Adverse Effects and Complications of Mechanical Ventilation

Nursing Role in Preventing complications of MV

Outline2Outline3Injuries to mouth, lips and oropharynx

Trauma to the lips and cheeks from tube tiesAvulsion of skin due to adhesive tapeInjuries to the entrapped tonguePressure ulcers to the palate and oropharynx Perioral herpesSkin flap avulsion during extubation due to adhesive tape.

Endotracheal Tube Fixator

Slipped ETT

Chest X-Ray

3-4 cmCorrect ET Tube Placement

Correct ET Tube Placement

Secure ET tube in place, note the numberSedate patient with appropriate MAASAvoid accidental, or self extubation Laryngeal Inguries

Laceration and hematoma in the left vocal fold during direct laryngoscopy. Exam performed with rigid telescope

Laryngeal InjuriesBilateral intubation granulomas inserted in the vocal apophasis. Exam performed with rigid telescope.Ulcerated lesion in the posterior glottic commissure soon after extubation. Exam performed with rigid telescope.

Laryngeal Injuriesdiffuse posterior erythema, edema and piled-up mucosa of inter-arytenoid area

Cuff Related Injuries

Risk of aspirationRisk of mechanical complicationsPrince J S et al. Radiographics 2002;22:S215-S230Postintubation stenosis

Figure 1a.Postintubation stenosis. (a, b) Conventional radiographs obtained in a 42-year-old man (a) and a 70-year-old woman (b) demonstrate focal subglottic stenosis (arrow) that resulted from prolonged intubation. (c) Corresponding bronchoscopic image obtained in the same patient as in b shows marked subglottic narrowing.Tracheal and Glottic Stenosis

Tracheal stenosis (exam performed with flexible nasofibroscope)Glottic stenosis (exam performed with rigid telescope).Ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue

Tracheomalacia

Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalaciaAnapnoGuard

The AnapnoGuard system detects air leakage from the lungs by measuring the CO2 level above the cuff. Detection of high CO2 levels above the cuff represents leakageSphygmomanometers

Minimum Leak Volume TechniqueAir inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases.Place a stethoscope over larynx. Indirectly assesses inflation of cuff.Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration.Remove syringe tip, check inflation of pilot balloonOutline23Case Scenario64 year old male with history of COPD who presented with severe respiratory distress and required to be intubated and placed on CMV, VT of 650 ml and a rate of 24/min.Immediately post intubation, his systolic blood pressure dropped from 132 mm Hg to 73 mm Hg.Hypotension following MV

25Other reasons are25

PPV vs. Spontaneous Ventilation053-3120010053-311008

PPV vs. Spontaneous VentilationEffect of Lung Volume on Venous ReturnNo effect in Normal individual with PEEP less than 10 cmH2OMajor effect in patients with Dynamic Hyperinflation such as asthma and COPD, and in pre-existing pulmonary hypertensionSmall changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVRAvoid air trapping in these patients

28If the healthy cardiopulmonary system isventilated near normal FRC without excessiveshifts in lung volume, it is unusual to seeclinically important changes in RV afterloadwith a PEEP of less than 10 cm H2O. However,the situation can be very different in patientswho have hyperinflated lungs secondary toasthma or obstructive pulmonary disease; andin children with pre-existing pulmonary hypertension.For the reasons described above,apparently small changes in lung volume cancause considerable haemodynamic compromisesecondary to acute elevation of PVR inthese patients, and particular care should betaken to avoid additional gas trapping, or largeshifts in lung volume during mechanical ventilationSymptoms of hemodynamic effectsDecreased cardiac output, decreased venous returnObserve for:Decreased BPRestlessness, decreased LOCDecreased urine outputDecreased peripheral pulsesSlow capillary refillIncreasing TachycardiaOutline30Ventilator-associated lung injury (VALI)31Ventilation-Induced Lung Injury (VILI)Atelectrauma: Repetitive alveolar collapse and reopening of the under-recruited alveoliVolutrauma:Over-distension of normally aerated alveoli due to excessive volume delivery*Dreyfuss: J Appl Physiol 1992

