big savings for the hospital and the patient.

If the patient does not end up with a trach and peg in a LTC due to complications from an infection it is a big savings for the patient and the hospitals or insurers including State and Federal.

If the patient does not die due to infection then that might be a plus for the patient and his family especially if it is a young 20 something who might have a family. 

Don't just criticize the articles I posted. Find more articles searching Medscape.  Find articles in critical care, nursing or respiratory medicine journals.   Not all articles are the same but they do show an increased awareness of something which is preventable and people should not die from it.  It seems you and  a couple other put no faith in research, either good or bad, which could explain why EMS is just now hearing about this and some are getting involved.  It is good to have EMS such as in King County which gets involved but then that also shows education can lead to change. They have always been more willing to accept trials for change and adjust accordingly depending on the results.  If they don't agree with something, they do their own research to see if they get the same results.


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## Dwindlin (Feb 23, 2013)

Clipper1 said:


> You may need to sign in to Medscape or PubMed to see the full articles. Registration is free.
> 
> I have read alot of the studies since many of them have been posted in ICUs and EDs. You might try looking around the hospitals to where they post current news.
> 
> ...



Really?  I just told you I read through them all this morning.  I have access to most journals (not just medicine) through school (I am a grad student).  And most of the ones you posted are flawed.  Does that make them invalid? No.  But it does mean that better studies are necessary.  Though my suspicion is it isn't possible, given the population being studied.  

Yes, pneumonia kills people?  What is your point?  So far there is NO SHOWN MORTALITY BENEFIT from cleaning patients mouths with antiseptics, nor are there any decreases in vent days required, and outside of post-op cardiac patients no decreased LOS.  So why keep doing this?  The evidence doesn't support it.  The only thing the evidence you have presented supports is that this practice lowers CPIS scores, which again probably isn't actually diagnosing many cases of pneumonia.

I am well aware of how to search the literature, I do it everyday.  I am at this point in my career very comfortable reading and evaluating research.  

I am all about increasing ones education, and I really enjoy some many of the discussion had on this site, but as I said, other than expedient arrival at the hospital very little of what happens pre-hospital provides any mortality benefit to the patients.  I don't work in a archaic system that doesn't allow us to do anything, in fact its the opposite.  But as I've said many time in this thread alone the ability to do something doesn't make it the right thing to do.  My over arching goal is to get people delivered to the ED as quickly and safely as possible (if that is what they want), everything I do has that goal in mind.


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## Veneficus (Feb 23, 2013)

*cut for brevity*



Clipper1 said:


> Don't just criticize the articles I posted. Find more articles searching Medscape.  Find articles in critical care, nursing or respiratory medicine journals.   Not all articles are the same but they do show an increased awareness of something which is preventable and people should not die from it.  *It seems you and  a couple other put no faith in research*, either good or bad, which could explain why EMS is just now hearing about this and some are getting involved.  It is good to have EMS such as in King County which gets involved but then that also shows education can lead to change. They have always been more willing to accept trials for change and adjust accordingly depending on the results.  If they don't agree with something, they do their own research to see if they get the same results.



I don't think anyone doubts the seriousness of VAP. 

But there are many examples of spending money on infection control policies and treatments that do not work or make significant difference.

I think that is really the issue being discussed here.

Even in the medical specialty of infectious disease, there is growing questions about the use of single antibiotic therapy and development of resistant organisms.

Perhaps the total aseptic environment is not realistic or beneficial?

As for no faith in research, I actually do research all the time. Some 30-40 hours a week. I can tell you most studies are not worth the paper they are printed on. Studies from a particular profession are considered notoriously biased towards their procedures and are not even citable in most credible scientific circles.

People who also spend a lot of time in research also understand the limits of research. 

I also caution against using "faith" in research like it is the true and proper religion. Studies are designed to test a specific point. They are by design limited to attempt to find one or a small number of direct correlations in a dynamic environment. Biological systems also change over time. So even the most true and factual research today might be moot 20 years from now.

You speak of people needlessly losing their lives, and I think we all get behind that. But people lose their lives because of cookbook medicine too. Are they less deserving of effective treatment because they do not fit into the epidemiology?

Should we be using treatments we know will likely fail as the first or only choice to satisfy consensus?

Of course not. 

In an earlier post I asked if there was significant difference in chloro swabbing compared to brushing teeth. (and by extension other oral hygine) It was not sarcastic, we know hand washing is the best way to prevent transmission of disease. It is also the cheapest. 

One poster (I don't recall or I would give credit) cited antibiotic coated ET tubes. I am not sure that is such a good idea. It may cut down on infections today, but there is not only risk of increasing resistant organisms, there is also the problem of killing bacteria and permitting infections of fungal organisms. 

I would say there are 2 very important things to consider.

1. People were not designed or evolved to lay in bed with plastic tubes in them. 

2. Not all infections are preventable. 
While there have been some successes in preventing infection in certain procedures, and that is a good thing, the limited nature of those infections is not the same as a common pathway between a intrinsicaly colonized GI tract and a respiratory tract, the lower part of which is an ideal petri dish, with multiple natural defenses bypassed by medical intervention.


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## Clipper1 (Feb 23, 2013)

old school said:


> That is a good question. Has pre-hospital intubation even been shown to improve survival? If we're really worried about contaminating the airway, why not stick to SGA's?
> 
> You seem to be assuming that this will improve survival, while there is no proof of that. People once assumed that hard spine boards and intra-cardiac epi would improve survival, too.
> 
> ...



Steps are being taken in the hospital now to look at the tubes used which is a consideration before intubation.

The meds and pre-oxygenation methods are looked at in hospitals how which has led to the use of HFNCs rather than just the BVM.  Steps to prevent aspiration are taken. The standard "cricoid pressure" has bee re-examined. 

More accountability for the competency of the intubators, including doctors, is enforced.  Availability of equipment such as the Glidescope to facilitate ease of intubation is now prevalent in many hospitals. 

Training ED nurses for managing ventilator patients for extended time periods are done. 

