Infection Control Today - 05/2004: Clinical Update

Reducing the Risk of Ventilator-Associated Pneumonia

By Tina Brooks

Ventilator-associated pneumonia (VAP) remains a common complication of mechanically ventilated patients, contributing substantially to morbidity and mortality. The incidence of VAP varies greatly, ranging from 6 percent to 54 percent of intubated patients depending on patient risk factors. Additional length of stay for patients who develop VAP is approximately 13 days.¹ The estimated average cost per episode of nosocomial pneumonia is $3,000 to $6,000.²

Reducing the risk of VAP has proved to be controversial, with varying levels of science-backed methodologies advocated by professionals as well as industry representatives.

“In some places, we have lots of science to prove what should be done now, but because of historical patterns it’s difficult for people to learn and accept new things,” says Loretta Litz Fauerbach, MS, CIC, director of infection control at Shands Hospital at the University of Florida, and board member of the Association for Professionals in Infection Control and Epidemiology (APIC). “On the other hand, there are some products and practices that are being suggested as prevention technology, and yet we are still gathering truly conclusive data for them. The pendulum swings both ways with VAP.”

As an example of how confusion still surrounds certain methodologies, Fauerbach recalls her experience with a recent infection control and epidemiology course she taught at APIC. Asking attendees, “What is the right time to do mouth care?” she tried to solicit answers reflecting the appropriate number of times and the necessity of a kit. Among 58 people in the room, not one had the same idea. There wasn’t one study that she could point to in order to provide the answer, and she says that’s why controversy as well as confusion persists.

Diagnosing VAP is no easy task. It is usually diagnosed on a combination of clinical, microbiological, and radiographic criteria.³ Although these criteria have a high sensitivity, specificity is low.⁴ “If you get multiple doctors in a room to look at a chest X-ray and give them a case presentation, there may be discrepancy as to whether it is truly pneumonia, colonization, or atelectasis,” Fauerbach says. “So the first controversy begins with do or do they not have pneumonia. How often do you change routine parts of that ventilator? What kind of care do you give the patient?”

Early onset of VAP is commonly caused by antibiotic-sensitive community-acquired organisms (e.g., Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus) as where late-onset VAP is commonly caused by antibiotic-resistant nosocomial organisms (e.g., Pseudomonas aeruginosa, methicillinresistant Staphylococcus aureus, Acinetobacter species, and Enterobacter species).⁵

When asked what is working to reduce VAP, Fauerbach cites a study by Drakulovic in the Lancet in 1999: “Having the patient in a semi-recumbent 30 degree angle or higher has been shown very nicely to decrease the risk rate of infection. Basically, he studied semi-recumbent and supine patients. Ventilator associated pneumonia was 50 percent in the patients that were supine and had enteral feeding. There is an odd ratio that was significantly different between those two.”

Fauerbach adds that clinicians can consider the use of non-invasive ventilation vs. mechanical ventilation, which has been shown to reduce the risk of VAP. It not only decreased the pneumonias and lengths of stay, it decreased the mortality of patients. But there are patients that this can not be used on for other considerations, she says.

Fauerbach recommends using standard definitions, doing good surveillance to identify causative organisms, and then providing this feedback to the clinical team that is caring for the patient.

“One of the things that definitely doesn’t work and that adds costs without value is performing routine surveillance cultures — where people go in and swab patients every week on a Monday or go and swab their equipment every week looking for trends and information that they think will help,” she says. “It is not proven to be effective and costs a lot. Culturing should be done based on clinical need and judgment, and not on a routine basis.”

Prevention of VAP relies on basic infection control practices.6 Hand hygiene, wearing gloves and using standard precautions reduce the transmission of organisms from patient to patient. It is the key in managing nosocomial pneumonia.

Fauerbach adds, “I think we have a lot to learn about nosocomial pneumonia. It’s going to require a disciplinary team to sort through these controversies that exist and come up with costeffective patient safety solutions that can be implemented in healthcare. We have lots of things to study and learn.”

