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Multiple Interventions Reduce VAP Rates

Briefings on Infection Control, January 12, 2010

Although The Joint Commission's National Patient Safety Goals force many organizations to focus primarily on MRSA, central line-associated bloodstream infections, and surgical site infections, ventilator-associated pneumonia (VAP) is a high priority for anyone in the hospital setting.

Mortality rates alone force hospitals to take a critical look at prevention processes. VAP is the leading cause of death among hospital-acquired infections, according to the Institute for Healthcare Improvement (IHI). Hospital mortality of patients already ventilated who develop VAP is 46%, compared to 32% for those who are ventilated and do not develop VAP.

Just as most facilities have implemented central line and surgical site bundles, the IHI has published a ventilator bundle with four evidence-based practices:

  • Elevation of the head of the bed
  • Daily "sedation vacations" and assessment of readiness to extubate
  • Peptic ulcer disease prophylaxis
  • Deep venous thrombosis prophylaxis

A study published in the October 2009 American Journal of Infection Control focused on prevention of VAP in the intensive care setting. The study implemented interventions in three different phases to reduce the incidence of VAP in the ICU.

In the study's first phase, from March 2001 to December 2002, researchers evaluated the effectiveness of Centers for Disease Control and Prevention (CDC)-recommended evidence-based practices, including no routine changing of humidified ventilator circuits, periodically draining and discarding condensation collecting in the ventilator tubing, and changing the heat and moisture exchangers when they malfunctioned mechanically or became visibly soiled.

From January 2003 to December 2006, researchers intervened in the processes while performance monitoring was occurring at the bedside.

Finally, from January 2007 to September 2008, the researchers continued interventions and implemented the IHI bundle in addition to oral decontamination with chlorhexidine and the use of continuous aspiration of subglottic secretions (CASS) endotracheal tubes, says Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil.

The incidence density of VAP in the ICU per 1,000 days was reduced from 16.4 in phase one to 15.0 in phase two to 10.4 in phase three. The study noted that achieving a rate of zero VAP was possible only in phase three, when all interventions exceeded 95% compliance. In November 2009, the hospital celebrated one year without VAP.

"Our main reason for doing the study was to show that VAP prevention using the majority of evidence-based measures for controlling this hospital-acquired infection in the ICU is a difficult process that involves the accountability of many healthcare workers who care for ventilated patients," Marra says.

The initial results
The first phase of CDC evidence-based practices yielded disappointing results, particularly regarding compliance rates, Marra says.

"It was necessary to have a lot of discussions and changing ideas with the ICU team to make a better performance in our compliance rates," he says. The ICU team was composed of doctors, nurses, and respiratory therapists.

In early 2007, the hospital's CEO declared zero tolerance for VAP. Intervention measures continued, but with more intensity and urgency, Marra says. At that point, phase three was also initiated as an added measure.

Implementing all three phases at once
Although Marra's study gradually implemented each phase over the course of more than seven years, implementation of all three phases yields optimum results.

"Our recommendation is to begin using all the sources at the same time: VAP bundle, oral decontamination with chlorhexidine, and CASS endotracheal tubes," says Marra. "It is important to mention that VAP bundle is not a checklist, but a process that is necessary to intervene for improving compliance with these processes at the same time that performance monitoring is occurring at the bedside."

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