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The impact of a newly implemented “Antiaspiration Protocol” in post-cardiothoracic surgery patients Christy Harbert MS, CCC/L-SLP Bobbie Starks RN,MSN,CCRN √ Differentiate between types of healthcareassociated pneumonias (HAP) √ Analyze ways to minimize development of aspiration pneumonia in specific patient populations √ Describe post-surgery care before/after implementation of anti-aspiration protocol √ Review implementation of protocol and means of attaining staff buy-in √ Identify benefits of aspiration prevention Hospital-acquired pneumonia • Mechanically ventilated patients are 6 to 21 times more likely to develop hospital-acquired pneumonia (HAP) than non-ventilated patients • Ventilator-associated pneumonia (VAP) is most common infectious complication among ICU patients – 47% of all infections – 10 – 65% of ventilated critical care patients with mortality rate as high as 70%. » Carson, CL, et al., Am J Critical Care, 2007 Jan, 16(1) » Sole, ML, et al. Am J Critical Care, , 2002 Mar; 11(2) » Rello J, et al., Chest. 2002 Dec, 122 (6): 2115-21 The costs: Ventilatorassociated pneumonia • • • • • • 9.6 additional days on mechanical ventilation 6.1 extra days in ICU 11.5 more days in hospital Mean length of stay – 23 days Mortality rate: 29.3% Mean hospital charges - $150,841 » Rello J, et al., Chest. 2002 Dec, 122 (6): 2115-21 » Kollef MH, et al., Chest. 2005; 128 (6): 3854-62 Non-ventilated patients & pneumonia • Risk increases with dysphagia, stroke, COPD, SOB/labored breathing, generalized weakness, neurological disease, malignancy, renal or liver disease and dementia. • Enteral feedings increase risk Hospital-acquired aspiration pneumonia • 2nd most common healthcare-associated infection in the US • A lower respiratory tract infection that develops in hospitalized patients in whom the infection is neither present nor incubated at the time of admission • Develops after 2 days » Centers for Disease Control and Prevention, 2003 » Horan et al. AJIC. June 2008: 36 (5): 327 Hospital-acquired pneumonia • Mortality rate of 18.8% • Mean length of stay – 15.2 days • Mean hospital charges - $65,292. Aspiration Pneumonia Definition: • Subcategory of pneumonia • Direct consequence of ingestion of foreign material into the airway or distal lung • Developing pneumonia from aspirates involves or impacts, in some way, nearly every major body system! Aspiration Pneumonia • Represents 8% to 33% of all healthcareassociated infections. • Most common cause of death in elderly is from healthcare-associated infections. • Results in functional decline and increased health care expenditures. • One study suggests 70% of patients with history of pneumonia aspirate saliva during their sleep. • #1 risk factor for aspiration pneumonia is POOR ORAL CARE! Micro-aspiration • Most micro-aspiration will be asymptomatic. How do you know if micro-aspiration is occurring? – Chest x-ray: watch for right lobe infiltrates, particularly in the right middle and lower lobes. – General fatigue and weakness for unknown reasons – Mild cough and throat clearing, possibly increased with oral intake. – Increased shortness of breath or decreasing oxygen saturation for unknown reasons – Possible elevated temperature for unknown reasons. Serious Illness: Aspiration pneumonia risk factors • • • • • • • • • • Increased age Mental Status change Dysphagia GERD Alcoholism Seizures Diabetes Heart Disease Malignancy Head Trauma CVA Anesthesia Nasogastric feeding Drug addiction Guillain-Barre Syn. Myasthenia Gravis Malnutrition Congestive Heart failure COPD Decreased level of consciousness CABG and Pneumonia, how do they go together? Respiratory dysfunction • Expected in cardiothoracic surgery – Median sternotomy incision – Dissection of an internal mammary artery – Induced hypothermia – Use of extracoporeal circulation » Valentine L, et al. Crit Care Med. 1998; 23(3), 486-90 » Wynne R & Botti M. Am J Crit Care. 2004; 13: 384-393. » Bicer Y, et al. Crit Care. 2005; 9(Suppl 1): P10. Pneumonia • Diagnosis based on: – The presence of new or progressive infiltrates on chest radiograph, plus two or more of the following: – Fever greater than 38.5 C or hypothermia less than 36 C – Leukocytosis greater than 12,000 – Tracheobronchial purulent secretions – Or a reduction of partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) of 15% or higher in the past 48 hours » Centers for Disease Control and Prevention, 2003 Study Results Risk factors Hogue, et al. (1995) Swallowing dysfunction in 34 patients (N = 865) Increased frequency of pnx, (p < .0001) Increased LOS (p = .0001) Use of TEE (p < .03) Age > 65 (p < .001) Agnew et al. (2002) Gastroesophageal reflux in 28% or patients 27% developed pnx (p < .001) Age > 65 (p < .001) Pre-existing CVD (p = .01) Harrington, et al. (1998) Silent aspiration in over 40% or patients (N = 5000) Increased frequency of pnx (p < .0001) Use of TEE (p < .01) Age > 65 (p < .005) Ferraris, et al.(2001) Dysphagia in 3% of patients (N = 1042) Increased frequency of pnx (p < .0001) Age > 65 (p < .001) Pre-op HF (p < .001) Aspiration pnx Pnx infiltrates Problem statement • October 2007 to March 2008, 7 of 64 cardiothoracic surgery patients developed post-operative pneumonia • Incidence of postop pneumonia 10.9% – 2007 STS database: incidence of postop pneumonia 3.8% in comparable facilities » Duke University, STS Database, 2008 Setting • 190 bed Midwestern community hospital • 24 bed ICU • STS database: 130 cardiothoracic surgeries annually • PDSA Cycle Risk Factors • • • • • • • • • • Increased age Mental Status change Dysphagia GERD Alcoholism Seizures Diabetes Heart Disease Malignancy Head Trauma CVA Anesthesia Nasogastric feeding Drug addiction Guillain-Barre Syn. Myasthenia Gravis Malnutrition Congestive Heart failure COPD Decreased level of consciousness Oral stage of swallow • Manipulation of food and liquid in and through the mouth Signs of oral dysphagia • • • • Difficulty chewing food Inability to eat specific foods Loss of food or liquid from mouth Food staying in mouth after the meal, usually in the cheek Pharyngeal stage of swallow • Food and liquid pass over the tongue base, through the pharynx, and pass through the Upper Esophageal Sphincter. Signs of pharyngeal dysphagia • Coughing, choking or gagging during or after the swallow • “wet” or “gurgly” voice • “wet” breath sounds (vocal stridor when breathing) • Sensation of something “stuck in throat” • May or may not have any signs Esophageal stage of swallow • Involves the transport of food/liquids through the esophagus to the stomach. Signs of esophageal dysphagia • • • • Frequent reflux after meal Difficulty managing solid foods Food “sticking” in lower throat or chest area C/O difficulty swallowing without overt choking • Excessive/uncontrolled belching during or after meals • PDSA Cycle Plan • Changes to post-operative care – Extended time to oral intake from 2 hours to 6 hours after extubation – Required bedside swallow evaluation by speech therapist prior to beginning intake – Program of gradual intake over 8 hours with ongoing fluid restriction Do • Development of the protocol • Staff education – PowerPoint presentation – Multiple sessions • Implementation of the protocol – All patients on the cardiothoracic surgery service were prospectively enrolled – Ongoing reinforcement at the bedside – Expanded education to the Telemetry unit 3 weeks after implementation Study • Six months of data collected for analysis – Exclusions: two with pneumonia on admission, one with pre-existing neuromuscular disease 100 80 60 40 PNEUMONI Count 20 pneumonia 0 no pneumonia preprotocol PATIENT Cases w eighted by FREQUENC postprotocol 60 50 40 30 ICULOS 20 less than 4 days Count 10 5 to 8 days 9 or more days 0 preprotcol PROTOCOL Cases w eighted by FREQUENC postprotocol Act • The protocol continues to be used for all patients on the cardiothoracic service • April 2008 through September 2010 – Over 480 patients have had a postoperative course uncomplicated by pneumonia Staff buy-in • Overcome reluctance – Ongoing reinforcement – Preliminary results shared at 3 months – Celebrate successes General guidelines for safe swallowing • Minimize distractions • Keep foods moist and soft • Sit in chair or 90 degree angle for all oral intake and for 45 minutes following • Encourage to chew well and take small bites • Alternate food with liquid • Discourage “chugging” drinks • Check for any pocketing after meal • BRUSH TEETH AFTER EACH MEAL! Number of visits Number of patients 2 25 2 or more with 10 diet modification 2 or more with 9 ST intervention % of patients with intervention 56 22 20 Plan • As part of the PDSA cycle, revisions are made to the plan as needed – Expansion of protocol to all patients after extubation Safe navigation of patients thru the health care system • We have enhanced patient safety • By preventing aspiration – We reduce the risk of complications – Decrease length of stay in the ICU – Decrease the need for re-intubation due to the development of pneumonia. REFERENCES • Agnew NM, Kendall JB, Akrofi M, et al. Gastroesophageal reflux and tracheal aspiration in the thoracotomy position: Should rantidine premedication be routine? Anes Ann. 2002; 95: 16451649. • Bicer Y, Simsek S, Yapici N, Aydm O, Segat F, Aykac, C. Risk factor analysis of pneumonia developing after open heart surgery. Crit Care. 2005; 9(Suppl 1): P10. • Cason, CL, et al. Nurses’ implementation of “Guidelines for Ventilator-Associated Pneumonia” from the Centers for Disease Control and Prevention. Am J Crit Care. 2007; Jan:16(1): 28-38. • Hixon S, Sole ML, King T. Nursing strategies to prevent ventilator-associated pneumonia. AACN Clinical Issues. 1998; 9:76-90. • Ferraris V, Ferraris S, Mortiz D, & Welch S. Oropharyngeal dysphagia after cardiac operations. Annals of Thor Surg. 2001; 71(6), 1792-96. • Groenveld ABJ, Jansen EK, Verheij J. Mechanisms of pulmonary dysfunction after on-pump and offpump cardiac surgery: A prospective cohort study. J Cardiothoracic Sur. 2007; 2(11): 1278-1282. • Guidelines for the management of hospital-acquired, ventilator-associated and healthcare-associated pneumonia. Joint statement the American Thoracic Society and the Infectious Diseases Society of America. Am J Respir Crit Care Med. 2005; 171: 388416. • Campbell DL & Ecklund MM. Development of a research-based oral care procedures of patients with artificial airways. NTI (a publication of AACN’s National Teaching Institute). 7 May 2002. • Harrington O, et al. Silent aspiration after coronary artery bypass grafting. Annals of Thor Surg.1998. Retrieved May 5, 2008 from ats.ctsnetjournals.org. • Hogue CW, Lappas GD, Creswell LL, et al. Swallowing dysfunction after cardiac operations: Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardivasc Surg. 1995; 110: 517-522. • Horan TC, Andrus M. RN, & Dudeck M. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting, AJIC, June 2008: 36 (5): 327 • • • • ICP Report. New oral care routing eliminates VAP at Florida hospital. 2004; Vol 9(1). Kollef MH, et al.Epidemiology and outcomes of healthcare-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005,128:3854-62. Morgado JV, Nouer SA, Porto AD et al. Features and markers of nosocomial pneumonia in patients undergoing heart surgery. Crit Care. 2001; 9(Suppl 3): P66. Munro CL, Grap MJ. Oral health and care in the intensive care unit: State of the science. Am J Crit Care. 2004; 13(1): 65-74. • Rello J. et al. Epidemiology and outcomes of VAP in a large US Database. Chest. 2002; Dec,122 (6): 2115-21. • Sole, ML, et al. Bacterial growth in secretions and on suctioning equipment of orally in tubated patients: A pilot study. Am J Crit Care. 2002, March; 11(2): 14149. • Society of Thoracic Surgeons Participant Summary. 2008. Duke University. • Valentine L, et al. Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med. 1998; 23(3), 486-90. • Wynne R & Botti M. Postoperative pulmonary dysfunction in adults after cardiac surgery with cardiopulmonary bypass: Clinical significance and implications for practice. Am J Crit Care. 2004; 13: 384-393.