Feature

Using Evidence-Based
Practice to Prevent Ventilator-
Associated Pneumonia
Mary Beth Sedwick, RN, BSN, MS, CCRN
Mary Lance-Smith, RN, MSN, CCRN
Sara J. Reeder, RN, PhD
Jessica Nardi, RN, BSN, CCRN

BACKGROUND Strategies are needed to help prevent ventilator-associated pneumonia. increases in death rates, length of
OBJECTIVE To develop a ventilator bundle and care practices for nurses in critical stay, and health care costs.3 The death
care units to reduce the rate of ventilator-associated pneumonia. rate for VAP exceeds the rate of
METHOD The ventilator bundle developed by the Institute for Healthcare Improve- death due to infections associated
ment was expanded to include protocols for mouth care and hand washing, head- with central vascular catheters,
of-bed alarms, subglottic suctioning, and use of an electronic compliance feedback severe sepsis, and respiratory tract
tool. Compliance audits were used to provide immediate electronic feedback.
infections in nonintubated patients.4,5
RESULTS Adherence to practices included in the bundle increased. Compliance
Among patients treated with mechan-
rates were greater than 98% for prophylaxis for peptic ulcer disease and deep-vein
thrombosis, interruption of sedation, and elevation of the head of the bed. The com-
ical ventilation, mortality rates are
pliance rate for the oral care protocol increased from 76% to 96.8%. Readiness for 46% in patients with VAP and 32%
extubation reached at least 92.4%. Rates of ventilator-associated pneumonia decreased in those without VAP.6 The cost of
from 9.47 to 1.9 cases per 1000 ventilator days. The decrease in rates produced an care for a patient with VAP is approx-
estimated savings of approximately $1.5 million. imately $40000 to $57000 higher
CONCLUSION Strict adherence to bundled practices for preventing ventilator- per occurrence than the cost of care
associated pneumonia, enhanced accountability for initiating protocols, use of a of a patient treated with mechanical
feedback system, and interdisciplinary collaboration improved patients’ outcomes ventilation in whom VAP does not
and produced marked savings in costs. (Critical Care Nurse. 2012;32[4]:41-51) develop.6 Additionally, patients in
whom VAP develops stay in the ICU
4 to 19 days longer than do patients
CNEContinuing Nursing Education

H
ealth care–associated who were intubated and did not
This article has been designated for CNE credit. infections (HAIs) are acquire VAP.5
A closed-book, multiple-choice examination the most common The Centers for Medicare and
follows this article, which tests your knowledge
of the following objectives: complications in hos- Medicaid Services7 recently listed VAP
1. List the components of the 2010 Institute pitalized patients.1 as one of the “reasonably preventa-
for Healthcare Improvement ventilator Ventilator-associated pneumonia ble diseases” leading to increased
bundles
2. Discuss the financial implications of patients (VAP) is the second most common morbidity, mortality, and health
developing ventilator-associated pneumonia
3. Identify strategies to help implement venti-
HAI in the United States and is care costs. Because the centers view
lator bundles successfully in a hospital responsible for 25% of the infections VAP and other HAIs as preventable,
©2012 American Association of Critical-Care Nurses
that occur in intensive care units soon hospitals may not be reim-
doi: http://dx.doi.org/10.4037/ccn2012964 (ICUs).2 VAP is associated with bursed for care provided to patients

www.ccnonline.org CriticalCareNurse Vol 32, No. 4, AUGUST 2012 41

in whom VAP and other HAIs, such a combination of radiological, clini- against infection by negating effec-
as infections caused by methicillin- cal, and laboratory criteria. VAP is tive cough reflexes and mucocilliary
resistant Staphylococcus aureus or suspected when a patient receiving clearance of secretions.12 Impairment
associated with vascular catheters, mechanical ventilation has evidence of the cough reflex, accumulation of
develop.8 If reimbursement for VAP of a new or progressive pulmonary contaminated secretions within the
is discontinued, hospitals will expe- infiltrate along with fever, leukocy- oropharynx, and placement of an
rience a profound economic deficit. tosis, and purulent tracheobronchial endotracheal tube substantially
Patients at risk for VAP present secretions. Pneumonia is considered increase the risk for VAP in criti-
a unique challenge to critical care ventilator associated if the patient cally ill patients.
nurses. To prevent VAP, nurses must was intubated and receiving
develop strategies to incorporate mechanical ventilation at the time Review of the Literature
evidence-based practices into the of or within 48 hours before the In 2005, the IHI disseminated
daily care provided to patients receiv- onset of infection. its first report on the 100000 Lives
ing mechanical ventilation. In this According to an expert panel Campaign, a project that involved
article, we describe an innovative from the American Thoracic Society,11 the use of ventilator bundles to pre-
project in which ventilator bundles placement of an endotracheal tube vent VAP. In May 2010, the institute
(a structured way of improving the can potentially increase the risk of reported the results of an updated
process of care or patients’ outcomes; VAP 6- to 20-fold in patients treated project, the 5 Million Lives Cam-
straightforward evidence-based prac- with mechanical ventilation. For VAP paign. Included in both campaigns
tices that when performed collec- to develop, microorganisms must were recommendations for best
tively and reliably improve patients’ gain access to the normally sterile practices or bundles that could be
outcomes9) developed by the Insti- lower part of the respiratory tract. used to reduce VAP rates.13 Compo-
tute for Healthcare Improvement Critically ill patients are at risk for nents of the 2010 bundle included
(IHI) and care practices developed microorganisms getting into the elevation of the head of the bed
by nurses in our critical care units lower part of the tract because these (HOB) 30º to 45º, prophylaxis for
were used to reduce VAP rates and patients have a depressed level of peptic ulcer disease (PUD), prophy-
enhance the quality of care and well- consciousness and an impaired gag laxis for deep-vein thrombosis (DVT),
being of patients receiving mechani- reflex, which may lead to pooling of daily interruption of sedation, daily
cal ventilation. approximately 100 to 150 mL of assessment of readiness for extuba-
contaminated secretions within the tion, and daily oral care with
Etiology of VAP oropharynx within a 24-hour period. chlorhexidine. Several investiga-
The Centers for Disease Control Placement of an endotracheal tube tors9,14,15 examined the efficacy of
and Prevention10 define VAP by using impedes the body’s natural defense the IHI bundled practices and
found that bundled practices were
effective in reducing the rate of VAP.
Authors
Mary Beth Sedwick is a clinical nurse educator in the intensive care and cardiothoracic HOB Elevation
intensive care units at Lankenau Medical Center, Main Line Health System, Wynnewood, Metheny et al16 examined the
Pennsylvania.
effects of HOB elevation in the pre-
Mary Lance-Smith is a patient care manager in the intensive care unit at Lankenau
Medical Center, Main Line Health System. vention of VAP in a prospective study
Sara J. Reeder is an associate professor at Villanova University, Villanova, Pennsylvania, of 360 trauma patients. In that study,
and a nursing research consultant for Main Line Health System. the incidence of pneumonia, deter-
Jessica Nardi is a staff nurse in the intensive care unit at Lankenau Medical Center, mined by using the Clinical Pul-
Main Line Health System. monary Infection Score (calculated
Corresponding author: Mary Beth Sedwick, RN, BSN, MS, CCRN, Lankenau Hospital, 100 Lancaster Ave, Wynnewood, by using body temperature, white
PA 19096 (e-mail: sedwickm@mlhs.org)
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
blood cell count, assessment of tra-
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. cheal secretions, oxygenation, ratio

