Welcome to my world
Been in your world for a while now. . .
Just rarely bring it up. <_<
Preventing VAP in your patients?
- Thread starter KingCountyMedic
- Start date
Been in your world for a while now. . .
Just rarely bring it up. <_<
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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.
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.
cut for brevity
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.
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.
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.
And I'm out. . .
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.
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.
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.
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.
VFlutter
Flight Nurse
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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.
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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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.
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.
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?
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.
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.
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.
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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What on earth are you talking about? What does any of that have to do with VAP?
OK, you obviously read nothing that I wrote.
I'll be moving on.....
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.
JPINFV
Gadfly
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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.
JPINFV
Gadfly
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[YOUTUBE]http://www.youtube.com/watch?v=gRdfX7ut8gw[/YOUTUBE]
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.
Smash
Forum Asst. Chief
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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.
KingCountyMedic
Forum Lieutenant
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The best line of this whole thread.
Sublime
LP, RN
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n7lxi said:
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.