Ventilator-Associated Pneumonia Bundle - American Association of

13 Pages·2014·0.94 MB·English

AACN Advanced Critical Care
Volume 25, Number 2, pp. 163 – 175
© 2014 AACN
Ventilator-Associated Pneumonia Bundle
Reconstruction for Best Care
Nancy Munro , RN, MN, CCRN, ACNP-BC
Margaret Ruggiero , RN, MS, CCRN, ACNP-BC
ABSTRACT
The ventilator-associated pneumonia (VAP) variance in definitions, the Centers for Dis-
bundle is a focus of many health care institu- ease Control and Prevention developed a
tions. Many hospitals are conducting pro- ventilator-associated event algorithm. Health
cess-improvement projects in an attempt to care institutions are under pressure to reduce
improve VAP rates by implementing the bun- the VAP infection rate, but correctly identify-
dle. However, this bundle is controversial in ing VAP can be very challenging. This article
the literature, because the evidence support- reviews the current evidence related to VAP
ing the VAP interventions is weak. In addi- and provides insight into implementing a
tion, definitions used for surveillance are suggested revision of the care of patients
interpreted differently than definitions used being treated with mechanical ventilation.
for clinical diagnosis. The variance in defini- Keywords: bundle , VAP , ventilator-associated
tions has led to lower reported VAP rates, bundle , ventilator-associated events , ventilator-
which may not be accurate. Because of the associated pneumonia
Ventilator-associated pneumonia (VAP) is a 3. Peptic ulcer disease prophylaxis
major contributor to morbidity and mor- 4. Deep vein thrombosis (DVT) prophylaxis
tality in the intensive care unit (ICU). Little 5. Daily oral care with chlorhexidine (added
disagreement exists with this statement in the in 2010)
literature. Many guidelines have been devel-
oped to try to deal with this serious condition. The VAP bundle was described as evidence-
The Centers for Medicare & Medicaid Services based interventions that would help prevent
offers an extensive list of resources for VAP VAP. However, this premise has been debated
prevention implementation (T able 1) .1 The by researchers. To operationalize this bundle
VAP bundle was proposed in 2005 as part of concept, regulatory bodies developed defini-
the 100,000 Lives Campaign, an initiative that tions and guidelines for VAP. The guidelines
was launched by the Institute for Healthcare remain an area of controversy because VAP is a
Improvement (IHI).2 This initiative changed diagnosis that remains elusive and not as easily
the direction of how many institutions
approached VAP. “The IHI Ventilator Bundle
is a series of interventions related to ventilator
Nancy Munro is Senior Acute Care Nurse Practitioner,
care that, when implemented t ogether , will
National Institutes of Health, Critical Care Medicine Depart-
achieve significantly better outcomes than ment/Pulmonary Consult Service, 10 Center Dr, Bldg 10-CRC,
when implemented individually.”3 The bundle Room 3-3677, Bethesda, MD 20892 (m [email protected]) .
includes the following components: Margaret Ruggiero is Acute Care Nurse Practitioner, National
Institutes of Health, Critical Care Medicine Department/Pul-
1. Elevation of the head of the bed (HOB) monary Consult Service, Bethesda, Maryland
2. Daily sedation vacations and assessment The authors declare no conflicts of interest.
of readiness to extubate DOI: 10.1097/NCI.0000000000000019
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Table 1: The Centers for Medicare & Medicaid Services’ Recommendations for
Ventilator-Associated Pneumonia Prevention Resourcesa
Resource Description
Guidelines for Prevention of Nosocomial This document updates and replaces the CDC’s
Pneumonia (US Department of Health & previously published Guidelines for Prevention of
Human Services, Centers for Disease Control Nosocomial Pneumonia (I nfect Control. 1982;3:327–
and Prevention [CDC]): h ttp://www.cdc.gov/ 33, Respir Care . 1983;28:221–232, and Am J Infect
mmwr/preview/mmwrhtml/00045365.htm Control . 1983;11:230–244). This revised guideline
is designed to reduce the incidence of nosocomial
pneumonia and is intended for use by personnel
who are responsible for surveillance and control of
infections in acute-care hospitals; the information
may not be applicable in long-term-care facilities be-
cause of the unique characteristics of such settings.
