By Nancy M. Case, BSN, RN; Terri Townsend, RN, MA, CCRN, BC, CVN-II; Renee Samples Twibell, DNS, RN, CNE; Shelia Simons, BSN, RN; Karrie Osborne, BSN, RN; Debra S. Hurst, BSN, RN, CIC; Carolyn Sanders, MS, MT (ASCP), CIC; Debra Siela, PhD, RN, CCNS, APRN, BC, CCRN, RRT
Note: Tables and figures available in the July 2008 issue of ICT.
Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation. Between 10 percent and 20 percent of patients who are intubated and receive mechanical ventilation develop VAP.1 The incidence is related to the duration of mechanical ventilation, with patients who are intubated more than 72 hours demonstrating incidence rates near 20 percent.2 This high incidence rate is of particular concern because the mortality rate is doubled in critically ill patients who develop VAP.1 In ICU patients of a private community teaching hospital, ventilated patients with VAP had mortality rates of 45.5 percent compared with 32.2 percent in ventilated patients without VAP.3
Economic Impact of VAP
The economic costs associated with VAP care are high, and as reimbursement for hospital-acquired conditions declines, hospitals and healthcare providers will shoulder more of the cost burden. Rello et al.4 found that the development of VAP was associated with an additional mean hospital cost exceeding $40,000 per patient. In a cost comparison of community-acquired pneumonia of patients with VAP, Kollef et al.5 found costs of community-acquired pneumonia ranged from $25,218 to $40,577, whereas VAP costs ranged from $150,841 to $151,155.
Pathogens Associated with VAP
The most common pathogens isolated in patients with VAP are Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Staphylococcus species, and Acinetobacter species.6 In a study of patients who had been intubated for more than 72 hours, 57 percent were infected with strains of bacteria that were resistant to multiple antibiotics,2 which would likely add to the cost of care.
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 evidence7-11 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.
Modified ventilation bundle intervention
The initial oral care protocol did not contain CHG rinse and was used only during intubation. The initial protocols were continued and updated during the ventilation bundle intervention period from March 2007 through May 2007, but during this time period, the oral care products were changed to a kit containing a 0.12 percent CHG/11.6 percent alcohol rinse manufactured by Sage Products Inc.
The modified intervention bundle was implemented from March 2007 through May 2007 in the cardiovascular intensive care unit at Ball Memorial Hospital in the open-heart surgery patient population. All patients undergoing cardiac surgery were treated with the ventilator bundle. Based on discussions with the IRB officer, it was determined the project did not require IRB review on the basis of government regulation 45 CFR 46 102 (d)14. Historical VAP rates were collected from 2004 through end-2006 for comparative purposes. It was determined that if VAP rates were improved and nursing satisfaction was high over the three months of modified ventilator bundle implementation, the bundle would be adopted as standard of practice.
A prepackaged oral care system provided supplies for oral care to be administered in three phases during the three-month period using the updated protocol and modified intervention bundle. The CHG protocol was added to the standing open-heart order set to ensure delivery of the new oral care protocol. Pharmacy services added the CHG oral care system to the electronic medication administration record for documentation as a reminder of each dose that was due. Every two-hour oral care was documented in the electronic medical record by nurses. An audit form was completed daily on each intubated patient and faxed to epidemiology (See Figure 2). The primary outcome measure was the incidence of VAP.
Figure 2: VAP Prevention Audit Form
Phase I: Before Surgery
On the morning of surgery, the patients brushed their teeth with the 0.12 percent CHG solution with alcohol (15 mL prepackaged solution) and used the solution to brush their teeth and swab their mouths with the provided swab, rinsed, and expectorated.
Phase II: Ventilated Patient
Patients began the oral care protocol immediately postoperatively during intubation. The oral cavity was swabbed with 1.5 percent peroxide mouthwash and moisturizer was applied inside the mouth and to the lips to protect the mucous membranes every two hours and as needed. Oral care consisted of brushing the teeth and swabbing the mouth with 0.12 percent CHG with alcohol every 12 hours while intubated. The brush or swab was connected to suction and rotated around the oral cavity to remove plaque and secretions during the cleansing process. Three types of suctioning were implemented in between episodes of oral care protocol. Suction of the oral cavity occurred with a Yankauer catheter, while continuous suctioning around the endotracheal tube occurred by subglottic suction. Suctioning inside of the endotracheal tube occurred through an in-line catheter. Care was taken to ensure minimal breakage of the patient’s suction lines occurred, and suction lines were dedicated specifically and maintained separately for each of the three types of suctioning.
