Oral Care Protocol Combined with Ventilator Bundle Reduces VAP Rates

VAP rates in the open-heart recovery unit at Ball Memorial Hospital were higher than desired. In 2004, the rate of VAP was 37.¹ cases/1,000 ventilator days and in 2005 the rate was 39.¹ cases/1,000 ventilator days. In response to these high rates, we implemented a VAP prevention protocol incorporating a ventilator bundle and an oral care system that did not contain chlorhexidine gluconate (CHG). These changes led to an initial decrease in VAP rates in 2006, but the high rates returned with no clear etiology (See Figure 1). Over the course of the following quarter, the staff searched the literature and found evidence^7-11 supporting the use of 0.12 percent CHG with alcohol in oral care for VAP prevention. With the benefits of oral care in reducing rates of VAP in mind, we developed a new prevention protocol and educational program for nurses for the care of cardiac surgery patients. After an initial trial period with a standard oral care system for intubated patients, a new evidence-based protocol was introduced.^12-13

Figure 1: Monthly VAP Rate for 2006

Patients and Methods

Initial ventilation bundle implementation

The ventilator bundle adopted in 2005, based on recommendations from the Institute for Health Care Improvement (IHI), Voluntary Hospital Association (VHA) and the Centers for Disease Control and Prevention (CDC), contained several key elements as follows: Every two-hour oral care with every eight-hour deep pharyngeal suctioning of pooled secretions; head of bed elevation 30 degrees to 45 degrees on all intubated patients; reverse Trendelenburg position for patients with femoral lines (i.e., intra-aortic balloon pumps) to achieve increased head of bed effects without compromising femoral site integrity; deep venous thrombosis prophylaxis; and prophylaxis for peptic ulcer disease. In 2006, our ventilator bundle was updated to include continuous subglottic suctioning to assure continued suctioning of pooled secretions above the endotracheal tube cuff.