Cytokines, complement, prostanoids, leukotrienes, O2- ProteasesBiotrauma32

Pinsp = 40 mbar

Recognized Mechanisms of Airspace Injury

StretchShearAirway Trauma34

Gas Extravasation Barotrauma35Barotrauma

Barotrauma

Barotrauma

VolumePressureZone ofOverdistentionSafeWindowZone ofDerecruitmentand AtelectasisInjuryInjuryOptimized Lung Volume Safe Window Overdistension Edema fluid accumulationSurfactant degradationHigh oxygen exposureMechanical disruption

Derecruitment, AtelectasisRepeated closure / re-expansionStimulation inflammatory responseInhibition surfactantLocal hypoxemiaCompensatory overexpansion

Diseased Lungs Do Not Fully Collapse,Despite Tension PneumothoraxAnd they cannot always be fully openedDimensions of a fully Collapsed Normal Lung41Outline42Oxygen Toxicity : FIO2 > 60 % for > 24hAbsorptive atelectasisO2/N2 = 21/79 >>>>>> 50/50Accentuation of hypercapniaChronic respiratory failure: PCO2 with PO2Damage to airwaysBronchopulmonary dysplasia Diffuse alveolar damage

Carbon dioxideWater vapourOxygenNitrogen

Diffuse Alveolar Damage

Oxygen toxicity Reduce FiO2?PEEPAlveolar recruitment maneuvers Alternative modes of ventilationInverse-ratio , APRV, HFV, ..Inhaled nitric oxide (iNO)Extracorporeal membrane oxygenation (ECMO) Diuresis if pulmonary edema is possibleBronchopulmonary hygiene if secretions are prominentAugmentation of antioxidants??Outline46Path to VAP

Ventilator Associated Pneumonia: Definitions VAP ventilator associated pneumonia>48 hours on ventCombination of:CXR changesSputum changesFever, WBCpositive sputum cultureOccurs secondary to micro-aspiration of upper airway secretionsRisk Factors for VAPNo 1 risk factor is endotracheal intubation Factors that related to cross contamination:Poor adherence to infection control standardsFactors that enhance colonization of the oropharynx &/or stomach:Poor oral hygieneConditions favoring aspiration into the respiratory tract or reflux from GI tract:Supine positionNGT placementRe-Intubation and self-extubationSurgery of head/neck/thorax/upper abdomenGERDComa/ depressed Glascow coma scaleChest X-Ray: VAP

Prevent Contamination: Hand Wash

Prevent Contamination: Hand Wash

Prevent Contamination: Personal Protective Equipments

Prevent Contamination: Change gloves when changing from contaminated to clean area

Prevent Contamination: Environmental Cleaning

Prevent Contamination: Use closed inline system for MDIs

Prevent Contamination: Use condensate traps

Prevent Contamination: Chnage HME every 48 hrs

Reduce Colonization: Oral Hygien, frequent tooth brushing

Reduce Colonization: Oral Hygien mouth swabbing with chlorhexidine

Reduce Colonization: Oral Hygien suctioning of oral secretion

62Prevent Colonization: Closed suction system

Prevent Colonized Circuits: Changed when visibly soiled

Prevent Colonization: Periodically drain the condensate

Prevent Aspiration: Head of Bed 40 degrees

Prevent Aspiration: HOB Elevation

HOB at 30-45CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005 45o head-up tilt is the goal in all patients unless contraindicated No benefit of semi-recumbency ~30o over standard care ~10o

Supine position is harmful67Prevent Aspiration: Measure cuff pressure 20-25 mm Hg

Prevent Aspiration: Subglottic suctioning

VAP prevention :VAP BundleElevation of the head of the bed 30-45o Use 15-30o for neonates and small infants, otherwise 30-45o Daily sedation vacations (minimize duration of intubation) Daily assessment of readiness to extubate Peptic ulcer disease (PUD) prophylaxis Oral care protocol (chlorhexidine) DVT prophylaxis optionHOB Elevation Leads to Significant reduction in VAP

