Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs in patients who are 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.1 Estimates of VAP rates in the intensive care unit (ICU) range from one to four incidents per 1,000 ventilator days, with rates exceeding four in some neonatal and surgical patient populations.4,5 VAP accounts for more than 80% of nosocomial pneumonia infections and is associated with increased mortality rate, longer hospital stay, increased hospitalization costs, and increased morbidity.1-6 Male trauma admission and intermediate predicted risks of mortality are independent risk factors associated with VAP.7 Patients with VAP spend an average of 9.6 additional days on mechanical ventilation, 6.1 additional days in the ICU, and 11.5 additional days in the hospital.6
Epidemiology and Prevention
In a systematic literature review of articles published after 1990, VAP was found to occur in 10% to 20% of patients receiving mechanical ventilation for >48 hours.2 Critically ill patients who develop VAP appeared to be twice as likely to die than similar patients without VAP (pooled odds ratio: 2.03) and also have longer lengths of stay in the ICU (mean: 6.10 days).2 Furthermore, the development of VAP is associated with additional hospital costs of at least $10,019 per patient.2 Given the increased mortality, morbidity, and hospitalization costs associated with VAP, national efforts have been undertaken to identify effective strategies for VAP prevention.
VAP prevention measures have been advocated by various entities, including the Institute for Healthcare Improvement (IHI)7 and the Society for Healthcare Epidemiology of America (SHEA).8
The “ventilator bundle” proposed by the IHI to prevent VAP suggests implementation of four components of care: 1) elevation of the head of the bed to between 30° and 45°; 2) daily sedation interruptions; 3) daily assessment of readiness to extubate; and 4) prophylaxis for peptic ulcer disease and deep venous thrombosis.7
The SHEA strategies for monitoring and preventing VAP include education of health care personnel, direct observation of compliance with VAP—specific prevention processes, active surveillance for VAP, implementation of practices and policies for cleaning respiratory equipment, assurance of proper patient positioning, performance of regular oral care, and provision of noninvasive ventilation options within a hospital system.8
Despite implementation of the IHI and SHEA VAP prevention measures, cases of VAP continued to be reported in Central duPage Hospital’s two ICUs. A VAP prevention quality improvement (QI) project was initiated in 2007 in an attempt to reduce the incidence of VAP, which combined the clinical efforts of the nursing and respiratory therapy teams. The QI initiative was felt to be successful, and Institutional Review Board (IRB) approvals were sought to retrospectively analyze the results of our QI initiative, and prospectively study VAP prevention efforts for an additional year through end-July 2011.
The objective of this outcomes story is to share our evidence-based approach to VAP prevention, including the interdisciplinary team approach, interventions, and keys to successful change management; how we measured the effectiveness of our efforts; and how we determined that our approach was a long-term, sustainable approach for VAP prevention.
Clinical Setting and Design. The clinical setting for this VAP prevention QI initiative were two 16-bed ICUs. After the QI project was felt to be successful, permission was obtained from the facility’s IRB to analyze the QI data retrospectively, and prospectively study the VAP prevention initiative for an additional year.
Institutional Review Board Approval. An expedited review was conducted by the IRB as authorized by the Department of Health and Human Services (45 CFR 46.110), which determined that the proposed research involved no more than minimal risk to human subjects and was approved under category 5 (documentation of informed consent). The study met all criteria for approval. The IRB waived the requirement for seeking prospective informed consent under the DHHS regulations at 45 CFR 46.116(d).
Interdisciplinary Team. An interdisciplinary team was formed that included representatives from the nursing and respiratory care teams in an effort to combine nursing and respiratory care efforts and collaborate on improving patient outcomes. The team included the clinical practice specialist in respiratory care, physicians, registered nurses, respiratory care practitioners, and infection preventionists.
The team conducted a review of the literature and determined which best practices, change-management strategies, and educational strategies were most applicable for the facility and clinical setting for successful VAP prevention efforts.
