Ventilator-associated pneumonia (VAP) is the leading cause of death among hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the nonintubated patient. Hospital mortality of ventilated patients who develop VAP is 46% compared to 32% for ventilated patients who do not develop VAP.1

VAP: Why Is It Important?

VAP occurs in approximately 10% to 25% of patients who are undergoing mechanical ventilation. This accounts for roughly four to 16 cases per 1,000 ventilator days. Patients who develop VAP stay in the intensive care unit (ICU) on average 4 to 9 more days compared to mechanically ventilated patients without VAP. Patients who develop VAP have an attributable mortality of 20% to 70%. Clearly, there is a high morbidity and mortality associated with VAP. Caring for a patient with VAP can cost anywhere from $12,000 to $40,000+ more than the standard cost for caring for similar patients who do not have VAP.

Ventilator-associated pneumonia is a clinically defined pneumonia that is associated with a ventilator, with the pneumonia occurring 48 hours or more after the patient is placed on a ventilator, or within 48 hours following extubation. When discussing the incidence of VAP, the terminology typically will involve the number of VAPs per number of ventilator days times 1,000 (# of VAPs/1,000 vent days).

In addition, VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU.2 Strikingly, VAP can add as much as $40,000 to the cost of a typical hospital admission.3 The most important and compelling factor regarding VAP is that it is preventable.

Bundling Up

Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence-based practices. According to the Institute for Healthcare Improvement (IHI), “The Ventilator Bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually.”4

According to the IHI, the key components of the ventilator bundle include elevating the head of the bed to 30° or higher, performing a daily sedation vacation and assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis (DVT) prophylaxis.

One Hospital’s Experience

Table 1. BWH Vent Bundle Team

  • Respiratory Therapist (RRT)
  • Staff Nurse
  • Nurse Educator
  • Nurse Manager
  • Physician
  • Quality Program Manager
  • Pharmacist
  • Infection Control Practitioner
  • Quality Data Analyst

Setting out on a mission to improve practice related to the care of the mechanically ventilated patient requires a planned and deliberate process. Gaining administrative sponsorship of such a program is critical if staff buy-in is desired. Once such sponsorship is obtained, a multidisciplinary team needs to be formed, since attempting to change a culture is not likely to be achieved without the involvement of all disciplines involved in the care of such patients.

This team would then be required to define the interventions that take place in the management of patients receiving mechanical ventilatory support, particularly those that might improve patient care. The vent bundle process has been designed to reduce the incidence of ventilator-associated pneumonia and also reduce the incidence of DVT development and gastrointestinal (GI) bleeding.

Vent Bundle Elements

As described previously, the elements of a vent bundle program have included four different items including elevation of the head of the bed, daily reductions in sedation with an assessment of ability to breathe spontaneously, GI prophylaxis, and DVT prophylaxis. Our team chose to expand on these elements by monitoring six separate items (Table 2).

Table 2. BWH Vent Bundle Elements

  1. Elevation of head of bed > 30 degrees
  2. Daily sedation vacation/holiday
  3. Daily assessment of readiness for extubation (RSBI or SBT)
  4. GI prophylaxis
  5. DVT prophylaxis
  6. Oral care

Following the IHI guidelines, adopting the “all or none” recommendation as a measure of successful outcome was the direction we chose to take. In addition to the potential of improving patient care and safety, monitoring these bundles, as well as their individual elements, helps to facilitate the identification of failures in design. Once failures are identified, the failures themselves may then be used to redesign the process. This can be done as many times as necessary until the desired outcome(s) is (are) achieved.

After identifying the six vent bundle elements, the multidisciplinary team held a series of meetings to define what it meant to be in compliance and also to define contraindications for each of the individual six elements of the vent bundle. The next important step was to define the process for data entry.

Since the RTs already had a ventilator database that is used to collect significant information about each patient, including clinical and ventilator data, modifying the database to incorporate the vent bundle information was felt to be less cumbersome than creating an entirely new system. The RTs accepted the challenge of taking ownership of the data entry, along with ownership of directly monitoring two of the elements: elevation of head of bed and daily assessment of readiness to extubate.

Vent Bundle Pilot

Prior to the implementation of a pilot in the medical intensive care units (MICUs), the RTs developed a process built around the daily rounds of the ICU using their unit patient care planning sheets. Responsibilities were assigned to each of the representatives, and education sessions were held to be sure that everyone understood their roles and responsibilities. As the pilot began, changes to the process were quickly carried out as problems were identified. The evaluation process involved weekly meetings to discuss compliance of individual components and overall trends. Barriers and gaps in the process were identified, and modifications were immediately instituted. Throughout the week, the team monitored the reliability of the collected data as well as the completeness of the documentation of the data collection tool.

