Ventilator-Associated Pneumonia (VAP)
Can Be Eradicated
Successful VAP Prevention
Program in a
Comprehensive Cancer
Center Surgical ICU
Joseph L. Nates, MD MBA-HCA FCCM.
Professor, Deputy Chair, ICU Medical Director
Critical Care Department; Division of Anesthesiology and Critical Care
The University of Texas MD Anderson Cancer Center
Multidisciplinary Team


Kristen Price, Chair
Joseph Nates, Deputy Chair, ICU Medical Director
Donna Calabrese, Quality and Safety Committee
Egbert Pravinkumar, Infection Control Committee

Infection Control/Infectious Diseases:
–
–
–
–

– Patricia Hannon, ICU Nursing Director
– Nicole Harrison, ICU Associate Nursing
Director
– Marylou Warren, ICU Nursing Education
– Kimberly Curtin, ICU Nursing Education
– Staci Eguia, Clinical Nurse
Critical Care:
–
–
–
–
Nursing:
Issam Raad, Chair
Roy Chemaly, Director of Infection Control
Cheryl Perego, Infection Control
Polly Williams, Infection Control

Pharmacy:
– Todd Canada
– Jeffrey Bruno
– Tami Johnson
VAP Task Force:
– Staci Eguia, Nursing
– Cynthia Segal, Performance Improvement
– Dolores Mejia, Respiratory Therapy


–
–
–
–
–
Performance Improvement:
– Victoria Jordan, Director, Quality
Engineering and Clinical Operations
Informatics
– John Terrel, Quality Engineer
Respiratory:

Kristen Price, Medical Director
Clarence Finch, Respiratory Care Director
Laura Withers, Respiratory Care Coordinator
Quan Nguyen, Respiratory Care Coordinator
Dolores Mejia, Respiratory Care Educator
Other:
– PT/OT, Nutrition, Social
Work, Liaisons, Clerks, etc.
Health Care-Associated Infections
and Deaths in US Hospitals, 2002

Objective. The purpose of this study was to provide a national estimate of the number of healthcare-associated
infections (HAI) and deaths in United States hospitals.

Methods. No single source of nationally representative data on HAIs is currently available. The authors used a multistep approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance
(NNIS) system, data from 1990–2002, conducted by the Centers for Disease Control and Prevention. Data from the
National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to
supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or
associated with the HAI from NNIS data was used to estimate the number of deaths.
 Results. In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to
include federal facilities, was approximately 1.7 million: 33,269 HAIs among
newborns in high-risk nurseries, 19,059 among newborns in well-baby
nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among
adults and children outside of ICUs. The estimated deaths associated with
HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia,
30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for
surgical site infections, and 11,062 for infections of other sites.