42 CriticalCareNurse Vol 32, No. 4, AUGUST 2012 www.ccnonline.org

of PaO2 to fraction of inspired oxy- DVT and PUD Prophylaxis spontaneous breathing trials. A total
gen, findings on chest radiographs, Prophylaxis to reduce DVT and of 336 patients at 4 tertiary care
and results of cultures of tracheal PUD are the second and third hospitals who were treated with
aspirates; scores of 6 or higher indi- aspects of the VAP bundle. Both mechanical ventilation were included
cate pneumonia), increased from DVT prophylaxis and PUD prophy- in the study. Of these, 168 had daily
24% on day 1 of mechanical ventila- laxis have been considered standard spontaneous awakening trials fol-
tion to 48% by day 4 of mechanical practices in critical care units for lowed by a spontaneous breathing
ventilation. Patients with pneumo- many years. Because patients treated trial; the other 168 patients, the
nia on day 4 (42.2%) had significantly with mechanical ventilation are essen- control group, had sedation per
more pepsin-positive tracheal secre- tially sedentary, DVT prophylaxis usual care plus a daily spontaneous
tions than did patients without pneu- with administration of antithrom- breathing trial. The primary study
monia (21.1%; P<.001). In addition, botic medications and/or use of end point was time breathing with-
low backrest elevation (≤30º) was a antiembolism stockings is war- out assistance. Patients in the inter-
significant risk factor for aspiration ranted.19 PUD prophylaxis is needed vention group spent more days
(P=.02) and pneumonia (P=.02). to combat the stress of being treated breathing without assistance during
Grap et al17 conducted a descrip- with mechanical ventilation. By the 28-day study period than did
tive study of 66 patients treated with providing medications such as his- patients in the control group (14.7
mechanical ventilation in a medical tamine2 blockers to increase the pH days vs 11.6 days; 95% CI, 0.7-5.6;
ICU to determine the relationship of gastric contents and defend the P =.02) and were discharged from
between backrest elevation and the airway against acidic contents, the ICU at a median time of 9.1 vs
development of VAP. Data were patients can be protected against a 12.9 days (P=.01). Girard et al20
obtained from laboratory results pulmonary inflammatory response concluded that for every 7 patients
and medical records from the start due to aspiration, and their risk for treated with the intervention, 1
of mechanical ventilation up to day VAP can be lowered.13 life was saved (number needed to
7 of mechanical ventilation. Backrest treat, 7.4; 95% CI, 4.2-35.5). The
elevation was continuously monitored Interruption of Sedation and researchers also suggested that a
by using a transducer system. Back- Readiness for Extubation wake-up-and-breathe protocol
rest elevations were less than 30º 72% Daily interruptions of sedation paired with daily spontaneous
of the time and less than 10º 39% of and daily assessment of readiness awakening trials (interruption of
the time. Mean backrest elevation for extubation are other integral sedation) and daily spontaneous
for the entire study period was 21.7º. components of the ventilator bun- breathing trials resulted in better
The researchers17 concluded that dle. Traditionally, critical care physi- outcomes for patients receiving
spending the majority of time at a cians attempted to minimize the mechanical ventilation than did
backrest elevation less than 30º and duration of mechanical ventilation current standard approaches.
severity of illness affected the inci- by manipulating ventilator modes In another study, Schweickert et
21
dence of VAP. In a randomized clini- and slowly decreasing ventilatory al performed a retrospective chart
cal trial reported by Drakulovic et al,18 support. However, research has review of a database from a previ-
among patients receiving mechanical revealed that management of seda- ous trial of 128 patients treated
ventilation, 39 were assigned to a tion can have a more profound effect with mechanical ventilation who
semirecumbent position (45º) and on the duration of mechanical venti- were randomized to daily interrup-
47 to a supine position. The patients lation and other patient outcomes tion of sedative infusions or to usual
in a semirecumbent body position than can manipulating ventilator care. They found that patients who
had a lower frequency and risk for modes.1 In a multicenter, random- had daily interruption of a sedative
nosocomial pneumonia, specifically ized control trial described by Girard infusion experienced significantly
patients who received enteral feed- et al,20 paired spontaneous awaken- fewer complications (13 complica-
ings, and 18% fewer confirmed cases ing trials (daily interruption of tions; 2.8%) than did patients
of pneumonia (P=.02). sedatives) were compared with treated with conventional sedation