Intubation itself is being looked at with the articles written for EMS and prehospital intubation during a cardiac arrest.

If you believe intubation is the only way, why bother with putting CPAP on ambulances.

Do you believe nothing should be done to improve intubation success in EMS for the patients which do require it?

Should there be no research and hospitals should just continue to accept patients dying and not get reimbursed? 

I don't know how you can say the guidelines not established for the prevention of VAP is not working and there is no evidence of improving survival.  Every ICU in the US is now required to monitor their infections and every ICU in the US has implimented changes. Even the EDs have had to do that along with OP clinics. 

All this data has been around for many years and implimenting a nationwide awareness has been slow because of attitudes which might come from one article they like which suits their argument. But, people who have ICU experience can tell you it is frustrating to see patient die when it is not from the initial injury or illness. 

This is a good article.
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=1

I think just like CPR, the chain of survival for prevention of VAP has to start at the beginning and not at the middle.   As I mentioned before, EM doctors have had to realize this when their procedures are critiqued by the next physician who might redo or repeat his work. 

I think one difference between the attitudes of EMS and hospitals is that the hospitals have oversight regulatory bodies, research and incentives now in the form of reduced mortality or face monetary punishment for their failures. They have produced guidelines lines and have put them into effect nationwide as well as in many other countries.   

If EMS truly believes backboards are wrong, why are they still in the protocols for much of EMS?    Intracardiac epi administration changed as ACLS changed which came about through research.  Hospitals were also the ones who did the studies on intracardiac epi, NaHCO3 and so on and stopped utilizing them before EMS.

 The use of prehospital central lines declined but there are still those who will put up a fight that they are a standard even with the I/O available.  Intubation is still a skill EMS does not want to admit it may not be necessary for all patients. But, EMS in the US also has not done much to promote their competency level or provide enough material to counter the data which says their intubation rates are poor or that it should be first line over CPAP or supraglottic devices. Hospitals have been using CPAP for at least 50 years.  EMS did not put for the technology which was being used for critical care IFT by nurses. 

I also suggest you visit an ICU or even the ED and see what their protocols are for reducing VAP.  See if they are initiating early oral care and using special ETTs such as those with a subglottic suction port.  You might ask if they have changed their medication protocols for intubation or the use of an OG vs an NG. Ask if they have changed their competency requirements for their intubators.


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## Dwindlin (Feb 23, 2013)

Clipper1 said:


> If EMS truly believes backboards are wrong, why are they still in the protocols for much of EMS?



And I'm out. . .


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## Clipper1 (Feb 23, 2013)

Veneficus said:


> But there are many examples of spending money on infection control policies and treatments that do not work or make significant difference.




The research and policies have made a difference and have eliminated many unnecessary invasive procedures. Infection rates have declined. 

But, to make sure everyone takes infection seriously and monitors their policies, CMS has gotten tougher when it comes to HAIs and will not reimburse. 

It would be difficult for EMS to monitor infections since they spend only a short time with the patient and hospitals do have policies inplace for prehospital interventions.  But, EMS could start by monitoring the number of attempts it takes for a successful intubation, how IVs are started and med errors.  If backboards are dangerous they should be able to gain the confidence of their MD to initiate change. If change does not come it might not be due to the lack of evidence based medicine but the reluctance of the Paramedics to change or train for another set of protocols.



> One poster (I don't recall or I would give credit) cited antibiotic coated ET tubes. I am not sure that is such a good idea. It may cut down on infections today, but there is not only risk of increasing resistant organisms, there is also the problem of killing bacteria and permitting infections of fungal organisms.



Coated ETTs are site specific much like nebulized antibiotics. Silver ETT will not have the same effects as systemic antibiotics.

But was there a big debate here when some wanted to start giving antibiotics freely in the field without specific cultures? 

I also know that some in EMS assume that the hospital will just give antibiotics anyway so there is no reason to use precautions in the field. 



> As for no faith in research, I actually do research all the time. Some 30-40 hours a week. I can tell you most studies are not worth the paper they are printed on. Studies from a particular profession are considered notoriously biased towards their procedures and are not even citable in most credible scientific circles.



Share some of the studies you have done in EMS.  Are they published?  Has the ambulance service you work for implimented the changes as Seattle has? 

I do not think people should be discouraged from doing research because you think it is rubbish. The study may be relative to another area of medicine and not just EMS. It also demonstrates people are questioning how and why something is done.  When you stop questioning that is when you get cookbook medicine.  But, there is also a difference between cookbook medicine and a need for consistency.  The thing about guidelines is that they can be deviated from just like those for ACLS if necesary. You would not do oral care for someone who has had extensive oral surgery with grafts the same as you would someone who has not.


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## Clipper1 (Feb 23, 2013)

Dwindlin said:


> Yes, pneumonia kills people?  What is your point?  So far there is NO SHOWN MORTALITY BENEFIT from cleaning patients mouths with antiseptics, nor are there any decreases in vent days required, and outside of post-op cardiac patients no decreased LOS.  So why keep doing this?  The evidence doesn't support it.  The only thing the evidence you have presented supports is that this practice lowers CPIS scores, which again probably isn't actually diagnosing many cases of pneumonia.
> 
> I am well aware of how to search the literature, I do it everyday.  I am at this point in my career very comfortable reading and evaluating research.



I think you are looking for a quick cure and believe I am saying oral care is the only factor.

Read the articles and understand the many steps involved in the VAP bundle. Oral care is just one but it is taken seriously just like the studies with oral hygiene and cardiac disease for those not in the hospital.


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## VFlutter (Feb 23, 2013)

I am all for reducing VAP but I do not think mouth cleansing in the pre-hospital setting is really going to make a significant difference but it is so cheap and quick then why not  if possible. 

We do daily oral care on our intubated patients in the ICU but as far as I know there is no solid evidence that shows direct reduction in VAP. It is more of the mentality mentioned above, It is cheap, easy and may be beneficial.

The best way to prevent VAP is to get people off the vent. We need to reduce the unnecessary intubations and utilize NIPPV as much as possible. In the ICU we need to do daily sedation vacations and breathing trials and get them extubated as soon as possible. We also know that bed positioning and proper hygiene plays a role. There are a few other things like using OG instead of NG tubes that may help.