Conclusion. HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method
described for estimating the number of HAIs makes the best use of existing data at the national level.
Klevens RM et al. Estimating Health Care-Associated Infections and Deaths in
U.S. Hospitals, 2002. Public Health Reports . March-April 2007; (122) 160-166.
Hospital-Associated Pneumonia (HAP)
In 5-10 patients/1000 admissions
HAP is estimated to be increased 6-10 fold in
ventilated patients (VAP)
VAP occurs in 9-27% of all intubated patients
In ICU, 90% of all HAPs occur during
mechanical ventilation
Chastre J, Fagon JY. Ventilator-associated pneumonia.
Am J Respir Crit Care Med 2002;165:867–903.
Incidence of HAP
 VAP is the second most common cause of hospital infections overall,
but the most common documented in the ICU.
–
–
–
Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator-associated pneumonia in a community hospital: risk
factors and clinical outcomes. Chest. 2001;120:555-561.
Craven DE, Steger KA. Nosocomial pneumonia in mechanically ventilated adult patients: epidemiology and
prevention in 1996. Semin Respir Infect. 1996;11:32-53.
Rello J, Ollendorf DA, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US
database. Chest. 2002;122:2115-2121.
 HAP and VAP produce the highest mortality associated with
nosocomial infections.
 In 2008 Report by the National Healthcare Safety Network:
– NHSN 50th percentile for VAP in T-ICU was 8.3 cases per 1000
ventilator days
– NHSN 50th percentile for VAP in Neuro-ICUs was 4.5 cases per
1000 ventilator days
National Healthcare Safety Network (NHSN) Report, data
summary for 2006 through 2007, issued November 2008.
Am J Infect Control 2008; 36:609-26.
HAP Associated LOS and Costs
 HAP increases hospital stay by an average of 7 to 9 days!
– Estimated to be about $40,000
 However, VAP is associated with increasing ICU stay by
up to 22 days and hospital stays by up to 25 days
– Warren D, Shukla S, Olson M, et al. Outcome and attributable cost of ventilatorassociated pneumonia among intensive care unit patients in a suburban medical
center. Critical Care Medicine. 2003;31:1312-1317.
 A study in a shock trauma ICU found that VAP costs an
additional $57,000 per occurrence
– Cocanour C, Ostrosky-Zeichner L, Peninger M, et al. Cost of a ventilatorassociated pneumonia in a shock trauma intensive care unit. Surgical Infections.
2005;6:65-72.
HAP and VAP Associated Mortality
Mortality
HAP
VAP
18.8%
29.3%
Length of Stay 15.2 days
Mean Hospital
$65,292
23 days
$150,841
Charges
Kollef MH, et al. Epidemiology and Outcomes of Health-Care-Associated Pneumonia.
Results From a Large US Database of Culture-Positive Pneumonia. Chest. Dec
2005;128(6):3854-62.
SICU in 2002!
VAP rate
34.2/1,000
VD
>10 VAP
cases per
month
>200
patientdays per
month
>$570,000
Previous Infection Control
Performance Improvement Program
Neurological ICU VAP Rates Reduction:1998 to 2000
60
Per 1,000 Vent Days
50
40
30
20
10
0
NNIS 50th
Percentile
1998 UT and
Memorial-Hermann
Critical Care
Collaborative Initiative
1. IHI initiatives
implementation
2. Collaboration
among ICUs
3. Monitoring
4. Meetings
5. “Stealing”
successful
strategies
6. Critical Care
Council
Hypothesis
• “An effective
infection control
program
combining
education with
evidence-based
interventions can
reduce VAP rates”
Aim
Statement
• “To reduce the
adult MD
Anderson
Surgical ICU
(SICU) VAP
Rates by 25%
within 6 months”
Alignment
• Dr. John
Mendelsohn’s
Strategic Vision
• NQF, IHI,
AHRQ, NHSN,
CDC, JCAHO,
APIC, etc….
Measures
of
Success
• CDC infections
definitions
• CDC monitoring
tools
• Infection Control
Surveillance
Data
Ishikawa Diagrams
PDSA Cycles
Act
Plan
Study
Do
SPC Charts
Overall plan: To
maintain a steady
improvement
process with
progressive
reduction of our
VAP rates
Program was
initiated using a
multidisciplinary
team and
evidence-based
approach
Four major
intervention stages
Preparing the Ground
Multiple internal
meetings to
identify
representatives
from the
different teams
and telephone
conferences
with IHI team
Organizing the
metrics