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techniques (26 complications; 6.2%; lactoferrin), changes in oral health Design
P=.04). They concluded that inter- status during the first 7 days after The process of reducing the
ruption of sedation in critically ill intubation, and microbial coloniza- number of cases of VAP in the ICUs
patients undergoing mechanical ven- tion of the oropharynx and trachea. began in July 2008. An interdiscipli-
tilation reduced ICU length of stay Data on oral health and Clinical Pul- nary team consisting of nurses,
and in turn decreased the incidence monary Infection Scores were col- physicians, and respiratory thera-
of complications of critical illness lected at baseline, day 4 (n=37), pists shared roles and responsibili-
associated with prolonged intubation. and day 7 (n=21). A regression ties for implementing the project.
model was used to predict risk of Members of the staff were educated
Oral Care pneumonia at day 4. about each aspect of the VAP bundle.
Microbes colonizing the mouth Results indicated that the amount Nurses, physicians, and therapists
markedly increase the risk for VAP.19 of dental plaque and the number of were given fact sheets describing the
Pathogens linked to VAP in orally oral organisms increased over time. VAP bundle and the importance of
intubated patients become colonized Correlations were significant for VAP as it related to patients’ out-
in dental plaque and in the oral baseline and day 4 dental plaque comes and cost of care. “ZAP VAP”
mucosa. Within 48 hours of admis- (P <.001), baseline salivary level of signage was placed at every patient
sion to an ICU, patients have changes lactoferrin and day 4 plaque (P=.01), bedside. Compliance data were col-
in the oral flora, which predominantly and lower salivary volume and higher lected from October 2008 through
include gram-negative and other vir- Clinical Pulmonary Infection Scores. December 2009.
ulent organisms.22 In addition, dental The authors24 concluded that higher Compliance audits were done by
plaque can provide an environment dental plaque scores indicate a greater personnel from the quality depart-
for respiratory pathogens such as risk for VAP. In addition, they pro- ment. The decision to use these per-
methicillin-resistant Staphylococcus posed that salivary volume and sonnel was based on 2 factors. First,
aureus and Pseudomonas aeruginosa.17 salivary level of lactoferrin, which the interdisciplinary team thought
Results from a meta-analysis23 of influences oropharyngeal coloniza- that having an auditor from outside
11 trials that included 3242 patients tion, may also affect the risk for VAP. the nursing department would help
receiving mechanical ventilation Evidence-based clinical practice eliminate bias in reporting audit
who were treated with oral applica- guidelines to reduce VAP have been findings. Second, the team did not
tion of antibiotics or antiseptics or available for several years. Unfortu- want to disrupt patient care by hav-
with placebo or standard oral care nately, widely published guidelines ing nurses pulled away from the
alone indicated that the incidence do not always bring about changes bedside to conduct audits. Because
of VAP was significantly reduced by in behavior. Because clinicians are members of the nursing department
use of oral antiseptics, such as not consistently incorporating the were collaborating with members of
chlorhexidine (relative risk, 0.56; evidence into their practice, VAP other departments to address VAP,
95% CI, 0.39-0.81), but not by oral continues to be an important health the team was able to negotiate with
applications of antibiotics (relative care challenge. the quality department, and a mem-
risk, 0.69; 95% CI, 0.41-1.18). In a ber of that department’s existing
study of 66 patients treated with Methods staff conducted the audits.
mechanical ventilation, Munro et al24 This project was conducted in the In order to increase the likelihood
examined the relationship between ICUs at Lankenau Hospital, Main of success, the SMART approach
VAP, oral health status (a baseline Line Health System, Wynnewood, described by Kollef25 was used. The
count of decayed, missing, and filled Pennsylvania, a suburb of Philadel- SMART approach includes specific,
teeth; an assessment of the oral cav- phia. A total of 105 staff nurses were measurable, achievable, relevant,
ity; culture of an oral specimen; meas- employed on the units at that time. and time-bound approaches to
urement of salivary volume; and A total of 4709 ventilator days were address HAIs. Kollef recommended
salivary levels of the immune com- audited for the project from January that nurses and other involved care
ponents immunoglobulin A and 2009 through December 2009. providers choose specific objectives

