Thursday, June 1, 2023
This activity is intended for critical care nurses, respiratory therapists, and other healthcare professionals interested in learning more about preventing ventilator-associated pneumonia (VAP).
The goal of this activity is to provide critical care health professionals with a current evidence base for interventions to prevent VAP.
Upon completion of this activity, participants will be able to:
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A care "bundle" is a set of evidence-based clinical practices that individually improve care and, when combined, magnify improvement.[14] The scientific evidence for each element of a bundle is sufficient for that element to represent a standard of care.[14] The Institute for Healthcare Improvement's (IHI) ventilator bundle combines 4 components of care: elevating the head of the bed, daily sedative interruption and assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep vein thrombosis prophylaxis.[14] The ventilator bundle was initially designed as an overall strategy to improve care of ventilated patients, not necessarily to prevent VAP. However, many hospitals documented a reduction in VAP rates (by an average of 45%) following implementation of the bundle. When teams in some facilities unfailingly apply every bundle element on every patient every time, they have experienced months without a single case of VAP.[14]
The IHI ventilator bundle is not intended to be a comprehensive plan of care to prevent VAP. The IHI recognizes that oral care, subglottic suctioning, gut decontamination, and continuous lateral rotation are also important preventive strategies.[14] Many hospitals have added one or more of these strategies to their VAP prevention protocols. Care should be taken to avoid overly extensive care bundles, because care bundles are most effective when the number of elements is small.[14] The IHI emphasizes that implementing the ventilator bundle requires planning and takes time; it will not be achieved overnight.[14] Recommendations for how to implement and evaluate the ventilator bundle, including useful documentation forms, are available online from the IHI.
Other VAP prevention bundles have been published as well. A bundle of interventions collectively known as FASTHUG (daily evaluation of feeding, analgesia, sedation, thromboembolic prophylaxis, elevation of the head of the bed, ulcer prophylaxis, and glucose control), consistently applied for 2 years, led to a significant drop in VAP (from 19.3 to 7.3 per 1000 ventilator days) among surgical intensive care patients.[34]
Some experts recommend going "beyond the bundle," and employing other evidence-based processes that may lead to a zero VAP rate. Linda Greene emphasizes that hospitals should first "hardwire the basics," such as compliance with handwashing, and then gradually incorporate evidence-based practices into the routine standard of care. "Measure your basic processes, such as head-of-bed elevation, hand hygiene, and oral care, first," suggests Greene. "If you're not doing well there, introducing advanced, extensive protocols will not be successful."
