Tony L Smith DNP MSN RN ACNP Vanderbilt LifeFlight Flight Nurse/Clinical Educator

1. Tony L Smith DNP MSN RN ACNP Vanderbilt LifeFlight Flight Nurse/Clinical Educator

2. Primary Purpose Incidence of pneumonia in the first 48 hours post intubation in patients who were admitted to the Vanderbilt Trauma ICU and intubated by Vanderbilt LifeFlight Nurses based on radiology reports

3. Secondary Purpose • Overall incidence of pneumonia post intubation in patients who were admitted to the Vanderbilt Trauma ICU and intubated by Vanderbilt LifeFlight Nurses based on positive BAL during hospitalization

4. Why 48 Hours Postintubation? • To distinguish if there is a pneumonia that develops within the first 48 hours related to the injury/trauma and risk factors such as type of injury, location of intubation, Glasgow Coma Scale (GCS) prior to intubation and Injury Severity Score (ISS)

5. Classifications: Pneumonia • Community Acquired Pneumonia (CAP): pneumonia caused by an infection that was currently present in the community and diagnosed within the first 48 hours of admission. • Common Pathogens: Streptococcus pneumoniae and Haemophilus influenza Mandell LA, Bartlett JG, Dowell SF, et al: Update of practice guidelines for the management of community-acquired pneumonia . Clin Infect Dis 2003;37:1405-1433.

6. Hospital Acquired (HAP): an infection of lungs–bronchoalveolar unit in a patient who has been hospitalized ≥ 48 hours, and acquired during the hospital visit • Common pathogens: Staphylococcus aureus Pseudomonas aeruginosa, Klebsiella pneumoniae, and E. Coli. Hospital-acquired pneumonia: Risk factors, microbiology, and treatment. Chest. 119: 2001; 373S-384S.

7. Is there a third?

8. Trauma Acquired Pneumonia TAP • The concept that pneumonia develops within the first 48 hours after intubation posttraumatic event and related to risk factors such as injury (trauma), location of the prehospital intubation, GCS and ISS.

9. Relevance • Vanderbilt LifeFlight transport • > 2800 critically ill patients per year • Wide range in age, acuity and diagnoses (Medical and Trauma) • 400 patients required intubation during study period • neonate (n=59, 14%) pediatric medical (n=18 4%)/trauma (n=19=5%) and adult medical (n=108,27%)/trauma • Adult trauma (n=196, 49%) intubations admitted to Vanderbilt Trauma Intensive Care Unit (TICU)

10. Review of Literature • Pneumonia has accounted for approximately 15% of all hospital-associated infections • The second most common hospital-associated infection • Primary risk factor for the development of hospital-associated bacterial pneumonia is mechanical ventilation • Median rate of ventilator-days is 14.7 in trauma ICUs Centers for Disease Control and Prevention (2003). Guidelines for preventing health-care associated pneumonia, 2003

11. Review of Literature • Trauma patients + Intubation= Pneumonia → ↑morbidity and mortality (Bochicchio et al 2003) • Severe Head Injury, GCS <8, and location of intubation → ↑mortality (Murray et.al. 2000) • Emergent & Prehospital intubations→↑ mortality &pneumonia (Croce et al. 2001;Eckert et al. 2006)

12. Review of Literature • One of the most common complications that can occur post intubation → pneumonia (Eckert et al., 2006) • Higher ISS, less than optimal location of intubation prehospital setting → ↑pneumonia & mortality (Sing et al. 1999) • Location of intubation, Higher ISS, and Low GCS→Pneumonia (Miller et al. 2008) • Bacterial Origin is different in prehospital intubation & support early antibiotics (Miller et al. 2008)

13. Improvement ProjectPLAN/DO • Explored the incidence of TAP in trauma patients intubated by Vanderbilt Medical Center’s LifeFlight nurses and admitted to Vanderbilt TICU within the first 48 hours postintubation and identify risk factors • Retrospective data from a 142 trauma patients intubated by LifeFlight personnel and admitted to Vanderbilt TICU from July 1, 2008 through June 31, 2009

14. Inclusion Criteria • All trauma patients intubated by LifeFlight Nurses and admitted to the Trauma Intensive Care Unit at Vanderbilt Medical Center within the set time frame

15. Exclusion Criteria: • Patients unsuccessful oral intubation requiring a rescue airway (Laryngeal Mask Airway -LMA), Combi-tube, Surgical or needle cricothyrotomy • Burn patients

16. Variables • Flight Number • Medical record number • Age • Gender • Month of intubation • Location of intubation • Attempts prior to LF crew • Attempts per LF • Glasgow coma scale (GCS) at intubation • Initial CXR report • Pneumonia diagnosis by CXR • Antibiotic name, date, time, route, dosage • Date of positive bronchoalveolar lavage (BAL) report • BAL organism • Injury severity score (ISS)

18. Data Analysis • Data were analyzed using descriptive statistics and independent t-test to determine the incidence of pneumonia in this study sample

19. RESULTS

20. Results Age: <=40 65% 41-50 15% 51-60 13% >60 9% Ethnicity 1% Hispanic (2) 8% Af. American (11) 91% Caucasian (129/142) Gender 30% Female (43) 70% Male (99/142) GCS Mean 8 ISS Mean 27