Dravulovic et al. Lancet 1999;354:1851-185871Studies have also shown a dramatic decrease in VAP when a simple HOB elevation is done. These data are from a study by Drakulovic et al in 86 intubated and mechically ventilated patients in a medical and respiratory ICU.Subjects were randomly assigned to either 0 degrees or 45 degree HOB elevation.VAP was detected in 2 of 39 patients (5%) in the HOB elevation to 45 degree group and 11 of 47 patients (23%) of the 0 degree HOB elevation.The risk reduction was 78% for patients placed in the HOB elevation to 45 degrees.Does the VAP bundle work in real life

NHSN 50th Percentile 4.1Outline73Pulmonary Embolism

Bilateral pulmonary embolism

VAP prevention :VAP BundleElevation of the head of the bed 30-45o Use 15-30o for neonates and small infants, otherwise 30-45o Daily sedation vacations (minimize duration of intubation) Daily assessment of readiness to extubate Peptic ulcer disease (PUD) prophylaxis Oral care protocol (chlorhexidine) DVT prophylaxis optionOutline77Asynchrony with the ventiaitorFighting the ventilatorsInconsistent tidal volumeIncrease work of breathingBarotraumas and thoracic air leakInsufficient gas exchangeDisturbances in the cerebral blood flowOutline790100200300100Stage 1Stage 2Stage 3Stage 4REMNon REMAge 40Age 40MVSleep Time (minutes)81012141618202202468Stage 1Stage 2Stage 3Stage 4REMNormal Sleep Pattern81012141618202202468Stage 1Stage 2Stage 3Stage 4REMHyponogram for a Patient on Mechanical VentilationMechanisms by which mechanical Ventilation Disrupt SleepNoise disruptionVentilator alarm: inappropriate thresholdDelayed alarm inactivationHumidifier alarmsDisruption by nursing interventionsAirway suctionNebulizer deliveryVentilation-related pharmacological disruptionBenzodiazepines (REM, deep NREM)Opioids (REM, deep NREM)Neuromuscular blocking drugs

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Thank you

Chart214.7451.2679

Sheet1Oxygen14.74Carbon dioxide5Water vapour1.26Nitrogen79

Sheet1

Sheet2

Sheet3

Chart400.1400.3813.10.710116.1118.2117.9124.410115.91010150.9601810101

VAP Infection RateVAP Bundle Compliance%CCU VAP Bundle Compliance Vs Infection Rate

MSICU-D VAP Feb 08 ReportMICU - D VAP Bundle ComplianceFebruary ReportData Collection Period: 1 - 29 February 2008Data Collected by: MICU Staff NursesNumber of Patients Assessed Daily During Above Period: 39Report prepared by: Ghiwa Najjar, Quality Analyst, QRMDMICU - D Bundle ElementsBundle ElementAchievedCommentsHead of Bed 30 - 45100%Sedation VacationNAPeptic Ulcer Disease Prophylaxis100%DVT Prophylaxis100%100%FindingsAll MICU D Pts were not sedated and 97% were trachedRecommendationsHead Nurse to share this report with all end-users and to post on the MICU Bulletin Board for more commitmentBaseline data14%Feb-07100%Mar-07100%Apr-07100%May-07100%Jun-0790%Jul-07100%Aug-07100%Sep-07100%Oct-0727%Nov-07100%Jan-08100%Feb-08100%MSICU - DVAP Infection RateVAP Bundle Compliance%Feb-070100%Mar-070100%Apr-079.8100%May-070100%Jun-07090%Jul-070100%Aug-070100%Sep-0711.8100%Oct-0712.827%Nov-070100%Dec-0722.7Jan-080100%Feb-080100%No VAP compliance data provided by MSICU-D for the unplotted data

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MSICU-D VAP Feb 08 Report10111

Overall Bundle complianceAchievedMICU - D VAP Bundle Compliance100%NA

MSICU-C VAP Feb 08 Report

MICU - D VAP Overall Bundle Compliance

SSCU-B VAP Feb 08 Report

VAP Infection RateVAP Bundle Compliance%MICU-D VAP Bundle Compliance Vs Infection Rate