Fauerbach looks forward to the release of new guidelines for the prevention of nosocomial pneumonia from the CDC, which will lay out some of the controversial issues and where more study is needed. “Everybody wants some real direct answers on this, and the problem is there’s none totally identified,” she says.

Wining the War Against VAP
Success Stories and Recommendations

“We have been part of the idealized ICU, which is a VHA project. In 2001, we put in place a ventilator bundle. In April 2003, we began using the Sage mouth-care kit on the ventilator patients. After that, the rate in one particular unit decreased dramatically. We had no nosocomial VAP for eight months after we started that. We then had two cases that were long-term patients compromised with cancer and underlying conditions, which put them at risk.”

Mary Ann Tate, RN, MSN, CCRN
Critical Care Clinical Nurse Specialist
Lynchburg, Va.

“In addition to the standards that are used, we’ve instituted a therapist-implemented protocol for weaning patients from respirators. The analysis of the 2003 data shows us that we were able to wean 26 of 30 patients in 16 days. These are people who were unable to be weaned from a respirator at the host institution.”

Paul Venizelos, MD
Medical Director of the Grace Hospital Unit Lakewood Hospital
Lakewood, Ohio “

Part of it is having a well-defined infection control program and also a quality management program, so you’re focusing on the expected outcomes in a unit. Once you have an increase, you need to target that particular area to implement improvement processes. Second, is insuring staff education on various techniques on what prevention protocols should be followed to prohibit pneumonia from developing in high-risk patients. Also, have staff involved with the quality management or the performance improvement processes, so they get rates on a monthly basis. They know that the VAP rates are not increasing but, actually going down. It reinforces what they are doing is the right thing.”

Donna Armellino, RN, CIC
Infection Control Coordinator North Shore University Hospital
Manhasset, N.Y.

“We’re involved with the IHI improvement project called the Transition of the ICU. We are involved with about 20 other hospitals nationwide. What we’ve come up with is called bundles, which are basically a group of treatment that together improve patient outcomes. The ventilator bundle can reduce mortality by 12 percent. We have an order sheet that is filled out and contains components which we expect to be done on the ventilated patients.”

Cindy Kelbert, RN, CCRN, CNS
Presbyterian Intercommunity Hospital
Whittier, Calif.

“There are several practices that clinicians can implement to reduce the incidence of VAP, such as: keeping the head of the bed slightly inclined; aspirating subglottic secretions with the Hi-lo Evac Tube; following proper hand washing procedures; maintaining a closed ventilation circuit; using in-line suction catheters; and educating staff to risk factors associated with ventilator associated pneumonia.”

Lorelee Goehle, RRT, BHS
Clinical Marketing Specialist
Nellcor Tyco Healthcare

“We make sure a patient’s head is at 30 degrees. We’ve also been keeping our patients’ blood sugars between 80 and 110. We’ve been working at this for probably a year and a half. As we improved the percentage of patients’ blood sugars, we had a steady decrease in our ventilator-associated pneumonias. Prior to this, we had 20 VAPs per 100 ventilator days and right now we are down to about 5 per 100 ventilator days.”

Patti Gleason, RN
Staff Nurse Hartford Hospital
Hartford, Conn.

“This isn’t something that I’ve done at this facility but, it is what I’ve done at another facility. What we did was collaborate with a unit educator. We got respiratory therapy and nursing involved. They did a Zap VAP campaign, a kind of social marketing scheme with big, neon-colored signs that went on every ventilator. They read ‘Wash your hands.’ That was a big part of it, but what really turned the corner — they got a 75 percent decrease in their rates — was they started doing mouth care with Sage products every couple of hours. With that, the hand washing, and everything, they really had success.”

Lynette Tellefsen, RN, CIC
Assistant Director of Infection Control
Florida Hospital Orlando, Fla.

Compiled by Tina Brooks