Download VAP Bundle: Evidence of Benefit

Ruben D Restrepo MD RRT FAARC
Professor of Respiratory Care
The University of Texas Health Science Center at San Antonio
Disclosure: Ruben D. Restrepo, MD, RRT, FAARC
• Teleflex Medical
– Speaker
– Member, Medical Advisory Board
• Oridion Capnography (Covidien)
– Consultant and investigator
• Salter Labs
– Consultant
• Fisher & Paykel
– Investigator
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• Upon completion of this module, participants should
understand and be able to communicate:
– Impact of VAP
– Diagnostic criteria for VAP and VAE
– Recommended strategies to minimize contamination
of equipment used during mechanical ventilation
– Evidence Based Clinical Practice Guidelines
directed to reduce incidence of VAP
– Role of the VAP Bundle
– Risks associated with breathing circuit condensation
and the advantages and disadvantages of current
options available for condensation management
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• ICU environment:
– Patients are sicker and maybe immunocompromised
– Mechanically ventilation: use of life-saving, but
invasive devices (catheters and ETTs)
• Superhighways for bacterial invasion
• Magnitude of HAI:
– Pneumonia
• 15% of HAI
• 27% of ICU acquired infections
• 24% of infections in coronary care units
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• Magnitude of VAP:
– 2nd most common HAI in the US1
• Most common HAI in the ICU
– CDC 2006-2007: 2.1-11.0 per 1,000 ventilator days2
– Increased length of stay (LOS) by:
• 25 hospital days
• 22 ICU days
– Associated cost: $40,000?3 $60,000?4
– 1st cause of death from HAI5
– Attributable mortality as high as 27%5
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1. Klevens et al. Public Health Reports 2007;122:160-166. 2. Centers for Disease Control and Prevention.
MMWR 2004;53(No. RR-3). 3. Rello J et al. Chest. 2002;122:2115-2121.
4.Warren D et al. CCM. 2003;31:1312-1317. 5. Fagon JY et al. Am J of Med. 1993;94:281-288.
http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
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Scott II RD. The Direct Medical Costs of Healthcare-Associated Infection in US Hospitals and the Benefits of
Prevention. CDC 2009; http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
• 4.5 HAIs/100 hospital admissions
• Overall annual direct medical costs of HAI
– $28.4 - $33.8 billion - urban consumers
– $35.7 - $45 billion - inpatient hospital services
• Benefits of prevention
– $5.7 - $6.8 billion (20% preventable - urban
consumers)
– $25.0 - $31.5 billion (70% preventable - inpatient
hospital services).
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Scott II RD. The Direct Medical Costs of Healthcare-Associated Infection in US Hospitals and the Benefits of
Prevention. CDC 2009; http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
• According to Stone et al2005
–
–
–
–
$36,441 BSI
$25,546 SSI
$9,969 VAP
$1,006 CAUTI
Stone PW, et al. Systematic review of economic
analyses of health care-associated infections.
Am J Infect Control 2005;33:501-509.
• According to Anderson et al2007
–
–
–
–
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$23,242 BSI
$10,443 SSI
$25,072 VAP
$758 CAUTI
Anderson DJ, et al. Under resourced hospital
infection control and prevention programs: penny
wise, pound foolish?
Infect Control Hosp Epidemiol 2007;28:767-773.
• NASCENT Study (n= 30 VAP vs. n=90 no VAP)
• Median total hospital charges for patient case
– $198,200 vs. $96,540 (P< .001)
• Median loss to hospital for patient case
– $ 32,140 vs. $19,360 (P= .151)
• Services with the highest median charges:
– hospital ($23,190 vs. $11,110) p <0.05
– respiratory ($4,838 vs. $2,787) p<0.05
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VAP: An Expensive Proposition
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VAP
• New or progressive
infiltrates on CXR
• Fever
• Abnormal WBC count
• Purulent sputum
MV > 48 h 10%-20%
Most common HAI in critical care patients.
Clinical Diagnostic Strategy
Clinical suspicion
Differential diagnosis
• Patient on Mechanical
Ventilation + infiltrate
CXR
+ 2/3 findings
• Symptoms  infection:
 Chemical aspiration
– (1) Fever, (2) purulent
tracheal secretions
• Laboratory  infection:
– (3) Leukocytosis or
leukopenia
– [Hypoxemia]
without infection
 Atelectasis
 Pulmonary embolism
 ARDS
 Pulmonary hemorrhage
 Lung contusion
 Drug reaction
 Other
VAP Definition(s) Halpern NA et al. CCM 2012
• CDC's National Healthcare Safety Network
– Pneumonia that occurs in a patient who was intubated and
ventilated at the time of, or within 48 hrs, “before” the onset
of the pneumonia
• ATS and the IDSA (clinically oriented)
– Pneumonia that arises >48–72 hrs “after” intubation
• VAP diagnostic criteria require the presence of a new or
progressive and persistent radiographic opacity, a
change in pulmonary secretions or symptoms, or
evidence of impaired gas exchange and systemic signs
of infection
– Microbiological evidence of lower respiratory tract infection is
optional
NHSN Surveillance for VentilatorAssociated Events in Adults
NHSN Surveillance for VentilatorAssociated Events in Adults
How Will I Find Cases of VAP?
