Executive Summary Checklist
In order to establish a program to reduce ventilator-associated pneumonia (VAP) the following implementation plan will require these actionable steps. The following checklist was adapted from the prevention strategies recommended by the California Department of Public Health (CDPH) \cite{00001}, American Association of Critical Care Nursing \cite{adults}, the American Thoracic Society and Infectious Disease Societies of America \cite{2005}.
- Commitment from hospital leadership to support a program to eliminate VAP.
- Implement evidence-based guidelines to prevent the occurrence of VAP.
- Prevent aspiration of secretions
- Maintain elevation of head of bed (HOB) (30-45 degrees)
- Avoid gastric over-distention
- Avoid unplanned extubation and re-intubation
- Use cuffed endotracheal tube with subglottic suctioning
- Maintain the endotracheal tube cuff pressure at greater than 20 cmH20
- Encourage early mobilization of patients with physical/occupational therapy
- Ensure that patient is conscious and responsive prior to extubation.
- Reduce duration of ventilation
- Conduct “ sedation vacations”
- Assess readiness to wean from ventilator daily
- Conduct spontaneous breathing trials
- Reduce colonization of aero-digestive tract
- Use non-invasive ventilation methods when possible (i.e. CPAP, BiPap)
- Use oro-tracheal over naso-tracheal intubation
- Use cuffed Endotracheal Tube (ETT) with subglottic suctioning
- Perform regular oral care with an antiseptic agent
- Reduce opportunities to introduce pathogens into the airway
- Prevent exposure to contaminated equipment
- Use sterile water to rinse reusable respiratory equipment
- Remove condensation from ventilator circuits
- Change ventilator circuit only when malfunctioning or visibly soiled
- Store and disinfect respiratory equipment effectively
- Measure adherence to VAP prevention practices and consider monitoring compliance
- Daily sedation vacation/interruption and assessment of readiness to wean
- Regular antiseptic oral care
- Semi-recumbent position of all eligible patients
- Monitor ventilated patients for: positive cultures, temperature chart/log, pharmacy reports of antimicrobial use, and change in respiratory secretions
- When complications exist, raise them on top of the patient’s EHR problem list.
- Develop an education plan for attendings, residents and nurses to cover key curriculum pertaining to the prevention of VAP.
- Encourage continuous process improvement through the implementation of quality process measures and metrics and a monthly display through a dashboard
The Performance Gap
Ventilator-associated pneumonia (VAP) is an infection that appears in the lungs when a patient is mechanically ventilated. Mechanically ventilated hospital patients are typically critically ill and treated in an intensive care unit (ICU). The infection develops after 48 hours or more of mechanical ventilation and is caused when bacteria reaches the lower respiratory tract via the endotracheal tube or tracheostomy; in addition, when airways are not properly maintained intubation may allow oral and gastric secretions to enter the lower airways \cite{00002a}.
VAP is the leading cause of death associated with healthcare-associated infections (HAIs) \cite{00003}. In the US, a multi-state prevalence survey estimated the incidence of VAP in the US at 49,900 cases annually \cite{2014}. As many as 28% of all patients who receive mechanical ventilation in the hospital will develop VAP and the incidence increases with the duration of mechanical ventilation. The crude mortality rate for VAP is between 20% and 60%; and incidence ranges from 4% to 48% \cite{9735080}\cite{10194173}. Depending on the type of pneumonia the mortality rate may vary; Pseudomonas and Acinetobacter are associated with higher mortality rates than other strains of bacteria \cite{Fagon_1996}. It is believed that when antibiotic therapy is delayed or improperly dosed, mortality also increases. These factors are largely preventable.
Patients who acquire VAP have significantly longer durations of mechanical ventilation, length of ICU stay as well as hospital stay \cite{Rello_2002}. In addition, the development of VAP is associated with significant increase in hospital costs and poor economic outcomes. VAP is associated with greater than $40,000 in mean hospital charges per patient.
It is estimated that the use of process change and technology to reduce VAP can save up to $1.5 billion per year while significantly improving quality and safety \cite{00006}. Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans, examples of which are delineated below for utilization or reference. This is provided to assist hospitals in prioritizing their efforts at designing and implementing evidence-based bundles for VAP reduction.
Leadership Plan
- Hospital governance and senior administrative leadership must champion efforts in raising awareness to prevent and manage VAP infections safely.
- Healthcare leadership should support the design and implementation of an antimicrobial stewardship program.
- Senior leadership will need to integrate surveillance and metrics to ensure prevention measures are being followed.
- Leadership commitment and action are required at all levels for successful process improvement.