Ventilator-associated pneumonia (VAP) accounts for as much as 15 percent of all hospital-acquired infections (HAIs) and approximately 27 percent of all infections acquired in the intensive care unit (ICU). The primary risk factor for the development of hospital-associated bacterial pneumonia is mechanical ventilation. Ibrahim, et al. (2001) note that hospital mortality of ventilated patients who develop VAP is 46 percent compared to 32 percent for ventilated patients who do not develop VAP. According to the Institute for Healthcare Improvement (IHI), VAP prolongs ICU and hospital stay, adding an estimated cost of $40,000 to admission. In addition, VAP is the leading cause of death amongst hospital-acquired infections and a recent addition to the Centers for Medicare and Medicaid Services (CMS)’s list of “never events.”

As Greene, et al. (2009) point out, “Recent quality improvement initiatives suggest that many cases of VAP might be prevented by careful attention to the process of care. The successful management of patients on ventilation is necessary to ensure the best possible outcomes for individual patients while reducing the morbidity and mortality associated with these infections.”

The IHI is a proponent of the bundle concept to help fight VAP; the ventilator bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually. The key components of the ventilator bundle are: Elevation of the head of the bed; daily “sedation vacations” and assessment of readiness to extubate; peptic ulcer disease prophylaxis; and deep venous thrombosis prophylaxis. Oral care has also been recommended as a preventive strategy. The Centers for Disease Control and Prevention (CDC, 2004) guidelines for preventing VAP include the following interventions: airway management, gastric reflux prevention, oral care, and the prevention of cross-contamination through the use of gloves and meticulous hand hygiene.

A fan of the ventilator bundle approach is Christopher Kowal, MSN-MOL, RN, CCRN-CMC, of St. Joseph’s Hospital Health Center’s surgical intensive care unit in Syracuse, N.Y. “The bundle approach is so efficacious because it comprises the most importance levels of prevention-evidence into a consistent interdisciplinary practice and plan of care,” Kowal explains. “It makes it easier to facilitate care and provide for best-practice outcomes for both patients and their families. It also causes combined-care outcomes. For example, you’ve hit the ‘trifecta’ when you do oral care. The caregiver has the patient sitting up at least 30 degrees or more, because you don’t want the patient to choke, they receive mouth care, and then the caregiver must wash their hands before leaving the room. What a bargain – three for one! Packaging a product kit, such as oral care, provides easier delivery of a key component of the bundle. All supplies are contained, and staff members are able to provide standardized, consistent and reproducible care to all their applicable patients without having to leave the bedside to obtain necessary equipment. Therefore, time is saved to be able to spend with patients.”

When St. Joseph’s Hospital Health Center saw its VAP rates as high as 13.5, targeting the ventilated critical care population by implementing a comprehensive oral care program became their critical mission. Unit stakeholders met in July 2008 to discuss the oral care program in its 21-bed ICU where VAP rates were 4.4, 13.5, and 9.2, respectively for the three months preceding. Targeting a zero VAP rate, the hospital implemented a stepped up re-education program and adopted a new comprehensive oral care program with IHI’S ventilator bundle and Sage Products’ Q- Care oral cleansing system. By educating staff on the risk factors of VAP, applying new products and nearly 100 percent staff compliance, the hospital’s VAP rates dropped to zero within two months. The facility has maintained a zero VAP rate over the last nine months. With ICU staff and the purchasing department working closely together, the hospital was also able to realize reimbursement cost avoidance from January 2008 to September 2008 of approximately $400,000.

“The one true challenge was global buy-in to the need to change practice,” Kowal says. “This was addressed through mandatory education followed by implementation of consistent, standardized, and reproducible methods of care from the shared efforts of our interdisciplinary team (nursing, respiratory therapy, critical care medicine, pharmacy, and infection prevention). Culture change was an inherent part of the process. It was also a separate change occurring globally throughout our institution. The premise was that the patient and their family is under everyone’s care—not just nursing or medicine. Therefore, implementation of interdisciplinary methods of care and the building of relationships in a caring way were the foundations of this change. In this case, everyone became responsible for carrying out the VAP bundle. For example, it even became habit for non-bedside caregivers to bring to someone’s attention (not just nursing’s) when they noticed a vented patient’s head of bed (HOB) was too low as they would pass by rooms. That’s teamwork!”

To ensure 100 percent education, staff members were informed of new initiative online and attended a mandatory presentation that included education pieces provided by the Centers for Disease Control and Prevention (CDC) and IHI. The presentation included a brief history of VAP and its financial and clinical impact, as well as an explanation of all the pieces in the ventilator bundle.

“Simply showing the evidence to the staff was enough to convince them to buy-in to the concept of prevention,” Kowal explains. “When one sees statistics of what happens with ventilator pneumonia rates as a result of simple changes that can be made by anyone at the bedside, it is a 'no-brainer.' Ownership of best practice was at the point-of-care, and in the case of VAP prevention, nursing became the primary leader because they were at the bedside the most. However, everyone owned the practice changes. These are fundamental practices if you think about them: 'Sit me up so I won’t choke. Brush my teeth to kill all the germs.' How many of us (healthy people) would go to bed at night or out in public in the morning, without brushing our teeth? Is it more or less important to perform healthy practices when we are not well? That, too, was enough convincing for staff to want to change.”