Guide to the Elimination of Ventilator- The purpose of this guide is to provide evidence-
Associated Pneumonia (Association for Profes- based practice guidelines for the elimination of
sionals in Infection Control and Epidemiol- ventilator-associated pneumonia (VAP).
ogy [APIC]): h ttp://www.apic.org/Resource_/
EliminationGuideForm/18e326ad-b484-471c-
9c35-6822a53ee4a2/File/VAP_09.pdf
Preventing Ventilator-Associated Pneumonia This educational brochure developed by APIC
(APIC): http://www.apic.org/Resource_/Educa- discusses strategies to prevent VAP.
tionalBrochureForm/c32ad147-d1ed-4043-8ad1-
8476b710f5e8/File/Preventing-Ventilator-Associ-
ated-Pneumonia-Brochure.pdf
Round-the-Clock Intensivists Eliminate Ventilator- This innovation profi le from the AHRQ discusses how
Associated Pneumonia, Central Line Infections, Texas Health Presbyterian Hospital Dallas was able
and Pressure Ulcers in Intensive Care Unit to eliminate VAP, central catheter infections, and
(US Department of Health & Human Services, pressure ulcers in intensive care units (ICUs).
Agency for Healthcare Research and Quality
[AHRQ]): h ttp://www.innovations.ahrq.gov/con-
tent.aspx?id=2625
Safe Critical Care Project: Testing Improvement This quality tool provided by AHRQ and developed
Strategies (AHRQ): h ttp://www.innovations. by the Hospital Corporation of America provides an
ahrq.gov/content.aspx?id=1939 intervention toolkit for reducing VAP.
Comprehensive Initiative to Create a Culture of This innovation profi le from AHRQ highlights Sentara
Safety Signifi cantly Reduces Harm Caused by Healthcare’s implementation of an initiative to cre-
Medical Errors, Length of Stay, and Hospital- ate and sustain a culture of safety in 2002. This ef-
Acquired Pneumonia and Infections (AHRQ): fort led to signifi cantly improved patient outcomes,
http://www.innovations.ahrq.gov/content. including reducing patient harm caused by errors,
aspx?id=1819 mortality rates and length of stay in the ICU, and
hospital-acquired pneumonia and infection rates.
Evidence-Based Bundle for Adults Is Adapted by This innovation profi le provided by AHRQ
Pediatric Intensive Care Units, Reducing Ventilator- highlights Children’s Healthcare of Atlanta and how
Acquired Pneumonia and Lowering Costs they developed and implemented a program to
(AHRQ): http://www.innovations.ahrq.gov/content. reduce incidence of VAP in 3 ICUs, including 2
aspx?id=1888 pediatric ICUs and 1 cardiac ICU.
Daily Multidisciplinary Patient Rounds and Best The implementation of daily multidisciplinary patient
Practice Bundle Decrease Use of Ventilators in rounds and a bundle of best-practice guidelines
the Intensive Care Unit (AHRQ): h ttp://www.in- reduced the use of ventilators for patients in the
novations.ahrq.gov/content.aspx?id=1810 ICU and enhanced communication among physi-
cians and nurses in a hospital with private practice
physicians and no advanced practice nurses.
(continues)
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VOLUME 25 (cid:129) NUMBER 2 (cid:129) APRIL–JUNE 2014 RECONSTRUCTION OF THE VAP BUNDLE
Table 1: The Centers for Medicare & Medicaid Services’ Recommendations for
Ventilator-Associated Pneumonia Prevention Resourcesa (Continued)
Resource Description
Prevent Ventilator-Associated Pneumonia This how-to guide specifi cally tailored for pediatrics
(Pediatric Supplement) (Institute for Healthcare describes key evidence-based care components for
Improvement [IHI]): h ttp://www.ihi.org/resourc- preventing VAP, describes how to implement these
es/Pages/Tools/HowtoGuidePreventVAPPediat- interventions, and recommends measures to gauge
ricSupplement.aspx improvement
Implement the IHI Ventilator Bundle (IHI): h ttp://www. This website documents the importance of working
ihi.org/resources/Pages/Changes/Implement- to decrease VAP, discusses the key components of
theVentilatorBundle.aspx the IHI Ventilator Bundle, and provides resources to
implement the bundle.
Prevent Ventilator-Associated Pneumonia (IHI): This how-to guide describes key evidence-based
http://www.ihi.org/resources/Pages/Tools/How- care components for the IHI Ventilator Bundle,
toGuidePreventVAP.aspx which has been linked to reductions in VAP in
patients in intensive care, describes how to imple-
ment these interventions, and recommends meas-
ures to gauge improvement.
Prevent Ventilator-Associated Pneumonia (IHI): This website provides tools and resources that will
http://www.ihi.org/resources/Pages/Tools/How- help a hospital work toward preventing VAP. This
toGuidePreventVAP.aspx site also includes resources on measures to guide
the improvement.
Ventilator-Associated Pneumonia: Getting to This site provides stories from hospitals that have
Zero … and Staying There (IHI): http://www.ihi. successfully improved their VAP rates. Many of the
org/resources/Pages/ImprovementStories/VA- hospitals highlighted have been able to get to zero
PGettingtoZeroandStayingThere.aspx and stay there.
