Implementasi

Bundles
Pencegahan HAP dan VAP

Ida Bagus Sila Wiweka

Pokja PPI Kemenkes
Kabid Medis RSPI-SS
Ketua Subpokja PINERE RSPI-SS

Curriculum vitae

Instansi
: RS Penyakit Infeksi Prof. DR.SulianG Saroso
Nama Lengkap : Dr.Ida Bagus Sila Wiweka, Sp.P
Jabatan
: Kepala Bidang Medis RSPI-SS, Ketua Pokja PINERE RSPI-SS,
Anggota Pokja PPI Kemenkes
Pendidikan Terakhir : Spesialisasi Paru dan Ilmu Kedokteran Respirasi, Universitas Indonesia, 2003
Alamat Rumah : Jalan Yanatera 14 no 16. JaG MelaG, Pondok MelaG, Bekasi. Kode Pos :
17415
No Hp

: +62 812 813 2978
Alamat e-mail : swiweka@yahoo.co.id atau belego@gmail.com
Alamat Instansi : Jalan Baru Sunter Permai Raya, Jakarta Utara. Kode Pos 14340
No Telp
: (021) 6506559, No Fax : (021) 6401411

Riwayat Pekerjaan

- Kepala Puskesmas Wolojita, Ende, Flores, NTT (1993-1996)

- Pendidikan Spesialisasi Pulmonologi dan Kedokteran Respirasi (1998-2003)
- Dokter Ahli Paru, Rumah Sakit Penyakit Infeksi. (2004- 2007)
- Kepala SMF Paru, Rumah Sakit Penyakit Infeksi (2007-2009)
- Kepala Bidang Medik, Rumah Sakit Penyakit Infeksi (2009-sekarang)

Pelatihan/Workshop/ Course

Inter

Country Training HIV/ AIDS Care Including Antiretroviral Treatment, WHO,

Bangkok (2005)
Pandemic Preparedness Training Program, Queensland University of Technology,
Brisbane(2006)
Rapid Respon for Avian and Pandemic Influenza Workshop, Mabes TNI- US NAVY,
Jakarta(2007)
Exercise Management Training Workshop, Asian Disaster Preparedness Center,
Bandar Seri Begawan, Brunei (2008)
Key Decisions for Using Community Mitigation Measures During Pandemic
Workshop, CDC, Jakarta (2010)
Pelatihan Modul Praktek Klinik KURFAK 2005, Bagi Staf RS Jejaring FKUI,
Fakultas Kedokteran Universitas Indonasia,Jakarta (2010)
USPACOM / COE Pandemic Influenza Workshop: Societal Disaster Planning,
Response and Recovery, USAID-Mabes TNI, Bogor (2011)
Pendidikan dan Pelatihan Kepemimpinan Tingkat III (Diklat PIM Tk III),
Kementerian Kesehatan Angkatan I Tahun 2011, LAN,Jakarta (2011)
Workshop The Specialist Healthcare Associated Infection Control and Prevention,
JICA-NCGM, Tokyo, 2011
Workshop Global Outbreak Alert and Response Networks (GOARN), WHO,
Brastagi, Medan, Indonesia, 2012

Denisi
Bundles

Bentuk langkah yg perlu dilakukan saat pelayanan

kesehatan guna membantu petugas kesehatan agar
<ndakan berhasil dan HAIs dapat dicegah

HAP

Pneumonia yang didapat di RS setelah perawatan 48 jam

dan semua infeksi yang inkubasinya terjadi sebelum masuk
RS disingkirkan

VAP

Pneumonia yang terjadi setelah se 48 jam atau lebih pada

pasien yang terpasang ven<lasi mekanik dan atau
tracheostomi

Epidemiologi
VAP adalah infeksi
nosokomial yang paling
sering pada pasien ven<lasi
mekanik
Insiden 25-75 % pada
pasien yang di ICU
Masalah yang sangat serius
Angka meningkat : 5-10
kasus per 1000 pasien
Biaya kesehatan <nggi
Angka kema<an HAP:
20-50% (USA)

Patogenesis
HAP
Aspirasi
Inhalasi
Hematogenik
Penyebaran langsung

VAP
Barier saluran napas hilang
Invasive mikroorganisme
purulen
Kolonisasi dari traktus
diges<f aspirasi
Proses biolm
Berbaring terlentang

Mikroorganisme Penyebab HAP/ VAP

Early onset
Hemophilus inuenza
Streptococcus pneumoniae
Staphylococus aureus yang
(sensi<ve methicillin)
Escherichia coli
Klebsiela pneumoniae

Late Onset
Pseudonomas aeruginosa
Acinetobacter
Staphylococus aureus
(MRSE/MRSA)

Pola Kuman Setempat Yang TERBAIK

Diagnosis Pneumonia
Gambaran inltrat baru atau progresif
ditambah 2 atau lebih gejala:
1.
2.
3.
4.