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## Clipper1 (Feb 23, 2013)

Chase said:


> We do daily oral care on our intubated patients in the ICU but as far as I know there is no solid evidence that shows direct reduction in VAP. It is more of the mentality mentioned above, It is cheap, easy and may be beneficial.



Have you ever seen a mouth which has not had oral care for even a few hours in the ICU?  It is not pretty. It is disgusting to see patients with food particles decaying in their teeth, furry tongues and thick coating of scum on the roof of their mouth. In the ICU in a dry environment with a heated tube in their open mouth, this is a reality.  Even for people not in the hospital, dirty mouths or dry mouths have been known to cause problems.


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## jwk (Feb 23, 2013)

Clipper1 said:


> I think you are looking for a quick cure and believe I am saying oral care is the only factor.
> 
> Read the articles and understand the many steps involved in the VAP bundle. Oral care is just one but it is taken seriously just like the studies with oral hygiene and cardiac disease for those not in the hospital.



Dude, no offense, but you're just all over the place with this, and very little of it relates to VAP which MIGHT BE caused by ETT's, and even less about preventing it.

Oral care in the ICU on ventilated patients in the ICU has far more to do with bacteria growing unabated in the mouth and oropharynx and causing bacteremia due to periodontal disease than it does with trying to prevent little bugs from crawling down the ETT and trachea.  

And quite honestly, EMS and the ED/ER are not, and will never be, the place where standards for endotracheal intubation, advanced airway management, ventilatory support, RSI, etc. are developed.   People who intubate a few times a year simply don't have the clinical experience to develop "standards" - that comes from people who do it all the time.


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## Veneficus (Feb 23, 2013)

Clipper1 said:


> Share some of the studies you have done in EMS.  Are they published?  Has the ambulance service you work for implimented the changes as Seattle has?



I have never done an EMS specific study and would not waste time doing one. Even if invited to participate. Mostly because the recommendations would never be adopted because of EMS tradition and most EMS studies are too short sighted for my taste. 

Care ends at pt discharge, not at the ED 

I have multiple published studies in many different medical disciplines all somehow connected to pathophysiology. I have been acknowledged for my contributions in an equal amount.

Additionally, my original PhD research is in effective detection and treatment of septic shock in neonates. I expect the data to be published in 3 parts in the next year or two as it is quite comprehensive. 

I have sent copies and pubmed links to many people on this website once I have established them as respectable people and not simply online personalities, As my name and where I work appears on all of them. I have also freely given of my powerpoints and lectures.

With 14 posts I would be curious to your contribution?



Clipper1 said:


> I do not think people should be discouraged from doing research because you think it is rubbish.



I don't think research is rubbish and I do not discourage it. 

I do recognize, acknowledge, and attempt to teach people about its value and limitations because it is not perfect.

I am particularly critical of journals that will not publish anything that goes against conventional ideas as part of their requirements because I think that completely negates the value of research and downplays discovery, particularly in favor of common beliefs. 

One of the things you keep mentioning is payment, and much of EBM is studies used to justify payment. Because people want to be paid for it.



Clipper1 said:


> The study may be relative to another area of medicine and not just EMS. It also demonstrates people are questioning how and why something is done..



In EMS this means nothing. There have been questions for years and nothing in the US has changed. 

Outside EMS, personally, I always question why things are done. It is part of my charm.



Clipper1 said:


> When you stop questioning that is when you get cookbook medicine.  But, there is also a difference between cookbook medicine and a need for consistency..



But many providers at all levels use guidlines as cookbook medicine. Worse yet, definitive care. (such as the case of ACLS)

Consistency is valuable only if it is consistently good. But there is a real danger of treating epidemiology and not individuals.

Personalized treatment is the future of medicine. It is why we spend so much money on genetics, molecular biology, and biochemistry. Perhpas not in my lifetime, but I expect shortly after, DNA treatment for many conditions, emergent or otherwise will be the norm.   



Clipper1 said:


> The thing about guidelines is that they can be deviated from just like those for ACLS if necesary. You would not do oral care for someone who has had extensive oral surgery with grafts the same as you would someone who has not.



Only by providers who have the authority and will to deviate. In my experience, it is not that common. Especially when those deviations are not easily reimbursed.


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## Carlos Danger (Feb 23, 2013)

Clipper1 said:


> Steps are being taken in the hospital now to look at the tubes used which is a consideration before intubation.
> 
> The meds and pre-oxygenation methods are looked at in hospitals how which has led to the use of HFNCs rather than just the BVM.  Steps to prevent aspiration are taken. The standard "cricoid pressure" has bee re-examined.
> 
> ...



What on earth are you talking about? What does any of that have to do with VAP?




Clipper1 said:


> I don't know how you can say the guidelines not established for the prevention of VAP is not working and there is no evidence of improving survival.  *Every ICU in the US is now required to monitor their infections and every ICU in the US has implimented changes*. Even the EDs have had to do that along with OP clinics.
> 
> All this data has been around for many years and implimenting a nationwide awareness has been slow because of attitudes which might come from one article they like which suits their argument. *But, people who have ICU experience*can tell you it is frustrating to see patient die when it is not from the initial injury or illness.
> 
> *I also suggest you visit an ICU or even the ED and see what their protocols are for reducing VAP. * See if they are initiating early oral care and using special ETTs such as those with a subglottic suction port.  You might ask if they have changed their medication protocols for intubation or the use of an OG vs an NG. Ask if they have changed their competency requirements for their intubators.



OK, you obviously read nothing that I wrote.

I'll be moving on.....


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## jwk (Feb 23, 2013)

Clipper1 said:


> I also suggest you visit an ICU or even the ED and see what their protocols are for reducing VAP.  See if they are initiating early oral care and using special ETTs such as those with a subglottic suction port.  You might ask if they have changed their medication protocols for intubation or the use of an OG vs an NG. Ask if they have changed their competency requirements for their intubators.