44 CriticalCareNurse Vol 32, No. 4, AUGUST 2012 www.ccnonline.org

that precisely define and quantify mostly nurses. Specimens for cul- brushed at 8 AM and 8 PM with
desired outcomes, such as reducing ture were obtained from one hand chlorhexidine, and the mouth was
the rate of HAIs in an ICU by 25%. before hand hygiene and from the cleansed with tooth sponges 10
He indicated that managers should other hand after hand hygiene was times per day. Respiratory thera-
monitor staff adherence to infection performed. Ring wearing was asso- pists and nurses discussed this pro-
prevention protocols and provide ciated with a 10-fold higher risk of tocol at length and decided that
feedback about how well the staff skin organism counts and contami- they would share in implementing
members complied with established nation with S aureus, gram-negative the protocol to conserve resources.
guidelines. Kollef advocated having bacilli, or Candida species. In addi- Documentation in the medical
adequate resources to support the tion, use of an alcohol-based hand record of completion of the proto-
team and ongoing communication rub resulted in significantly less fre- col was used for the audit.
to reinforce educational tactics. quent hand contamination. DVT and PUD Prophylaxis. Physi-
Implementation of the SMART A wash-glove-wash protocol was cians were expected to complete a
approach included providing specific established by the nursing staff at DVT screening tool and use the
directions to all personnel on the steps Lankenau Hospital on the basis of results to order antithrombotic
needed to implement each aspect of evidence from hand-washing stud- therapies. They also used standard-
the VAP bundle. The interdisciplinary ies.27,29,30 Adherence to this protocol ized orders for DVT and PUD pro-
team established measurable goals was determined on a monthly basis. phylaxis. Flagged notices in each
for success: to achieve 100% compli- Random monthly observations of patient’s medical record were used
ance with the VAP bundle and to hand washing were conducted by to remind physicians to write
reduce the rate of VAPs to 0. In order personnel selected by the quality orders for DVT prophylaxis and
to meet the goals, staff members department. PUD prophylaxis. Compliance with
were provided with resources such HOB Alarms. Nurses’ compliance this aspect of the bundle was con-
as checklists, flagged order sheets, with the recommendation that the firmed by chart audit.
and consistent feedback. Finally, the HOB remain elevated higher than Interruption of Sedation and
team decided that the time allowed 30º was enhanced by installing Readiness for Extubation. Nurses
to meet the goals would be 1 year. alarms on all beds in the critical worked collaboratively with respira-
care areas. Adherence to this aspect tory therapists to implement daily
The VAP Bundle of the protocol was determined via interruption of sedation and assess-
The VAP bundle adopted at documentation on the chart that the ment of readiness for extubation.
Lankenau Hospital differed from HOB was elevated more than 30º. Each patient’s sedation was inter-
the IHI bundle (see Table). Mouth-Care Protocol. The mouth- rupted and readiness for extubation
Hand-Washing Protocol. Hand care protocol was developed in col- was assessed by both a nurse and a
washing can reduce the frequency of laboration with the respiratory respiratory therapist. Documenta-
HAIs, but health care workers rarely therapy department. The old proto- tion of this aspect of the bundle was
achieve greater than 50% compliance col consisted of mouth care every 4 done on a respiratory therapy flow
with guidelines for hand washing hours with toothettes. With the new sheet. Compliance was monitored
and other infection control meas- protocol, mouth care was done every via chart audit. Nurses and respira-
ures.26 Washing and decontaminat- 2 hours or 12 times in 24 hours. The tory therapists received real-time
ing hands before and after contact decision to increase mouth care to feedback on this aspect of the bun-
with patients and wearing gloves are every 2 hours was based on the dle via the feedback tool.
important actions in the prevention studies of oral health and the devel- Subglottic Suctioning. Conven-
of VAP.27,28 Trick et al27 determined opment of VAP.12 The mouth-care tional endotracheal tubes were
risk factors for hand contamination protocol was accomplished by alter- placed with Hi-Lo Evac endotra-
and compared the efficacy of 3 ran- nating responsibility for mouth care cheal tubes (Covidien). These tubes
domly allocated hand hygiene agents between respiratory therapists and have an extra port above the
in a group of health care workers, nurses. Each patient’s teeth were inflated cuff that was connected to

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 Table Ventilator-associated pneumonia bundle
Institute of Healthcare Improvement Rationale for modification
bundle Expanded bundle or addition
Daily interruption of sedation and Daily interruption of sedation and assessment of No change
assessment of readiness for extubation readiness for extubation
Peptic ulcer disease prophylaxis Peptic ulcer disease prophylaxis No change
Deep-vein thrombosis prophylaxis Deep-vein thrombosis prophylaxis No change
Daily oral care with chlorhexidine Oral care with chlorhexidine plus additional mouth Bundle modified because increasing
care mouth care to every 2 hours can
decrease development of ventilator-
associated pneumonia12,17,24
Elevation of the head of the bed Elevation of the head of the bed plus alarms Alarms added to alert staff if the
head of the bed is elevated less
than 30°16,17
Handwashing protocol Added because hand washing can
reduce the frequency of hospital-
Health care professionals required to (1) wash their
acquired infections26-30
hands with alcohol-based hand rub and don a pair
of gloves before patient contact, and (2) after each
patient contact, remove the gloves and wash their
hands again with an alcohol-based hand cleanser
Subglottic suctioning Added because low continuous
subglottic suctioning promotes
Conventional endotracheal tubes replaced with Hi-Lo
drainage or oral secretions from
Evac endotracheal tubes, which have an extra port
above the cuff, decreasing the
above the inflated cuff that was connected to low
chance that secretions might seep
continuous suctioning
into the lungs31

Feedback tool consisting of a database for tracking Added because using computerized
and determining trends in compliance with the audit tools to calculate bundle
expanded bundle, developed by the quality compliance can decrease rates of
department, nursing staff, and information ventilator-associated pneumonia32,33
technology department
Each component assigned to a specific group of
health care practitioners
Documentation on the medical record indicating
bundle compliance monitored daily and informa-
tion on compliance or needed improvements
e-mailed to the patient’s nurse, physician, and
respiratory therapist and copies sent to nurse
managers
When all requirements met, congratulatory notes for
staff members
For consistent trends of noncompliance, meetings
between nurse managers and staff to develop
strategies for improvement

low continuous suction. Continuous into place, compliance with the Cocanour et al32 used a computer-
low suction promoted drainage of VAP bundle continued to be less ized audit tool to calculate weekly
oral secretion from above the cuff, than expected. The interdiscipli- bundle compliance, the VAP rate
therefore decreasing the chance that nary team decided that the process decreased to less than the National
secretions would seep into the lungs. for implementing the VAP bundle Nosocomial Infections Surveillance
The cost of the tubes used for sub- should be evaluated and that a System 25th percentile and was sus-
glottic suctioning was $12.42. mechanism was needed for holding tained for the remainder of their
Feedback Tool. Even after an exten- nurses accountable for the practices study. Zaydfudim et al33 made com-
sive educational program was put included in the bundle. When pliance a key factor in their VAP

