Your ventilated patient may be at risk for VAP
They're "often already on the road to an infection"
If your patient has aspirated prior to being intubated, he or she is at increased risk for ventilator-associated pneumonia (VAP), warns Nicole Schiever, RN, MSN, ED team leader at Riverside Medical Center in Kankakee, IL.
"If patients have significant pulmonary edema, the large amount of secretions present can put them at risk," she says. "The tube doesn't allow for the cough reflex, which would clear and protect the airway."
Also, the tube allows bacteria direct access to the lower airways, which increases the risk of pneumonia, adds Schiever. "Perform frequent suctioning and keep the head of the bed elevated," she advises. "Inquire about starting prophylactic antibiotic treatment," she adds.
Mark Goldstein, RN, MSN, EMT-P I/C, clinical nurse specialist at the Emergency Center at Beaumont Hospital in Grosse Pointe, MI, says to prevent VAP by utilizing the Hi-Lo Tracheal Tube (manufactured by Boulder, CO-based Covidien-Nellcor), which allows suctions beyond the balloon cuff near the distal end.
"Provide daily oral care to the intubated patient," he advises. "Secure endotracheal tubes with commercial devices rather than tape."
If your patient was intubated by emergency medical technicians in the field, keep in mind that those conditions are often very unclean, says Debbie Griffin, a respiratory therapist who works in the ED at University of Colorado Hospital in Aurora. "Paramedics are challenged to maintain clean conditions under impossible conditions," she says. "Field-intubated patients are often already on the road to an infection before they come through the door."
Griffin says that University of Colorado "has had one of the most remarkable turnarounds in the United States. In 2008, we had 55 VAP cases — as much as three deviations above the national norms. So far this year, we've had just six cases."
Certain ED nursing practices can put patients at much higher risk for VAP, warns Griffin. "Some nurses still insist on pre-opening sterile items like [endotracheal] tubes and leaving them open to the environment until used," she says.
Nurses may fail to elevate the head of the patient's bed above 30 degrees, adds Griffin. "As we are often at capacity, I know sometimes vented patients have to hang out in the ED much longer than would be 'normal.' And they often do this laying flat," she says. (See related stories on starting oral care in the ED, and how one ED accomplished a 0% VAP rate, below.)
For more information on preventing ventilator-associated pneumonia in the ED, contact:
- Mark Goldstein, RN, MSN, EMT-P I/C, Emergency Center, Beaumont Hospital — Grosse Pointe, MI. Phone: (313) 417-6487. Fax: (313) 343-1073. E-mail: Mark.Goldstein@beaumonthospitals.com.
- Debbie Griffin, RN, Emergency Department, University of Colorado Hospital, Aurora. E-mail: Debbie.Griffin@uch.edu.
- Nyssa Hattaway, RN, CEN, Emergency Center, Medical Center of Central Georgia, Macon. Phone: (478) 633-1809. E-mail: Hattaway.Nyssa@mccg.org.
- Nicole Schiever, RN, MSN, Emergency Department, Riverside Medical Center, Kankakee, IL. Phone: (815) 935-7500. Fax: (815) 935-7824. E-mail: firstname.lastname@example.org.
Start oral care while patient is still in ED
Begin doing oral care for a ventilated patient in the ED instead of waiting for the patient to be transferred to the intensive care unit (ICU), advises Debbie Griffin, a respiratory therapist who works in the ED at University of Colorado Hospital in Aurora.
"A patient may get a tube, have some tests, and sits waiting for an ICU room for six hours," says Griffin. "It might take them another six hours to get their first oral care."
Accomplish a 0% VAP rate
Emergency nurses at the Medical Center of Central Georgia in Macon made several practice changes to prevent ventilator-associated pneumonia (VAP), and got some dramatic results.
"We currently have a 0% VAP rate. We are proud of our accomplishment," says Nyssa Hattaway, RN, CEN, the hospital's ED educator.
Hattaway notes that the typical intensive care unit (ICU) VAP "bundle" includes four elements: Elevating the head of the bed to between 30-45 degrees, providing deep venous thrombosis prophylaxis, providing peptic ulcer disease prophylaxis, and daily sedation "vacations" with assessment of readiness to extubate.
"Generally, the VAP bundle is considered an ICU measure, but there are simple interventions that can be done in the emergency setting," she says. "These interventions lay the foundation for good pulmonary hygiene and VAP prevention." Here are the interventions that prevent VAP in Hattaway's ED:
• ED nurses elevate the head of the bed as soon as an intubated patient's cervical spine has been cleared, if applicable.
• Nurses remind the admitting physician to address deep venous thrombosis and peptic ulcer disease prophylaxis.
"This is done when receiving admission orders, particularly if we are transcribing them from a physician over the phone," says Hattaway.
• Nurses insert an orogastric (OG) or nasogastric (NG) tube if the patient has been intubated in the field, or is intubated via rapid sequence intubation upon arrival to the ED.
"We try to do this before the chest X-ray, confirming ET tube placement is obtained," says Hattaway. "In our ER, we stock 16 and 18 French NG tubes in our critical care beds along with a 60 cc catheter tip syringe."
The patient's chest X-ray is used to confirm proper placement of the OG or NG tube, she adds. "We then decompress the abdomen and remove gastric contents by attaching the OG or NG tube to low intermittent suction to prevent aspiration," she says.
• ED nurses address the patient's nutrition needs as soon as possible, since the intubated patient's metabolic needs are high.
"With the OG/NG tube placed and confirmed in the ED, the ICU nurse can initiate tube feeds that much earlier," explains Hattaway.
• Nurses move ventilated patients to hospital beds without delay.
"This intervention is primarily to prevent skin breakdown, but has benefits for breathing as well, including allowing for more complete lung inflation and decrease in atelectasis," says Hattaway.