Improving Surveillance for Ventilator Associated Events in Adults

1. Economic Impact of VAP in a Large Matched CohortInfection Control and Hospital Epidemiology March 2012, Vol. 33, No. 3Marin H. Kollef, MD; Cindy W. Hamilton, PharmD, Frank R. Ernst, PharmD, MS Conclusion: Our findings suggest that VAP continues to occur as defined by the new specific ICD-9 code and is associated with a statistically significant resource utilization burden, which underscores the need for cost-effective interventions to minimize the occurrence of this complication.

2. Improving Surveillance for Ventilator Associated Events in Adults • “It is necessary to have objective reliable surveillance for definitions for use in public reporting and inter-facility comparisons of event rates and federal pay-for-reporting and performance programs.” • New Definition • Detects complications and conditions including, but not limited to VAP • Requires a minimum period of time on ventilator • Focuses on readily available, objective, clinical date • Does not include chest radiograph findings • The goal for implementation in NHSN (National Healthcare Safety Network) is January 2013.

3. The Product Selected Must Address Three Risk Factors for VAP • Colonization of dental plaque with respiratory pathogens. 2. Bacterial colonization of the oropharyngeal area. 3. Aspiration of subglottic secretions. Schleder B, et al., J Advocate Health Care. 2002;4(1):27-30.

4. Professional organizations are now recognizing comprehensive oral care as key to addressing VAP and HAP. • APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia7 • Key prevention strategies: • Perform routine antiseptic mouth care • Example mouth care and documentation form includes the following: • Perform routine antiseptic mouth care • Brush teeth q12 • Provide oral care every 2 to 4 hours with antiseptic • Apply mouth moisturizer to oral mucosa and lips • Suction orally as necessary CDC Guidelines for preventing Healthcare-Associated Pneumonia1,5 “… Develop and implement a comprehensive oral-hygiene program (that might include use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities who are at risk for health-care associated pneumonia (II)” AACN Procedure Manual for Critical Care – Oral Care Interventions; 2005, 20101,6 “Assess oral cavity and lips every 8 hours, and perform oral care every 2 to 4 hours and as needed.2 With oral care, assess for buildup of plaque on teeth or potential infection related to oral abscess.” “Perform oral hygiene, using pediatric or adult (soft) toothbrush, at least twice a day. Gently brush patient’s teeth to clean and remove plaque from teeth.” 2 “Use toothpaste or cleansing solution that assists in the breakdown of debris.” “Cleansing solution should contain additives that assist in the breakdown of mucus in the mouth.  Sodium bicarbonate assists in the removal of debris accumulation on oral tissue and teeth”. “In addition to brushing twice daily, use oral swabs with a 1.5% hydrogen peroxide solution to clean mouth every 2 to 4 hours.”2 “Antiseptic oral rinses (chlorhexidine, cetylpyridinium chloride [CPC], added after brushing or done in conjunction with comprehensive oral care did achieve elimination of VAP.”9 “With each cleansing, apply a mouth moisturizer to the oral mucosa and lips to keep tissue moist.”2 “Suction oral cavity/pharynx frequently.”3 • IHI Guidelines8 Recommendations • Doctors and nurses can help prevent VAP by using a bundle of 5 “care steps.” The bundle of care steps are as follows: • Elevation of the Head of the Bed • Daily "Sedation Vacations" and Assessment of Readiness to Extubate • Peptic Ulcer Disease Prophylaxis • Deep Venous Thrombosis Prophylaxis • Daily Oral Care with Chlorhexidine 1. In addition to other interventions. 2. Level IV: Limited clinical studies to support recommendations. 3. Continuous suctioning: Level II: Theory based, no research data to support recommendations; recommendations from expert consensus group may exist. Intermittent suctioning: Level IV: Limited clinical studies to support recommendations. 4. Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. 5. Tablan OC, et al., Guidelines for preventing health-care-associated-pneumonia, 2003, Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003. 6. Scott JM, Vollman KM, Endotracheal tube and oral care. In DJ Lynn-McHale Wiegand and KK Carlson (Eds.) AACN Procedure Manual for Critical Care, Fifth Ed., pp. 28-33, Sixth Ed., p. 34., Elsevier Saunders, St. Louis, MO. 7. APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia, pp. 28,40. 8. 5 Million Lives Campaign. Getting Started Kit: Prevent Ventilator-Associated Pneumonia How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2010 (Available at www.ihi.org). 9. Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.