Sorry, I missed this jewel.  So you think a paramedic, most with their certificate or perhaps associates degree in EMS, should walk into an ICU and start questioning whatever protocols and "competency requirements for their intubators" are in place?  

There's some really bright people on this board all trying to tell you the same thing.  You're wayyyyy off base.  

ETT with subglottic suction port?  Never seen one and for the life of me can't imagine why you would need one.  We have these nice cheap things called suction catheters or Yankauer suckers that work great.

Change medication protocols for intubation?  I don't have a medication protocol for intubation - I give what I think the patient needs - and the choice of medication has no bearing on VAP.


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## JPINFV (Feb 23, 2013)

KingCountyMedic said:


> Maybe this is the case where you work. Not so in many other progressive parts of the world, mine included. Please tell me you don't rely on a patients O2 Sats to determine your course of treatment?




Shrug, then why even use a pulse ox?

I guess my attending is an idiot. She weaned a 2 month old admitted for bronchiolitis today by turning off the oxygen and watching the saturation stay in the mid 90s. You know... using a SpO2 to determine the course of treatment.


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## JPINFV (Feb 23, 2013)

Clipper1 said:


> If EMS truly believes backboards are wrong, why are they still in the protocols for much of EMS?    Intracardiac epi administration changed as ACLS changed which came about through research.  Hospitals were also the ones who did the studies on intracardiac epi, NaHCO3 and so on and stopped utilizing them before EMS.


[YOUTUBE]http://www.youtube.com/watch?v=gRdfX7ut8gw[/YOUTUBE]



> I also suggest you visit an ICU or even the ED and see what their protocols are for reducing VAP.  See if they are initiating early oral care and using special ETTs such as those with a subglottic suction port.  You might ask if they have changed their medication protocols for intubation or the use of an OG vs an NG. Ask if they have changed their competency requirements for their intubators.


Oh, yes. Please march right into the closest ICU and question the attending physician on his medication practices. Better yet, find a closed ICU and go toe to toe with a pulm/CC specialist.


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## Smash (Feb 24, 2013)

Veneficus said:


> Care ends at pt discharge, not at the ED



It's not a good result unless they go back to paying taxes.

On the original subject, I take as much care as is practicable to maintain cleanliness when intubating.  I then position the patient semi-recumbent and make sure I suction the ETT and the oropharynx.
I have no idea how much, if any, effect that has on VAP, but it costs me no effort or time and just seems like good care to me anyway.  There is some limited data that positioning reduces aspiration risk, so I guess I can hang my hat on that.


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## KingCountyMedic (Feb 24, 2013)

Smash said:


> It's not a good result unless they go back to paying taxes.




So awesome!  I'm stealing this line to use at work


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## Veneficus (Feb 24, 2013)

Smash said:


> It's not a good result unless they go back to paying taxes.



The best line of this whole thread.


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## Sublime (Feb 25, 2013)

n7lxi said:
			
		

> Of course, you guys intubate more CHF/COPD patients than we do, patients that stay on a vent. For us, CPAP has made most of those tubes vanish.
> 
> I'd be curious to see if there's any correlation.


 
Wait so king County does use CPAP? 

If not why are you guys worrying about VAP when you could be preventing people from being tubed in the first place?  

Seems like that would be a priority to me.


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## VFlutter (Feb 25, 2013)

Sublime said:


> If not why are you guys worrying about VAP when you could be preventing people from being tubed in the first place?
> 
> Seems like that would be a priority to me.



+1, That is a fantastic point. I totally forgot they do not do CPAP

I am amazed how well many of our CHF/COPD patients do on BiPAP when without they would certainly have gotten a tube. Just a few days ago I had a patient w/ flash pulmonary edema who I was sure would end up reintubed but did amazing on Bipap with IV lasix and Solu-Medrol.


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## Clipper1 (Feb 25, 2013)

jwk said:


> And quite honestly, EMS and the ED/ER are not, and will never be, the place where standards for endotracheal intubation, advanced airway management, ventilatory support, RSI, etc. are developed.   People who intubate a few times a year simply don't have the clinical experience to develop "standards" - that comes from people who do it all the time.



Does this mean the ED/ER should not adhere to some of the guidelines already established by the hospital and actually nationwide whenever possible?   

EMS may believe it is an entity separate from healthcare which is why some of its practices do get questioned. Without any idea about the whys some things are done after they drop the patient off just leads to futher distancing from healthcare. Yes you might not see a need to understand or even have standards for ETI, RSI or any form of advanced ventilatory support for prehospital providers but that does not mean it is not viewed by others who are concerned about patient outcome from beginning to end.


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## Clipper1 (Feb 25, 2013)

JPINFV said:


> Shrug, then why even use a pulse ox?
> 
> I guess my attending is an idiot. She weaned a 2 month old admitted for bronchiolitis today by turning off the oxygen and watching the saturation stay in the mid 90s. You know... using a SpO2 to determine the course of treatment.



Your attending? A doctor in a hospital? 

I suppose you could say this person might have an understanding of the difference between ventilation and oxygenation along with a definitive disease diagnosis. If this was in a hospital then there may also have been known lab values and other diagnostics to work with which would be unknown in the field.


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## Clipper1 (Feb 25, 2013)

Chase said:


> +1, That is a fantastic point. I totally forgot they do not do CPAP
> 
> I am amazed how well many of our CHF/COPD patients do on BiPAP when without they would certainly have gotten a tube. Just a few days ago I had a patient w/ flash pulmonary edema who I was sure would end up reintubed but did amazing on Bipap with IV lasix and Solu-Medrol.



That person might not even been in the ICU. However, there are still some considerations for a HAI protocol which still must be considered.

But, don't count on CPAP or BIPAP to be the cure all for all patients. The ICUs are still full of patients who have required intubation and sometimes right after they arrive at the ED. Just because you did not see them get intubated when you dropped them off does not mean they may not have gotten intubated later. Do you follow up with all of the patients you drop off at an ED?