Sample Business Case for Reducing Ventilator- This document provides a sample business case for
Associated Pneumonia (IHI): h ttp://www.ihi.org/ reducing VAP.
resources/Pages/Tools/SampleBusinessCasefor
ReducingVentilatorAssociatedPneumonia.aspx
Strategies to Prevent Ventilator-Associated The intent of this document is to highlight practical rec
Pneumonia in Acute Care Hospitals (Society for ommendations in a concise format designed to
Healthcare Epidemiology of America/Infectious assist acute-care hospitals in implementing and
Diseases Society of America [SHEA/IDSA]): prioritizing their VAP prevention efforts. Refer to the
http://www.jstor.org/stable/10.1086/591062 SHEA/IDSA “Compendium of Strategies to Prevent
Healthcare-Associated Infections” Executive Sum-
mary and Introduction and accompanying editorial
for additional discussion.
Ventilator-Associated Pneumonia (VAP): Best This best-practice document was developed by
Practice Strategies for Caregivers (Kimberly- Kimberly-Clark Health Care and discusses the
Clark Health Care): h ttp://en.haiwatch.com/data/ principles and strategies that make best practice
upload/tools/VAP_CEU_Booklet_Z0406.pdf possible. It outlines these strategies and discusses
their impact on VAP.
Ventilator-Associated Pneumonia (American The site provides case studies, initiatives, campaigns,
Hospital Association, Hospitals in Pursuit of toolkits, methodologies, and other tools and
Excellence): http://www.hpoe.org/resources/ resources to support reduction in VAP.
case-studies/1078
Preventing Ventilator-Associated Pneumonia in This study determines what practices are used by
the United States: A Multicenter Mixed-Meth- hospitals to prevent VAP and, through qualitative
ods Study (University of Michigan): h ttp://www. methods, to understand more fully why hospitals
med.umich.edu/psep/Preventing%20Ventilator- use certain practices and not others.
Associated_ICHE.pdf
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Table 1: The Centers for Medicare & Medicaid Services’ Recommendations for
Ventilator-Associated Pneumonia Prevention Resourcesa (Continued)
Resource Description
Preventing Health Care Acquired Infections (Society This toolkit provides practical strategies, guidelines,
of Hospital Medicine): h ttp://www.hospitalmedicine. and tools for reducing VAP.
org/AM/Template.cfm?Section=CME&Template=/
CM/HTMLDisplay.cfm&ContentID=4124
Ventilator-Associated Pneumonias (VAP) (Johns This Web site describes and links to the VAP
Hopkins Medicine): h ttp://www.hopkinsmedi- Opportunity Estimator, which estimates yearly
cine.org/armstrong_institute/improvement_ numbers of deaths, dollars, and ICU days attribut-
projects/ventilator_associated_pheumonias/ able to VAPs within an ICU, hospital, or health care
estimator.html system. In addition, the Opportunity Estimator
quantifi es the potential impact of VAP interventions
by calculating the number of infections, deaths,
dollars, and ICU days that could be prevented if the
VAP rate was reduced.
a Reprinted from the Centers for Medicare & Medicaid Services.1
defined as was initially thought by regulatory mechanical ventilation. Changing breathing
bodies. Practitioners need to understand the circuits when visibly contaminated or malfunc-
controversy, so that they can make appropriate tioning was endorsed. Also recommended was
decisions in directing practice. the use of an endotracheal (ET) tube with a
dorsal lumen to allow drainage of upper air-
History of the VAP Guidelines way respiratory sections that have pooled
The Centers for Disease Control and Preven- above the ET tube balloon. Recommendations
tion (CDC) published guidelines to prevent to use gastric acid suppressive drugs for peptic
nosocomial pneumonia. The guidelines4 pub- ulcer disease prophylaxis or interventions for
lished by the CDC in 1983 for the prevention DVT prophylaxis were never included in any
of nosocomial pneumonia were fundamental guidelines for VAP prevention. These guide-
infection-control measures. These guidelines lines continue to evolve as the definitions for
focused on perioperative prevention measures, VAP change in an effort to clarify a very com-
hand washing, and handling of respiratory plicated clinical condition. However, a clinical
fluids, medications, and equipment, which are definition for VAP is different from a surveil-
now routine measures in institutional infection lance definition, which makes the application
control. In 1997, the guidelines5 were revised of a guideline very challenging.
