Microsoft word - 2011 03 14 vap hii final.doc
High Impact Intervention
Care bundle to reduce ventilation-association pneumonia
To reduce the incidence of ventilation-associated pneumonia (VAP).
The aim of the care bundle, as set out in this high impact intervention, is to ensure appropriate and
high quality patient care. Regular auditing of the care bundle actions will support cycles of review
and continuous improvement in care settings.
Registered providers must audit compliance against key policies and procedures for infection
prevention, inline with the relevant legislation at the time of publication1.
Ventilation-associated pneumonia (VAP) is the most frequent infection occurring in patients after
admission to the intensive care unit (ICU)2. In a recent large European observational study, almost
25% of patients developed an ICU-acquired infection, and the respiratory site accounted for 80% of
these infections. The attributable mortality of VAP continues to be debated3, but VAP can be linked
with increased duration of ventilation, ICU and hospital length of stay, and significantly increased
costs4. Prevention of VAP is possibly one of the most cost-effective interventions currently attainable
in the ICU5.
VAP is a consequence of tracheal intubation in critically ill patients. Subsequent bacterial
colonisation of the oropharynx and then silent and continuous aspiration past the cuff of the tracheal
(endotracheal or tracheostomy) tube with contaminated secretions is the likely pathogenesis.6
Many evidenced-based guidelines have been published by different organisations from around the
world 7,8,9 and there is now substantial data suggesting that using a bundle approach in this setting
is highly effective in reducing VAP 10,11.
It is acknowledged that there is no universally accepted definition of VAP, but this should not be a
reason to delay improvement. Indeed, simple interventions that encourage best practice can
significantly reduce the rate of VAP, and currently represent the optimum strategy for reducing
morbidity and cost of this nosocomial infection 12.
This VAP bundle incorporates 6 key actions that are simple, cost effective to implement, and are
frequently cited as the most evidenced-based interventions. Three of these care actions; oral
hygiene, subglottic aspiration and tracheal tube cuff pressure monitoring are new additions to this
current version of the care bundle. Oral hygiene with adequate strength antiseptics has been found
to reduce the risk of VAP, as poor oral hygiene is associated with colonisations by potential
pathogens and lead to secondary pulmonary infection 14.
The use of tracheal tubes with subglottic drainage ports can reduce VAP by preventing
contaminated oral secretions that accumulate above the tracheal cuff intubated patients leaking past
the cuff into the lungs 15,16. Maintaining an appropriate inflation pressure in the tracheal cuff is
important, since underinflation (<20cm H2O) is associated with VAP 17. Over inflation (>30cm H2O) is
also harmful and contributes to long-term tracheal damage.
Although not included as an auditable element, ventilator tubing should be managed and positioned
effectively to ensure condensate flows away from the patient and does not enter the patients’
It is acknowledged that VAP is also an issue for ventilated patients in the non-acute setting. Not all
the care actions outlined in this HII will be relevant to this patient group; however, it is recommended
that it is adapted and agreed with clinicians in the non-acute care setting to reflect the needs of their
local patient group.
These measures should be part of an overall strategy to reduce healthcare acquired infections in
the care setting. This strategy should also include, hand hygiene, the use of personal protective
equipment and good environmental cleaning.
At the present time, this ventilator bundle should not be used as a quality indicator 22, but
considered as dynamic standardisation of best practice in the management of a ventilated patient.
The recommendations will evolve as new evidence emerges.
Why use the care bundle?
This care bundle is derived from evidence-based guidance and expert advice.
The purpose is to act as a way of improving and measuring the implementation of key elements of
care. The risk of VAP increases when one or more elements are excluded or not performed.
Staff competence and training
In line with policy, staff should be appropriately trained and competent in any stated procedure or
care process. Assessment of competence is not a specific care action within the HII as it is a pre-
requisite for any care delivered. Registered care providers will have mechanisms for assuring
training, assessment and recording of competence.
Elements of the care process
The 6 actions outlined below are the recommended good practice. 1. Elevation of the head of the bed
The head of the bed is elevated to 30-45° (unless contraindicated) 8.
2. Sedation level assessment
Unless the patient is awake and comfortable, sedation is reduced/held for assessment at least
3. Oral hygiene
The mouth is cleaned with chlorhexidine gluconate (≥1-2% gel or liquid) 6 hourly 14, 23, 24 (as
chlorhexidine can be inactivated by toothpaste, a gap of at least 2 hours should be left between its application and tooth brushing).
Teeth are brushed 12 hourly with standard toothpaste.
4. Subglottic aspiration
A tracheal tube (endotracheal or tracheostomy) which has a subglottic secretion drainage port is
used if the patient is expected to be intubated for >72 hrs 15, 16.
Secretions are aspirated via the subglottic secretion port 1-2 hourly.
5. Tracheal tube cuff pressure
Cuff pressure is measured 4 hourly, maintained between 20-30cm H2O (or 2cm H2O above
peak inspiratory pressure) and recorded on the ICU chart 17.
6. Stress ulcer prophylaxis
Stress ulcer prophylaxis is prescribed only to high-risk patients according to locally developed
Prophylaxis is reviewed daily 6, 19, 20, 21.
Using the care bundle and the electronic tool
The use of this care bundle will support cycles of review and continuous improvement, which will
deliver appropriate and high quality patient care.