Literature Review. The literature review included a search of the US National Library of Medicine PubMed database utilizing the MeSH terms “Pneumonia, Ventilator-Associated” and “Evidence-Based Practice” between January 1, 2005 and January 1, 2007. The search identified 10 articles.11-20 The review assessed best practices in VAP prevention, change-management strategies, and educational strategies for preventing VAP. Updated recommendations (2008) from the IHI7 on VAP prevention were also downloaded from the IHI Web site.
Interventions. The team identified the need for the following evidence-based interventions in VAP prevention:
- Utilize validated plan-do-check-act methodology for developing, implementing, and monitoring a VAP prevention initiative that ensures best practices in VAP prevention are in place at the patient’s bedside
- Improve communications regarding VAP prevention between health care staff and families of critically ill patients using education
Definition of VAP
At the beginning of the VAP prevention initiative, the CDC defined VAP by the criteria of the National Nosocomial Infections Surveillance System, which was changed to the National Healthcare Safety Network (NHSN) in 2008. The definition of VAP is: “pneumonia in persons who had a device to assist or control respiration continuously through a tracheostomy or by endotracheal intubation within the 48-hour period before the onset of infection, inclusive of the weaning period.”21
The infection control team received all positive sputum cultures and reported this information to the manager of respiratory care services. A process was then initiated for determining whether the patient met the NHSN definition of VAP. Sputum culture-confirmed infections were reviewed by a team consisting of infection control team members, the medical director of infection control, the medical director of adult ICUs, the medical director of quality and safety services, and the clinical practice specialist in respiratory care.
Plan-Do-Check-Act Approach to VAP Prevention
An action plan was developed by the interdisciplinary team using “plan-do-check-act” methodology,22 and was reviewed on an ongoing basis. The plan included benchmark dates and objectives for completing the QI project. The action plan also identified milestones, each with a detailed description, start and end date, responsible team member (primary, support, and resource), milestone status, and a section for miscellaneous comments.
The VAP prevention efforts on the units already included the IHI ventilator bundle; however, a protocol incorporating additional oral care and efforts to ensure compliance with both the ventilator bundle and oral care was developed by the interdisciplinary team. The protocol included the components of the preexisting IHI ventilator bundle, use of an every-2-hour oral care kit consisting of suction toothbrush and swabs and cetylpyridinium chloride (CPC) cleansing solutions, and detailed guidance on change-management strategies and compliance monitoring.
An “Adult Respiratory Performance Improvement Monitor” flow sheet (Figure 1) was used on an ongoing basis to ensure compliance with the VAP prevention bundle. Individually packaged oral care kits, consisting of suction toothbrushes and swabs with hydrogen peroxide and CPC solutions, were kept at each patient’s bedside. Each time a kit was used (by a nurse, respiratory care practitioner, or family member), the time when the next cleaning was due was indicated with a black marker on the kit. Use of the flow sheet, visibility of the kit, and time of the next cleaning served as a constant reminder to nurses and family as to when the next oral care treatment was due. In addition, a tool was integrated into the electronic medical record to provide visual reminders of all aspects of the IHI ventilator bundle.
Comprehensive and mandatory in-service training was provided for all respiratory care practitioners and registered nurses. The in-service training reemphasized the importance of the IHI ventilator bundle, every-2-hour oral care, and the preventable nature of VAP. Hourly rounds were initiated, and the nurses and clinical staff met frequently to provide updates on clinical care and the needs of individual patients. A total of 25, 1-hour in-service training sessions were provided from November 2006 through December 2006 for different shifts, for different days, and on weekends. The educational program reviewed the oral care protocol and supportive studies on the effectiveness of oral care, VAP prevention strategies, and the team’s goal for reaching 0 VAPs. The concept of “peers monitoring peers” also was introduced in these educational sessions. In addition, “ZAP VAP” posters and associated scripts for family members were described, discussing National Patient Safety Goal #13 (encourage patient’s active involvement in their own care as a patient safety strategy) and why family member education was important in the clinical environment.