and included measures to decrease aspiration,
prevent cross-contamination or colonization of Definitions in the
health care workers’ hands, and ensure appro- VAP Guidelines
priate disinfection of respiratory equipment; The 2003 CDC guidelines6 strongly recom-
the use of vaccines to protect against certain mended that surveillance should be conducted
infections; and hospital staff education. New for bacterial pneumonia in patients in the ICU
investigational measures such as reducing oro- who are being treated with mechanical ventila-
pharyngeal and gastric colonization of patho- tion to facilitate identification of trends and for
genic microorganisms also were included.5 interhospital comparison. However, microbio-
In 2003, these guidelines6 were again logical surveillance, VAP surveillance, and clini-
updated, expanded, and replaced with guide- cal diagnosis of VAP differ significantly. The
lines for preventing health care–associated clinical diagnosis of VAP is neither sensitive nor
pneumonia. The changes in the recommenda- specific.7 Clinical suspicion for VAP requires
tions focused on preventing bacterial pneumo- intubation for more than 48 hours. Most
nia, especially VAP. Orotracheal intubation infection-control professionals and hospital epi-
was recommended over nasotracheal intuba- demiologists use definitions developed by the
tion when initiating mechanical ventilation. CDC National Health and Safety Network,
The use of noninvasive ventilation was recom- which are based on 3 groups of criteria: radio-
mended to reduce the duration and need for graphic, clinical, and optional microbiological
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VOLUME 25 (cid:129) NUMBER 2 (cid:129) APRIL–JUNE 2014 RECONSTRUCTION OF THE VAP BUNDLE
criteria.8 The definition of VAP may be the most specificity are related to many variables, some
subjective of the common device-associated of which are standardization of the procedure,
infections. dilutional effects, technique, and choice of
sampling site. Even the best technique for sam-
Radiographic Criteria pling may not give definitive microbiological
Radiographic signs include 2 or more serial data in up to 25% of cases.1 1
chest radiographs with new or progressive and
persistent pulmonary infiltrates, consolidation, Clinical Criteria
or cavitation. The difficulty in using the chest Clinical signs for VAP must include at least one
radiograph as the only radiographic test in of the following: temperature higher than 38° C
determining VAP is that opacities may not fol- with no other recognized cause, leukopenia
low usual anatomic distribution and can be (white blood cell count < 4000/μ L) or leukocy-
distorted or hidden by pleural effusions, atelec- tosis (white blood cell count > 12 000/μ L),
tasis, or pulmonary edema.9 Relying solely on purulent respiratory secretions, or altered men-
the chest radiograph limits accuracy and does tal status for adults 70 years or older. 6 In addi-
not include the use of computed tomographic tion, clinical signs must include at least 2 of the
scans in diagnosing VAP.9 , 10 following: new onset of purulent sputum or
change in character of sputum; increased res-
Microbiological Criteria piratory secretions, increase in suctioning, or
Microbiological criteria are optional, but if new onset or worsening cough, dyspnea,
used, at least one of the following must be pre- tachypnea, or bronchial breath sounds; or
sent: a positive blood culture not related to worsening gas exchange as evidenced by desat-
another source of infection, positive growth in uration, Pao /fraction of inspired oxygen
a culture of pleural fluid, a positive quantitative (Fi o ) ≤ 240 m2m Hg, increased oxygen require-
2
culture from bronchoalveolar lavage (BAL) ments, or increased ventilation demands.6
( > 104 colony-forming units [CFU]/mL) or > 103 Although these criteria are widely used and
CFU/mL from a protected brush specimen, 5% recognized, many studies use different cutoff
or more cells with intracellular bacteria on points for fever and leukocytosis, and individ-
direct microscopic examination of gram-stained ual interpretation of other clinical signs and
BAL fluid, or histopathological evidence of radiographic data increase subjectivity in VAP
pneumonia.6 That the microbiological criteria diagnosis.1 2 A Clinical Pulmonary Infection
are optional in a definition for an infection is Score (CPIS) was developed to serve as a tool
interesting, but the intent was to use these crite- to help facilitate the diagnosis of VAP; how-
ria for surveillance use and not for clinical diag- ever, no well-designed studies to validate the
nosis, which may be because of the difficulty in CPIS in acute lung injury or trauma are availa-
obtaining accurate information about microbi- ble. The CPIS uses a scoring system that
ological growth with the diagnosis of VAP. includes clinical criteria (eg, temperature,
Endotracheal suctioning does not retrieve a blood leukocyte levels, tracheal secretions/
deep enough sample. Protected brush sampling purulence, and oxygenation-to-Pao /Fi o
2 2
is a better technique, but it is a blind sampling ratio) and radiographic criteria ranging from
process and accesses limited areas of the lungs. no infiltrate to diffuse patchy infiltrates to
Bronchoalveolar lavage is considered the better localized infiltrates.1 3 The CPIS also has user
method for microbiological sampling, because variability.1 3 The multiple attempts to define
the sample is obtained under direct visualiza- VAP for guideline use indicate the challenges of
tion using fiber-optic technology and it samples capturing the essence of this clinical entity.