CCU VAP Feb 08 ReportMICU - C VAP Bundle ComplianceFebruary ReportData Collection Period: 1 - 29 February 2008Data Collected by: MICU Staff NursesNumber of Patients Assessed Daily During Above Period: 266Report prepared by: Ghiwa Najjar, Quality Analyst, QRMDMICU - C Bundle ElementsBundle ElementAchievedCommentsHead of Bed 30 - 45100%97%Peptic Ulcer Disease Prophylaxis100%DVT Prophylaxis100%Oral Gastric Rather than Nasogastric Tube100%* 64% of the assessed Pts were not sedated and 49% were tracheostomy PtsFindingsExcellent documentation awareness among the MICU C staff nurses - Keep it upRecommendationsHead Nurse to share this report with all end-users and to post on the MICU Bulletin Board for more commitmentOverall bundle complianceJul-0636%Aug-0645%Sep-0699%Oct-0672%Nov-0680%Dec-0680%Jan-0770%Feb-0763%Mar-0796%Apr-0780%May-0788%Jun-0797%Jul-0786%Aug-0778%Sep-0784%Oct-0790%Nov-0789%Dec-07100%Jan-08100%Feb-0897%MICU -CVAP Infection RateVAP Bundle Compliance%Jul-061636%Aug-066.545%Sep-064.199%Oct-068.172%Nov-069.180%Dec-0612.380%Jan-0713.570%Feb-0711.563%Mar-079.996%Apr-07380%May-0710.488%Jun-074.997%Jul-0713.886%Aug-0714.178%Sep-077.484%Oct-072.990%Nov-0717.489%Dec-073.1100%Jan-080100%Feb-0812.297%

NHSN 50th percentile: 2.8Page &P of &N

CCU VAP Feb 08 Report

Overall Bundle complianceAchievedMICU - C VAP Bundle Compliance

CSICU VAP Feb 08 Report

Overall bundle complianceMSICU VAP Overall bundle compliance

Bundle Element Checklist

Overall bundle complianceMICU - C VAP Overall Bundle Compliance

Bundle Elements

VAP Infection RateVAP Bundle Compliance%MICU-C VAP Bundle Compliance Vs Infection Rate

Run Chart at KFSHRC 08SSCU - B VAP Bundle ComplianceFebruary ReportData Collection Period: 1 - 29 February 2008Data Collected by: SSCU-B Staff NursesNumber of Patients Assessed Daily During Above Period: 179Report prepared by: Ghiwa Najjar, Quality Analyst, QRMDSSCU - B Bundle ElementsBundle ElementAchievedCommentsHead of Bed 30 - 45100%Sedation Vacation99%Peptic Ulcer Disease Prophylaxis100%DVT Prophylaxis100%Oral Gastric Rather than Nasogastric Tube100%44% of the assessed patients were not sedated and 21% were tracheostomy patientsFindingsGood documentation awarenessRecommendationsHead Nurse to share this report with all end-users at staff meetingBaseline data14%May-0638%Jun-0653%Jul-0616%Sep-0680%Oct-0682%Nov-0688%Dec-0685%Jan-0791%Feb-0787%Mar-0794%Apr-0799%May-0767%Jun-0765%Jul-0776%Aug-0788%Sep-0790%Oct-0769%Nov-0790%Dec-07100%Jan-08100%Feb-0899%SSCU - BVAP Infection RateVAP Bundle Compliance%Jul-061816%Aug-0627.9Sep-0618.780%Oct-06082%Nov-0624.488%Dec-064.485%Jan-078.291%Feb-074.287%Mar-0713.894%Apr-0711.299%May-075.367%Jun-074.665%Jul-0737.376%Aug-0724.788%Sep-072990%Oct-074.869%Nov-071290%Dec-070100%Jan-086.7100%No VAP compliance data provided by SSCU-B for the unplotted data

NHSN 50th percentile: 2.8Page &P of &N

Run Chart at KFSHRC 08

SSCU - B VAP Overall bundle compliance

Graphs and Table

Overall Bundle complianceAchievedSSCU - B VAP Bundle Compliance

Data

VAP Infection RateVAP Bundle Compliance%SSCU-B VAP Bundle Compliance Vs Infection Rate