Compliance with the ventilator bundle and oral care protocol was monitored by the clinical practice specialist in respiratory care, who reviewed the “Adult Respiratory Performance Improvement Monitor” flow sheets on an ongoing basis. In addition, the clinical practice specialist in respiratory care reviewed ventilator-days and product-ordering ratios to ensure appropriate amounts of oral care product were ordered based on the number of ventilator-days.
If compliance was greater than 90% with the ventilator bundle, the clinical practice specialist in respiratory care communicated this positive outcome during staff meetings. If compliance dropped to less than 80%, she raised concerns and reeducated staff on the importance of adhering to the oral care protocol for VAP prevention during staff meetings.
A best practices program was initiated whereby clinicians were provided incentives to comply with the VAP prevention protocol. Individual incentives were $5 gold coins that could be used in the cafeteria or gift shop and were provided to the clinical practice specialist in respiratory care by the administration. A caregiver (nurse or respiratory therapist) qualified for one gold coin by 100% compliance with the VAP prevention bundle, which was witnessed and reviewed by the clinical practice specialist. Unplanned visits were conducted by the clinical practice specialist in respiratory care on various days and shifts, and compliance and qualification for incentives were determined at that time.
Group incentives included staff celebrations with sheet cakes when the staff as a whole met project milestones. For example, the first milestone was “100 days without VAP,” followed by “365 days without VAP.”
To assess the effectiveness of VAP prevention efforts, VAP rates were measured before and after the QI intervention, and were analyzed to test the hypothesis that VAP rates would decrease with an enhanced VAP prevention bundle and staff compliance with VAP prevention efforts.
Results of the preventive efforts (eg, the number of potential VAP incidents prevented and the estimated lives saved) were made available visually to all staff through frequently updated charts, and shared by the clinical practice specialist in respiratory care during regular staff meetings. In the event an incident of VAP occurred, a root-cause analysis was conducted to identify and address any weaknesses in caregiving efforts or processes.
Education for Patients’ Families
In an effort to educate patients’ families, ZAP VAP posters (Figure 2) were hung in the patient rooms. The posters described the facility’s promise to patients and their families and provided information about how families can help with VAP prevention. A script was developed by the clinical practice specialist in respiratory care for members of the ICU team, which described the ZAP VAP posters and how the oral care and VAP prevention protocols were designed to provide the most excellent care for their family member.
The posters and script approach was well received by patients’ families and was felt to enhance communications between the health care staff and families of critically ill patients.
The preintervention period for the initial QI initiative was from July 2006 through end-March 2007; April 2007 was the “wash-out” period for staff education. The QI intervention period was ongoing from May 2007 through end-July 2009. Between July 2009 and end-June 2010, IRB permissions were sought to review data retrospectively and prospectively, and prospective observation extended from July 2010 through end-July 2011.
Outcome Measures and Statistical Analysis
The retrospective analysis of the QI intervention reviewed the statistical impact of VAP prevention efforts. The VAP rate was calculated as number of VAP cases, divided by number of patients, multiplied by 1,000 ventilator-days. Statistical comparisons of VAP rates assessed the change in VAP rate over time, and counts per VAP days were presented as VAP rates. Fisher’s exact test was used to assess the change in the VAP rate over time, and a P value <0.05 was considered statistically significant. Prospective monitoring of the VAP prevention initiative assessed the change in VAP over time to ensure prevention efforts were sustainable and effective.
The retrospective statistical analysis conducted to assess the impact of VAP prevention efforts during the QI intervention reviewed data from over 13,000 ventilator-days for both the historical baseline and intervention period. There was adequate statistical power to detect an absolute difference as small as 12.5% as a statistically significant decrease. Data analysis revealed the VAP rate decreased from 1.9 (4/2,089) per 1,000 ventilator-days to 0.28 (2/7,229) per 1,000 ventilator-days, representing a statistically significant 85% relative reduction (test statistic = 6.76, P = .009) (Figure 3).