Batuk-batuk bertambah
Perubahan karakteris<k dahak / purulen
Suhu tubuh > 380C (aksila) / riwayat demam
Pemeriksaan sis : ditemukan tanda-tanda
konsolidasi, suara napas bronkial dan ronki
5. Leukosit > 10.000 atau < 4500

Prognosis akan lebih buruk bila di jumpai

salah satu kriteria:
Usia > 60 tahun
Koma
Rawat intensif
Syok
Memakai VM lama
CXR : abnormal Bilateral
Krea<nin serum > 1,5
mg/dl
Penyakit dasar berat

Pengobatan awal <dak

tepat
Bakteri Resisten
(Pseudomonas sp. MRSA)

Onset kuman lanjut dan

sangat virulen
Gagal mul< organ
Penggunaan penyekat
H2

Diagnosis

danleukositosisdisertaigambaraninfiltratbaruataumapun

perburukan

di

fototoraksdanpenemuanbakteripenyebabinfeksiparu
Spesifisitas

diagnosis

dapatditingkatkandenganmenghitungclinical

pulmonary

infection score (CPIS) yang mengkombinasikan data klinis, laboratorium,

perbandingantekananoksigendenganfraksioksigen (PaO2/FiO2) danfototoraks.
Clinical pulmonary infection score (CPIS
Komponen

Nilai

Skor

Suhu (C)

36,5 dan 38,4

38,5 dan 38,9

39,0 dan 36,0

4000 dan 11000

<4000 dan>11000

Leukosit per mm3

Sekrettrakea

Sedikit

Oksigenasi PaO2/FiO2 (mmHg)

Fototoraks

PenilaianCPIS

Bila Skor CPIS > 6

Klinis dan biakan kuman
(+) setelah 48 jam VM

0
Sedang

Banyak

Purulen

+1

> 240 atauterdapat ARDS

240 dantidakada ARDS

Tidakadainfiltrat

Bercakatauinfiltratdifus

Infiltratterlokalisir

awaldilakukandalam

CPIS (Clinical Pulmonary

Infec<on Score)
VAP POSITIF

48

pasienterintubasidanmenggunakanventilasimekanik

jam

Bukan VAP
Gejala Awal Pneumonia
CPIS < 6

sejakpertama

kali

di

ICU

danpemeriksaanmikrobiologidilakukanjikaterdapatgejalaklinis.SelanjutnyapenilaianC

Pencegahan
1. Kebersihan tangan (5 Moments)
2. Posisi <dur kepala 30-45 derajat
3. Kebersihan Mulut

1. (clorhexidine0,02%) @ 2 s/d 4 jam

2. Gosok gigi @ 12 jam

4. Manajemen sekresi oroparingeal

5. Pengkajian se<ap hari sedasi dan ekstubasi
1. Obat sedasi dan dosisnya
2. Respon pasien dengan obat sedasi

6. Pencegahan penyakit ulcus pep<cus

7. Pencegahan trombosis vena dalam
8. Pendidikan dan pela<han petugas

Bundles VAP (1)

Posisi Kepala (2)

Elevasi kepala > 30
derajat
Mengurangi Work of
Breath
Memudahkan
ekspektorasi dahak
Oksigenasi meningkat

Number of I

patients at the time of admission. Representatives from Sage

Products, Inc (Cary, IL), the Service Leader, and the unit
Performance Improvement representative collaborated to train
the staff on how to implement the protocol. The protocol was
reinforced and outcomes were reviewed quarterly, and a Cerner
documentation screen was created.

sav
pre
be

1.5
1.0

Oral Hygiene Protokol (3)

0.5
0

Jan Feb

Mar Apr May Jun

Oral-care protocol:

Bersihkan rongga mulut

se<ap2- 4 jam dgn
Clorhexidine 0,02%
Bersihkan gigi se<ap 12
jam dengan sodium
bicabornat
Additional pneumonia prevention strategies:
Berikan pelembab
mulut pada bibir dan
mukosa mulut se<ap 4
jam
Brush teeth every 12 hours with the sodium bicarbonate
impregnated suction toothbrush from the oral-care kit
which contains Anti-Plaque Solution to help dissolve mucous
and biofilm.