CCU VAP Bundle ComplianceFebruary ReportData Collection Period: 1 - 29 February 2008Data Collected by: Staff NursesNumber of Patients Assessed During Above Period: 42Report prepared by: Ghiwa Najjar, Quality Analyst, QRMDCCU VAP Bundle ElementsBundle ElementAchievedCommentsHead of Bed 30 - 45100%Sedation Vacation100%Peptic Ulcer Disease Prophylaxis100%DVT Prophylaxis100%Oral Gastric Rather than Nasogastric Tube100%52% of the Pts were not sedated and 12% were trachedFindings:Recommendations:Head Nurse to share report with CCU end-users and to congratulate the CCU staff Nurses on their commitment to the VAP Bundle elements - Keep it up the hard workBaseline Data4%Jul/Aug 0656%Sep-0627%Oct-0614%Nov-0638%Dec-0671%Jan-07100%Feb-07100%Mar-07100%Apr-07100%May-07100%Jun-07100%Jul-07100%Aug-07100%Sep-07100%Oct-0796%Nov-07100%Dec-07100%Jan-08100%Feb-08100%CCUVAP Infection RateVAP Bundle Compliance%NHSN 50th percentile 2.3Oct-06014%2.3Nov-06038%2.3Dec-0613.171%2.3Jan-070100%2.3Feb-0716.1100%2.3Mar-0718.2100%2.3Apr-0717.9100%2.3May-0724.4100%2.3Jun-070100%2.3Jul-0715.9100%2.3Aug-070100%2.3Sep-070100%2.3Oct-07596%2.3Nov-070100%2.3Dec-078100%2.3Jan-080100%2.3Feb-080100%2.3

NHSN 50th percentile: 4.1&CPage &P of &N

Overall Bundle ComplianceAchievedCCU Bundle Compliance

CCU VAP Overall bundle compliance

VAP Infection RateVAP Bundle Compliance%CCU VAP Bundle Compliance Vs Infection Rate

CSICU VAP Bundle ComplianceFebruary ReportData Collection Period: 1 to 29 February 2008Data Collected by: CSICU Nurse (CNC)Number of Patients Assessed During Above Period: 5Report prepared by: Ghiwa Najjar, Quality Analyst, QRMDCSICU VAP Bundle ElementsBundle ElementAchievedCommentsHead of Bed 30 - 45100%Sedation Vacation100%Peptic Ulcer Disease Prophylaxis100%DVT Prophylaxis100%Oral Gastric Rather than Nasogastric Tube100%Findings:RecommendationsHead Nurse to share the report with all end-usersThe Overall Bundle Compliance Run ChartBaseline Data42%Jul-0688%Aug-06100%Sep-0658%Oct-0629%Nov-0680%Dec-06100%Jan-07100%Feb-07100%Mar-07100%Apr-0795%May-0792%Jun-0796%Jul-07100%Aug-07100%Sep-07100%Oct-07100%Nov-07100%Jan-08100%Feb-08100%CSICUVAP Infection RateVAP Bundle Compliance%Jul-06088%Aug-0612.3100%Sep-0611.858%Oct-06029%Nov-067.380%Dec-0610100%Jan-0722100%Feb-0726.3100%Mar-0718.2100%Apr-079.495%May-0729.492%Jun-071096%Jul-079.2100%Aug-070100%Sep-0716.5100%Oct-078.6100%Nov-070100%Dec-0716.9Jan-0821.3100%Feb-0819.4100%No VAP compliance data provided by CSICU for the unplotted data

NHSN 50th percentile: 2.3Page &P of &N

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Bundle ComplianceAchievedCSICU Bundle Compliance

0.420.8810.580.290.811110.950.920.961111111

The Overall Bundle Compliance Run ChartCSICU VAP Overall Bundle Compliance

00.8812.3111.80.5800.297.30.810122126.3118.219.40.9529.40.92100.969.210116.518.610116.93942321.3119.41

VAP Infection RateVAP Bundle Compliance%CSICU VAP Bundle Compliance Vs Infection Rate

