Ventilator Associated Pneumonia

Vivian Agbobu
Ashley Black
Robert Davila
Trixy Ridoloso
Nina Siregar
What is VAP?
Ventilator-associated pneumonia (VAP) is an infection of the lower
respiratory tract that develops after 48 hours (or longer) in a patient with an
endotracheal tube or tracheostomy and the use of mechanical ventilation.

It is seen in about 28% of patients with mechanical ventilation.

The diagnostic triad for VAP consists of the following clinical criteria:
Pulmonary infection: Signs include fever, purulent secretions, and leukocytosis

Bacteriologic evidence of pulmonary infection

Radiologic suggestion of pulmonary infection

Medscape, 2015
Background
To prevent VAP, healthcare providers should do the following:
Keep the head of the patients bed raised between 30 and 45 degrees unless
contraindicated.

Check the patients ability to breathe on his or her own every day so that the
patient can be taken off of the ventilator as soon as possible.

Clean their hands with soap and water or an alcohol-based hand rub before
and after touching the patient or the ventilator.

Clean the inside of the patients mouth on a regular basis.

Clean or replace equipment between use on different patients.

CDC, 2010
 Background
78-year old male was diagnosed with coronary artery disease.

Admitted for Coronary Artery Bypass surgery.

PMH:

Hyperlipidemia, renal insufficiency, myocardial infarction, obesity, pneumonia and

urinary tract infection, bilateral cataracts, cholecystectomy 10 years ago, unstable
angina.

Admission Vital Signs & Labs:

BP 130/70, HR 88, R 20, Temp 37.1, Na 135, K 3.8, BUN 15, Cr

1.5, WBC 8.7, HCT 36

Admitted to CTICU after surgery. Transferred to the Med/Surg floor 9 days Post Op.

HANYS, 2008
 The Problem
Post Op Day Temp Findings

day of surgery Afebrile Lungs clear; intubated.

Day 1 97.7 F Bilateral rhonchi; Thin yellow blood-tinged secretions.

Chest x-ray shows slight congestion with infiltrate in
RLL. Blood gases WNL. Extubated.

Day 2 101.48 F Labored respirations (R=36), episodes of bradycardia, BP-96/50. Decreased

O2 saturation,CXR-opacity in RLL. Bilateral rales on rhonchi. Suctioned for
thick tan secretions. Sputum and blood cultures sent for C&S. IV antibiotics
q6h. Nasal 02 at 6L.

Day 3 100.4 F CXR: persistent RLL consolidation. Coughing yellow secretions. Blood
gases improved. Still some rales and rhonchi. Nasal 02 decreased to 3L.

Day 4 99.7 F Sputum gram stain, many GPC in clumps and many WBC. Preliminary
sputum culture- gram positive cocci,
Blood culture no growth.

Day 6 97.5 F Preliminary blood culture no growth. Final sputum culture -S. aureus

Day 9 97.5 Final blood culture - one of two (peripheral) grew CNS
HANYS, 2008
 People Process
Not performing oral care q4h in
intubated patient

Lack of appropriate staff Inadequate hand washing

Lack of knowledge to hospital

Improper cleansing of the area
procedure guidelines

Inadequate training or skills to minimize DVT prophylaxis not being done

infections
Lack assessment for weaning trials
Inadequate practice use of sterile procedures Inadequate suctioning in
Communication problems between HCP intubated patient
VAP
Contaminated endotracheal tube
Lack of sedation vacation during intubation

Closed suction system not in

Infected equipment (i.e use at all times
endotracheal tube, bite
block, fastener) Supine
Not having the proper
position
material available
Episodes of reintubation
Improper cleaning of
Lack of guidelines regarding using one cleaning equipment
appropriate cleaning of ventilator material vs. another
during and between uses Lack of specialized
equipment

Ventilator Material Environment

Root Cause Analysis
1. Patient X underwent Coronary Artery Bypass surgery and was
intubated.

2. Had been on the ventilator for the last 48 hours

3. Day 1 of post op new onset of thin yellow blood-tinged

secretions. Pt extubated.