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## Clipper1 (Feb 25, 2013)

Smash said:


> It's not a good result unless they go back to paying taxes.
> 
> *On the original subject, I take as much care as is practicable to maintain cleanliness when intubating.  I then position the patient semi-recumbent and make sure I suction the ETT and the oropharynx.
> I have no idea how much, if any, effect that has on VAP, but it costs me no effort or time and just seems like good care to me anyway.  There is some limited data that positioning reduces aspiration risk, so I guess I can hang my hat on that*.



This is the best advice. A few seconds should not cost you any more effort especially if it might improve the overall outcome of the patient.  You sometimes create your own emergencies by being under educated about the over all situation and procedure or lack confidence in your own skills and knowledge.


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## Clipper1 (Feb 25, 2013)

Veneficus said:


> Only by providers who have the authority and will to deviate. In my experience, it is not that common. Especially when those deviations are not easily reimbursed.



No, in EMS you will not be able to deviate. That does not mean it can not be done in a hospital.  CMS does not write ACLS protocols. They will see that there are a set of guidelines which might be followed in some given situations.


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## JPINFV (Feb 25, 2013)

Clipper1 said:


> Your attending? A doctor in a hospital?
> 
> I suppose you could say this person might have an understanding of the difference between ventilation and oxygenation along with a definitive disease diagnosis. If this was in a hospital then there may also have been known lab values and other diagnostics to work with which would be unknown in the field.




Considering that I was rounding on the patient writing notes over the weekend, I can verify that the only lab value we had was a positive RSV test and a clinical diagnosis of bronchiolitis. There's nothing wrong with using a SpO2 to guide treatment. However, just like any other bit of information, be it a piece of the history, an exam finding, or a test result, it can't be used in isolation, but as a part of the whole picture. 

There's no reason that EMS can't look at the whole picture using what information they can obtain.


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## Clipper1 (Feb 25, 2013)

JPINFV said:


> Considering that I was rounding on the patient writing notes over the weekend, I can verify that the only lab value we had was a positive RSV test and a clinical diagnosis of bronchiolitis. There's nothing wrong with using a SpO2 to guide treatment. However, just like any other bit of information, be it a piece of the history, an exam finding, or a test result, it can't be used in isolation, but as a part of the whole picture.
> 
> There's no reason that EMS can't look at the whole picture using what information they can obtain.



What was the course of treatment? Was a CXR done which detremined hyperinflation which can increase carbon dioxide levels?  Was racemic epinephrine given?   What were the other possible disease diagnoses?  How much pediatric education do EMTs and Paramedics get? 

Of course SpO2 can be use but ventilation should not be ignored.   A much more indepth explanation can be discussed about this concerning a curve which can demonstrate SpO2 and the amount of oxygen in the blood.  As your instructor about this or maybe the doctor you were rounding with might be available to explain this.  Sometimes doctors and other health care professionals do things which seem to be based only on one factor but their education gives them a more expansive knowledge. You might have to ask them to explain things which come easily to them in their assessment but might not be that evident to you as an EMT or Paramedic student.


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## Rialaigh (Feb 25, 2013)

Let me preface by saying I have done nothing more than read a few abstracts and a little deeper into a few studies posted in this thread. I simply do not have the interest or time in this subject to bother right now.

 One thing however is it amazes me the number of PhD's and MD's (or DO's) who do research that is well respected in some arenas. But when you look at their research you would swear no one ever taught them the difference in *correlation* and *causation*. 

Some studies may show a impressive decrease in VAP in patients that receive oral care every 2 hours. But odds are the hospitals doing oral care every 2 hours also have less med administration errors, higher quality staff, better dosing and choice in drugs. More proactive breathing trials, etc

Many of these "front line" studies really don't account for all the variables. I personally think bed positioning, and proper antibiotic choice and dosing would go a long way. Much further than anything we could even hope to do in the field.


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## VFlutter (Feb 25, 2013)

Clipper1 said:


> That person might not even been in the ICU. However, there are still some considerations for a HAI protocol which still must be considered.
> 
> But, don't count on CPAP or BIPAP to be the cure all for all patients. The ICUs are still full of patients who have required intubation and sometimes right after they arrive at the ED. Just because you did not see them get intubated when you dropped them off does not mean they may not have gotten intubated later. Do you follow up with all of the patients you drop off at an ED?



You are correct they were not in the ICU but rather on Cardiac step down unit after getting bumped out of the unit by some codes. I never said it was a cure for all but I do believe it works for a majority of the patients I encounter, many who would most likely be intubated by the more "progressive" agencies. 

I am actually the place these patients go after they hit the ED so I have a fair understanding of what happens. CHF patients are a large portion of my patient population.


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## JPINFV (Feb 25, 2013)

Clipper1 said:


> What was the course of treatment? Was a CXR done which detremined hyperinflation which can increase carbon dioxide levels?  Was racemic epinephrine given?   What were the other possible disease diagnoses?  How much pediatric education do EMTs and Paramedics get?



There's no indication for a CXR these patients most of the time. Are you suggesting that the need for supplemental oxygen is dependent on bronchodilators (be it albuterol or racemic epi)? If a patient receives a breathing treatment and maintains an appropriate SpO2, then is supplemental oxygen really needed? The possible diseases for a 2 month old with symptoms of a URI, wheezes, and a positive RSV test is basically... wait for it... bronchiolitis. 

As far as pediatric education, I'm not saying paramedics could or should treat or street these patients, but there's a difference between that and, say, titrating oxygen in a relatively eupneic patient (at worst, occasional mild abdominal retractions) to SpO2. This concept that all medical decisions are made off of non-POC lab values or that every disease requires confirmatory testing is patently false. Similarly, the concept that there's two categories, perfectly healthy and near death, is similarly false.  



> Of course SpO2 can be use but ventilation should not be ignored.   A much more indepth explanation can be discussed about this concerning a curve which can demonstrate SpO2 and the amount of oxygen in the blood.  As your instructor about this or maybe the doctor you were rounding with might be available to explain this.  Sometimes doctors and other health care professionals do things which seem to be based only on one factor but their education gives them a more expansive knowledge. You might have to ask them to explain things which come easily to them in their assessment but might not be that evident to you as an EMT or Paramedic student.



