Preventing VAP in your patients?

[KingCountyMedic]

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.

 

[NomadicMedic]

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.

 

[Carlos Danger]

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.

 

[Dwindlin]

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. . .

 

[STXmedic]

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.

 

[Hunter]

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.

 

[usalsfyre]

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.

 

[Clipper1]

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.

 

[Veneficus]

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

I think this is very reasonable.

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.

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.

 

[KingCountyMedic]

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

 

[Veneficus]

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.

 

[Dwindlin]

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. . .

 

[Veneficus]

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. . .

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?

 

[KingCountyMedic]

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. . .

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.

 

[Clipper1]

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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[Clipper1]

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.

 

[KingCountyMedic]

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.

 

[Clipper1]

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.

 

[Dwindlin]

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.

 

[Wheel]

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.