How to Collect and Monitor Ventilator Associated Pneumonia Rates
Contents:
1) CDC Definition of Ventilator Associated Pneumonia
2) Sample Ventilator Bundle Checklist
3) Sample Ventilator Bundle Audit Form
4) Sample Ventilator Bundle Checklist
5) Measurement Information Form: Ventilator-Associated Pneumonia Rate in ICU
6) Sample Collection Tool for Ventilator Days
7) Sample Collection Tool for Ventilator and CVC Days
8) Sample Collection Tool for Device Days
9) Sample Collection Tool for Device Days
10) Sample Ventilator Associated Pneumonia Brochure
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CDC/NNIS Ventilator-Associated Pneumonia Definition
Pneumonia must meet at least one of the following criteria:
Criterion 1. Patient has rales or dullness to percussion on physical examination of the chest and at least one of the
following:
a.
new onset of purulent sputum or change in character of sputum
b.
organisms cultured from blood
c.
isolation of an etiologic agent from a specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
Criterion 2. Patient has a chest radiographic examination that shows new or progressive infiltrate, consolidation,
cavitation, or pleural effusion and at least one of the following:
a.
new onset of purulent sputum or change in character of sputum
b.
organisms cultured from blood
c.
isolation of an etiologic agent from a specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
d.
isolation of virus from or detection of viral antigen respiratory secretions
e.
diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for
pathogen
f.
histopathologic evidence of pneumonia
Criterion 3. Patient < 1 year of age has at least two of the following signs or symptoms: apnea,
Tachypnea, bradycardia, wheezing, rhonchi, or cough and at least one of the following:
a.
increased production of respiratory secretions
b.
new onset of purulent sputum or change in character of sputum
c.
organisms cultured from blood or diagnostic single antibody titer (lgM)
or fourfold increase in paired sera (lgG) for pathogen
d.
isolation of an etiologic agent from a specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
e.
isolation of virus from or detection of viral antigen in respiratory secretions
f.
histopathologic evidence of pneumonia
2
Criterion 4: Patient < 1 year of age has a chest radiologic examination that shows new or progressive infiltrate, cavitation,
consolidation, or pleural effusion and at least one of the following:
a.
increased production of respiratory secretions
b.
new onset of purulent sputum or change in character of sputum
c.
organisms cultured from blood or diagnostic single antibody titer (lgM)
or fourfold increase in paired sera (lgG) for pathogen
d.
isolation of an etiologic agent from a specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
e.
isolation of virus from or detection of viral antigen in respiratory secretions
f.
histopathologic evidence of pneumonia
COMMENTS:
 Expectorated sputum cultured are not useful in the diagnosis of pneumonia but may help identify the
etiologic agent and provide useful antimicrobial susceptibility data.
 Findings from serial chest x-rays may be more helpful than a single x-ray.
Ventilator-Associated Pneumonia (VAP)
The same measure for ventilator-associated pneumonia was endorsed in both the hospital and the nursingsensitive care projects. A synopsis of the measure is as follows:4
Adults
Numerator: number of ventilator-associated pneumonias x 1000; Denominator:
number of ventilator-days for ICU patients; Exclusions: None
Pediatric
Numerator: Number of ventilator-associated pneumonias x 1000; Denominator:
number of ventilator-days for patients; Exclusions: None
3
VENTILATOR BUNDLE CHECKLIST
(Individual Patient)
Patient:______________________
Admit Date:___________________
ICU Day
1
2
3
4
5
6
7
8
9
10
1. Head of the Bed 30O