The VAP rate during the prospective observational period from July 2009 to end-June 2010 was 0.57 per 1,000 ventilator days (2/3,511). One incident of VAP occurred in February 2011 and one in March 2011, and root-cause analyses of both cases identified the common variable was long-term ventilation (greater than 7 days). As a result, we instituted use of subglottic suction endotracheal tubes in patients ventilated 7 days or more. From April 2011 through July 2011, there were no additional cases of VAP.
Our facility initiated a QI initiative in 2007 that considered the state of the science, best practices, national preventive efforts, and change-management strategies to reduce the incidence of VAP.11-20 When the interdisciplinary team recognized the perceived success of VAP prevention efforts, they sought approval to retrospectively analyze the results of the QI intervention and prospectively observe VAP prevention for an additional year to ensure efforts were sustainable and effective. The retrospective analysis revealed the multifaceted approach to VAP prevention resulted in a statistically significant reduction in VAP. The prospective observation of VAP prevention efforts revealed a VAP rate of 0 was sustained throughout the year, except for two instances of VAP (1 in February 2011; 1 in March 2011), which were tied to prolonged mechanical ventilation. After implementing subglottic suction endotracheal tubes in patients ventilated 7 days or longer, the rate of VAP remained 0 for the remainder of the prospective observational period. After reviewing the VAP rates from 2007 through end-July 2011, the team determined the multifaceted VAP prevention efforts were sustainable and effective within this clinical setting.
Previous research has demonstrated VAP prevention requires a multifaceted approach that incorporates standardized, evidence-based VAP intervention bundles, in addition to oral care.23 Furthermore, the inclusion of an oral care protocol may inhibit the oral bacterial burden and reduce VAP rates,24,25 and inclusion of a comprehensive oral care system in VAP prevention strategies and care bundles has been shown to significantly reduce VAP rates.23,26-31
Our VAP prevention QI efforts differed from prior studies in that we placed a focus on combining the efforts of the nursing and respiratory care professionals as a team to assess our unique practice challenges, utilizing benchmarks and incentives and incorporating change-management32 to gain both caregiver and family support of our evidence-based VAP prevention efforts. Ongoing compliance monitoring ensured caregiver accountability and adherence to the VAP prevention protocol. In addition, family members were able to participate in patient care as a result of communications and posters, and were provided a means for communicating safety and care concerns.
This project was originated and continued as a VAP prevention QI initiative, and due to the multifaceted approach, we cannot definitively state the observed decrease in VAP rates was a direct result of any specific interventions associated with this project.
Our interdisciplinary and multifaceted approach to VAP prevention is felt to be sustainable and effective in our intensive care clinical setting.
Patricia A. DeJuilio, BS, RRT-NPS, is manager, respiratory care services,Cadence Health; Sallie Jo Rivera, RN, MSN, CID, is infection preventionist, Cadence Health, Winfield, Ill; Jeffrey P. Huml, MD, FCCP, SCCM, is a physician with the Central duPage Physician Group, DeKalb, Ill. For further information, contact [email protected].
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- Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control. 2009;37:783-805.
- Rello J, Ollendorf DA, Oster G, et al; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122:2115-21.
- Institute for Healthcare Improvement. 5 million lives campaign. Getting started kit: prevent ventilator-associated pneumonia how-to guide. Available at: www.ihi.org/explore/VAP/Pages/default.aspx. Accessed February 16, 2011.
- Coffin SE, Klompas M, Classen D, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S31-40.
- The National Healthcare Safety Network. The National Healthcare Safety Network (NHSN) manual: patient safety component protocol. Atlanta: Division of Healthcare Quality Promotion, National Center for Preparedness, Detection and Control of Infection Diseases; 2009. Available at: www.cdc.gov/nhsn/PDFs/pscManual/pscManual_current.pdf. Accessed May 15, 2012.
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