Preventing VAP in your patients?

[VFlutter]

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.

 

[Clipper1]

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.

 

[Clipper1]

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.

 

[Clipper1]

+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?

 

[Clipper1]

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.

 

[Clipper1]

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.

 

[JPINFV]

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.

 

[Clipper1]

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.

 

[Rialaigh]

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.

 

[VFlutter]

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.

 

[JPINFV]

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.

 

[JPINFV]

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!

 

[Rialaigh]

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.



...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.




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.

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...

 

[JPINFV]

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.

 

[jwk]

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...

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.

 

[Veneficus]

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.

 

[18G]

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.

 

[Summit]

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

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.

 

[Dwindlin]

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.

 

[usalsfyre]

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.)