Significantly Decreasing Ventilator-Associated Pneumonia Incidence in 2 Adult ICUs
Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs in patients
intubated and ventilated at the time of or within 48 hours before the onset of the pneumonia.1-3
VAP is the most commonly reported hospital-acquired infection among patients requiring
mechanical ventilation. Current estimates of VAP rates range from 1 to 4 incidents per 1000
ventilator days, with rates exceeding 4 in some neonatal and surgical patient populations.4,5
VAP is often associated with increased morbidity and mortality, extended length of stay in the
intensive care unit (ICU), and increased economic expenditures.
The “ventilator bundle” proposed by the IHI to prevent VAP includes implementation of 4
components of care: elevation of the head of the bed to between 30 and 45, daily sedation
interruptions, daily assessment of readiness to extubate, and prophylaxis for peptic ulcer
disease and deep venous thrombosis. The SHEA strategies for monitoring and preventing VAP
include education of healthcare personnel, direct observation of compliance with VAP-specific
processes, active surveillance for VAP, implementation of practices and policies for cleaning
respiratory equipment, checking for proper patient positioning, performance of regular oral care,
and provision of noninvasive ventilation options within the hospital system.6
The Joint Commission’s National Patient Safety Goal (NPSG) #138 encourages the
active involvement of patients in their own care as a patient safety strategy. This includes
educating patients and their families about the methods available for reporting concerns related
to patient care, treatment, safety, and services.
Despite implementation of the IHI and SHEA clinical prevention measures, cases of VAP
have continued to be reported. In an attempt to reduce and/or eliminate the incidence of VAP, a
quality improvement (QI) initiative was undertaken in 2007 that incorporated changemanagement and education strategies in order to increase compliance with our VAP-prevention
measures and NPSG #13.
The following modifications were made:
1. Increased tracking of compliance with the VAP-prevention bundle.
2. Additional compliance tracking to ensure every 2 hour oral care (measured product usage
and ventilator days).
3. Intensive change-management strategies, including an evidence-based caregiver bundle
and oral-care-protocol education using a multidisciplinary team approach.
4. Perform Oral Cleansing Every 2 Hours
a. Replace covered oral suction device every 24 hours.
b. Use suction toothbrush twice a day.
c. Remove any oral appliances prior to brushing. Brush teeth and gums using suction
toothbrush with q2h oral care kit consisting of a cetylpyridinium chloride (CPC)
suction toothbrush and swabs treated with hydrogen peroxide plus CPC solution.
Brush for approximately 1-2 minutes. Suction after brushing is complete to remove
any particles in the mouth. Gently brush the surface of the tongue.
d. Use suction swabs every 2 hours to clean teeth and tongue.
e. Follow suction with moisturizer to lips and oral mucosa.
f. Perform deep oropharyngeal suctioning as needed to assist in removing secretions.
Use disposable suction catheter to perform this task.
5. Invite responsible family members to perform non-suction tasks when appropriate utilizing
green swabs with mouth moisturizer, or assisting with maintaining head of bed at least 30
degree elevation.
6. Hang poster in room and discuss with family.
7. Wash hands, start assessment with ETT then proceed to oral care and remaining
assessment.
8. Keep head of bed elevated to at least 30 degrees at all times.
9. Provide daily “sedation vacation” coupled with daily assessment of the patient’s readiness
for weaning.
10. Resuscitation bags should never be placed on the bed. Hang at bedside and replace when
visibly soiled.
11. Ballard suction catheters will remain continuously attached to suction tubing and will be
changed when visibly soiled or mechanically malfunctioning.
12. Reduce inadvertent extubations. Diligently check ETT stabilization, document date and time
on tape, change tape and positioning of tube a minimum of every 24-48 hours.
13. Keep ETT cuff pressures between 20 and 30 cmH2O.
14. Staff empowerment and awards for protocol compliance.
15. Development of family education and involvement posters.
16. Ongoing qualitative metrics to understand the need for additional education and changemanagement strategies and to identify knowledge gaps that should be addressed.
17. Quantitative metrics that demonstrate compliance and VAP rates and the need to visually
share this information with staff on an ongoing basis.
RESULTS
The results indicated that compliance with the oral care protocol increased from 30% in July
2006 to 96% by the end of 2008, and the VAP rate decreased from a rate of 1.9 (4/2089 per
1000 ventilator days) to 0.28 (2/7229 per 1000 ventilator days) during this time period. An 85%
relative reduction in the VAP rate was achieved, which was found to be statistically significant
(test statistic = 6.76, p = 0.009).
REFERENCES
1. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical
intensive care units in the United States: National Nosocomial Infections Surveillance
System. Crit Care Med 1999;27:887-892.
2. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of
ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33:2184-2193.
3. Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH. The occurrence of ventilator-associated
pneumonia in a community hospital. Chest 2001;120:555-561.
4. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcareassociated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
5. Institute for Healthcare Improvement. Ventilator-associated pneumonia (VAP) rate per 1000
ventilator days [Internet].
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Measures/VentilatorAss
ociatedPneumoniaRateper1000VentilatorDays.htm. Accessed December 19, 2009.
6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to
prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp
Epidemiol 2008;29(suppl 1):S31-S40.