5. Validate the Product - It’s all about the Outcomes… • Toothette Oral Care: • 5 Manuscript Publications • AJCC, AJIC, Journal of Nursing Care Quality, Advocate Journal of Health, Nursing Management, Journal of Neuroscience Nurses • 23 Poster Presentations • AACN, APIC, IHI, AARC, and more • 20 Case Studies • ICT Today, HPN News, Nursing, and more

6. Guidelines: CDC Guidelines, 2003 AACN Procedure Manual, 2005, 2010 SHEA/ IDSA Compendium, 2008 APIC Guide to Eliminate VAP, 2009 IHI VAP Bundle, 2010 • Peer Reviewed Publications including but not limited to: • Garcia, AJCC, 2009 • Hutchins and Karras, AJIC, 2009 • Fields, Journal of Neuroscience Nursing, 2008 • Powers, Journal of Nursing Care Quality, 2007 • Schleder, Journal of Advocate Health Care, 2002 • Posters Presented at Conferences Including: • Heck, APIC, 2010 • DeJulio, AARC, 2009 • Bugg, IHI, 2008 • Button, IHI, 2008 • Lipke, APIC, 2008 • Orr, APIC, 2008 • Dozens of other posters oral care usage….. Adapted from Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine what it is and what it isn’t. BMJ. 1996;312(7023);71-2

7. Sage Suction Toothbrush • Nylon Bristles • 3100 contact points • Swab on the back • More than 6 times the solution • Sodium Bicarbonate • 3 Suction Ports • 1-piece configuration

8. Sage Suction Brush and Plaque Removal • 25% more effective in plaque removal when compared to plastic brush.

9. Sage Suction Swab • Perpendicular Ridges • Side Suction Ports • Sodium Bicarbonate • 1-Piece Configuration

10. Q-Care Burst Pouch • Ease of use to aid in compliance • No set up required • No tearing or pouring • No mixing, no mess, burstable solution packets

11. Covered Yankauer • Protected between uses • Soft Tip • 1-Piece configuration • Available individually as well as in systems

12. Key Ingredients

13. Evolution of Compliance

14. CustomerOne is a program that performs customized measurement and analysis, then compiles your results into valuable actionable reports for your facility. This program is confidential and at no cost to you. Your dedicated Resource Specialist will work closely with your facility to meet your needs and expectations. • We track Product Utilization, Compliance, Clinical Outcome, Compliance to IHI Bundle, and Return on Investment. Reports can be customized to analyze any type of information you need. There are no limitations to the types of reports that can be generated. • Utilization Program for all Sage Products lines or your focused intervention. • Shares positive outcomes and highlights areas for continued improvement. • We match up data and provide easy to recognize graphic presentations to share with your internal staff.

15. Sage’s Commitment to Continuing Education • Over 80 Annual Events • Reducing Hospital Acquired Pneumonia including Ventilator Associated Pneumonia and Aspiration Pneumonia • Skin breakdown due to Incontinence Associated Dermatitis • Pressure Ulcer Prevention • Reducing SSIs • National Conferences • Sage Products University • CME/CPME/CNE Accredited.

16. Compliance in the Outcomes • September 2009 AJIC • 80% compliance leads to drop in VAPs • November 2009 AJCC • 85% compliance leads to drop in VAPs, Length of Stay in ICU and Time on the vent.

17. Any Questions? Thank you!