Phase III: Post-extubation
The patients received oral care after extubation by swabbing and brushing teeth with the 0.12 percent CHG with alcohol rinse. Suction was done as needed, or the patient rinsed and expectorated. This process was repeated every 12 hours for 48 hours after extubation. The staff was educated to ensure documentation and consistent use of the protocol. Group education on VAP was conducted by an infection control nurse. Education on the bundle protocol was carried out by the unit educational staff and by a clinical support representative from the manufacturer of the oral care system. Instruction and reinforcement before and during the ventilator bundle intervention were provided during rounds by the nurse manager and the nurse educator. Laminated posters of the oral care protocol were displayed for the staff. Staff conducted informal daily audits by counting the number of oral care systems used in order to ensure that the oral care was provided every two hours. Staff provided peer review and encouragement to each other to maintain compliance with the new protocol. Feedback was also provided in monthly staff meetings, during which time VAP rates were reported. VAP rates were also posted on the “Nursing Report Card” to encourage nurse ownership of the outcomes through performance improvement, peer accountability, goal-setting, and celebrating improvements. Nurses’ pride in the project and outcomes rose, as they participated in preparing data and gave presentations at clinical and research conferences.
VAP rates were calculated monthly by trained staff in the epidemiology/infection prevention and control department. The criteria for diagnosing VAP were based on the NNIS Pneumonia Flow Diagram15 (See Figure 3).
Historical VAP rates
The historical monitored rates of VAP were 37.4/1,000 ventilator days in 2004 (when only the ventilator bundle was used), 39.1/1,000 days in 2005 (when the non-CHG oral care system was introduced), and 14.8/1,000 ventilator days in 2006. (See Table 1)
Table 1: Patient and VAP numbers by year
*March 2007 is the date that the protocol using the CHG-containing oral care product was initiated.
Modified ventilator bundle results
From March 2007 to May 2007, a total of 40 patients were treated with the ventilator bundle intervention and the CHG-containing oral care system. After adoption of the protocol with the CHG-containing oral care system, VAP rates decreased by 74 percent compared to 2006 (See Figure 4), and one patient developed VAP during the three-month period. After an audit, it was discovered this patient had been changed from the three-phase oral care system with CHG to non-CHG oral care during the intubation phase. The procedures were reevaluated to ensure all patients received CHG oral care during the entire perioperative period.
Monitoring for VAP after the conclusion of the three-month ventilator bundle intervention showed sustained improvement with no additional cases of VAP reported for all of 2007 (annualized VAP rate was 3.7/1,000 ventilator days). No adverse events were reported during the three-month bundle intervention period, and the CHG-containing oral kit and modified ventilator bundle were continued as standard of practice throughout 2007, ongoing in 2008. The annualized rate/1,000 ventilator days in 2006 was 14.8 compared to an annualized rate in 2007 of 3.7 (p= 0.37).
Figure 4: VAP rates 2004-2007
Evidence-based Research on VAP Reduction/Prevention
Recent research has suggested adding comprehensive oral care to reduce the oral bacterial load also reduces rates of VAP. Oropharyngeal colonization with potentially pathogenic bacteria is pivotal in the development of VAP.16 This may be due to migration of the bacteria, aspiration, or other factors associated with bacterial spread from the oral cavity to the lungs. The use of oral antiseptics and oral care regimens has been investigated as a means of reducing the rates of VAP. Chan et al17 conducted a systematic review and meta-analysis of randomized controlled trials and concluded that oral application of antibiotics was not useful but that oral application of antiseptics did reduce rates of VAP, with a relative risk reduction of 0.39 to 0.81. Oral care programs in the ICU have led to reduced rates of VAP, with a relative risk of VAP of 0.37 in patients receiving oral care.18
Patients undergoing surgery may also benefit from oral care. VAP is the most common nosocomial infection in patients who have undergone cardiac surgery.19 Previous studies have demonstrated that oral care that includes 0.12 percent CHG oral rinse with alcohol helps reduce VAP rates in surgical patients.7-9 In August 2006, the American Association of Critical Care Nurses released a practice alert encouraging the use of CHG oral rinse in adult cardiac surgery patients.10
A comprehensive oral care regimen that includes the use of an oral CHG rinse clearly adds benefit to the effort to reduce VAP. In a meta-analysis looking at seven trials (including trials conducted with surgical patients) of oral care regimens that incorporated CHG, five of the seven trials reported reduced VAP rates. The authors of the meta-analysis found cardiac surgery patients benefited the most from oral care intervention.20
Our intervention incorporated preprocedural and postprocedural oral care, starting with a toothbrush and oral CHG, and advancing to oral suction brushes and swabs for plaque and secretion removal and CHG and hydrogen peroxide. After adding the CHG-containing oral care kit to the protocol, our approach led to a 74 percent reduction in VAP, probably because of the combination of mechanical and chemical cleansing. In addition to the benefits of better mechanical removal of contaminated secretions via suction devices, there may be added benefit to including hydrogen peroxide in the regimen in addition to its ability as an oxidizing oral debrider. Steinberg et al.21 found that the use of both CHG and hydrogen peroxide for oral cleansing demonstrated a synergistic effect in reducing bacterial counts. The preoperative care and the post-extubation care are likely to have contributed to our outcomes as well as the addition of subglottic suction endotracheal tubes.
