Ventilator-associated pneumonia (VAP) accounts for as much as 15 percent of all hospital-acquired infections (HAIs) and approximately 27 percent of all infections acquired in the intensive care unit (ICU). The primary risk factor for the development of hospital-associated bacterial pneumonia is mechanical ventilation. Ibrahim, et al. (2001) note that hospital mortality of ventilated patients who develop VAP is 46 percent compared to 32 percent for ventilated patients who do not develop VAP. According to the Institute for Healthcare Improvement (IHI), VAP prolongs ICU and hospital stay, adding an estimated cost of $40,000 to admission. In addition, VAP is the leading cause of death amongst hospital-acquired infections and a recent addition to the Centers for Medicare and Medicaid Services (CMS)’s list of “never events.”
As Greene, et al. (2009) point out, “Recent quality improvement initiatives suggest that many cases of VAP might be prevented by careful attention to the process of care. The successful management of patients on ventilation is necessary to ensure the best possible outcomes for individual patients while reducing the morbidity and mortality associated with these infections.”
The IHI is a proponent of the bundle concept to help fight VAP; 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. The key components of the ventilator bundle are: Elevation of the head of the bed; daily “sedation vacations” and assessment of readiness to extubate; peptic ulcer disease prophylaxis; and deep venous thrombosis prophylaxis. Oral care has also been recommended as a preventive strategy. The Centers for Disease Control and Prevention (CDC, 2004) guidelines for preventing VAP include the following interventions: airway management, gastric reflux prevention, oral care, and the prevention of cross-contamination through the use of gloves and meticulous hand hygiene.
A fan of the ventilator bundle approach is Christopher Kowal, MSN-MOL, RN, CCRN-CMC, of St. Joseph’s Hospital Health Center’s surgical intensive care unit in Syracuse, N.Y. “The bundle approach is so efficacious because it comprises the most importance levels of prevention-evidence into a consistent interdisciplinary practice and plan of care,” Kowal explains. “It makes it easier to facilitate care and provide for best-practice outcomes for both patients and their families. It also causes combined-care outcomes. For example, you’ve hit the ‘trifecta’ when you do oral care. The caregiver has the patient sitting up at least 30 degrees or more, because you don’t want the patient to choke, they receive mouth care, and then the caregiver must wash their hands before leaving the room. What a bargain – three for one! Packaging a product kit, such as oral care, provides easier delivery of a key component of the bundle. All supplies are contained, and staff members are able to provide standardized, consistent and reproducible care to all their applicable patients without having to leave the bedside to obtain necessary equipment. Therefore, time is saved to be able to spend with patients.”