Executive Summary

Ventilator-Associated Pneumonia (VAP) is pneumonia occurring more than 2 days after patients have been intubated and received mechanical ventilation. About 8 of every 10 patients with nosocomial pneumonias are related to mechanical ventilator use. An average of 1 in 4 acutely ill patients in the Intensive care unit (ICU) come down with VAP. 1 Our dashboard VAP bundle compliance percentage in all 8 ICUs has not met the Institute for Healthcare Improvement (IHI) benchmark of 95% to ensure adequate VAP care leading us to have an average of 6.69 VAP per 1000 ventilator days. The evidenced based proposed recommendation from IHI and other literatures reveal that 95% compliance to the VAP bundle elements with continuous staff education and monitoring for adherence has yielded effectiveness of reducing VAP clinical and microbiological diagnosis between 45 – 80% from different studies.1-5 Therefore, recruiting an infection prevention staff on full time basis who is responsible for daily assessment with checklists or goal sheets, monitoring adherence to the implementation of all bundle elements for patients, and continuously engaging and educating staff on the importance of the intervention to reduce VAP rates across the ICUs is recommended.

Our action plan is to get the hospital executive leaders to engage all ICU managers, senior physicians and frontline ICU staff and create a platform for continuous engagement and education to drive the intervention. The execution of the bundle elements is driven by policy to embed it into the culture and strong leadership buy-in with adequate allocation of resources for smooth implementation. We will engage the infection prevention staff to conduct daily audits and monthly data publishing with charts for monitoring and evaluation. The rationale for this intervention at City Hospital is due to the load of cancer patients with various co-morbid conditions and the associated higher risk of mortality with VAP. Secondly, the high average estimated cost of VAP treatment per diagnosis which is above $10,000. And adherence to the full bundle has been shown to prevent VAP, reduce mortality, reduce ICU and hospital length of stay by 3 – 10 days, reduced onset of VAP by more than 45%, and reduced institutional budget per diagnosis of VAP. 1,2 Finally, the City Hospital dashboard data also reveals a good correlation between high bundle compliance as seen in ICU 3,6, & 7 with reduced VAP per 1000 ventilator days whereas, ICU 2, 5, & 8 also showed poor compliance and increased VAP rates.

Compliance with VAP bundle as shown above has clear non-monetary benefits.2-4 Also, micro-costing analysis revealed average cost of VAP care per patient to be between $10,796.58 and $20,000. 1,2 Assuming all the 8 ICUs are occupied throughout the month with patients, at an average VAP rate of 6.69/1000 ventilator days (from the dashboard), this is 223 patients a month with VAP. With intervention success and estimated reduction of 45%, 0.45 x 223 = 100 VAP patients are prevented. At average lower cost of 10, 796.58 x 100 patients = $1,079,658.00 will be saved, if the bundles are well implemented with strict adherence and monitoring by recruiting an infection control specialist to execute the roles described above. The average cost of staff engagement and maintenance annually would be about $64,000/yr. 5 Cost of educational materials, postal, reminders, checklist per month can be estimated at $10,000. This means well implemented VAP bundle will save the hospital an average of $1,000,000 in cost in a month using the data from the City Hospital Dashboard. Therefore, Improving VAP bundle compliance increases monetary and non-monetary benefits for patients, our health institutions and reduced VAP rate across ICUs.

 

Goal Statement

ICU 5 has the lowest VAP bundle compliance of 75.4% and the average VAP bundle is 85% across all the 8 ICU. The S.M.A.R.T intervention goal is to increase VAP bundle minimum compliance in all of the ICU to 95 % over the next 6 months. The proposed VAP bundle is high to moderate evidence-based interventions which are to be achieved. The evidenced based proposed recommendation from Institute for Healthcare Improvement and other literatures reveals that achieving 95% adherence to the elements of the VAP bundle has yielded effectiveness of reducing VAP clinical and microbiological diagnosis in the ICU between 45 – 80% from different studies. 1,3,6-8

 

A description of the intervention

The intervention involves developing an evidenced-based VAP bundle, as well as the policy for the implementing the bundle elements by the ICU staff and to ensure sustainable compliance. This will be achieved by recruiting an infection prevention staff on full-time basis who is responsible for working with the nurses and other healthcare professionals to ensure all bundle elements are executed for each patient on ventilation as required. The staff is responsible for monitoring adherence for implementation of all bundle elements across all the ICU patients.

The monitoring of adherence of all bundle elements for patients on ventilator is done with a daily checklist and also to continuously engage staff on the importance of the intervention. The checklist will be used to track the following bundle elements for all patients on the ventilator daily:

  1. Elevation of the head of the bed by 300 – 450 to avoid aspiration – this has been found to be associated to about 80% reduction in onset of VAP. 3
  2. Daily sedation interruption and assessment of readiness to extubate – found to reduce ventilation days and ICU length of stay by average of 3 – 5 days in literature. 3
  3. Use of subglottic secretion drainage, avoidance of scheduled ventilator circuit changes, and regular oral care with chlorhexidine. 1,3
  4. Administration of deep venous thrombosis prophylaxis and gastrointestinal stress ulcer prophylaxis. 1,3,6-9

Compliance with the VAP Bundle is the percentage of ICU patients on ventilation for whom all the above four elements of the bundle are documented on daily checklist and the electronic medical record. It is an all or none model meaning once an element is missing, it counts as no implementation for that patient on that day. 8

 

Evaluation

The goal is to increase VAP bundle minimum compliance in any of the 8 ICUs to 95 % over the next 6 months. To achieve this critical outcome measure is to calculate the number of patients on ventilators daily who have all the bundle element implemented for them that day, this is divided by total number of patients on ventilator in the ICU. This data is collated and calculated on daily basis for each ICU using the checklist and the average monthly figure for the ICU is gotten and used to plot a bar chart. To determine that the goal has been reached, the average bar chart monthly must show all ICU having 95% minimum across all the 8 ICUs.