•http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.
pdf JUNE 2011
VAP Definition
Early Onset VAP2
• Occurs in the period of 2-5 days
post intubation
• Pathogens responsible are
susceptible to antibiotic therapy
– Staphylococcus Aureus
(Meth sensitive)
– Streptococcus pneumoniae
– Hemophilus influenzae
– Proteus species
– Serratia species
– Klebsiella pneumoniae
– Escherichia coli
•
•
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Late Onset VAP2
• >5 days post intubation
• Usually caused by antibioticresistant organisms
– Pseudomonas aeruginosa,
– Methicillin-resistant
Staphylococcus aureus
(MRSA),
– Acinetobacter species
– Enterobacter species
– Vancomycin-resistant
enterococcus (VRE)
1 Mayhall G. C. Special Issue: Ventilator-Associated Pneumonia or Not? Contemporary Diagnosis. Emerging Infectious Diseases
Vol. 7, No. 2, March-April 2001 p. 201.
2 Davies, J. Pathogens Associated with the Intensive Care Unit Environment : Considerations for the Respiratory Therapist. Clinical
Foundations: A Patient-focused Education Program for Respiratory Care Professionals. December 2009.
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Gacouin A, et al. Late-Onset Ventilator-Associated Pneumonia in Nontrauma Intensive Care Unit Patients Anesth Analg 2009;109:1584-1590
VAP Pathogenesis
• Bacterial invasion of the pulmonary parenchyma in a
patient receiving mechanical ventilation
• Inoculation of the formerly sterile lower respiratory tract
typically arises from:
– Aspiration of secretions
– Colonization of the aero digestive tract
– Use of contaminated equipment or medications
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
VAP Pathogenesis
Endotracheal Tube
Subglottic
Secretions
Endotracheal
Tube Cuff
Biofilm on ETT
Pooled Secretions in
Airway
Dispersal of Biofilm With
Ventilation
Curr Opin Infect Dis. 2013 Jan 2. [Epub ahead of print]
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Risk Factors for VAP
• Risk factors for VAP include:
– Modifiable:
– Duration of ventilation
– Position in bed (supine)
– Enteral feeding
– Witnessed aspiration
– Paralytic agents
– Prior antibiotic use
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Risk Factors for VAP
• Risk factors for VAP include:
– Nonmodifiable:
– Extreme ages
– Comorbidities
•
•
•
•
•
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Pulmonary disease
HIV/AIDS
Head trauma
MOF
Immunosupression
Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Prevention of VAP
• Every Choice Matters
– Quality improvement initiatives suggest that many
cases of VAP might be prevented by careful attention
to the process of care
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Existing Guidelines and Recommendations
AARC – CDC – IHI - IDSA
• Reducing risk of VAP
– Active surveillance
– Hand-hygiene guidelines
– NIV whenever possible
– Minimize the duration of MV
– Daily assessments of readiness to wean and use
weaning protocols
– Educate healthcare personnel who care for patients
undergoing ventilation about VAP
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
SHEA/IDSA Guidelines
• “Compendium of Strategies to Prevent HealthcareAssociated Infections”
– SHEA-Society for Healthcare Epidemiology of America/ IDSAInfectious Diseases Society of America
– Prioritizing VAP as highly preventable
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
SHEA Guidelines: Core Recommendations
• Designed to interrupt the three most common
mechanisms by which VAP develops:
1. Aspiration of Secretions
2. Colonization of the aero digestive tract
3. Use of contaminated equipment
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Strategies to Reduce Aspiration of Secretions
• Maintain patients in a semi recumbent position (30-45°
head of the bed elevation) unless contraindicated
– 67% reduction in early onset VAP
• Avoid gastric over distention
• Avoid unplanned extubation and reintubation
• Use a cuffed endotracheal tube with in-line or subglottic
suctioning
– effective in preventing early-onset VAP
• Maintain an endotracheal cuff pressure of at least 20cm
H20
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Strategies to Reduce Colonization of the Aero
digestive Tract
• Orotracheal intubation is preferable to nasotracheal
intubation
– Nasotracheal intubation increases the risk of sinusitis,
which may increase the risk for VAP
• Avoid H2–blocking agents and proton pump inhibitors
– Unless at high risk for developing a stress ulcer or stress
gastritis.