Audits of compliance with the care bundle should be carried out regularly and the results recorded
at the point of care. They should be carried out by peers and the results can be collected manually
or electronically depending on what is appropriate. The use of an electronic, graphical package such
as the HII electronic tool provided is recommended, as this will increase the understanding and
usefulness of the overall results.
• Collect, collate and produce different views of the information • Clearly identify when actions within the care bundle have or have not been performed • Provide information to support the development of plans to resolve any issues and improve the
• Support a culture of continuous improvement.
Recording and making sense of the results
• Print an audit sheet from the HII electronic tool or alternatively create one such as the example
• When a care bundle action is performed, insert a Y in the relevant column. If the action is not
performed, insert an X in the relevant column.
• When the care action is not performed, as it is not applicable (for example local policy has
determined it as not applicable in all or certain situations) insert an N/A to demonstrate that local policy is being adhered to (this is then recognised as a Y when total compliance is being calculated).
• Calculate the totals and compliance levels manually or enter the results into the HII electronic
• The goal is to perform every appropriate action of care every time it is needed and achieve
100% compliance with the care bundle. The “all actions performed” column should be filled with a Y when all the appropriate actions have been completed on every required occasion (see the example below).
• Where actions have not been performed, overall compliance will be less than 100%. This
provides immediate feedback for users on those care bundle actions not completed, and action can then be taken to improve compliance levels.
Example audit sheet
• This example tool shows that while most care actions were performed, on only two occasions
were ALL actions performed correctly while all actions was only 40% and as a result the risk of infection was significantly increased. (Please note for observation no 3. the N/A was calculated as a Y and overall compliance was achieved)
• When the information has been entered into the HII electronic tool a compliance graph for each
action of care and for overall compliance with the care bundle can be produced. This will show where to focus the improvement efforts to achieve full compliance and achieve high quality patient care.
1. Department of Health. The Health and Social Care Act 2008: Code of Practice on the prevention
and control of infections and related guidance. Department of Health, London, 14 Dec 2010.
2. Vincent J-L et al. Sepsis in European intensive care units: Results of the SOAP study. Critical
Care Medicine 2006, 34:344-353
3. Melson WG et al. Ventilator-associated pneumonia and mortality: a systematic review of
observational studies. Critical Care Medicine 2009, 39:2709-18
4. Safdar N et al. Clinical and economic consequences of ventilator-associated pneumonia: a
systematic review. Critical Care Medicine 2005, 33:2184-93
5. Shorr AF & Wunderink RG. Dollars and sense in the intensive care unit: the costs of ventilator-
associated pneumonia. Critical Care Medicine 2003, 31:1582-3
6. Kollef MH. Prevention of hospital-acquired pneumonia and ventilator-associated pneumonia.
Critical Care Medicine 2004, 32:1396-1405
7. The Scottish Intensive Care Society Audit Group. VAP Prevention Bundle – Guidance for
implementation. Available at:
8. Muscedere J et al. Comprehensive evidence-based clinical practice guidelines for ventilator-
associated pneumonia: prevention. Journal of Critical Care 2008, 23:126-37
9. Guidelines for the management of adults with hospital-acquired, ventilator-acquired and
healthcare-associated pneumonia. American Journal of Respiratory and Critical Care Medicine
10. Hawe et al. Reduction of ventilator-associated pneumonia: active versus passive guideline
implementation. Intensive Care Medicine 2007, 35:1180-86
11. Marra AR et al. Successful prevention of ventilator-associated pneumonia in an intensive care
setting. The American Journal of Infection Control 2009, 37:619-25
12. Kollef MH. SMART approaches for reducing nosocomial infections in the ICU. Chest 2008,
13. Girard RD et al. Efficay and safety of a paired sedation and ventilator weaning protocol for
mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a
randomised controlled trial. Lancet 2008, 371:126-34
14. Tantipong H et al. Randomised controlled trial and meta-analysis of oral decontamination with
2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp
Epidemiol 2008, 29:131-36
15. Lorente L et al. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion
drainage on pneumonia. American Journal of Respiratory and Critical Care Medicine 2007,
16. Dezfulian C et al. Subglottic secretion drainage for the prevention of ventilator-associated
pneumonia. The American Journal of Medicine 2005, 118:11-18
17. Diaz E, Rodriguez AH, Rello J. Ventilator-associated pneumonia: issues related to the artificial airway. Respiratory Care
2005, 50:900–6 18. Quenot J-P et al. When should stress ulcer prophylaxis be used in the ICU? Current Opinion in Critical Care 2009, 15:139-43 19. Safdar N et al. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Respiratory Care 2005, 50:725-39 20. Isakow W & Kollef MH. Preventing ventilator-associated pneumonia: an evidenced-based approach of modifiable risk factors. Seminars in Respiratory and Critical Care Medicine 2006, 27:5-17 21. Miano TA et al. Nosocomial pneumonia risk and stress ulcer prophylaxis: a comparison of pantoprazole vs. ranitidine in cardiothoracic surgery patients. Chest 2009, 136:440-7 22. Zilberberg MD et al. Implementing quality improvements in the intensive care unit: Ventilator bundle as an example. Critical Care Medicine 2009, 37:305-9 23. Panchabhai TS et al. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open label randomized trial with 0.01% potassium permanganate as control. Chest 2009, 135:1150-56 24. Scannapieco FA et al. A randomised trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Critical Care 2009, 13:R11
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