46 CriticalCareNurse Vol 32, No. 4, AUGUST 2012 www.ccnonline.org

 Figure 1 Compliance data and feedback tool.

bundle program. When implemen- days was 4709, a decrease from the 2009. Readiness for extubation was
tation of a bundle program with 4964 ventilator days for January 1, 100% for 5 months but decreased
intermittent compliance monitoring 2008, to December 31, 2008. near the end of the project to 92.4%.
did not reduce the incidence of VAP The first month after education From January 2008 through
at Lankenau, a real-time VAP bundle of staff members, compliance was December 2008, a total of 47 cases
compliance dashboard was installed 100% for PUD prophylaxis, DVT of VAP occurred, with 4964 ventila-
on every ICU computer monitor prophylaxis, daily interruption of tor days, yielding 9.47 cases per
(Figure 1). Real-time compliance sedation and assessment of readi- 1000 ventilator days. From January
feedback resulted in an increase in ness for extubation, and HOB eleva- 2009 through December 2009, a
total bundle compliance from approx- tion. Generally, the compliance rate total of 9 cases of VAP occurred,
imately 20% to 90% during a year remained greater than 98%, and for with 4709 ventilator days, yielding
and the overall VAP rates improved. several months, compliance was a VAP rate of 1.9 cases per 1000
100% for PUD prophylaxis, DVT ventilator days (Figure 2).
Results prophylaxis, daily interruption of Use of the VAP bundle resulted
We began preliminary data col- sedation and assessment of readiness in a marked cost savings for
lection in October 2008. In January for extubation, and HOB elevation. Lankenau Hospital and improve-
2009, daily audits were started, and The protocols for oral care and ment in patient outcomes. If the
use of the feedback tool was initiated. readiness for extubation were much hospital’s costs for each case of
Compliance with each aspect of the more challenging. Compliance with VAP is $40000 (the calculated
VAP bundle was monitored and the oral-care protocol never reached costs per episode of VAP accord-
reported monthly. The findings 100%. In October 2008, compliance ing to the data from the IHI 5 Mil-
from January 1, 2009, to December was 76%, and the rate stayed within lion Lives Campaign), the project
31, 2009, are presented here. During a range of 91.4% to 96.8% from Feb- resulted in an estimated savings of
2009, the total number of ventilator ruary 2009 through December $1.5 million.

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 8

6
No. of cases

0
July September November January March May July September November
2008 2008 2008 2009 2009 2009 2009 2009 2009
Time

800
No. of ventilator days

600

400

200

0
July September November January March May July September November
2008 2008 2008 2009 2009 2009 2009 2009 2009
Time

20

15
Rate

10

0
July September November January March May July September November
2008 2008 2008 2009 2009 2009 2009 2009 2009
Time

Figure 2 Ventilator-associated pneumonia. Top, Number of cases. Middle, Number of ventilator days. Bottom, Rate, calculated
as number of cases per 1000 ventilator days.

Discussion VAP rates. One of the earliest pro- indicates that implementation of
The success of our program was grams was described in the 1990s. each element of the VAP bundle
attributable to several factors. First, The VAP-bundle concept has grown reduces the mortality and morbidity
we think that the implementation from the IHI 100000 Lives Cam- of patients receiving mechanical
of bundled practices contributed to paign in 2002, which had 4 ele- ventilation. In a 38-month study in
a reduction of the VAP rates. Over ments—HOB elevation, daily a surgical ICU, Bird et al34 compared
the years, without consistent suc- sedation vacation, PUD prophylaxis, VAP rates before and after initiation
cess, an enormous effort has been and DVT prophylaxis—to include a of the IHI bundle. Before use of the
spent overcoming barriers to imple- fifth element: oral care with bundle, the VAP rate was 10.2 cases
mentation of guidelines to reduce chlorhexidine. Clinical evidence13 per 1000 ventilator days. During

