Download The impact of a newly implemented “Anti

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
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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
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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
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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
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•
•
•
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
•
•
•
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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.