2. Daily Sedation Vacation










3. Daily Assessment
of readiness to wean










4. Daily Spontaneous
Breathing Trial










5. PUD Prophylaxis










6. DVT Prophylaxis










4
VENTILATOR BUNDLE CHECKLIST
Date
Bed/Pt
Initials
HOB
>
30O



















Daily
Sedation
Vacation
Daily
assessment
of
Readiness
to wean






































Daily
Spontaneous
PUD
breathing
Prophylaxis
trial






































DVT
Prophylaxis



















5
Ventilator Bundle Audit Form
Date
Patient
SS #
HOB up 30
degrees or
higher
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Stress Ulcer
Prophylaxis w/in
24 hrs
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
DVT
Prophylaxis w/in
24 hrs
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Yes/Unable
No
Daily sedation
vacation
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Daily Assessment
of readiness to
wean
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Daily Spontaneous
Breathing Trial
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
Yes/Unable/NA
No
6
Patient:
DOB:
Date:
Action: ↑ HOB >
Procedure
Elevate head (and chest) > 30º
Report Date:
Date:
Date:
30º
Time
Init.
Prophylactic treatment for deep
venous thrombosis
Time
Init.
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
3-11
11-7
7-3
3-11
11-7
7-3
3-11
3-11
11-7
7-3
3-11
11-7
7-3
3-11
3-11
11-7
7-3
3-11
11-7
7-3
3-11
Action: :
 RT to check for
readiness to wean
11-7 7-3
3-11
11-7
3-11
11-7
7-3
3-11
Action:  TED
socks
 Turn q
_____
:
11-7
7-3
Action: 
Rx_________
:
Treatment for peptic ulcer
disease
Time
Init.
11-7
7-3
Action:  Sedation
vacation
daily
:
Sedation Vacation (interruption
of sedation to point of alertness)
11-7
7-3
Time
Init.
Assessment for Readiness to
Wean
Time
Init.
7-3
Action: :
 RT to check for
spontaneous breath
Test spontaneous breathing
capability daily
(T tube or other means)
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
Time
Init.
Action: * Gluc
WNL
 WBG q_______
 Insulin coverage
Insulin therapy to keep blood
sugar between
80-110
11-7
7-3
3-11
Time
Init.
7
Measurement Information Form:
Ventilator-Associated Pneumonia (VAP) Rate in ICU
Per 1000 Ventilator Days
Calculation Details
Numerator Definition: Total number of VAP cases in the ICU during the set time interval
Denominator Definition: Total number of ventilator days in the ICU in same time interval used in numerator
Definition of Terms:

Ventilator-Associated Pneumonia: Nosocomial pneumonia in a patient on mechanical ventilatory
support (by endotracheal or tracheostomy) for greater than or equal to 48 hours.

Ventilator Day: Total number of days of exposure to ventilators by all patients in the selected
population during the selected time period
Related Websites:
http://www.cdc.gov/ncidod/hip/NNIS/members/pneumonia/Final/PneumoCriteriaV1.pdf
http://www.cdc.gov/ncidod/hip/NNIS/NosInfDefinitions.pdf
Measurement Period: Measure monthly
Calculate as: (Number of Ventilator-Associated Pneumonias / Number of ventilator days)
x 1000 = VAP rate per 1000 ventilator days
Example of VAP Rate
For example, if in February there were 12 cases of VAP, the number of cases would be 12 for that month.
Thus, if 25 patients were ventilated during the month and each, for purposes of example, was on mechanical
ventilation for 3 days, the number of ventilator days would be 25x3=75. The Ventilator-Associated Pneumonia
Rate per 1000 ventilator days then would be 12/75 x 1000 = 160 per 1000 ventilator dates.
(Total number of VAP cases/Ventilator Days) x 1000 = VAP Rate
8
Vent Days
Unit: ____________
Date: ____________
# of Patients
Sunday
___________________
Monday
___________________
Tuesday
___________________
Wednesday
___________________
Thursday
___________________
Friday
___________________
Saturday
___________________
Total:
___________________
Please leave sheet on the unit assignment clipboard for the charge nurse to complete every
morning with the day shift assignment
Count the number of patients each day that are on the ventilator.
Sheets should be sent to the Infection Control Department at the end of the month
9
VENTILATOR AND CENTRAL VENOUS LINES MONTHLY REPORT
The Infection Control Committee greatly appreciates your help with CVL surveillance. The magnitude of the potential to cause
morbidity and mortality resulting from infectious complications has been well documented. Treatment of line related infections are
estimated to cost between $34,000 to greater than $56,000 per patient.
INSTRUCTIONS:


Please document the date and unit in the appropriate blanks following instructions.
Please count the number of patients with central venous lines every day at the same time and
record the number in the second column.
 A separate column requests the number of patients with catheters for dialysis. Do not include these
in the total number of central lines.
 Please do the same count of the number of patients on the ventilator.
 PLEASE NOTE THE UPDATED DEFINITION OF CENTRAL LINES. PLEASE DO INCLUDE THE
FOLLOWING:
PICC, Long arm Groshong, Broviac, Hickman, IABP, IJ, Portacath, Double or triple lumen
catheters regardless of site and Swan
 Please submit this form to Infection Control by the end of the first week of each month.
THANKS!
Month and Year: _________________________
Unit: ______________
Date
Total # of
Patients with
Central Lines
Total # Patients with
Dialysis Catheters
Total # of Patients
on Ventilator
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
10
NATIONAL NOSOCOMIAL INFECTIONS SURVEILLANCE SYSTEM
ADULT AND PEDIATRIC INTENSIVE CARE UNIT (ICU) MONTHLY REPORT FORM
NNID# ___________
Month and Year: ______________
Circle type of ICU: Burn
Coronary Care
Respiratory
Surgical
Hospital’s code for this ICU: _________
CardioThoracic
Medical
Trauma
Other (specify): _________________________
Number of patients in ICU . . . . . . . First Day of Month: ___________________
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
# New Arrivals
# Patients
Indwelling urinary catheter
Med/Surg
Neurosurgical
Pedatric
First Day of Next Month: ___________________
Number of Patients with:
Central line(s)
Ventilator
Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a
guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the
individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and m(d)).
Public reporting burden of this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE,
MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0012).
CDC 57.58B REV. 9-00
IDEAS Version 6.06
11
May
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
3
4
5
6
7
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
10
11
12
13
14
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
15
16
17
18
19
20
21
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
22
23
24
25
26
27
28
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
29
30
31
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
8
# pts. with C
lines___
# of vent
pts.______
# pts. with C
lines___
# of vent
pts.______
9
2005
12

Remember to order daily “sedation vacations” on
your patients receiving continuous intravenous
sedation so that assessment of readiness to wean
from mechanical ventilation can be completed on
AM rounds.
Each day, document in your notes your clinical
impressions regarding the patients’ potential for
weaning on that day.
Remember to order any additional testing (labs,
blood gases, CXR, weaning parameters) that you
feel will assist you in this assessment process on
the next morning rounds with your attending
physician.
Inform the nurse promptly after placing an order
for a spontaneous breathing trial so that it can be
initiated promptly.
 Peptic ulcer disease (PUD) prophylaxis.
The IHI (2005) has found that when PUD
prophylaxis is applied as part of a set of
interventions for ventilator care, the rate of
pneumonia decreases precipitously.
What is your role in the process? Please
remember to order PUD prophylaxis on all
mechanically ventilated patients.

Deep venous thrombosis (DVT)
prophylaxis (unless medically
contraindicated).
The IHI (2005) has found that when DVT
prophylaxis is applied as part of a set of
interventions for ventilator care, the rate of
pneumonia decreases sharply.
What is your role in the process? Please
remember to order DVT prophylaxis on all
mechanically ventilated patients.
other mechanisms to reduce vap at
the Dayton, VAMC:


A gastric tube management and tube
feeding protocol for mechanically
ventilated patients.
A repositioning and head of the bed
elevation protocol for mechanically
ventilated patients
A trial of endotrachial tubes that have a
dorsal lumen to facilitate the removal of
subglottic secretions.
thank you!
Thank you for your assistance in this process. You
will also receive an instruction sheet that will assist
you in the ordering of protocols that can make the
process easier.
The Dayton VAMC
Ventilator Associated
Pneumonia (VAP)
Reduction Program
References:
1.
Drakulovic, M.B., Torres, A., Bauer, T.T., Nicolas, J.M., Nogue,
S., & Ferrer, M. (1999). Supine body position as a risk factor for Nosocomial
pneumonia in mechanically ventilated patients: a randomized trial. Lancet,
354, 1851 – 1858.
2.
Ely, E.W., Baker, A.M., Dunagan, D.P., Burke, H.L., Smith,
A.C., Kelly, P.T., et al. (1996). Effect on the duration of mechanical
ventilation of identifying patients capable of breathing spontaneously. New
England Journal of Medicine, 335, 1864 – 1869.
Date of publication
3.
Institute for Healthcare Improvement. (2005). Getting started
kit: preventing ventilator associated pneumonia. Boston, MA.
4.
Kress J.P., Pohlman A.S., O'Connor M.F., & Hall, J. B. (2000).
Daily interruption of sedative infusions in critically ill patients undergoing
mechanical ventilation. New England Journal of Medicine, 20, 1471 – 1477.
5.
Rello, J., Ollendorf, D.A., Oster, G., Vera-Llonch, M., Bellm, L.,
Redman, R., & Kollef, M.H. (2002). VAP Outcomes Scientific Advisory
Group: Epidemiology and outcomes of ventilator-associated pneumonia in
a large US database. Chest, 6, 2115 – 2121.
6.
Richards, M.J., Edwards, J.R., Culver, D.H., & Gaynes, R.P.
(2000). Nosocomial infections in combined medical-surgical intensive care
units in the United States. Infection Control Hospital Epidemiology, 21, 510
– 515.
7.
Tablan, O.C., Anderson, L.J., Besser, R., Bridges, C., &
Hajjeh, R. (2004). Healthcare Infection Control Practices Advisory
Committee. Guidelines for preventing health-care–associated pneumonia,
2003 recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee. Morbidity and Mortality Weekly Report
Recommendations and Reports, 2004, 53, 1 – 36.
Some other interventions that the facility is utilizing
to reduce VAP are:
 An oral care protocol for all mechanically
ventilated patients.
13
Welcome to the critical care units of the dayton,
vamc!
The attending physicians and nurses of the
Dayton, VAMC Intensive Care and Coronary Care
Units hope that your rotation through our facility will
be an enjoyable and sentinel learning experience
for you.
Our facility has adopted an assertive approach in
the prevention of VAP at our institution and we
need your help. You are a pivotal element of our
process.
WHY SHOULD VAP BE
PREVENTED?
The Centers for Disease Control and Prevention
(CDC) have found that pneumonia causes 15% of
all hospital-acquired infections and is the leading
cause of nosocomial infection related death
(Tablan, Anderson, Besser, Bridges, and Hajjeh,
2003). The mortality rate of patients with VAP is
higher than that of uninfected patients (50% versus
34%) and varies between the populations
considered (Warren, et al., 2003).
Rello, et al. (2002) found that VAP increases a
patient’s length of stay in the ICU by 6.1 days and
hospitalization by 10.5 days. This study also found
length of stay and the additional need for antibiotics
significantly impact health care expenditures by
adding an estimated $16,050 to $41,294 to the cost
of a hospital admission. Additionally, VAP has been
reported to be the most common hospital-acquired
infection among patients requiring mechanical
ventilation in the United States (Richards, Edwards,
Culver, and Gaynes, 1999).
HOW CAN VAP BE
PREVENTED?
The Institute for Healthcare Improvement (2005)
has developed a system of intervention sets which
they term care bundles. Care bundles, in general,
are groupings of best evidenced based practices
with respect to a disease process that individually
improve care. When the groupings are applied
together the result is substantially superior
improvement.
The ventilator bundle is a group of evidence
based practices that, when placed into daily
practice for all patients on mechanical ventilation,
result in a dramatic reduction in the incidence of
VAP. With this in mind, our facility has adopted the
ventilator bundle into the daily care of ventilated
patients in the ICU and CCU of our institution
IHI (2005) PROGRAM
OVERVIEW AND YOUR ROLE
IN THE PROCESS:
The ventilator IHI bundle has four
components:
Elevation of the patients’ head of the
bed to between 30 and 45 degrees
(unless medically contraindicated).
In a randomized controlled trial conducted by
Drakulovic, et al. (1999) it was found that when
intubated patients on mechanical ventilation were
assigned to semi-recumbent positioning (30 to 45
degrees), there were 18% fewer confirmed cases
of VAP.

sedation per protocol until the patient was awake or
interruption only at the clinician’s discretion, the
duration of ventilation was decreased from 7.3 days
to 4.9 days in the group randomized to routine
awakening per protocol.
Ely, et al. (1996) found, in a randomized,
controlled trial involving 300 adult patients receiving
mechanical ventilation in medical and coronary
intensive care units, that daily systematic screening
of the respiratory function of adults receiving
mechanical ventilation reduced the duration of the
mechanical ventilation from a median of 6 days to
median of 4.5 days and reduced the hospitalization
costs from a median of $20,890 to a median of
$15,740.
What is your role in the process? When utilizing
continuous intravenous sedation, order that the
sedation be titrated to a specific sedation level. The
critical care units of our facility currently utilize a
modified Ramsay Scale to monitor intravenous
sedation. We suggest, in most ventilated patients,
that a target sedation level of ‘4’ is a good place to
start.
What is your role in the process? Please order
that the head of the bed be elevated to between 30
and 45 degrees on all of the ventilated patients that
you care for (if not contraindicated). Note the head
of the bed position of your ventilated patient during
your rounds and remind the nursing staff if the
height is too low. Remember, however, that for
certain procedures (linen changes, repositioning)
nurses do (briefly) lower the head of the bed to
prevent back injuries.
Daily “sedation vacation” AND daily
assessment of readiness to extubate
(unless medically contraindicated).
Kress, Pohlman, O’Conner, and Hall (2000)
found that when 128 adults on mechanical
ventilation were randomized to daily interruption of
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