Education, Education, Education

A comprehensive education program included the nursing, medical, and respiratory therapy staffs. Unit, as well as department-based, in-services were held around the clock and included a direct review of the data, pertinent literature articles, bedside resource manuals, and access to a sharepoint site that was dedicated to the vent bundle program.

Regular communication of the results is required so that all participants will be clear about which things are working effectively and which require improvement. The data was, and still is, regularly posted in the ICU, respiratory staff room, and physician teaching conference room; and the results are also reviewed at nursing and respiratory therapy staff meetings and disseminated via e-mail to all ICU attending physicians.

Program Expansion

Once the pilot unit data was considered to be reliable, the decision was made to expand the program to other ICUs within the facility. The expansion was staggered among the ICUs rather than implement the bundle in all units simultaneously. This approach provided the opportunity to continue to identify defects in the process and modify as necessary.

Now that all of the hospital’s ICUs are fully functional with the vent bundle program, weekly monitoring results are sent out to the champions in each area. They, in turn, share the information with their staffs (Figure). Slow and steady progress has been observed in each of the ICUs, and monthly updates are presented to the ICU leadership committee, making the compliance results quite visible

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Figure 1

Figure 1

Key Summary Points

It is important to incorporate the vent bundle into daily practice in order to support a collaborative team approach. This will ensure that all aspects of care are addressed, adding to the consistency of care and work toward improving outcomes. An evaluation plan is needed once the program has been implemented to address any gaps that are identified within the process design. During the first month of roll-out, the work group should be actively involved in the entire vent bundle process. As design flaws are identified, they must be immediately modified and changes communicated to the entire team.

Do Vent Bundles Work?

There remains unfinished work in this area before a consensus can be reached on the relationship between vent bundle usage and VAP rates. A study by Blamoun et al,5 looking at the efficacy of vent bundles, demonstrated a statistically significant reduction in VAPs, while a study by Zilberberg et al6 suggested a “lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundle’s effectiveness or cost effectiveness.” The authors went on to write, “To assure efficient allocation of the limited healthcare resources, rigorous evaluation of optimal strategies for VAP prevention is needed to 1) establish best practices and 2) create a benchmark against which new technologies’ value can be assessed.”

Additional Measures

In addition to the vent bundle elements, which—although they may or may not have been proven to reduce the incidence of VAP—appear to perhaps constitute what might be considered best practice, there are several additional measures that are being considered or incorporated. These measures include the utilization of a subglottic suction endotracheal tube, as well as the use of silver-coated endotracheal tubes. Although these devices are significantly more expensive compared to standard endotracheal tubes, some argue that if the more expensive devices help to curtail one incident of VAP, they will more than pay for the additional expense. Other measures that are incorporated in the ICU include proper hand hygiene, consistent cuff pressure monitoring, maintaining a closed ventilator circuit, use of metered-dose inhalers in place of small-volume nebulizers, and intrahospital transports using the patient’s ICU ventilator to eliminate the need to disconnect the circuit.

Respiratory therapists are in a key position to be the champions of the vent bundle and other best practices within the ICU setting. The RT is considered the expert when it involves patients who are receiving mechanical ventilatory support, and the vent bundle is clearly an excellent opportunity for the RT to take the lead in an important aspect of caring about the patients we serve.

When is the optimal time to start a vent bundle program? There is an old Chinese proverb that states: “The best time to plant a tree is 20 years ago. The second best time is now.”7


Paul Nuccio, MS, RRT, FAARC, is the Director of Pulmonary Services at Brigham and Women’s Hospital, Boston.. For further information, contact [email protected]

References

  1. 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;120:555-61.
  2. 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.
  3. Tablan OC, Anderson LJ, Besser R, Bridge SC, Hajjeh R; CDC 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. MMWR Recomm Rep. 2004;53(RR-3):1-36.
  4. Implement the Ventilator Bundle. Available at: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm. Accessed April 19, 2010.
  5. Blamoun J, Alfakir M, Rella M, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator associated pneumonia in the medical intensive care unit. Am J Infect Control. 2009;37:172-5.
  6. Zilberberg M, Shorr A, Kollef M. Implementing quality improvements in the intensive care unit: ventilator bundle as an example. Crit Care Med. 2009;37:305-309.
  7. “The best time to plant a tree is 20 years ago. The second best is now.” Available at: [removed]climatechallenge.org/blog/best-time-plant-tree-20-years-ago-second-best-now-chinese-proverb[/removed]. Accessed April 19, 2010.