a larger number of alveolar units.1 1
However, BAL also has its weakness. The Implementation of the VAP
sensitivity of quantitative BAL fluid cultures Bundle Components
ranges from 42% to 93%, implying that BAL Although the VAP definition was not clear, the
fluid is not diagnostic for VAP in approxi- VAP bundle was introduced, and implementa-
mately 25% of cases.1 1 The specificity of quan- tion was expected.2 To evaluate the effective-
titative BAL fluid cultures ranges from 45% to ness of the VAP bundle in its entirety, clinicians
100%, which implies that an incorrect diagno- must evaluate the evidence used to support
sis (a false-positive result) occurs in 20% of the effectiveness of each component of the
cases.1 1 Reasons for the varying sensitivity and bundle.
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HOB Elevation medical interventions, and patient wishes; and
Elevation of the HOB to prevent aspiration has (3) a semiupright position can be recommended
been a nursing standard for many years. only as a preferred position. This review also
Although intuitively this intervention seems indicated inconsistency in measuring and main-
logical, the evidence to support its efficacy in taining exact HOB elevation, and no study was
patients being treated with mechanical ventila- able to replicate clinical practice.1 8 Additional
tion is not clear. In the original IHI proposal, adverse effects of 45° HOB elevation, such as
the suggested elevation for HOB was a range of venous stasis in lower extremities and hemody-
30° to 45° . This range was established in earlier namic instability, were also considered by this
studies performed from 1992 to 19991 4–17 test- study group, but the evidence was inconclusive
ing the HOB elevation to prevent aspiration.1 8 , 19 as to the occurrence of these adverse effects.1 8
These studies used either randomized 2-group In consideration of these scientific results, the
or 2-period cross-over design, but the number evidence to favor HOB elevation to help pre-
of patients was small and the conclusions were vent VAP is not apparent. Clinicians also must
variable but seemed to favor the 30° to 45° realize that the guidelines for HOB elevation
HOB elevation.1 9 The patients in the study by with VAP are somewhat contradictory to those
Drakulovic et al1 7 were in a complete horizon- guidelines used to prevent pressure ulcers,
tal position and receiving supine enteral nutri- which favor lower HOB elevation.1 9 The clini-
tion, which is not the standard of care in most cian is now challenged as to what the proper
ICUs.2 0 The evidence from these studies is not intervention is for patients being treated with
clear in that the designs were weak, the results mechanical ventilation.
were not significant in 3 of the 4 studies, and
the best degree of HOB elevation was never Oral Hygiene Care
established. Oral hygiene care is another nursing domain
Four more studies were conducted from that can affect development of VAP. The oro-
2006 to 2010.2 1–24 More patients were enrolled pharynx is colonized with potential pathogens
in 3 of the 4 studies, and the designs ranged such as S taphylococcus aureus , Streptococcus
from prospective descriptive to a randomized pneumoniae , P revotella species, B acteroides fra-
controlled trial (RCT); however, this trial had gilis, and more than 700 other microbes, many
only 30 patients. Results from these studies of which have not been identified yet.2 5 Within
were somewhat stronger but still variable.1 9 48 hours after a patient is admitted to the ICU,
Metheny et al2 1 suggested that HOB elevation the flora of the oral cavity undergoes a trans-
less than 30° was a significant risk factor for formation to predominantly gram-negative
aspiration, while the authors of 2 other stud- microbes, which can be more virulent.2 6 Oral
ies2 2 , 23 suggested that the 45° elevation was hygiene care methods, including mouthwashes,
either not feasible in critically ill patients or gel, toothbrush, or combination techniques,
poorly accepted by patients.1 9 Therefore, a rec- have been used to combat possibly pathogenic
ommendation for the degree of HOB elevation flora.
remains an elusive target. Research has focused on interventions to
Because of the variable evidence related to promote oral hygiene in this population and
HOB elevation in prevention of VAP, a Bed minimize microbes that can lead to infection.