standardization
and collection
Developing the
core
multidisciplinary
team, plan, and
logistics
Developing the
education
materials
Travels to IHI
National
meetings to
expose the
teams’
representatives
to other teams
and hospitals
experiences
Act
Plan
Study
Do
ZAP VAP Project: Stage I
 Physician Champion behind efforts
 Implemented the IHI initiatives to prevent VAP:
Ventilator Bundle
 Implemented the CDC Guidelines for preventing HealthCare Associated Pneumonia, 2003
 Revised our Ventilator protocol and standardized
mechanical ventilation to Bi-Level (biphasic) ventilation
 Added evening intensivists to staff
Act
Plan
Study
Do
ZAP VAP Project: Stage I
 Divided patients into teams by service to reduce the
physician-to-patient ratio
 For education purposes we developed:
– A slide presentation
– Educational Video
– Screen saver pictures with images of what not to do
– Poster
– Newsletter
 Reported VAP rate and bundle compliance to staff on
regular basis
Ventilator Bundle
“key components”
Elevation of
the Head of
the Bed
Daily
"Sedation
Vacations"
and
Assessment
of Readiness
to Extubate
Peptic Ulcer
Disease
Prophylaxis
Deep Venous
Thrombosis
Prophylaxis
Daily Oral
Care with
Chlorhexidine
Ventilator Bundle Order Set
CDC Guidelines:
Focus of the Guidelines
Education
Microbiologic
surveillance
Prevention of
transmission of
micro-organisms
Modifying risks for
infection
American College of Critical Care Medicine
Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult
 Guidelines focus
• Prolonged sedation and analgesia
• Patients older than 12 years
• Patients during mechanical ventilation
 Assessment and treatment recommendations
•
•
•
•
Analgesia
Sedation
Delirium
Sleep
Jacobi J, et al. Crit Care Med. 2002;30:119-141.
Act
Plan
Study
Do
ZAP VAP Project: Stage II
 Non-invasive ventilation protocol developed
 Continued:
– performing audits of compliance with guidelines
– providing feedback of personal and group performance
– adjusting Evidence-Based interventions
 Sedation and analgesia protocols revised focusing on
weaning rather escalating
 Introduction of the RASS score
 Sedation holiday protocol developed and implemented
Act
Plan
Study
Do
ZAP VAP Project: Stage III
 Early mobilization was initiated in thoracic surgery
 Tracheostomy algorithm was introduced
 “Plaquenators” Program, after 9/2007
 Spontaneous breathing trials protocol was developed and
implemented in 6/2008
 Rapid weaning protocol modified in 2/2009
 Enforcing the daily sedation holidays and spontaneous
breathing trials protocols
The “Plaquenators”!
ZAP VAP - Oral Care Q 4 hours
Oral Care every 4 hours
Cetylpyridinium Chloride
ZAP VAP Project: Stage IV
 We have focused on continuous monitoring and
enforcement of the practitioners compliance with the
interventions already in place including:
– Continuous education of the multidisciplinary team on infection
prevention strategies
– CDC Prevention of Healthcare-Associated Pneumonia Guidelines
– Institute of Healthcare Improvement ventilator bundle initiative
including aggressive ventilator weaning protocol, head elevation,
and others.
Processes
Poor
communication
Lack of standardized
approach to
mobilization
Procedures
Nasal
intubation
Surgery (Head and
Neck, GI, Thoracic)
Re-intubation
Lack of standardized
approach to daily sedation
holidays
Need for
nasogastric/
nasoenteral tubes
Lack of standardized approach to
assessing readiness for
weaning/extubation
Respiratory Care
Policies
Infection Control
Policies
Nursing Polices
(oral care)
Critical Care Policies –
ICU Admission/Discharge
Criteria
Policies
Patient
HOB elevation
Prolonged hospital
stay
Prolonged time on the
ventilator
Sedation level
Immobilization
Poor Hand
hygiene
Poor adherence
to protocols
Poor adherence
to policies
Ventilators
Endo tracheal tubes
Beds
Lack of
knowledge
Facilities
Workforce
Risk Factors for
Developing VAP
Processes
Poor
communication
Lack of standardized
approach to
mobilization
Procedures
Nasal
intubation
Surgery (Head and
Neck, GI, Thoracic)
Re-intubation
Lack of standardized
approach to daily sedation