• Perform regular oral care with an antiseptic solution
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Strategies to Reduce Use of Contaminated
Equipment
1. Thoroughly clean all respiratory equipment to be sterilized
or disinfected (IA)
2. After disinfection, proceed with appropriate rinsing, drying,
and packaging, taking care not to contaminate the
disinfected items (IA)
3. DO NOT routinely change the ventilator breathing circuit.
ONLY when visibly soiled or mechanically malfunctioning.
(IA)
4. Periodically drain and discard any condensate that collects
in the tubing of a mechanical ventilator, taking precautions
not to allow condensate to drain toward the patient. (IB)
5. Wear gloves to perform the above procedure or handle the
fluid (IB)
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
General Measures
1. Decontaminate hands with soap and water (if hands are
visibly soiled) or with an alcohol based hand rub, after
performing the procedure or handling the fluid (IA)
2. Use sterile (not distilled non sterile) water to fill bubble
humidifiers (II)
3. Change any HME that is in use by a patient when it
malfunctions mechanically or becomes visibly soiled (II)
4. Do not routinely change more frequently than every 48 hours
a HME that is in use by a patient (II)
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Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.
Summary of General Recommendations
• You can make a difference!
– Quality improvement initiatives show VAP (and the
associated mortality) might be prevented by careful
attention to the process of care
• Focus on preventing three most common mechanisms
by which VAP develops:
1.Aspiration of Secretions
2.Colonization of the aero digestive tract
3.Use of contaminated equipment
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AARC Evidence-Based
Clinical Practice Guidelines
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Hess DR, et al. AARC Evidence-Based Clinical Practice Guidelines. Respir Care 2003:48(9):869-879.
VAP Bundle
• How do you take these best practices and
effectively implement them?
– VAP Bundle
• Group of best practices that an institution employs
to decrease their incidence of VAP
• Typically evidence based with a monitoring /
compliance component
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•VAP Bundle: Evidence of Benefit
• If we accept the reduction of the VAP rate (based on the
unreliable current VAP definition) as the only outcome to be
improved (independent of the absence of mortality and
morbidity benefits), then there is an argument to potentially
incorporate a few preventive measures (e.g., elevation of
the head of the bed, continuous aspiration of subglottic
secretions, oral topical antibiotics) into a VAP bundle.
• However, if we interpret the Joint Commission definition of
proven outcome benefits as a reduction in VAP-associated
mortality and morbidity, then there are no individual VAP
preventive measures that have undergone adequate
scientific replication that could be entered into any VAP
bundle.
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•VAP Bundle: Evidence of Benefit
• If we accept the reduction of the VAP rate (based on the
unreliable current VAP definition) as the only outcome to be
improved (independent of the absence of mortality and
morbidity benefits), then there is an argument to potentially
incorporate a few preventive measures (e.g., elevation of
the head of the bed, continuous aspiration of subglottic
secretions, oral topical antibiotics) into a VAP bundle.
• However, if we interpret the Joint Commission definition of
proven outcome benefits as a reduction in VAP-associated
mortality and morbidity, then there are no individual VAP
preventive measures that have undergone adequate
scientific replication that could be entered into any VAP
bundle.
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Klompas M MD, Prevention of ventilator-associated pneumonia. Expert Rev. Anti Infect. Ther. 2010;8(7):791-800.
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•VAP Bundle: Evidence of Benefit
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Benefits
VAP-Industrial Complex
Reporting of Quality Metrics
The Quest for Zero VAP
The VAP Bureaucracy
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Product Solutions and VAP
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Advanced Heat and Moisture Exchangers
Viral/Bacterial Filters
Water Traps
Closed System Water Traps
Heated-wire circuits
Advanced heated-wire circuits
Maintenance Free Water Removal Accessory
Advanced NIV products
•ETT: Beyond Silver-coated
Imanaka CCM 212
• At extubation, only one ETT in 12 patients with ETTs was
colonized in the Mucus Shaver group, whereas 10 ETTs
out of 12 patients with ETTs were colonized in the control
group.
• Scanning electron microscopy showed little secretions on
the ETT from the study group, whereas thick bacterial
deposits were on all the ETTs from the control group.
• No adverse events were observed and nursing staff
seemed to be satisfied by its feasibility.
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•ETT: Beyond Silver-coated
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•
•
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At extubation, only one ETT in 12 patients
with ETTs was colonized in the Mucus
Shaver group, whereas 10 ETTs out of 12
patients with ETTs were colonized in the
control group (8% vs. 83%; p <0.001).
Scanning electron microscopy showed
little secretions on the ETT from the study
group, whereas thick bacterial deposits
were on all the ETTs from the control
group.
No adverse events were observed and
nursing staff seemed to be satisfied by its
feasibility.
