Infection Control Today - 05/2004: Clinical Update

Reducing the Risk of Ventilator-Associated Pneumonia

By Tina Brooks

Ventilator-associated pneumonia(VAP) remains a common complication of mechanically ventilated patients,contributing substantially to morbidity and mortality. The incidence of VAP varies greatly, ranging from 6 percent to54 percent of intubated patients depending on patient risk factors. Additional length of stay for patients who develop VAP isapproximately 13 days.¹ The estimated average cost per episode of nosocomial pneumonia is $3,000 to $6,000.²

Reducing the risk of VAP has proved to be controversial, withvarying levels of science-backed methodologies advocated by professionals as wellas industry representatives.

In some places, we have lots of science to prove whatshould be done now, but because of historical patterns its difficult forpeople to learn and accept new things, says Loretta Litz Fauerbach, MS, CIC,director of infection control at Shands Hospital at the University of Florida,and board member of the Association for Professionals in Infection Control andEpidemiology (APIC). On the other hand, there are some products and practicesthat are being suggested as prevention technology, and yet we are stillgathering truly conclusive data for them. The pendulum swings both ways withVAP.

As an example of how confusion still surrounds certainmethodologies, Fauerbach recalls her experience with a recent infection controland epidemiology course she taught at APIC. Asking attendees, What is theright time to do mouth care? she tried to solicit answers reflecting theappropriate number of times and the necessity of a kit. Among 58 people in theroom, not one had the same idea. There wasnt one study that she could pointto in order to provide the answer, and she says thats why controversy as wellas confusion persists.

Diagnosing VAP is no easy task. It is usually diagnosed on acombination of clinical, microbiological, and radiographic criteria.³ Although these criteria have a high sensitivity, specificityis low.⁴ If you get multiple doctors in a room to look at a chest X-ray andgive them a case presentation, there may be discrepancy as to whether it istruly pneumonia, colonization, or atelectasis, Fauerbach says. So the first controversy begins with do ordo they not have pneumonia. How often do you change routine parts of that ventilator? What kind of care do you give thepatient?

Early onset of VAP is commonly caused by antibiotic-sensitivecommunity-acquired organisms (e.g., Streptococcus pneumoniae, Haemophilusinfluenzae, and Staphylococcus aureus) as where late-onset VAP iscommonly caused by antibiotic-resistant nosocomial organisms (e.g., Pseudomonasaeruginosa, methicillinresistant Staphylococcus aureus, Acinetobacter species, and Enterobacter species).⁵

When asked what is working to reduce VAP, Fauerbach cites astudy by Drakulovic in the Lancet in 1999: Having the patient in asemi-recumbent 30 degree angle or higher has been shown very nicely to decreasethe risk rate of infection. Basically, he studied semi-recumbent and supine patients.Ventilator associated pneumonia was 50 percent in the patients that were supineand had enteral feeding. There is an odd ratio that was significantly differentbetween those two.

Fauerbach adds that clinicians can consider the use ofnon-invasive ventilation vs. mechanical ventilation, which has been shown toreduce the risk of VAP. It not only decreased the pneumonias and lengths ofstay, it decreased the mortality of patients. But there are patients that thiscan not be used on for other considerations, she says.

Fauerbach recommends using standard definitions, doing goodsurveillance to identify causative organisms, and then providing this feedbackto the clinical team that is caring for the patient.

One of the things that definitely doesnt work and thatadds costs without value is performing routine surveillance cultures wherepeople go in and swab patients every week on a Monday or go and swab theirequipment every week looking for trends and information that they think willhelp, she says. It is not proven to be effective and costs a lot.Culturing should be done based on clinical need and judgment, and not on aroutine basis.

Prevention of VAP relies on basic infection controlpractices.6 Hand hygiene, wearing gloves and using standard precautions reducethe transmission of organisms from patient to patient. It is the key in managingnosocomial pneumonia.