holidays
Need for
nasogastric/
nasoenteral tubes
Lack of standardized approach to
assessing readiness for
weaning/extubation
Respiratory Care
Policies
Infection Control
Policies
Nursing Polices
(oral care)
Critical Care Policies –
ICU Admission/Discharge
Criteria
Policies
Patient
HOB elevation
Prolonged hospital
stay
Prolonged time on the
ventilator
Sedation level
Immobilization
Poor Hand
hygiene
Poor adherence
to protocols
Poor adherence
to policies
Ventilators
Endo tracheal tubes
Beds
Lack of
knowledge
Facilities
Workforce
Risk Factors for
Developing VAP
Jun-10
Mar-10
Dec-09
Sep-09
Jun-09
Mar-09
Dec-08
Sep-08
Jun-08
Mar-08
Dec-07
Sep-07
Jun-07
Mar-07
Dec-06
Sep-06
Jun-06
Mar-06
Dec-05
Sep-05
Jun-05
Mar-05
Dec-04
Sep-04
Jun-04
Mar-04
Dec-03
Sep-03
Jun-03
Mar-03
Dec-02
Sep-02
Days
Invasive & Non-Invasive Ventilation
September 2002 to June 2010
900
800
700
600
500
Invasive Ventilation
Non-Invasive Ventilation
400
300
200
100
0
Ventilator Bundle Compliance
100
90
80
70
60
CY 07
50
CY 08
40
CY 09
30
Jan - May 10
20
10
0
Hand Hygiene Compliance
90
80
84.5
82.6
78.6
83.4
85.4
80.7
78.9
81.8
75.6
70
% Compliant
60
50
40
30
20
10
0
FY2008
Q12009
Q22009
Q32009
Q42009
Q12010
Q22010
Q32010
Q42010
Infection Control Compliance
100
90
80
70
% Compliant
60
Accurate Isolation Signs
Isolation Doors Closed
50
Proper PPE
No Food/Drink in Pod
40
Sharps Less Than 3/4 Full
30
20
10
0
FY2008
Q12009
Q22009
Q32009
Q42009
Q12010
Q22010
Q32010
Q42010
Processes
Procedures
Poor
communication
Lack of standardized
approach to mobilization
Nasal intubation
Surgery (Head and
Neck, GI, Thoracic)
Lack of standardized approach to daily
sedation holidays
Re-intubation
Need for nasogastric or
nasoenteral tubes
Poor Hand hygiene
Poor adherence to
protocols
Infection Control Policies
Prolonged hospital
stay
Prolonged time on the
ventilator
Sedation level
Immobilization
Lack of standardized approach to
assessing readiness for weaning and
extubation
Respiratory Care
Policies
Patient
Head of bed
elevation
Poor adherence to
policies
Ventilators
Endotracheal tubes
Beds
Nursing Polices (oral care)
Lack of knowledge
Critical Care Policies – ICU
Admission/Discharge Criteria
Facility (ICU),
equipment
Workforce
Policies
(RT, RN, MD, MLP,
Residents, PT/OT)
Risk Factors for
Developing VAP
SICU Ventilator-Associated Pneumonia
FY03 - FY10
Sample Count Per Unit
60
_Stage 1
U=18.62
Stage
2
_
U=10.09
_Stage 3
U=2.62
_Stage 4
U=0
50
40
30
20
10
0
2
03
04
04
05
06
07
07
08
09
10
-0
r
r
r
r
r
e
e
e
e
ne
ch
ne
ch
ne
ch
r
r
r
be
b
b
b
b
u
u
u
a
a
a
J
J
J
M
M
M
em
em
em
em
em
t
t
t
c
c
p
p
p
e
e
D
D
Se
Se
Se
Month
LEGEND
Control Limits (Upper and Lower)
Average (U)
MICU Ventilator-associated Pneumonia: FY10
incidence per 1000 ventilator days
NHSN = 2.8
0.8
0.4
FY10 incidence rate
0.4
NHSN = National Healthcare Safety Network Surveillance 50 th percentile
Infection Control - Confidential
P Williams 9/21/2010
VAP attributed ICU LOS =
22 days
22 patient-days/month
avoided
12 cases/year X 22 = 264
patient-days/year/case
VAP case attributed
mortality = 20-30%
1 case/month
prevented
12 cases/year X 0.25
= 3 lives saved/year
VAP case cost =
$57,000
6/2003 - 5/2010 =
84 months
$57,000 X 84
=$4,788,000
Our hypothesis was
confirmed. As a result of
these interventions, VAP was
successfully controlled and
the rate reduced to zero
These results clearly
indicate that the entity
recognized as VAP today
is preventable, even in
this particularly vulnerable
cancer population
A multidisciplinary team
approach that combines
continuous education with
evidence-based interventions
can eradicate VAP while
significantly impacting outcomes
and healthcare costs
We were able to
replicate the
significant
improvements of our
infection control
program in the MICU
In the process, we
achieved Institutional and
major national safety
goals with great benefits
for our patients and the
healthcare system
We strongly
recommend adopting
our VAP prevention
program
“Whoever saves one life saves the world entire”
Babylonian Talmud Tractate ,
Mishnah Sanhedrin 4:5; Sanhedrin 37a
“Thank you”