Imanaka CCM 212
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Advanced HME’s
• New generation HME allows bypassing aerosol
Advantages:
– Eliminates caregiver exposure to de-pressurizing
circuits
– Reduces circuit manipulation and cross contamination
potential
Disadvantages:
– More expensive than traditional HME’s
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Viral/Bacteria Filters
• Reduce the risk of ventilator cross-contamination
between patients.
Advantages:
– Ease of use
– Depending on efficiency ratings, potential for risk
reduction against transmission of bacteria and viruses
Disadvantages:
– During HH, condensation leading to increased Raw =
frequent change
– Required frequent breaking of the circuit, exposing
patient and caregiver to cross-contamination
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Water Traps
• Collects the water that condenses in the breathing circuit.
Advantages:
– Relatively inexpensive and often Integrated into the
breathing circuit
Disadvantages:
– Labor intensive
– Potential clinician exposure to contaminants
– Requires circuit “breaks” = cross contamination
• “The condensate that accumulates in the ventilator circuit
is contaminated and care should be taken to avoid its
cross-contamination of other patients.” (AARC)
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Closed System Water Traps
• Vacuum-activated suctioning water traps
Advantages:
– Keeps condensate from collecting in the ventilator circuit
with the use of intermittent or continuous suction.
– Maintains a closed system: no circuit “breaks.
Disadvantages:
– Not Passive in nature--requires some clinician
interaction and management to suction out condensate
– Dew Point not lowered, some condensation may still
pass to the ventilator
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Heated-Wire Circuits (Advantages)
• Breathing circuit may decrease or eliminate condensate
(dependent on circuit and heated humidifier settings)
• Solution integrated into breathing circuit
• Clinician familiarity and comfort
• Some heated humidifiers allow for adjustment of heated
wire power (i.e. temperature gradient) to control the
amount of condensate in the breathing circuit
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Heated-Wire Circuits (Disadvantages)
• Ambient conditions that cool the circuit = circuit condensate
– air conditioning, window, cold rooms
– “milking” of the breathing circuit to fix is not recommended
and could be a safety hazard.
• Manufacturer change-out protocols may not be “duration of
patient stay” which requires “breaking” the ventilator circuit
making it difficult to comply with VAP risk reduction protocols
• Some circuits feature a super heated expiratory limb, which
can lead to condensate forming in the ventilator (ECRI)
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Advanced Heated-Wire Circuits
• Heated expiratory limb made from a unique material that
allows water vapor to diffuse through the tubing wall and
permeate to the atmosphere
Advantages:
–
–
–
–
Promotes a closed system for the expiratory limb
Reduces expiratory limb maintenance for the clinician
Extends the usable life of the expiratory limb filter
May reduce the humidity level enough to prevent the gas from
cooling and reaching its dew point within the ventilator flow
sensor
Disadvantages:
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– Fragile, highly susceptible to damage during normal handling
– Requires 7-day change out protocol
– Design does not allow for universal use
Maintenance Free Water Removal Accessory
• Maintenance free water removal from the expiratory limb
of the breathing circuit during mechanical ventilation
Advantages
– Reduce circuit manipulation and cross-contamination potential
– Eliminate the need to interrupt ventilation
– Reduce the amount of time handling and disposing of
condensation.
– Minimize exposure to de-pressurizing circuits
– Avoid accumulation of condensation in the ventilator
Disadvantages
– At ventilator placement may require caregiver to drain pooled
condensate into the device
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DO NOT INTUBATE: Advanced NIV
Products
• Advances in noninvasive positive pressure ventilation
(NPPV) products and protocols continue to improve the
success rates of therapy
– Masks:
• Designed exclusively for NIV, mask cushions are now
focused on patient comfort and therapy compliance
– Ventilators:
• New modes of ventilation are advancing use of NPPV
– Heated Humidifiers
• Heated humidifiers are now compatible with NPPV therapy,
allowing the delivery of heat and humidity, improving therapy
comfort
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DO NOT INTUBATE: High Flow Oxygen Therapy
• Sound alternative to NPPV
• Increased evidence:
– Indications
– Patient selection
– Positive outcomes
• Mechanical devices
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Summary
Infection Protection:
Every Choice Matters
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VAP Prevention: RTs Making a Difference
Arroliga A et al. Respir Care 2012
Accredited Respiratory Education Programs
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Advances in Respiratory Therapy
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• Clinical Foundations:
– Self-Study program available via mail or web
(www.clinicalfoundations.org)
– Topics Include Delivering Optimal Humidification,
Difficult airway management, Trends in NIV, and
Infection Prevention Strategies for the RT
• www. FirstDoNoHarm.com Website:
80
– Online resource devoted to preventing infections,
saving lives and cutting costs
– Includes latest unbiased, authoritative information
on preventing VAP
Thank you for your attention!