100K Lives CampaignVentilator Bundle ChecklistUnit: ________________Month:___________________________________DateMRN #HOB 30Trach PtSedation VacationPUD ProphylaxisDVT ProphylaxisOralgastric rather than NasogastricNewly Suspected VAPCommentY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY NY N CIY NY N CI NAY N CIY N CIO NAS CI NAY N*Adapted from a tool created by Dominical Hospital ( Santa Cruz, CA)Code Keys: y = Yes N = No CI = Contraindicated O = Oralgastric NAS = Nasogastric NA = Not Applicable (Circle appropriate code key)

NHSN 50th percentile: 4

Jog your MemoryThe Ventilator Associated Pneumonia (VAP) Bundle Elements Elevation of the head of the bed to between 30and 45 degrees Daily "sedation vacation" and daily assessment of readiness to extubate Peptic Ulcer Disease (PUD) Prophylaxis Deep Venous Thrombosis (DVT) Prophylaxis (unless contraindicated) Oral Gastric Tube rather than Nasogastric

Ventilator Associated Pneumonia (VAP) Infection RateJanuary - December 2008Dec-07JanFebMarAprMayJunJulAugSepOctNovDecAdult CSICU16.921.319.4MICU-C3.1012.2SSCU-B06.715.1MICU D22.700E2 ICUCCU2000 SSCU (Surgical) E2 ICU is closed effective June 29 2006 for renovation2* VAP Bundle Implementation in MICU - C, CSICU and CCU effective July 1st 2006VAP Ventilator DaysJanuary - December 2008Dec-07JanFebMarAprMayJunJulAugSepOctNovDecAdult CSICU5994103MICU-C318286327SSCU-B127150198MICU-D883238E2 ICUCCU505641

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253872314387233872338723213875410387543875438754038782103878238782387820388135.8388134.938813193884322.93884300373887420.43887400016183890438904012.36.527.93893538935011.84.118.73896638966008.10389963899607.39.124.4390273902701012.34.4390573905713.12213.58.2039089026.311.54.203912016.118.29.913.803914818.29.4311.29.83917917.929.410.45.303920924.4104.94.6303924009.213.837.303927015.9014.124.7039301016.57.42911.83933208.62.94.812.8393620017.416.5039393016.93.1022.7394232021.306.7039454019.412.215.10394850

2*1*Adult CSICUMICU-CSSCU-BMICU DE2 ICUCCUVAP Rate per 1000 Ventilator Days at KFSHRC

MSICU Infection Rates /1000 days of ventilationInfection Rate at KFSH & RCNNIS 50th PercentileNNIS 75th PercentileNNIS 90th Percentile200384.97.812.1200410.14.67.29.920059.34.67.29.9Adult CSICU Infection Rates /1000 days of ventilationInfection Rate at KFSH & RCNNIS 50th PercentileNNIS 75th PercentileNNIS 90th Percentile2003155.111.815.12004206.312.615.5200522.36.312.615.5

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VAP Bundle Implementation in MSICU#REF!#REF!#REF!#REF!Infection Rate per 1000 Ventilator days2006- VAP Rate per 1000 ventilator days at KFSH & RC

Infection Rate at KFSH & RCNNIS 50th PercentileNNIS 75th PercentileNNIS 90th PercentileInfection Rate/1000 Ventilator daysMSICU VAP Infection Rate/1000 ventilator days at KFSH & RC

Infection Rate at KFSH & RCNNIS 50th PercentileNNIS 75th PercentileNNIS 90th PercentileInfection Rate/1000 Ventilator daysAdult CSICU VAP Infection Rate/1000 ventilator days at KFSH & RC

Ventilator Associated Pneumonia (VAP)Jan 2006 OnwardsJan-06Feb-06Mar-06Apr-06May-06Jun-06Jul-06Aug-06Sep-06Oct-06Nov-06Dec-06Jan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07Jan-08Feb-08Adult CSICU2521001937012.311.807.3102226.318.29.429.4109.2016.58.6016.921.319.4MICU-C166.54.18.19.112.313.511.59.9310.44.913.814.17.42.917.43.1012.2SSCU-B1410105.822.920.41827.918.7024.44.48.24.213.811.25.34.6337.324.7294.816.506.715.1MICU D0009.8000011.812.8022.700E2 ICU4.900CCU000000013.1016.118.217.924.4015.900002000