We performed a cost savings analysis by using an estimate of $40,000 excess cost per case of VAP4 (See Table 2). Cost savings in 2007 compared with 2005 were estimated to be $400,000. If CMS regulations reduce reimbursement for VAP in the future, this cost will be borne directly by the hospital.
Table 2: CVICU Cost Savings
IHI’s VAP Prevention Bundle
The Institute for Healthcare Improvement (IHI) initiated the 5 Million Lives Campaign in 2006 to build on the success of the 100,000 Lives Campaign launched in 2004 to prevent 100,000 avoidable deaths nationwide in hospitals.22 One of the six goals from the original 100,000 Lives Campaign was to prevent VAP, which is defined as an airway infection that develops more than 48 hours after intubation. The IHI strategy for reducing VAP is to encourage healthcare providers to adopt the use of a ventilator bundle.23
The ventilator bundle consists of several interventions that as a group may reduce the risk of VAP if instituted with frequent audits and feedback.24 The four recommendations in the IHI ventilator bundle are to elevate the head of the bed 30 degrees, to provide daily trials of lightened sedation to assess patient responsiveness and readiness for extubation, to provide prophylaxis for deep venous thrombosis, and to provide prophylaxis for peptic ulcer disease.23
The CDC developed guidelines in 1994 for preventing VAP and published revised guidelines in 2003. The original guidelines recommend elevation of the bed to 30 degrees to 45 degrees, continuous clearance of subglottic collections of secretions, and to change the ventilation tubing no more often than every 48 hours. The updated guidelines also recommend disinfection and maintenance of equipment and devices to minimize bacterial transmission, hand hygiene (including glove use), and oropharyngeal cleaning and decontamination.13 The ultimate goal of these interventions is to decrease the incidence of pneumonia in the acute-care and other healthcare settings.
CMS Changes in Reimbursement
Prevention of complications, including VAP, that occur in the hospital is a focus of attention for the CMS. The CMS has adopted new payment rules that go into effect in 2008 that will deny reimbursement for certain preventable complications that might occur during hospitalization, including conditions such as certain surgical site infections and pressure ulcers. These conditions were chosen because the committee determined that they are associated with high costs, are high-volume complications, and can be reasonably prevented through the use of evidence-based medical guidelines. VAP was not included in the initial set of complications listed in the new reimbursement rules because of difficulty with coding issues; however, a unique ICD-9-CM code is being developed and therefore VAP will likely be added in the 2009 CMS reimbursement rules. At that point, VAP medical costs are unlikely to be eligible for reimbursement from CMS.25
Few studies have specifically addressed the issue of VAP and oral care in surgical patients. The results of the present project show that comprehensive oral care can dramatically reduce rates of VAP in the cardiac surgery patient population. To ensure ongoing success in reducing VAP, we instituted changes in communication and feedback with healthcare staff that ensure compliance with the oral care regimen. Our success with the three-phase perioperative oral care protocol using a prepackaged oral care system demonstrates how evidence-based oral care can improve patient outcomes.
In turn, reducing the incidence of VAP will reduce the costs of patient care, particularly in the future, when CMS begins to withhold reimbursement for VAP. The costs of care will be reduced both through reductions in direct costs and by avoiding the costs associated with denied reimbursements and increased lengths of stay. Future research should focus on whether additional patient populations would benefit from oral care intervention with this protocol and on how long to continue the protocol postoperatively.
Nancy M. Case, BSN, RN, is the clinical analyst RN for the Office of Legal and Regulatory Affairs at Cardinal Health System, Inc. in Muncie, Ind. Terri Townsend, RN, MA, CCRN, BC, CVN-II, is the educational services instructor at Ball Memorial Hospital. Renee Samples Twibell, DNS, RN, CNE, is an associate professor in the School of Nursing at Ball State University, as well as a nurse researcher at Ball Memorial Hospital. Shelia Simons, BSN, RN, works in the Cardiovascular Intensive Care Unit at Ball Memorial Hospital. Karrie Osborne, BSN, RN, works in the Cardiovascular Intensive Care Unit at Ball Memorial Hospital. Debra S. Hurst, BSN, RN, CIC, is the infection control nurse at Ball Memorial Hospital. Carolyn Sanders, MS, MT (ASCP), CIC, is the epidemiologist at Ball Memorial Hospital. Debra Siela, PhD, RN,CCNS, APRN, BC,CCRN, RRT, is a clinical nurse specialist at Ball Memorial Hospital and is an assistant professor in the School of Nursing at Ball State University.
The authors would like to thank Donna Coffman and Kersten Hammond for their medical writing and editorial assistance in the development of this manuscript. The authors have no financial interests or affiliations related to this interventional care bundle.
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