2006 OPEN FORUM Abstracts
RESPIRATORY THERAPIST LED EARLY VAP SURVEILLANCE: A PROACTIVE STRATEGY IN AN ONCOLOGICAL ICU
S. Egbert Pravinkumar MD, FRCP, FCCP, Clarence G. Finch
BS, BA, RRT, Kristen J. Price MD, FCCP, Joseph L. Nates MD, MBA, FCCM,
Background: Recent ATS/IDSA document provides recommendations for management of ventilator associated pneumonia (VAP) and health care associated pneumonia (HCAP) in immunocompetent, non-cancer patients. However, the document excludes patients with immunosuppression, hematological malignancy, chemotherapy-induced neutropenia, organ transplantation, bone marrow and peripheral blood stem cell transplantation, who are the main patient population in our comprehensive cancer center . We studied the impact of a proactive strategy for VAP surveillance in immunosuppressed critically ill cancer patients.
Method: All critically ill surgical and medical ICU patients intubated for 24 hours or more were screened for exclusion criteria. The respiratory therapist (RT) performed non-bronchoscopic bronchoalveolar lavage (NB-BAL) from both lower lobes according to a written policy; using Kimberley Clark protected 16 Fr BAL catheter. The adverse events were meticulously charted as part of respiratory care quality assurance program. A core group of RT was trained in NB-BAL and was periodically assessed for competency in skills.
Result: Between 9/1/2004 and 1/31/2006, a total of 109 NB-BAL procedures were performed by RT. The diagnostic yield from NB- BAL technique was 49%. Considering the bonemarrow suppression and coagulopathy our patients had no major adverse events. The therapists felt clinically engaged and empowered in this proactive strategy, and the morale of therapists was high. We developed a pneumonic to aide our goal for surveillance- "BITE for VAP", which stands for Bronchial sampling, ICU microbial profiling, Targeted and Empiric antibiotic therapy.
Conclusion: Implementation of early NB-BAL for VAP surveillance provides a proactive role for the respiratory therapist and intensivist in the treatment and prevention of VAP. This strategy may provide insight into true VAP and HCAP rates and also the specific microbial profile in this population of critically ill cancer patients, who are excluded in the recent ATS/IDSA recommendations on VAP.