...and ventilation status can often be determined based on physical exam and response to treatment. It shouldn't be ignored, but not every patient on oxygen needs an ABG or VQ scan. 




> You might have to ask them to explain things which come easily to them  in their assessment but might not be that evident to you as an EMT or  Paramedic student.



Cute. I'm a 3rd year medical student, so... yea... I understand the disassociation curve. I don't know... maybe non-cookbook medicine doesn't come easy to EMTs and paramedics. Hence the hesitance to use multiple tools at once to build a complete picture instead of focusing solely on one particular piece of the puzzle. Missing the forest because you're focused on the trees.


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## JPINFV (Feb 25, 2013)

Rialaigh said:


> One thing however is it amazes me the number of PhD's and MD's (or DO's) who do research that is well respected in some arenas. But when you look at their research you would swear no one ever taught them the difference in *correlation* and *causation*.



But the P value is <0.05, therefore it's SIGNIFICANT!


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## Rialaigh (Feb 25, 2013)

JPINFV said:


> There's no indication for a CXR these patients most of the time. Are you suggesting that the need for supplemental oxygen is dependent on bronchodilators (be it albuterol or racemic epi)? If a patient receives a breathing treatment and maintains an appropriate SpO2, then is supplemental oxygen really needed? The possible diseases for a 2 month old with symptoms of a URI, wheezes, and a positive RSV test is basically... wait for it... bronchiolitis.
> 
> As far as pediatric education, I'm not saying paramedics could or should treat or street these patients, but there's a difference between that and, say, titrating oxygen in a relatively eupneic patient (at worst, occasional mild abdominal retractions) to SpO2. This concept that all medical decisions are made off of non-POC lab values or that every disease requires confirmatory testing is patently false. Similarly, the concept that there's two categories, perfectly healthy and near death, is similarly false.
> 
> ...



My issue with this is seeing Doctors time and time again (ER and floor doctors, not so much critical care) write orders for tests based solely on a lab value.

I watch ER Doctors on a daily basis order head CT's for people in the waiting room because their triage was "headache". 

I see floor doctors order repeat this and repeat that and ohh their oxygen dropped from 98% to 92% on room air, let me order a chest x-ray and a chest CT and an ABG and a CBC, lets do the full workup because blah blah blah....all before they go in the room to see the patient and all without asking for a repeat SPO2. 

I understand that liability requires doctors to now cover every single angle of their tail prior to discharging a patient but I see doctors who on a daily basis, don't do a single thing that I would call practicing medicine.

 Ordering the same 3 broad spectrum antibiotics for every single kid and adult that has a slightly elevated white count (which you found after ordering a CBC on EVERYONE you admit) is not what I call practicing medicine. I have seen (and worked at) a hospital where the hospitalists (floor docs) and ER docs, dont do a single thing more than a paramedic does. ABD pain automatic CT. Headache automatic CT, chest pain automatic CT, any type of pain other than obvious ortho gets a full blood workup, any lab results abnormal than consult the doctor who does "that" kind of thing. Any patient over the age of 50 gets an EKG no matter what the complain. Any patient who has trouble breathing gets a chest X-ray no matter what the cause or specific complaint...its a terrible waste. 

Obviously not all hospitals are like this but I have lost a lot of faith in doctors ability to practice medicine when they have been for years practicing following a order set on a protocol list. 



*TLDR*  I see plenty of doctors order testing and X-rays and chest CT's and full blood workups based soley off of SP02's. They do it so we get a trickle down effect...


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## JPINFV (Feb 25, 2013)

Rialaigh said:


> *TLDR*  I see plenty of doctors order testing and X-rays and chest CT's and full blood workups based soley off of SP02's. They do it so we get a trickle down effect...



The funny thing is that this is exactly what Clipper1 is arguing to be done for this patient. I completely agree, however, that testing is often done just for the sake of testing. 



In regards to over testing to prevent liability and "malpractice," while I disagree that it should be done, I completely understand the reasoning behind it. As long as a malpractice suit is seen as a lotto win for the patient and physicians are sued despite doing everything right because of a less than optimum outcome, then I can't argue against it. Personally, I'd bankrupt the nation just with medical tests if it means preventing one lawsuit.


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## jwk (Feb 26, 2013)

Rialaigh said:


> My issue with this is seeing Doctors time and time again (ER and floor doctors, not so much critical care) write orders for tests based solely on a lab value.
> 
> I watch ER Doctors on a daily basis order head CT's for people in the waiting room because their triage was "headache".
> 
> ...



The issue is the buck stops with the doc, not with you..  As long as we have scumbag plaintiff's lawyers, you will see defensive medicine practiced ad nauseum.  The idiot in the White House hasn't touched on tort reform as part of his "solution" to health care problems.  Unless and until he and his Democratic trial lawyer Congressional buddies pull their heads out, that's not going to change.


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## Veneficus (Feb 26, 2013)

jwk said:


> The issue is the buck stops with the doc, not with you..  As long as we have scumbag plaintiff's lawyers, you will see defensive medicine practiced ad nauseum.  The idiot in the White House hasn't touched on tort reform as part of his "solution" to health care problems.  Unless and until he and his Democratic trial lawyer Congressional buddies pull their heads out, that's not going to change.



Amen.


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## 18G (Feb 27, 2013)

I didnt read the entire thread but in response to the OP, I think this is a good research area. 

Some research has been done in ambulances that surprisingly showed the majority of MRSA was not found on direct patient contact surfaces (ie equipment, stretcher, straps, etc) but instead on the action area where the suction is and often times intubation equipment is put together. What other pathogens are present???

How many providers take the STERILE suction catheter and STERILE suction tubing, open it up, and pre-connect it on the ambulance? This is an invitation for pathogens to be introduced into the pt's lungs and is a practice that needs to stop.  

I do inter-facility transfer of intubated patients all the time and think attention needs to be given to how we suction our patients which falls along the same lines as the actual intubation when considering VAP. Micro-aspiration occurs around the ETT cuff which is why good mouth care is important in these patients and is part of the strategy to reduce VAP. 