Head Elevation Study Group was formed by In one study,2 6 the use of chlorhexidine reduced
the European Society of Intensive Care Medi- the rate of VAP in patients who did not have
cine in 2010.1 8 This group of intensive care pneumonia at baseline. DeRiso et al2 7 con-
experts reviewed data in 3 meta-analyses to cluded that oropharyngeal decontamination
determine the quality of evidence for clinically with chlorhexidine oral rinse reduces the total
suspected VAP, microbiologically confirmed nosocomial respiratory tract infection rate and
VAP, and ICU mortality.1 7 , 22 , 23 All 3 meta-analy- results in decreases in the use of nonprophylac-
ses revealed that the quality of evidence for all tic systemic antibiotics in patients undergoing
3 areas was low, with wide confidence inter- cardiac surgery. Clinicians should recognize
vals.1 8 These data led the study group to the fol- that these results apply only to patients under-
lowing conclusions: (1) whether a 45° HOB going heart surgery. A systematic review and
elevation is effective or harmful is uncertain; meta-analysis of 7 trials with 2144 patients by
(2) maintaining a certain elevation 24 hours a Chan et al2 8 concluded that oral application of
day is not feasible because of nursing tasks, antiseptics significantly reduced the incidence
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VOLUME 25 (cid:129) NUMBER 2 (cid:129) APRIL–JUNE 2014 RECONSTRUCTION OF THE VAP BUNDLE
of VAP (relative risk: 0.56; 95% confidence Stress ulcer prophylaxis is a component of
interval: 0.39-0.81). The Cochrane Oral the VAP bundle that also may or may not have
Health Group2 9 recently reviewed 35 RCTs of a direct impact on VAP rates, but it does
oral hygiene care, of which only 14% were impact associated risk factors that are related
well conducted and described. A total of 17 to patients being treated with mechanical ven-
RCTs provided moderate-quality evidence for tilation in the ICU. In a multicenter prospec-
using either chlorhexidine mouthwash or gel.2 9 tive cohort study, Cook et al3 2 identified 2
The results of these studies showed a 40% strong independent risk factors for gastrointes-
reduction in the odds of VAP developing in tinal (GI) bleeding: respiratory failure and
patients who are critically ill. No evidence coagulopathy. The incidence of GI bleeding
existed to show a decrease in ICU mortality among patients with one or both of these risk
rate, the number of ventilator days, or dura- factors was 3.7% compared with 0.1% among
tion in ICU days.2 9 The combination of using patients with neither risk factor. Thus, stress
chlorhexidine and toothbrushing did not dem- ulcer prophylaxis in patients being treated with
onstrate a difference from using chlorhexidine mechanical ventilation may be important for
alone.2 9 the prevention of GI bleeding, though its role
Another variable is the frequency in the use in decreasing VAP is not clear.
of chlorhexidine in conjunction with addi- An interesting perspective about this inter-
tional oral care. Some oral care solutions and vention is the mechanism of how drugs that
gels contain bicarbonate, which may contrib- suppress gastric acid may increase the viru-
ute to the deactivation of chlorhexidine and lence of possible pathogens. Several studies3 2 , 33
negate its positive effects, providing another suggest that suppressive agents for gastric acid
example in which the evidence supporting an may increase the frequency of nosocomial
intervention is not clear. infection as compared to agents that do not
alter gastric acid. Some research has postu-
Prophylaxis Interventions lated that increased pH promotes GI bacterial
Two interventions in the bundle are specifi- growth (especially gram-negative bacteria);
cally directed at prevention of complications therefore, esophageal reflux and aspiration of
associated with mechanical ventilation: DVT gastric content along the ET tube may lead to
and peptic or stress ulcer disease. Deep vein endobronchial colonization or pneumonia.3 4 A
thrombosis can be a complication of mechani- meta-analysis of 10 RCTs concluded that
cal ventilation due to increased venous stasis in stress ulcer prophylaxis with a histamine-
the lower extremities,1 8 but it also can be a 2-receptor antagonist (H RA) as compared
2
complication of other conditions such as with sucralfate resulted in no difference in
sepsis, cancer, trauma, postoperative course, effectiveness in treating overt GI bleeding but
peripheral vascular disease, and immobility. had higher rates of gastric colonization and
Prophylaxis for DVT has been shown to VAP.3 5
reduce the incidence of venous thromboembo- A question of differences arises between the
lism in hospitalized patients. In a retrospective use of H RA and the use of proton pump
2
observational study3 0 of 175 655 patients inhibitors. A retrospective study3 6 comparing
admitted to 134 ICUs in Australia and New ranitidine with pantoprazole among cardiac
Zealand, crude mortality rates were lower in surgery patients concluded that the use of
patients receiving DVT prophylaxis than in pantoprazole for stress ulcer prophylaxis was
those who did not receive prophylaxis (6.3% associated with higher risk of nosocomial
vs 7.6%, respectively). The American College pneumonia compared with ranitidine. How-
of Chest Physicians3 1 has issued evidence-based ever, Lin et al3 7 did not find a significant differ-
guidelines that state that patients who are criti- ence between H RAs and proton pump
2
cally ill should be assessed for their DVT risk inhibitors in terms of stress ulcer prophylaxis,
at admission to the ICU. Although a direct cor- incidence of pneumonia, or mortality among
relation between DVT formation and VAP patients admitted to the ICU. Prevention of
does not exist, pulmonary embolism in a peptic ulcer disease as a complication of
patient being treated with mechanical ventila- mechanical ventilation has no relationship
tion is a part of the ventilator-associated event with the prevention of VAP, and stress ulcer
(VAE), and preventive interventions should be prophylaxis may actually increase the inci-
implemented. dence of gram-negative aspiration pneumonia.