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the study period, the rate decreased success of the project. Nursing staff and develop strategies to improve
to 3.4 cases per 1000 ventilator were committed to making a differ- patients’ care.
days. Bird et al concluded that use ence in patients’ outcomes. Nurses Nurses need to be consistently
of a VAP bundle was an effective stated in staff meetings that they apprised of patient safety issues and
method for reducing VAP rates would not be satisfied with mediocre provided with the support to deliver
when compliance with the protocols changes in the VAP rates. They high-quality care. The feedback
was maintained. established a zero-defect quality tool, use of the electronic medical
Second, having an interdiscipli- goal and welcomed the independent record, and other strategies can be
nary team involved in the project auditor. Staff viewed the independ- developed to address staff perform-
influenced the VAP rates. Nurses, ent auditors as nonbiased, and the ance and other quality issues.
physicians, respiratory therapists, nurses thought that having an audi- Interdisciplinary collaboration is
quality department personnel, and tor saved nursing time. Nurses indi- imperative when addressing issues
information technology specialists cated that they wanted to stay at the such as VAP. Each member of the
played key roles in the success of the bedside and not be taken away from health care team must be willing to
program. Use of an interdisciplinary patient care to do data collection. share in the responsibility for devel-
team was further exemplified in a Finally, we think that the real- oping strategies to address problems
study by Johnson et al35 in which time feedback on staff compliance in patient care and take an active
they examined the effect of multi- with the VAP protocol had the most role in implementing the plan.
disciplinary rounds on VAP rates in important effect on VAP rates. Feed- Our VAP project was extremely
trauma patients. They found that back sessions were used to give staff successful. Nurses and other health
the number of VAP cases per 1000 members positive feedback for their care professionals can use our project
ventilator days decreased from 34.4 efforts and to increase staff account- as a template for addressing other
to 23.4 between groups that did and ability for implementation of best quality projects, such as pressure
did not have multidisciplinary practices. Our use of real-time feed- ulcers, falls, and bloodstream infec-
rounds (P=.04). back was validated in another study33 tions. We plan to continue surveil-
Implementation of the mouth- in which use of bundled practices lance of compliance with protocols
care protocol could not have been along with electronic monitoring for managing other nurse-sensitive
successful without the assistance of resulted in a significant reduction indicators. We would like to build
the respiratory therapy department. of VAP rates. an infrastructure to collect data so
The willingness of respiratory thera- that nurses can monitor compliance
pists to alternate responsibility for Implications for with other protocols critical for
the mouth-care protocol enabled Nursing Practice improved patients’ outcomes.
nurses to preserve resources to man- Our results confirm that nurses
age other aspects of patient care as can improve patients’ outcomes Conclusions
well as the VAP bundle. through the use of evidence-based Health care costs surpassed $2.3
Third, we think that having an practices. The evidence supporting trillion in 2008 and account for 16%
independent auditor assess compli- VAP bundled practices is clear. We of the gross domestic product in the
ance with the VAP bundle was one showed that strict adherence to a United States.36 Intensive care costs
of the most important factors in the VAP bundle improved morbidity, account for 30% of hospital spend-
mortality, and health care costs. ing.37 Because 76% of patients in
Accountability for daily patient ICUs require ventilatory support
care is a key component to improv- and the use of mechanical ventila-
ing patients’ outcomes. Through tion makes patients susceptible to
To learn more about ventilator-associated
pneumonia, read “Patient to Nurse Ratio the use of a feedback system, using VAP, interventions based on credi-
and Risk of Ventilator-Associated Pneumo- daily monitoring and trend reports, ble evidence are warranted. Strict
nia in Critically Ill Patients” by Blot et al in
the American Journal of Critical Care, 2011; nurses can remain abreast of their adherence to VAP bundled prac-
20: e1-e9. Available at www.ajcconline.org. compliance with care protocols tices, enhancing accountability for