Even in the initial intubation in the field, we need to be thinking about this. We are bypassing the patients upper airway protection mechanisms and whatever is on that ETT or suction catheter, is going directly down into the patients lungs.


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## Summit (Feb 27, 2013)

Continuous above the cuff suction is a key feature I'd want on any patient tubed for more than just surgery. 



Veneficus said:


> I have read a lot of studies today, could you just tell me if any of these compared a cloro bath with brushing the pts teeth?



We brush with chlorhexidine... and are going to switch all patients who can TID chlorhexidine rinses. I was told there was evidence for it and I've asked for copies.


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## Dwindlin (Feb 27, 2013)

Summit said:


> Continuous above the cuff suction is a key feature I'd want on any patient tubed for more than just surgery.
> 
> 
> 
> We brush with chlorhexidine... and are going to switch all patients who can TID chlorhexidine rinses. I was told there was evidence for it and I've asked for copies.



There is, most of it has been posted in this thread.  The vast majority of it is marginal at best for reasons already talked about.


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## usalsfyre (Feb 27, 2013)

18G said:


> How many providers take the STERILE suction catheter and STERILE suction tubing, open it up, and pre-connect it on the ambulance? This is an invitation for pathogens to be introduced into the pt's lungs and is a practice that needs to stop.


Forest for the trees. It's great that you prevented the patient from having the possibility of ambulance pathogens introduced....meanwhile they've aspirated half of what's in their stomach while you fiddle-farted around with hooking the Yaunker up.

(Yes, I've dealt with intubated ICU patients. And every ICU and CCT provider I know pre-connects this stuff. Suction is one of the few items that when you need you need in a hurry.)


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## usalsfyre (Feb 27, 2013)

Summit said:


> Continuous above the cuff suction is a key feature I'd want on any patient tubed for more than just surgery.


My second to third hand understanding is the numbers on this are pretty iffy. To be fair I haven't looked at it myself.


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## 18G (Feb 27, 2013)

usalsfyre said:


> Forest for the trees. It's great that you prevented the patient from having the possibility of ambulance pathogens introduced....meanwhile they've aspirated half of what's in their stomach while you fiddle-farted around with hooking the Yaunker up.
> 
> (Yes, I've dealt with intubated ICU patients. And every ICU and CCT provider I know pre-connects this stuff. Suction is one of the few items that when you need you need in a hurry.)



Seriously, it takes 10secs to hook the stuff up when its on the action area sealed. It is sterile for a reason. Just because every ICU and CCT provider you know does it, doesn't make it right. That is a typical EMS mentality. Just saying. 

I guess we should have our BVMs and Defib pads pre-connected all the time too. Just saying. 

If the patient is already tubed, what is the big hurry? Take the extra time to avoid introducing pathogens and VAP and do the job right.


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## Carlos Danger (Feb 27, 2013)

Summit said:


> Continuous above the cuff suction is a key feature I'd want on any patient tubed for more than just surgery.



I have not searched the lit about this because, quite frankly, VAP is not a big interest or clinical concern of mine. 

However, I have never seen this done. Considering the financial incentives that hospitals have to keep VAP rates low, I think it'd be a lot more common if it worked.

I do know that a large, tertiary hospital that I used to work at used continuous-suction ETT's for a while, and eventually stopped when they could not show that it decreased their VAP rates. 

One I worked at before never used them that I know of, but at one point they had a big problem with VAP and tried everything under the sun. Again, I think if they had reason to believe that these continuous suction ETT's worked, they probably would have tried them.

My understanding is that mouth cleanliness is only a small contributing factor in the development of VAP. It is quite possible that we are worrying too much about this.

I'm all for looking at ways that our prehospital care and improve eventual outcomes, but I really don't think VAP is for us to worry about in the field.


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## Carlos Danger (Feb 27, 2013)

18G said:


> If the patient is already tubed, what is the big hurry? Take the extra time to avoid introducing pathogens and VAP and do the job right.



How is oral suction with a non-sterile yankauer going to cause VAP?


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## 18G (Feb 27, 2013)

old school said:


> How is oral suction with a non-sterile yankauer going to cause VAP?



Because it can introduce pathogens into the mouth which then make their way down the trachea into the lungs = microaspiration.


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## Aidey (Feb 27, 2013)

So should we only suction in sterile negative pressure environments?


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## Veneficus (Feb 27, 2013)

18G said:


> Because it can introduce pathogens into the mouth which then make their way down the trachea into the lungs = microaspiration.



perhaps, have you ever seen the list of pathogens already in the mouth?

The GI tube is definately not sterile.


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## 18G (Feb 27, 2013)

Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients: A Pilot Study

http://ajcc.aacnjournals.org/content/11/2/141.short


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## Veneficus (Feb 27, 2013)

18G said:


> Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients: A Pilot Study
> 
> http://ajcc.aacnjournals.org/content/11/2/141.short



lol. Did you read that?

It useda lot of words to say that the contamination was likely from the patient's own flora. 

(also, it is not convincing to cite sources from nursing publications or China)


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## 18G (Feb 27, 2013)

Veneficus said:


> lol. Did you read that?
> 
> It useda lot of words to say that the contamination was likely from the patient's own flora.
> 
> (also, it is not convincing to cite sources from nursing publications or China)



It is a very small study. My point with that is the issue deserves recognition and not to brush it off. 

And where are you getting a nursing publication in China????

The AMERICAN Journal of Critical Care is from China?


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## Veneficus (Feb 27, 2013)

18G said:


> It is a very small study. My point with that is the issue deserves recognition and not to brush it off.
> 
> And where are you getting a nursing publication in China????
> 
> The AMERICAN Journal of Critical Care is from China?



No, they are held in the same regard. Basically none.


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## Dwindlin (Feb 27, 2013)

18G said:


> It is a very small study. My point with that is the issue deserves recognition and not to brush it off.
> 
> And where are you getting a nursing publication in China????
> 
> The AMERICAN Journal of Critical Care is from China?