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Daily Sedation Vacations and work group, provides insight into the changes
Assessment of Readiness to in the definition. The algorithm was designed
Extubate to broaden the focus of surveillance to include
Early extubation may decrease incidence of complications of ventilator care and to attempt
VAP. Daily sedation vacations allow for proper to make surveillance more objective, thereby
assessment of the patient’s readiness to be decreasing the amount of “gaming” the sys-
extubated. Kress et al3 8 concluded that patients tem.4 1 It provides time frames as to when to
who received daily interruption of sedative look for changes and defines specific changes
drug infusions had decreased number of in Fi o and positive end-expiratory pressure
2
mechanical ventilator days as well as decreased instead of the original “worsening oxygena-
length of stay in the ICU. Appropriate timing tion” statement. The ventilator-associated con-
of sedation interruptions depends on a patient’s dition definition is nonspecific to capture more
stability, including evaluation of hemodynam- pulmonary (eg, atelectasis, acute respiratory
ics and the ability of the patient to protect the distress syndrome) and nonpulmonary compli-
airway. Daily sedation vacations were paired cations (eg, pulmonary edema, interstitial dis-
with spontaneous breathing trials, resulting in ease) that result in prolonged higher ventilator
earlier extubation and fewer ventilator days as support settings.4 1 With this definition, the goal
well as decreased ICU and hospital days.3 9 Of of having zero VAP rates may not be realistic.
the 5 interventions proposed in the VAP bun- In the third tier of the algorithm, the infection-
dle, this intervention is the most likely to help related ventilator-associated condition accom-
decrease the occurrence of VAP, because it has modates the variable of possible versus
been demonstrated that it expedites earlier probable VAP. This option is intended to cap-
extubation. The sooner the ET tube is removed, ture events that are ventilator related but are
the possibility of infection developing is lower. not clearly caused by infection, which is an
The previous 4 components either have issue that has been a major point of debate in
marginal evidence to support a role in decreas- defining VAP. Radiological criteria have not
ing VAP or had no relationship to VAP. With been included in the VAE algorithm criteria,
this lack of clear evidence, clinicians started to because interpretation of chest radiographs can
challenge the validity of the VAP bundle and be subjective and complex. The new algorithm
its effectiveness. will assist in a more meaningful benchmarking
process and reflect differences in patients and
CDC Response to VAP processes of care more clearly.4 1
Bundle Concerns
Because of the mounting concerns about a reli- Impact of Regulatory Pressure
able definition of VAP, the CDC convened a When IHI introduced the VAP bundle, regulatory
working group of stakeholder organizations in bodies at all levels (federal, national, state, and
2011 to address the limitations of the National corporate) started to consider how this bundle
Healthcare Safety Network p neumonia defi- would be integrated into practice. This regulatory
nitions. Representatives from critical care interest in the VAP bundle caused institutions to
nursing, physician, and respiratory therapist begin implementing the bundle to be in compli-
organizations as well as infection control and ance. However, benchmarking the quality of care
epidemiology societies were included in the of patients being treated with mechanical ventila-
work group. The revised definition was sepa- tion has been challenging. The clinical criteria for
rated into 3 levels to better describe the condi- VAP are intended to guide clinical care. These cri-
tions and complications that are associated teria assist with the diagnostic process when pres-
with adult patients being treated with mechani- ence of infection may not be clearly documented
cal ventilation and assist with improved surveil- and may be used to optimize patient care and
lance of this patient population. The VAE decrease mortality rate. However, these criteria
algorithm includes (1) ventilator-associated are subjective and leave room for interpretation,
condition, (2) infection-related ventilator-asso- which may differ between reasonable clinicians
ciated condition, and (3) possible and probable and surveyors. Applying subjective criteria more
VAP (see F igure 1) . 40 strictly can result in lower VAP rates.4 1
This VAE algorithm is more complex than More than 50% of nonteaching medical
the original CDC definition. Klompas,4 1 who is ICUs in the United States have reported VAP
an epidemiologist and a member of the CDC rates of 0.4 2 However, this statistic may not be
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VOLUME 25 (cid:129) NUMBER 2 (cid:129) APRIL–JUNE 2014 RECONSTRUCTION OF THE VAP BUNDLE
Figure 1: Ventilator-associated events surveillance defi nition algorithm. Abbreviations: CFU, colony-forming
units; F IO , fraction of inspired oxygen; PEEP, positive end-expiratory pressure; VAP, ventilator-associated
2
pneumonia. Reprinted from the Centers for Disease Control and Prevention.4 0
a true reflection of lower VAP rates but rather criteria for VAP did not have pneumonia.4 3