www.ccnonline.org CriticalCareNurse Vol 32, No. 4, AUGUST 2012 49

initiating protocols by using a feed- Health and Safety Network (NHSN) man- 25. Kollef M. SMART approaches for reducing
ual: patient safety component protocol. nosocomial infections in the ICU. Chest.
back system, and interdisciplinary http://www.cdc.gov/nhsn/PDFs 2008;134(2):447-456.
/pscManual/pscManual_current.pdf. Pub- 26. Eckmanns T, Bessert J, Behnke M, Gast-
collaboration most likely will lished March 2009. Accessed May 3, 2012. meir P, Ruden H. Compliance with antisep-
improve patients’ outcomes and 11. American Thoracic Society; Infectious Dis- tic hand rub use in intensive care units: the
eases Society of America. Guidelines for the Hawthorne effect. Infect Control Hosp Epi-
produce marked costs savings for management of adults with hospital- demiol. 2006;27(9):931-934.
acquired, ventilator-associated and health- 27. Trick WE, Vernon MO, Welbel SF, Demarais
hospitals. CCN care-associated pneumonia. Am J Respir Crit P, Hayden MK, Weinstein RA; Chicago
Care Med. 2005;171(4):388-416. Antimicrobial Resistance Project. Multicen-
12. Munro CL, Grap M. Oral health and care in ter intervention program to increase adher-
Now that you’ve read the article, create or contribute to the intensive care unit: state of the science. ence to hand hygiene recommendations
an online discussion about this topic using eLetters. Am J Crit Care. 2004;13(1):25-33. and glove use and to reduce the incidence
Just visit www.ccnonline.org and click “Submit a 13. Institute for Healthcare Improvement. Imple- of antimicrobial resistance. Infect Control
response” in either the full-text or PDF view of the ment the ventilator bundle. http://www.ihi Hosp Epidemiol. 2007;28(1):42-49.
article. .org/IHI/Topics/CriticalCare/IntensiveCare 28. Aiello AE, Coulborn RM, Perez V, Larson EL.
/Changes/ImplementtheVentilatorBundle Effect of hand hygiene on infectious disease
.htm. Accessed May 3, 2012. risk in the community setting: a meta-
Acknowledgments 14. Cason C, Tyner T, Sunder S, Broome L; analysis. Am J Public Health. 2008;98(8):
The authors thank the dedicated staff of Lankenau
Centers for Disease Control and Prevention. 1372-1381.
Medical Center’s ICU, cardiothoracic ICU, and
Nurses’ implementation of guidelines for 29. Creedon SA. Health care workers hand
VAP Committee, whose commitment to superior
ventilator-associated pneumonia from the decontamination practices: compliance
patient care makes these outcomes possible.
Centers for Disease Control and Prevention. with recommended guidelines. J Adv Nurs.
Am J Crit Care. 2007;16(1):28-34. 2005;51(3):208-216.
Financial Disclosures 15. Tolentino-DelosReyes A, Ruppert S, Shiao P. 30. Abbott CA, Dremsa T, Stewart DW, Mark DD,
None reported. Evidence-based practice: use of the ventilator Swift CC. Adoption of a ventilator-associated
bundle to prevent ventilator-associated pneumonia clinical practice guideline. World-
References pneumonia. Am J Crit Care. 2007;16(1):20-27. views Evid Based Nurs. 2006;3(4):139-152.
1. Eber MR, Laxminarayan R, Perencevich EN, 16. Metheny N, Clouse R, Chang U. Stewart B. 31. Dezfulian C, Shojania K, Collard HR, Kim
Malani A. Clinical and economic outcomes Oliver D, Kollef M. Tracheobronchial aspi- HM, Matthay MA, Saint S. Subglottic
attributable to health care-associated sepsis ration of gastric contents in critically ill secretion drainage for preventing ventila-
and pneumonia. Arch Intern Med. 2010; tube-fed patients: frequency, outcomes, and tor-associated pneumonia: a meta analysis.
170(4):347-353. risks. Crit Care Med. 2006;34(4):1007-1015. Am J Med. 2005;118(1):11-18.
2. Vallés J, Pobo A, García-Esquirol O, Mariscal 17. Grap MJ, Munro CL, Hummel RS III, 32. Cocanour CS, Peninger M, Domonoske BD,
D, Real J, Fernández R. Excess ICU mortality Elswick RK Jr, McKinney JL, Sessler CN. et al. Decreasing ventilator-associated
attributable to ventilator-associated pneu- Effect of backrest elevation on the develop- pneumonia in a trauma ICU. J Trauma. 2006;
monia: the role of early vs late onset. Inten- ment of ventilator-associated pneumonia. 61(1):122-130.
sive Care Med. 2008;33(8):1363-1368. Am J Crit Care. 2005;14(4):325-332. 33. Zaydfudim V, Dossett LA, Starmer JM, et al.
3. Buczko W. Ventilator-associated pneumonia 18. Drakulovic MB, Torres A, Bauer TT, Nicolas Implementation of a real-time compliance
among elderly Medicare beneficiaries in JM, Nogué S, Ferrer M. Supine body posi- dashboard to help reduce SICU ventilator-
long-term care hospitals. Health Care Financ tion as a risk factor for nosocomial pneumo- associated pneumonia with the ventilator
Rev. 2009;31(1):1-10. nia in mechanically ventilated patients: a bundle. Arch Surg. 2009;144(7):656-662.
4. Safdar N, Dezfulian C, Collard HR, Saint S. randomised trial. Lancet. 1999;354(9193): 34. Bird D, Zambuto A, O’Donnell C, et al.
Clinical and economic consequences of ven- 1851-1858. Adherence to ventilator-associated pneu-
tilator-associated pneumonia: a systematic 19. O’Keefe-McCarthy S, Santiago C, Lau G. monia bundle and incidence of ventilator-
review. Crit Care Med. 2005;33(10):2184-2193. Ventilator-associated pneumonia bundled associated pneumonia in the surgical intensive
5. Restrepo M, Anzueto A, Arrogliga A, et al. strategies: an evidence-based practice. World- care unit. Arch Surg. 2010;145(5):465-470.
Economic burden of ventilator-associated views Evid Based Nurs. 2008;5(4):193-204. 35. Johnson V, Mangram A, Mitchell C,
pneumonia based on total resource utiliza- 20. Girard T, Kress J, Fuchs B, et al. Efficacy and Lorenzo M, Howard D, Dunn E. Is there a
tion. Infect Control Hosp Epidemiol. 2010;31: safety of a paired sedation and ventilator benefit to multidisciplinary rounds in an
509-515. weaning protocol for mechanically venti- open trauma intensive care unit regarding
6. 5 Million Lives Campaign. Getting Started lated patients in intensive care (Awakening ventilator-associated pneumonia? Am Surg.
Kit: Prevent Ventilator-Associated Pneumonia: and Breathing Controlled trial): a randomised 2009;75(12):1171-1174.
How-to Guide. Cambridge, MA: Institute for controlled trial. Lancet. 2008;371(9607): 36. Centers for Medicare and Medicaid Services.
Healthcare Improvement; 2010. 126-134. National health expenditure data. http://
7. Centers for Medicare and Medicaid Services. 21. Schweickert WD, Gehlbach B, Pohlman A, www.cms.gov/nationalhealthexpenddata
CMS proposes additions to list of hospital- Hall J, Kress J. Daily interruption of sedative /01_overview.asp. Accessed May 4, 2012.
acquired conditions for fiscal year 2009. infusions and complication of critical illness 37. Mayo Clinic study: intensive care costs ris-
http://www.cms.hhs.gov/apps/media/press in mechanically ventilated patients. Crit Care ing. Minneapolis St Paul Business Journal.
/factsheet.asp. Published April 14, 2008. Med. 2004;32:1272-1276. July 12, 2006. http://www.bizjournals.com
Accessed May 2, 2012. 22. Abele-Horn M, Dauber A Bauernfeind A, et al. /twincities/stories/2006/07/10/daily22.ht
8. Federal Register Part II, Medicare Program. Decrease in nosocomial pneumonia in ven- ml. Accessed May 4, 2012.
Proposed changes to the hospital inpatient tilated patients by selective oropharyngeal
prospective payment systems and fiscal year decontamination (SOD). Intensive Care Med.
2009 rates: proposed rule, 42 CFR parts 411, 1997;23(2):187-195.
412, 413, 422, and 489. http://www.gpo.gov 23. Chan E, Ruest A, Meade MO, Cook DJ. Oral
/fdsys/pkg/FR-2008-04-30/pdf/08-1135.pdf decontamination for prevention of pneumo-
Accessed May 15, 2012. nia in mechanically ventilated adults: sys-
9. Resar R, Pronovost P, Haraden C, Simmonds tematic review and meta-analysis. BMJ.
T, Rainey T, Nolan T. Using a bundle approach 2007;334:889. doi:10.1136/bmj.39136
to improve ventilator care process and reduce .528160.BE.
ventilator-associated pneumonia. Jt Comm J 24. Munro CL, Grap MJ, Elswick RK Jr, McKin-
Qual Patient Saf. 2005;31(5):243-248. ney J, Sessler CN, Hummel RS III. Oral
10. Division of Healthcare Quality Promotion, health status and development of ventilator-
National Center for Preparedness, Detection, associated pneumonia: a descriptive study.
and Control of Infectious Diseases. National Am J Crit Care. 2006;15(5):453-461.