Perform incentive spirometry in patients together with coughing

and deep breathing.
Encourage and assist patients to early mobility when possible
(e.g., sit in a chair for meals; walk 100 feet 3 times daily).

Oct

Nov

Dec

Jan Feb

Mar Apr May Jun

Jul

Aug

Sep

Oct Nov Dec

2007

Rates of Hospital-Acquired Pneumonia

per 1000 Patient Days Before and After
Implementation of the Oral-Care Protocol
2.0
1.8

Number of Infections

Elevate the bed to at least 30 to 40 or as much as possible.

Aug Sep

The HAP rate per 1000 patient days decreased from 1.83 in
2004 to 1.0 in 2007 a 45% reduction.

Cleanse oral cavity every 4 hours with

foam suction swab and the prepackaged
cleanser which contains an anti-septic oral
rinse (cetylpyridinium chloride 0.05%) to
reduce bacterial load in the oral cavity.

Apply a mouth moisturizer to the lips and

oral mucosa every 2 to 4 hours.

Jul

2006

$
p
p

Re
1.83

45%
reduction

1.6

1.

1.4
1.2

1.15

1.0

1.1

0.8

2.

1
3.

0.6
0.4

4.

0.2
0

2004

2005

2006

2007

Managemen Sekresi Oroparingeal (4)

Suc<oning bila di
butuhkan
Petugas saat suc<oning
memakai APD
Gunakan yang sekali
pakai atau close sirkuit
Tidak membuka selang /
tubing ven<lator
Kelembaban humidire
ven<lator
Tubing ven<lator digan<
bila kotor

Pencegahan Ulkus PepGcum (6)

Kerusakan pada lapisan
mukosa, submukosa
sampai lapisan otot
saluran cerna yang
disebabkan oleh
ak<vitas pepsin dan
asam lambung yang
berlebihan
Untuk pasien dgn risiko
<nggi

Suctioning
Tidak dilakukan secara rutin hanya atas
indikasi untuk mencegah atelektasis
Dilakukan bila sangat diperlukan
adanya suara napas tidak normal
Tidak ada lagi perintah suctioning rutin
Banyak komplikasi
Dilakukan dengan teknik open or closed
suction

Prosedur suctioning
Preoxygenation:
Ventilasi pasien secara manual sebelum
melakukan suctioning dengan menggunakan bag
valve mask (10-15 l/m of O2) atau
Berikan O2 100% pada 6 x napas dengan
ventilator
Tujuannya mencegah hipoksemia

Evaluasi pengkajian sedasi dan intubasi (5)

Pengkajian obat sedasi dan dosis nya
Pengkajian ruGn respon pasien pada obat sedasi
Bangunkan pasien seGap hari dan menilai
responnya
Melihat apakah sudah dapat dilakukan
penyapihan
Modus pemberian venGlasi.

Pencegahan trombosis vena dalam (7)

Pembentukan bekuan darah
pada lumen vena dalam
yang
diiku< oleh reaksi inamasi
dinding pembuluh darah
dan jaringan perivena.
Banyak pada pasien kri<s
(10-33% kasus
900000 kasus / tahun
seper<ganya meninggal

 Faktor Resiko
Imobilisasi lama
Riwayat gangguan
pengumpalan darah
Bed rest, Cedera/
pembedahan
Kehamilan , Kanker
Inamatory bowel syndrome
Gg jantung
Pil KB hormon
Pace maker, Merokok, usia
Tua

Pencegahan:
Ambulasi dini,
Graduated compression
stockings ( extremitas
bawah)
Pneuma<c compression
devices ( sampai lutut
dan paha
An< koagulan

Pendidikan dan Pela<han Petugas (8)

20th Na onal Forum on Quality Improvement in Health Care: December 8-11, 2008
20th Na onal Forum on Quality Improvement in Health Care: December 8-11, 2008

Thomas C. Button, RN, CNA, BC, CIC, Director of Infection Prevention & Control; Tammy Southard, RRT, Director Cardio/Pulmonary;
Scott Donaldson, M.D., FCCP, Medical Director Critical Care
Medical Center of McKinney, McKinney, TX, USA

The objective was to ensure compliance with all ventilator bundle

processes, including routine q2 hour oral care, in order to reduce
the rate of ventilator-acquired pneumonia (VAP) at the Medical
Center of McKinney to 0.