The institute for Healthcare Improvement defines a benchmark of 95% goal for VAP bundle compliance to be associated with more than 40% reduction in onset of VAP and reduction is ventilation days and ICU stay. Therefore, achieving this goal is expected to decrease the average number of VAP patients per 1000 patient days across the ICUs. 8 A good intermediate measure to consider is to conduct a random monthly assessment of the knowledge and process of implementation of VAP bundle element amongst staff of the ICU. The percentage of staff who are able to adequately demonstrate and describe the process is then calculated on a monthly assessment basis. With increase in this intermediate measure amongst the staff, it is expected that the percentage compliance with the bundle will increase. And also, this measure demonstrates adequate engagement and education of ICU staff. For this measure, the goal will be to get 100% of staff to know and be able to describe the VAP bundle elements, their implementation process, and the documented policy.

Conclusion

VAP bundle intervention, when implemented effectively, has been demonstrated to save the institution on significant VAP cost of care, reduces morbidity or onset of VAP, reduce length of stay both in the ICU and hospital, and decrease mortality of patients. The healthcare cost saved when implementation is successful far outweighs the cost of education and engagement of a full-time staff for daily assessments with a checklist, continuous education, monitoring, and evaluation of bundle compliance with strict adherence to all the elements listed. The challenges of culture and willingness of staff to comply with the policy are inherent but we can overcome this change inertia with continuous engagement and education embedded into the implementation.

Summarized By Dr.Joshua Kolawole

(MD, MBA, MASc., FISQua, CPHQ, PMP)

Agile Program Manager & Transformational Leadership Expert, Valdymas Intelligence LLC, Grand Prairie, Texas, USA.

 valdymas@valdymasintelligence.org

References

1. Koenig SM, Truwit JD. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev. 2006;19(4):637-657.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/. Accessed Feb 18, 2022. doi: 10.1128/CMR.00051-05.

  1. Sosa-Hernández O, Matías-Téllez B, Estrada-Hernández A, Cureño-Díaz MA, Bello-López JM. Incidence and costs of ventilator-associated pneumonia in the adult intensive care unit of a tertiary referral hospital in mexico. American Journal of Infection Control. 2019;47(9): e21-e25. https://www.sciencedirect.com/science/article/pii/S0196655319301452. Accessed Feb 18, 2022. doi: 10.1016/j.ajic.2019.02.031.
  2. Hellyer TP, Ewan V, Wilson P, Simpson AJ. The intensive care society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. J Intensive Care Soc. 2016;17(3):238-243. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606527/. Accessed Feb 18, 2022. doi: 10.1177/1751143716644461.
  3. Luckraz H, Manga N, Senanayake EL, et al. Cost of treating ventilator-associated pneumonia post cardiac surgery in the national health service: Results from a propensity-matched cohort study. J Intensive Care Soc. 2018;19(2):94-100. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5956688/. Accessed Feb 19, 2022. doi: 10.1177/1751143717740804.
  4. Average infection control nurse salary 2022: Hourly and annual salaries. https://www.zippia.com/infection-control-nurse-jobs/salary/. Updated 2020. Accessed Feb 20, 2022.

6. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology.

1. Koenig SM, Truwit JD. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev. 2006;19(4):637-657. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/. Accessed Feb 18, 2022. doi: 10.1128/CMR.00051-05.

2. Sosa-Hernández O, Matías-Téllez B, Estrada-Hernández A, Cureño-Díaz MA, Bello-López JM. Incidence and costs of ventilator-associated pneumonia in the adult intensive care unit of a tertiary referral hospital in mexico. American Journal of Infection Control. 2019;47(9): e21-e25. https://www.sciencedirect.com/science/article/pii/S0196655319301452. Accessed Feb 18, 2022. doi: 10.1016/j.ajic.2019.02.031.

3. Hellyer TP, Ewan V, Wilson P, Simpson AJ. The intensive care society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. J Intensive Care Soc. 2016;17(3):238-243. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606527/. Accessed Feb 18, 2022. doi: 10.1177/1751143716644461.

4. Luckraz H, Manga N, Senanayake EL, et al. Cost of treating ventilator-associated pneumonia post cardiac surgery in the national health service: Results from a propensity-matched cohort study. J Intensive Care Soc. 2018;19(2):94-100. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5956688/. Accessed Feb 19, 2022. doi: 10.1177/1751143717740804.

5. Average infection control nurse salary 2022: Hourly and annual salaries. https://www.zippia.com/infection-control-nurse-jobs/salary/. Updated 2020. Accessed Feb 20, 2022.

6. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology. 2014;35(8):915-936. https://www.jstor.org/stable/10.1086/677144. Accessed Feb 7, 2022. doi: 10.1086/677144.

7. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. The Joint Commission Journal on Quality and Patient Safety. 2005;31(5):243-248. https://www.sciencedirect.com/science/article/pii/S1553725005310312. Accessed Feb 18, 2022. doi: 10.1016/S1553-7250(05)31031-2.

8. IHI VAP. Ventilator bundle compliance | IHI – institute for healthcare improvement. http://www.ihi.org/resources/Pages/Measures/VentilatorBundleCompliance.aspx Web site. http://www.ihi.org:80/resources/Pages/Measures/VentilatorBundleCompliance.aspx. Accessed Feb 19, 2022.

9. Frequently asked questions about ventilator-associated pneumonia | HAI | CDC. https://www.cdc.gov/hai/vap/vap_faqs.html. Updated 2019. Accessed Feb 18, 2022.

sign in
sign in
Shopping Cart
Scroll to Top