50 CriticalCareNurse Vol 32, No. 4, AUGUST 2012 www.ccnonline.org

CNE Test Test ID C1242: Using Evidence-Based Practice to Prevent Ventilator-Associated Pneumonia
Learning objectives: 1. List the components of the 2010 Institute for Healthcare Improvement ventilator bundles 2. Discuss the financial implications of
patients developing ventilator-associated pneumonia 3. Identify strategies to help implement ventilator bundles successfully in a hospital

1. Which of the following is true concerning the cost of ventilator-associated 7. What is a spontaneous awakening trial?
pneumonia (VAP)? a. Turning off the continuous intravenous sedation and assessing the patient’s
a. VAP represents 75% of all intensive care unit infections. respiratory status.
b. The mortality rate for patients acquiring VAP is 32%. b. Turning off the rate on the ventilator and seeing if the patient awakens.
c. VAP can increase length of stay by 4 to 19 days. c. Changing the delivery method of sedation from intravenous to by mouth.
d.VAP does not significantly increase the cost of care. d.Increasing the sedation at night to allow the patient to sleep.

2. What are the implications of the Center for Medicare and Medicaid Services 8. Which of the following were revealed in the meta-analysis on application of
declaring VAP to be a reasonably preventable occurrence? oral antiseptics, antibiotics, and placebo?
a. The potential for VAP may increase in hospitals. a. Applying oral antibiotics significantly decreased VAP incidence.
b. Hospitals will not be reimbursed for the cost of care associated with VAP. b. Applying oral antiseptics significantly decreased VAP incidence.
c. Hospitals with a high VAP rate will lose accreditation. c. Standard oral care only significantly decreased VAP incidence.
d.Hospitals will be rewarded for discovering VAP early. d.Applying oral antibiotics and antiseptics did not affect VAP incidence.

3. Which of the following patient assessment characteristics is most likely associated 9. What is the SMART approach to reducing hospital-acquired infections?
with VAP? a. Specific Measurable Achievable Redundant Time-bound approaches
a. Infiltrates on the chest radiograph clearing after 24 hours of mechanical ventilation b. Several Meaningful Achievable Relevant Time-bound approaches
b. Elevated white blood cell count and fever before intubation c. Specific Measurable Actively Relevant Time-bound approaches
c. Progressive infiltrates and fever on day 3 of mechanical ventilation d.Specific Measurable Achievable Relevant Time-bound approaches
d.Purulent secretions present during intubation
10. Which of the following is true according to the hand hygiene research cited
4. Which of the following patient findings increases the risk of microorganisms in the article?
entering the lower respiratory tract? a. There was a 50% increase in compliance rates of hand hygiene with the bundle
a. An increased gag reflex implementation.
b. Increased pooling of secretions in the oropharynx b. Use of alcohol rub was associated with higher hand contamination.
c. Increased mucocillary clearance of secretions c. Hand washing is not necessary if gloves are changed frequently.
d.Increased cough d.Ring wearing was associated with a 10-fold increase in Staphylococcus aureus and
Candida infections.
5. Which of the following patients is the least likely to develop VAP?
a. A patient with elevation of the head of the bed (HOB) 20°, receiving H2 blockers and 11. Which of the following results was achieved by the Lankenau Hospital bundle
oral care with toothettes every 4 hours implementation?
b. A patient with elevation of HOB 30°, receiving H2 blockers and oral care with a. Compliance with the oral care protocol was 100%.
chlorhexidine daily, and treated with a change in the mode of ventilation daily b. VAP occurrences decreased from 47 (2008) to 9 (2009).
c. A patient with elevation of HOB 30°, receiving H2 blockers, oral care with chlorhexidine c. Peptic ulcer disease and deep-vein thrombosis prophylaxis compliance rates were
daily, and continuous Propofol infusions 92%.
d. A patient with elevation of HOB 30°, receiving H2 blockers and oral care with chlorhexidine d.Ventilator days increased from 4709 (2008) to 4964 (2009).
daily, and treated with daily sedation awakenings with spontaneous breathing trials
12. According to a study cited in the article, how did multidisciplinary team
6. Which of the following is true concerning the Institute for Healthcare Improve- rounds affect VAP rates in trauma patients?
ment ventilator bundles? a. VAP rates were unaffected by multidisciplinary team rounds.
a. It is not necessary to implement all the components at once. b. VAP rates increased when teams conducted daily multidisciplinary rounds.
b. HOB elevation should remain less than 30° at all times. c. VAP rates decreased when teams conducted daily multidisciplinary rounds.
c. The results of the 100 000 Lives Campaign showed a decrease in VAP rates following
implementation of the bundles.
d.The 2005 bundles were unchanged in 2010.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. ❑ a 2. ❑ a 3. ❑ a 4. ❑ a 5. ❑ a 6. ❑ a 7. ❑ a 8. ❑ a 9. ❑ a 10. ❑ a 11. ❑ a 12. ❑ a
❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b
❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c
❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d
Test ID: C1242 Form expires: August 1, 2014 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Synergy CERP: Category A
Test writer: Marylee Bressie, MSN, RN, CCRN, CCNS, CEN

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