Kowal emphasizes, “VAP prevention needs to be a relationship-based, interdisciplinary team effort. Everyone must buy-in to the concept, receive education and ‘walk-the-talk.’ Coordinating care-efforts between the two frontline providers, respiratory therapy and nursing, made a large difference in care outcomes that were in favor of the patient. These efforts also led to other positive changes that resulted from multidisciplinary collaboration, such as earlier extubation of ventilated patients. These are the best times to be in nursing and healthcare in general. The heart of nursing is the patient and their family. We, as collaborative healthcare providers, need to be ever-conscious of that. Evidence-based practice drives process improvement facilitating patient- and family-centered best practice outcomes; thus providing quality healthcare from the collaborative efforts of a multidisciplinary team."

Mike Hewitt, RRT-NPS, FAARC, FCCM, director of respiratory, pulmonary, sleep and neurology at Peninsula Regional Medical Center in Salisbury, Md., says that when he was serving as director of respiratory care and pulmonary diagnostics at a large trauma center in the Southwest, he became concerned about the rising number of VAP cases and bounce-backs to his facility’s intensive care units. “In April 2006, we took our current VAP prevention bundle program and augmented it to take a more proactive stance. This augmentation involved us treating vented patients as if they were all at-risk for acquiring VAP. By increasing sigh breathing and vibratory therapy, our ultimate goal was to wean and keep patients off their ventilators as quickly as possible. The results on patient outcomes were significant. Bounce back rates to the ICU were decreased from 3 percent to 4 percent to almost zero; length of stay, cost of care and overall mortality rates were all decreased. During the 18-month period after enacting the new proactive bundling program, we saw VAP rates reduce by 48 percent.”

Hewitt says the facility incorporated several products into its bundle program that helped assist caregivers in easier diagnosis of VAP and treatment of ventilated patients to help wean off the ventilator as quickly as possible and help keep them off ventilators. “For example, to decrease the opportunity for infection, cross-contamination and alveolar derecruitment, we stressed the importance of using closed suction catheter systems when clearing a patient’s airway,” Hewitt recalls. “For this, we used the Kimberly-Clark/Ballard Trach Care Closed Suction System, which allowed us to get the secretions out of the airway without disconnecting the ventilator. Doing otherwise disrupts the circuit, giving the opportunity for infection to increase and alveolar derecruitment to occur. In addition, early and consistent diagnosis of VAP for nonbronchoscopic bronchoalveolar lavage is an underutilized, but major tool in the fight against VAP. We used the Kimberly-Clark/Ballard BAL-CATH System, which the catheter extends deeper into the lungs for a sample that can help determine if any specific organism is present, helping us to prescribe a more accurate antibiotic coverage. What is great about this procedure is that our trained respiratory therapists were able to perform the test themselves. Otherwise, they would have to wait for a doctor to come and perform a bronchoscope, which is more expensive, but offers no more beneficial information. We also incorporated the use of Kimberly-Clark’s MicroCuff Endotracheal Tube to help decrease the potential for microaspiration, which is a known cause of VAP.” Hewitt adds, “It is a known fact that the longer a patient is ventilated, the chances of developing VAP increase dramatically. So, in order to help get the patient off the ventilator as quickly as possible, we incorporated the use of vibratory therapy to mobilize secretions. During post-extubation we continued with vibratory therapy and added positive pressure to assist in expanding the airways.”

Like Kowal, Hewitt is a big believer in the ventilator bundle concept. “We know patients depend upon a collaborative sense of consistency and accountability shared among each caregiver responsible for providing patient care, and only through integrating standard VAP preventive best practices within their daily routines, would VAP rates begin to decrease,” Hewitt says. “By incorporating the recommendations made by organizations such as APIC, CDC, AACN as well as product bundling, we were able to effectively reduce our VAP rates. Our augmented VAP prevention bundle program involved each caregiver be held responsible for tracking and monitoring of such activities as frequency of handwashing, conducting early VAP diagnosis, providing consistent comprehensive oral care and other VAP preventative measures to ensure protocol standards were being adhered to and met. However, it can be difficult to overcome the challenge of transforming an organizational culture identified by individualized and sometimes conflicting routines, which can be deeply rooted in traditional practices and personal habits. By having the support of our top management personnel and through our team leading by example, we saw a cultural transformation within the organization begin to occur as old habits and behaviors began to be replaced by VAP prevention best practices.”