In 2003, the VAP rate spiked to 16.20 at the Medical Center of

McKinney. The implementation of processes to ensure compliance
with a comprehensive q2 hour oral care protocol decreased the VAP
rate to 0 from the rst quarter of 2004 to 2005 (21 consecutive months).
A subsequent Division O ce recommended change to q4 hour oral
care packaging with q2 hour supplementation was made; however, a
concomitant increase was noted in VAP rates. A thorough review of the
process and records indicated that a q4 hour oral care product was being
purchased instead of a q2 hour oral care product. Additional review of
the processes indicated that, in an e ort to avoid wasting the oral care
product, the sta had been using products le over from a previous
patient on subsequent patients. The aim of this quality-improvement
project was to ensure sta compliance with good infection-control
practices in the ventilated patient population, including the q2 hour
oral care protocol, and to ensure the adequate purchase of appropriate
products to meet this goal.

10-20% of patients receiving mechanical ventilatory support for

48 hours develop VAPthe most serious nosocomial infection.1,2
VAP results in longer hospital stays and in an increase in hospital
costs of approximately $40,000 per case.3
A ventilator bundle is a series of interventions identi ed
by the Institute for Healthcare Improvement (IHI) to reduce the
incidence of VAP, including elevation of the head of the bed to
30, daily breaks in sedation, daily assessment of the readiness
to extubate, peptic ulcer disease prophylaxis, and deep venous
thrombosis prophylaxis.4,5
Proper education of the healthcare sta and daily monitoring of
compliance with the ventilator bundle are crucial to the success of
this intervention program.6-8
The addition of routine oral care q2 hours to the ventilator bundle,
with the use of a prepackaged oral care kit, has been shown to
further reduce VAP rates.9,10
The Medical Center of McKinney in McKinney, Texas, USA
implemented a comprehensive oral care protocol in ventilated
patients in an e ort to eliminate VAP, and noted variability in VAP
rates which spiked during periods of time when q4 hour oral care
packaging was utilized vs q2 hour oral care packaging.

1.

Rello J, Ollendorf DA, Oster G, et a

Epidemiology and outcomes of ven
database. Chest. 2002;122(6):2115

2.

Ibrahim EH, Tracy L, Hill C, et al. Th

a community hospital: risk factors a

3.

Safdar N, Dezfulian C, Collard HR,

of ventilator-associated pneumonia
2005;33(10):2184-2193.

4.

Burger CD, Resar RK. Ventilator b

associated pneumonia. Mayo Clin P

5.

Tablan OC, Anderson LJ, Besser R

associated pneumonia, 2003: recom
Control Practices Advisory Commit

6.

Institute for Healthcare Improvemen

Programs/Campaign/Campaign.htm

7.

DuBose JJ, Inaba K, Shiett A, et a

in the trauma intensive care unit: th
Trauma. 2008;64(1):22-27; discuss

8.

Tolentino-DelosReyes AF, Ruppert

the ventilator bundle to prevent ven
2007;16(1):20-27.

9.

Chlebicki MP, Safdar N. Topical chl

pneumonia: a meta-analysis. Crit C

10. Fields LB. Oral care intervention to

pneumonia in the neurologic intens

Penerapan Bundles
2000 hari pemekaian ven<lator di ICU 2007-2008
Lokasi ;
Intensive care unit (ICU)
Cri<cal care unit (CCU)
Cardio vascular recovery (CVR)

Kebersihan rongga mulut dapat menghemat

$320.000 (1$= 15000)
Menurunkan 61,5% biaya pelayanan VAP

Penerapan bundles VAP

Hasil Penerapan Bundles

Kesimpulan
VAP masalah di ICU
Menerapkan Bundles mencegah HAIs
Meningkatkan mutu layanan

Terimakasih