Fauerbach adds, I think we have a lot to learn aboutnosocomial pneumonia. Its going to require a disciplinary team to sortthrough these controversies that exist and come up with costeffective patientsafety solutions that can be implemented in healthcare. We have lots of thingsto study and learn.

Fauerbach looks forward to the release of new guidelines forthe prevention of nosocomial pneumonia from the CDC, which will lay out some ofthe controversial issues and where more study is needed. Everybody wants somereal direct answers on this, and the problem is theres none totallyidentified, she says.

Wining the War Against VAP
Success Stories and Recommendations

We have been part of the idealized ICU, which is a VHAproject. In 2001, we put in place a ventilator bundle. In April 2003, we beganusing the Sage mouth-care kit on the ventilator patients. After that, the rate in one particular unit decreaseddramatically. We had no nosocomial VAP for eight months after we started that.We then had two cases that were long-term patients compromised with cancer andunderlying conditions, which put them at risk.

Mary Ann Tate, RN, MSN, CCRN
CriticalCare Clinical Nurse Specialist
Lynchburg, Va.

In addition to the standards that are used, weveinstituted a therapist-implemented protocol for weaning patients fromrespirators. The analysis of the 2003 data shows us that we were able to wean 26of 30 patients in 16 days. These are people who were unable to be weaned from arespirator at the host institution.

Paul Venizelos, MD
Medical Director of the Grace Hospital Unit Lakewood Hospital
Lakewood, Ohio

Part of it is having a well-defined infection control program and also a quality management program, so youre focusing on the expected outcomes in a unit. Once you have an increase, you need to target that particular area to implement improvement processes. Second, is insuring staff education on various techniques on what prevention protocols should be followed to prohibit pneumonia from developing in high-risk patients. Also, have staff involved with the quality management or theperformance improvement processes, so they get rates on a monthly basis. Theyknow that the VAP rates are not increasing but, actually going down. Itreinforces what they are doing is the right thing.

Donna Armellino, RN, CIC
InfectionControl Coordinator North Shore University Hospital
Manhasset, N.Y.

Were involved with the IHI improvement project calledthe Transition of the ICU. We are involved with about 20 other hospitalsnationwide. What weve come up with is called bundles, which are basically agroup of treatment that together improve patient outcomes. The ventilator bundle can reduce mortality by 12 percent. Wehave an order sheet that is filled out and contains components which we expectto be done on the ventilated patients.

Cindy Kelbert, RN, CCRN, CNS
PresbyterianIntercommunity Hospital
Whittier, Calif.

There are several practices that clinicians can implementto reduce the incidence of VAP, such as: keeping the head of the bed slightly inclined; aspiratingsubglottic secretions with the Hi-lo Evac Tube; following proper hand washingprocedures; maintaining a closed ventilation circuit; using in-line suctioncatheters; and educating staff to risk factors associated with ventilatorassociated pneumonia.

Lorelee Goehle, RRT, BHS
ClinicalMarketing Specialist
Nellcor Tyco Healthcare

We make sure a patients head is at 30 degrees. Weve also been keeping our patients blood sugars between80 and 110. Weve been working at this for probably a year and a half. As weimproved the percentage of patients blood sugars, we had a steady decrease inour ventilator-associated pneumonias. Prior to this, we had 20 VAPs per 100 ventilator days andright now we are down to about 5 per 100 ventilator days.

Patti Gleason, RN
Staff NurseHartford Hospital
Hartford, Conn.

This isnt something that Ive done at this facilitybut, it is what Ive done at another facility. What we did was collaboratewith a unit educator. We got respiratory therapy and nursing involved. They dida Zap VAP campaign, a kind of social marketing scheme with big,neon-colored signs that went on every ventilator. They read Wash your hands.That was a big part of it, but what really turned the corner they got a 75percent decrease in their rates was they started doing mouth care with Sageproducts every couple of hours. With that, the hand washing, and everything,they really had success.

Lynette Tellefsen, RN, CIC
AssistantDirector of Infection Control
Florida Hospital Orlando, Fla.

Compiled by Tina Brooks