Mark Rose, a respiratory therapist and respiratory manager at Texas Health and Presbyterian Hospital in Dallas, says that his facility, which has 800-plus beds, use a variety of VAP strategies, including utilizeing HOB elevation, supraglottic/subglottic suctioning via tonsil tip at least Q4 and pre/post turns/travel, GI prophylaxis, sedation vacations, and the Kimberly-Clark MicroCuff Endotrocheal Tube. Rose reports that the facility has only had one clinically diagnosed VAP in the past six months. “We were already well below the national average, and expect a continued decrease as we make our staff better aware of the benefits befalling a robust VAP reduction strategy.”

Rose maintains a different perspective on the bundling concept in relation to VAP prevention, due to what he calls the “disparate nature of VAP epidemiology.” As Rose observes, “I’m not sure that reducing one’s VAP rate can be isolated to a ‘vent bundle.’ Perhaps, the reduction in VAP is simply a reflection of the diligence paid to oral care, prudent suctioning, patient positioning, and GI protection. That said, vent bundles offer a standard of care that is clearly making headway in facilities that were struggling with their VAP rates. For us, the vent bundle makes it easy for physicians to deploy best practices. Clinicians put into practice those things that make sense and are relatively simple. Most of us, myself included, are not highly influenced by statements like ‘the data shows...’ or ‘our evidence is...’ We simply want to do what’s best for our patients and provide them the best opportunity to survive their clinical course with a great outcome. The vent bundle is a good way to ensure that all staff members are on the same page with regard to VAP reduction strategies.”

Rose says that achieving “buy-in” among clinical staff can be challenging. “When your VAP rates are already low, it becomes a relatively hard sell to the seasoned clinician/nurse, especially when they feel like the ‘new methods’ add unnecessary time/demands to an already busy shift,” Rose says. “VAP prevention strategies require constant education of the staff. We are only as strong as our weakest link. All the best practice in the world won’t negate the ‘cowboy clinician’ who refuses to follow the rules.”

For references and a checklist, see next page.

References:

Bouza E, Jesus Perz M, Munoz P, Rincon C, Barrio JM, Hortal J. Continuous aspiration of subglottic secretions (CASS) in the prevention of ventilator associated pneumonia in the postoperative period of major heart surgery. Chest. 134(5). November 2008.

Centers for Disease Control and Prevention (CDC). Guidelines for preventing healthcare-associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2004.

Greene L, et al. Guide to the elimination of ventilator-associated pneumonia. Publication of the Association for Professionals in Infection Control and Epidemiology. 2009.

Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator-associated pneumonia in a community hospital: Risk factors and clinical outcomes. Chest. 120(2):555-561. August 2001.

Checklist for Implementing VAP Prevention Best Practices

Mike Hewitt, RRT-NPS, FAARC, FCCM, director of respiratory, pulmonary, sleep and neurology at Peninsula Regional Medical Center in Salisbury, Md. Offers the following checklist:

1. All ICU patients shall be assessed upon admission, PRN and before discharge out of the ICU by the ICU therapists. Included in their assessment will be a current chest X-ray, cough ability and quality, oxygenation, secretions and patient mobility. A transfer report must be called to the receiving therapist on all patients leaving the ICU by the ICU therapist.

2. Patients who have atelectasis and/or consolidation shall be placed “bad” lung up to facilitate expansion and mobilization of secretions in the affected lung during delivery of their respiratory treatments.

3. Patients with a bilateral process shall be positioned appropriately positions as determined by the respiratory therapist  during their therapy.

4. Perform deep breathing and coughing therapy.

5. Evaluate trach suctioning every four hours and as needed.

6. Reassess patients every 72 hours to determine appropriateness of current therapies.

7. At these 72-hour intervals, the therapy must be discontinued, modified, or reordered as is. The therapy may be modified be-fore the 72-hour mandatory assessment period when indicated for changes in status. Appropriate documentation is required and will support whichever course of action is taken.

8. Assessments shall be performed between the mandatory 72 hour assessments as appropriate for monitoring the patient’s status.

9. Changes to therapy must be communicated to the primary team and the notification documented, including the name of the party notified.

Patient Entry Criteria to ICU:

-- Post operative laparotomy or thoracotomy

-- Two or more rib fractures

-- Prolonged bed rest (anticipated more than three days)

-- Chest tube in place

-- Pre-existing airway disease

-- Older than 65 years)

-- Any patient with IS ≤ 15 cc/kg/IBW

Patients shall remain on q4 therapy for as long as they meet any aspect of the entry criteria listed above. For patients that are 65 years of age or older, at least one additional component of the entry criteria must be met to continue q4 therapy.

Exiting Criteria from ICU:

--  More than five  days post-operative laparotomy or thoracotomy with none of the entry criteria present

--  Patient freely mobile

--  IS ≥ 15 cc/kg/IBW x 24 hours

--  No active respiratory process

--  No other evident factors placing the patient at risk for pulmonary complications

--  More than 72 hours post ICU discharge and absence of active or evident pulmonary complication

Once a patient meets the exit criteria, their treatments shall be changed to PRN and they shall receive a pulmonary assessment q12 until discharge. This assessment shall be documented.