surveillance discrepancies using traditional Concern arises over whether VAP rates were
clinical VAP diagnostic criteria.4 3 Many experts truly reduced or whether strict diagnostic crite-
doubt that a 0 VAP rate realistically can be ria were applied and alternative diagnoses such
achieved.4 3 An autopsy series revealed that one as ventilator-associated tracheobronchitis (VAT)
third to one half of patients who met clinical or sepsis syndrome were used.4 3 , 44 Dallas et al4 5
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MUNRO AND RUGGIERO WWW.AACNADVANCEDCRITICALCARE.COM
conducted a prospective study to clarify the the evidence behind the bundle components is
difference between VAT and VAP. The only variable. Organizing care around a specific
difference in the definition between VAT and diagnosis is a valid concept. The positive
VAP in this study was that VAP included the results of the bundle implementation have
presence of infiltrates on chest radiograph.4 5 been attributed to the fact that it heightened
Given the sensitivity of portable chest radio- awareness of VAP with the multidisciplinary
graphs, infiltrates may have been present but team and focused on the care of patients being
not identified, because routine chest computed treated with mechanical ventilation.4 7 How-
tomography scans were not done. Nonethe- ever, careful consideration must be given to
less, no significant differences were found in the specific care that is recommended to help
ICU or hospital length of stay, duration of prevent and/or combat that diagnosis. Regula-
treatment with mechanical ventilation, hospi- tory bodies are now reconsidering the adher-
tal mortality rate, tracheostomy, or antibiotic ence to the VAP bundle as a reportable
use between the VAT and VAP groups. When statistic. The Joint Commission has decided
the 9 patients with VAT who subsequently not to include the bundle in the 2014 National
developed VAP were removed from the analy- Patient Safety Goals, and the Centers for
sis, the authors4 5 still found no significant dif- Medicare & Medicaid Services has not
ferences between the VAT and VAP groups for included VAP on the list of nonreimbursable
any of the outcomes measured. Similar clinical diagnoses at this time,4 8 , 49 which is an opportu-
presentations to VAP can occur with other nity for nursing and advanced practice nurses
conditions, such as heart failure, sepsis, pulmo- to assist with the reconstruction of best care
nary embolism, acute respiratory distress syn- for patients being treated with mechanical
drome, and alveolar hemorrhage. In addition, ventilation. Nursing interventions may pri-
other noninfectious interstitial processes can marily focus on prevention. Clinicians must
appear similar on chest radiographs, such as recognize that measures to prevent a condition
cryptogenic organizing pneumonia. will be different but complementary to meas-
The IHI bundle has been credited with ures used to combat or treat a condition.
reducing VAP rates across the country. Because
VAP rates in institutions may be linked to Body Position
reimbursement and accreditation, institutions Body position has an impact on gravitational
have an incentive to “game the system,” so forces that influence the leakage of secretions
that VAP rates appear to be improving.4 3 Sig- around the ET tube.5 0 The semirecumbent posi-
nificant time, effort, and expense have been tion has been the standard practice, but the
used to try to implement the bundle. Process best degree of HOB elevation has not been
improvement has driven many projects sur- determined by the evidence. The 30° HOB ele-
rounding the VAP bundle implementation. vation is the recommended position that may
The health care industry has responded with decrease aspiration. The weakness of this
new devices to assist institutions with ensuring rationale is that secretions above the ET tube
that the IHI recommendations are monitored. balloon can pool and lead to microaspiration.
An example is a device to continually monitor Two other aspects of this intervention should
HOB elevation.4 6 However, these efforts are be considered: (1) what is the role of HOB ele-
being directed to a bundle that seems to have vation to help prevent skin breakdown and (2)
minimal evidence to support its use but is is the semirecumbent position the best position
required for compliance. Should the bundle to prevent leakage around the ET tube?
and its content be reconsidered? Metheny and Frantz1 9 described the conflict
between guidelines for HOB elevation to pre-
Reconstruction of the VAP vent aspiration (recommendation of 45° eleva-
Bundle to Promote Best Care tion) and guidelines for pressure ulcer
As the efficacy and validity of the VAP bundle prevention (recommendation of no more than
has been examined, expert clinicians have 30 ° elevation). Ironically, the Joint Commis-
called for a deconstruction of the bundle.9 sion National Patient Safety Goal 14 is preven-
This argument hinges on the issue that surveil- tion of health care–associated pressure ulcers.5 1
lance and clinical definitions are in conflict, Clinicians are faced with a perplexing decision
but the expectation of regulatory bodies is as to which regulatory body directive to fol-
that this bundle be implemented even though low, that is, the VAP bundle or prevention of
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