21. SAMPLE Location and Attempts ATTEMPTS LOCATION

22. Comparison: TAP vs. Non-TAP p= 0.02

23. TAP vs. Non TAPLocation and Attempts Location Attempt

24. Trauma-Associated PneumoniaTAP: Antibiotics 1st 48 hours • 58% (6/11) • (5/6): Cefazolin 84% • (1/6): Piperacillin/tazobactam (Zosyn) 16% • (2/11) TAP had BAL procedure;1 Reported (+) • 18 yo Caucasian Male; GCS 3; ISS 29 • Reported (+) Acinetobacter • Did not receive antibiotics first 48 hours • Vent days Prior to BAL report: 3 ** Miller et al (2008) bacterial variations in prehospital intubations

25. Non-TAP • 22/131: Bronchoscopy • 19/22: (+) BAL reported 48 hours post-bronchoscopy • Organisms Identified: • Haemophilus influenza ** • Methicillin-resistant Staphylococcus aureus** • Acinetobacter baumannii • Streptococcus pneumoniae ** • Moraxella (Branhamella) catarrhalis • Klebsiella • Pseudomonas and E coli ** Miller et al (2008) bacterial variations in prehospital intubations

26. Non-TAPAntibiotics 1st 48 hours • 38% (50/131) • 84% (42/50) Cefazolin • 36% (18/50) Gentamycin • 8%(4/50) Vancomycin • 6%(3/50) Clindamycin • 4%(2/50) PCN G ** • 4% (2/50) Tobraymycin • 2% (2/50) Piperacillin/tazobactam (Zosyn) ** • 2% (1/50) Ampicillin/sulbactam (Unasyn) ** Notation: some patients received combination therapy

27. Discussion • 7.7% (11/142)Patients intubated by LF Nurses developed TAP in the 1st 48 hours per CXR reports • Not congruent with Sloane et al (2001) prehospital patients had 4X higher pneumonia rate • Not Consistent with Eckert et al (2004) prehospital emergently intubated 25% higher incidence of pneumonia • Limitations: 48 hours limiting factor should be re-evaluated; CXR alone is not a reliable tool in dx of TAP in Trauma Patients

28. DiscussionRISK FACOTRS • AGE: (TAP M=41, Non-TAP M=40) • ISS: (TAP M=27, Non-TAP M=26) • Increase risk for hospital complications r/t injury Bochicchil et al (2003);Croce et al(2001);Baker et al(1974) • 21% Mortality rate age <49 and 42% 50-69 (Pohlman et al. 2009) • AGE & ISS where not risk factors r/t TAP in this sample • GCS: (TAP M=6, Non-TAP M=9) • Found to be a risk factor (p=0.02) (t-test) Sloane et al (2000);Croce et al(2001);Rello et al(1999)

29. Secondary OutcomeSAMPLE • Incidence of pneumonia associated with community acquired bacteria based on + BAL reports • 24/142 (17%) Bronchoscopy Procedure in the TICU • 19/24 (79%) +BAL Reports • Limitation: Inconsistency among Practitioners

30. Organisms +BAL Reports ** Miller et al (2008) bacterial variations in prehospital intubations

31. RecommendationsACT • Future Research: • Examine time frame from 48 to 72 Hours • Use strict CDC criteria for the diagnosis of Pneumonia • Improve consistency of timing of the Bronchoscopy among Practitioners • Post successful resuscitation and within the 1st 48 hours

32. References • Carr, B. G., Kaye, A. J., Wiebe, D. J., Gracias, V. H., & Schwab, W. C. (2007). Emergency department length of stay: A major risk factor for pneumonia in intubated blunt trauma patients. Journal of Trauma injury, Infection and Critical Care, 63, 9-12. • Centers for Disease Control and Prevention. (2008). Guidelines for preventing health-care associated pneumonia, 2008. Retrieved June10, 2009, from http://www.cdc.gov/ncidod/dhqp/id_pneumonia.html • Eckert, M. J., Davis, K. A., Reed, L., Esposito, T. J., Santaniello, J. M., & Poulakidas, S. (2006). Ventilator-associated pneumonia, like real estate: Location really matters. Journal of Trauma Injury, Infection, and Critical Care, 60, 104-110. • Manangan, L. P., Banerjee, S. N., & Jarvis, W. R. (2000). Association between implementation of CDC recommendations and ventilator-associated-pneumonia at selected US hospitals. American Journal of Infection Control, 28(3), 222-227. • Matsushima, A., Tasaki, O., Shimizu, K., Tomono, K., & Ogura, H. (2008). Preemptive antibiotic treatment based on gram staining reduced the incidence of ARDS in mechanically ventilated patients. The Journal of Trauma Injury, Infection, and Critical Care, 65, 309-315. • Miller, R. S., Carnevale, R. J., Norris, P. R., Riordan, W. P., Jenkins, J. M., & Morris, J. A. (2008). Quantitative microbiology in trauma patients with ventilator associated pneumonia: Implications for early bronchoscopy and empiric antibiotic therapy (). Nashville, TN: Vanderbilt University Medical Center.