Vanishing VAE
Introduction
Mechanical ventilation is an essential, life-saving therapy for patients in the modern intensive care unit (ICU).
Unfortunately, mechanical ventilation can increase patients’ risk of developing ventilator-associated events (VAE)
such as ventilator-associated pneumonia (VAP). It is estimated that 10-20 percent of ventilated patients develop
VAP [1]. VAP is associated with increased lengths of ICU and hospital stay, extended duration of mechanical
ventilation, increased mortality rates, increased use of antimicrobials, and increased costs [1,2,3]. VAP is the
most common and associated with the highest mortality among hospital-onset infections that occur in the ICU
setting [2,3].
VAP develops as a result of microorganisms reaching the normally-sterile lower respiratory tract. A major risk
factor for developing VAP is oropharyngeal colonization by the patient’s flora or by microorganisms acquired from
the environment – in particular the hands of healthcare personnel, in addition to contaminated respiratory
equipment, water, fomites, and air [3]. The greatest risk for developing VAP occurs early on during ventilation and
then decreases over time.
Evidence-based interventions can reduce the risk of complications and the occurrence of VAE. Examples of
essential prevention measures include excellent hand hygiene, patient positioning and mobilization, oral care,
managing oropharyngeal and tracheal secretions, and sedation vacation.
The Vanishing VAE work group was convened by the Minnesota Hospital Association under CMS’ Partnership for
Patients to develop and pilot a VAE bundle using rapid cycle improvement methodology. Led by VAE experts
from St. Cloud Hospital, the interdisciplinary group included professionals from Hennepin County Medical Center,
Sanford Bemidji Medical Center, and Essentia Health-Fosston.
1. Klompas M, Branson R, Eichenwald EC, et al. Strategies to Prevent Ventilator-Associated Pneumonia in
Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. 2014;35:915-936.
2. Bonten MJM, Kollef MH, Hall JB. Risk Factors for Ventilator-Associated Pneumonia: From Epidemiology
to Patient Management. Clinical Infectious Diseases. 2004;381141-1149.
3. Sadfar N, Crnich CJ, Maki DG. The Pathogenesis of Ventilator-Associated Pneumonia: Its Relevance to
Developing Effective Strategies for Prevention. Respiratory Care. 2005;50:725-741.
The Minnesota Vanishing VAE Bundle
The Vanishing VAE bundle is a succinct approach to VAE prevention for hospitals of all sizes. It covers patient
education, ventilator settings, elevation of the head of the bed, sedation vacation/ spontaneous breathing trial,
oral care, early progressive mobilization, documentation, and staff education. The bundle elements are supported
by CDC/HICPAC, Association for Professionals in Infection Control and Epidemiology (APIC), Society for
Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), American
Association of Critical-Care Nurses, and American Thoracic Society guidance documents. The Vanishing VAE
tool kit is a collection of supporting documents, resources, and tools to assist hospitals in implementing VAE
prevention strategies.
VAE Prevention Bundle Resources
VAE Prevention Guidance Documents
Society for Healthcare Epidemiology of America (SHEA)
Klompas M, Branson R, Eichenwald EC, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute
Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. 2014;35:915-936.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of
adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Resp Crit
Care Med. 2005;171:388-416. Available at:
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/HAP.pdf
American Association of Critical-Care Nurses. PracticeAlert. Ventilator-associated Pneumonia.
http://www.aacn.org/wd/practice/docs/practicealerts/vap.pdf
Tools for VAE prevention
Johns Hopkins Armstrong Institute for Patient Safety and Quality
CUSP for Mechanically Ventilated Patients - Ventilator Associated Pneumonia
(CUSP 4 MVP-VAP)
https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx
Health Research & Educational Trust, American Hospital Association, Partnership for Patients Ventilator
Associated Events (VAE) Change Package: Preventing Harm from VAE 2014 Update
http://www.hret-hen.org/index.php?option=com_content&view=article&id=10&Itemid=134
IHI How-to Guide: Prevent Ventilator-Associated Pneumonia
http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx
AHRQ Safe Critical Care Project: Testing Improvement Strategies
Hospital Corporation of America (HCA) and Vanderbilt University collaborative to compare the effectiveness of
two approaches to implementing evidence-based medicine practices in Critical Care.
https://innovations.ahrq.gov/qualitytools/safe-critical-care-project-testing-improvement-strategies
Centers for Medicare & Medicaid Services Partnership for Patients Resources: Ventilator-associated
Pneumonia (VAP)
http://partnershipforpatients.cms.gov/p4p_resources/tsp-ventilator-associatedpneumonia/toolventilatorassociatedpneumoniavap.html
Klompas M, Anderson D, Trick W, et al. The Preventability of Ventilator-Associated Events: The CDC Prevention
Epicenters’ Wake Up and Breathe Collaborative. American Journal of Respiratory and Critical Care Medicine.
2014. Published online at http://www.atsjournals.org/doi/pdf/10.1164/rccm.201407-1394OC
Sedwick MB, Lance-Smith M, Reeder SJ. Using Evidence-Based Practice to Prevent Ventilator-Associated
Pneumonia. Critical Care Nurse. 2012;32:41-50. Available at: http://www.aacn.org/wd/Cetests/media/C1242.pdf
ARDS Prevention Guidance
MacIntyre N. American Thoracic Society. Guidelines for Alternative Modes of Ventilation Used in the Management
of Patients with ARDS. http://www.thoracic.org/clinical/critical-care/refractory-ards/pages/alternative-modes.php
Saguil A, Fargo M. Acute Respiratory Distress Syndrome: Diagnosis and Management. Am Fam Physician.
2012;15:352-358. Available at http://www.aafp.org/afp/2012/0215/p352.html