If you can't see why this study isn't worth the paper it's printed on then there really is nothing to discus.


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## Clipper1 (Feb 27, 2013)

old school said:


> I
> I do know that a large, tertiary hospital that I used to work at used continuous-suction ETT's for a while, and eventually stopped when they could not show that it decreased their VAP rates.
> 
> One I worked at before never used them that I know of, but at one point they had a big problem with VAP and tried everything under the sun. Again, I think if they had reason to believe that these continuous suction ETT's worked, they probably would have tried them.
> ...



Did you happen to find out which tubes they went to when they stopped the continuous suction ETTs? There are several on the market now which also promote the shape of the cuff and they may also have instituted a Pressure EZ device or cuff monitoring.  

They may have tried to cuts costs since these tubes are very expensive. It all depends on their other protocols and monitoring systems in place.  The type of unit and the education of the staff is important.

VAP protocols do not consist of just one thing. If you read anything about it you will see this.

For EMS, it is just not rational to not see where so much of what you do could affect the patient.  To think the patient's vomit or a dirty ETT will affect the patient less if it is done in the field is not even rational.


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## VFlutter (Feb 28, 2013)

Clipper1 said:


> For EMS, it is just not rational to not see where so much of what you do could affect the patient.  To think the patient's vomit or a dirty ETT will affect the patient less if it is done in the field is not even rational.



I do not think anyone is trying to argue we should intubate with dirty ET tubes or not suction gross aspirate. Not sure where that came from.


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## Carlos Danger (Feb 28, 2013)

18G said:


> And where are you getting a nursing publication in China????
> 
> The AMERICAN Journal of Critical Care is from China?



He is saying that only MD's and DO's are capable of producing research worth reading.

The rest of us lack the intelligence to formulate, execute, and interpret a study of any type.


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## Veneficus (Feb 28, 2013)

old school said:


> He is saying that only MD's and DO's are capable of producing research worth reading.
> 
> The rest of us lack the intelligence to formulate, execute, and interpret a study of any type.



Not quite.

I am saying that because nursing is a collaborative profession, mostly because of social reasons, that their research is so often biased towards the results they want in order to generate evidence what they are doing or want to do is correct, that they have lost considerable credibility in the scientific community.

The same happens to places where plagiarizing or falsifying research is common, like China. 

I have actually been approached by research nurses who recognize the problems with research in their profession in order to help those individuals improve nursing research for the benefit of their profession. If they recognize there is a problem, why can't we be honest and admit it and talk about it?

As Dwindlin pointed out and after I read it I did. That paper was garbage. It said something that was already commonly known in medicine to publish something, anything, and as you can see, was directly aimed at promoting nursing procedures. Though at least they concluded it was inconclusive. If they had the forsight to even look in a medical text, they probably could have saved themselves a lot of trouble because the sources would even be cited for them.

I will point out that using the scientific method to demonstrate a point does not add credibility to that point. It can also cause considerable problems. 

If research is something you are interested in, I highly suggest:

http://www.amazon.com/The-Mismeasur...2049256&sr=8-1&keywords=the+mismeasure+of+man

It details the pitfalls of using the scientific method for politcal purposes, as well as how it happens by people with the best intentions.

It was written by one of the most respected scientists of all time.

Spare me the "nurses are great too" nonsense. There are great individuals in all professions. Just as there are dregs. But the individual does not reflect the credit of the whole, for good or ill.

Edit: and for the record, some groups of MDs are perhaps just as bad. But what you see in medicine that you don't see in nursing, is other calling them on the carpet for it.


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## Carlos Danger (Feb 28, 2013)

Veneficus said:


> Not quite.
> 
> I am saying that because nursing is a collaborative profession, mostly because of social reasons, that their research is so often biased towards the results they want in order to generate evidence what they are doing or want to do is correct, that they have lost considerable credibility in the scientific community.
> 
> If they recognize there is a problem, why can't we be honest and admit it and talk about it?




That's fair. I'm the first to admit that their is a TON of BS in nursing.

Much of the reason why you don't see much "calling each other out" is because 95% of RN's have no interest in research. They don't do it, read it, or understand how to evaluate it. 

That is a problem in itself, but it is not a conspiracy to help each other get away with shoddy research. 

Considering how much of an impact nursing interventions have on outcomes, research into nursing care should be extremely robust. The best medicine can be rendered pretty much worthless if the patient suffers from poor nursing care. We've all seen patients recover from whatever landed them in the ICU initially, only to suffer from sepsis or other complications 2° to VAP, pressure sores, or poor IV injection procedures, etc.


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## Veneficus (Feb 28, 2013)

old school said:


> That is a problem in itself, but it is not a conspiracy to help each other get away with shoddy research.



I don't think it is a conspiracy or even intentional. 

But in western society, females are raised to a collaborative environment. Because nursing is still a female dominated environment, coupled with an overzealous esprit de corps, I think there is just a serious problem with objectivity and self critique.

I agree nursing research should be done, but it should be from the perspective of "what should be done" not "look how good we do."


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## Dwindlin (Feb 28, 2013)

old school said:


> He is saying that only MD's and DO's are capable of producing research worth reading.
> 
> The rest of us lack the intelligence to formulate, execute, and interpret a study of any type.



I could give two :censored::censored::censored::censored:s what the title behind thier name is, garbage research is garbage.  This thread has highlighted the importance of actually tracking down the paper and reading it as opposed to just reading abstracts.


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## Carlos Danger (Feb 28, 2013)

Getting back to the original topic:

The idea that pre-intubation oral cleansing may reduce VAP incidence seems to hinge on the theory that the act of intubation itself (through a non-cleansed oral cavity) is a significant risk factor for VAP. Right?

But if intubation itself causes VAP, then why don’t any of the tens of thousands of people who are intubated annually for same-day surgery develop VAP?

And why does VAP typically only occur in patients who are intubated for more than 48 hours? Why doesn’t it occur in patients who are intubated for 24 hours, if it is the intubation itself that causes VAP?


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