4. Day 2 patient developed a temperature of 101.48 and had a

respiratory rate of 36 bpm

5. CXR RLL consolidation

 Problem

Problem:
PLAN DO

PDSA

ACT STUDY
PDSA: Aim
1. To assess the risk factors and causes of Ventilator-associated
Pneumonia

2. To develop standard documentations as well as integration of

interventions

3. To educate staff about the significance of hospital acquired

infections in the critically ill patients

4. To develop an interprofessional task to address practice changes

related to preventing VAP

5. To determinant compliance rate with ventilator bundle

interventions

6. To incorporate evidence based practice regarding VAP into practice

PDSA
What changes can we make that will result in
improvement?
New protocol of assessing and documenting
readiness to extubate daily, implement and
document oral care Q4H, subglottic
suctioning, and HOB elevation of 30-45
degrees.
PDSA: Plan
Tasks Person When Where
responsible
Daily assessment of readiness for RNs q am daily Pts bed
extubation RTs

Adding HOB documentation to the RNs q1h Pts bed

nursing flowsheet

Oral care bundle protocol and RNs q4h Pts bed

documentation

Subglottic suctioning RNs/ RTs as needed Pts bed

PDSA: Plan
Prediction Measures to determine if
prediction succeeds
RNs/RTs will document assessment of Documentation from RNs and MDs
readiness and collaborate with HCP are provided q am for at least 3 days
the need for extubation
RNs will document q4h of oral care Documentation are provided
everyday

RNs will provide suctioning as needed Airway clear with no signs of

secretions
PDSA: DO
Implementation of all tasks discussed in the plan.
RN/ RT re-education will be included. Manager will
continuously observe for compliance.
Will implement:
Daily assessment of readiness for extubation
Adding HOB documentation to the nursing flowsheet
Oral care protocol
Subglottic suctioning
Will also document any problems or unexpected
observations.

IHI, 2017
PDSA: Study
Prediction Outcome
RNs/RTs will document assessment of There was a statistically significant
readiness and collaborate with HCP increase (p <.001) number of
the need for extubation nurses who documented
readiness, and collaborated with
the HCP for extubation.
RNs will document whenever oral 95% of nurse on the floor
care is provided (q 4hrs) documented suctioning every 4 hours

RNs will document checking residual 80% of nurses reported documented

gastric volume of less than 200 ml in
order to prevent aspiration from NG
tube feeding
RN will HOB elevation of 30 degrees
to documentation of the nursing
flowsheet
residual gastric volume
There was a statistically significant
increase (P <.001) number of nurses
who documented elevation of HOB
at 30-45 degrees
PDSA: Study
Problem Solution
Documentation of suctioning, HOB
Nurses were not properly documenting
elevation, and NG tube placement is now
suctioning, elevating the patients HOB,
mandatory q 4 hrs
and check NG tube placement q 4 hrs
HCP and RNs are required to collaborate
once per shift in regards to the patient's
ventilator settings
HCP and RNs were not assessing for
readiness and collaborating with HCB for the
need of extubation

Summary of findings: The new protocols were successful in preventing VAP in patients
receiving mechanical ventilation. Our aim to decrease the incidence rate of ventilator acquired
pneumonia was reached. There was a statistically significant increase in the amount of nurses
that followed the VAP protocol. However, we would like to eventually reach of goal of a VAP
incidence rate of 0.
PDSA: Act
The new protocol of documenting oral hygiene,
suctioning, HOB elevation of 30-45 degrees, NG
tube placement will insure that the incidence of
VAP will decrease.
Stakeholder Analysis
Internal (unit) stakeholders
Nurses
Respiratory Therapists (RTs)
Nurse Managers
HCPs

External stakeholders
Community
Patients
Patient Families
 Force Field Analysis
Forces FOR Change Forces AGAINST Change
(Driving Forces) (Resisting Forces)

Prevent VAP. New protocol Staff Attitudes.

of assessing
and
Decrease length of documenting
hospital stay. Limited Resources.
readiness to
extubate, oral
care Q4H,
Greater bed capacity. subglottic Physicians.
suctioning,
and HOB
elevation of Ineffective Communication.
Decrease costs.
30-45
degrees.
 References
Centers for Disease Control and Prevention. (2010). Frequently asked questions
about ventilator-associated pneumonia. Retrieved from:
https://www.cdc.gov/hai/vap/vap_faqs.html
Healthcare Association of New York State.(2008). HANYS webinar VAP case
studies [PDF document]. Retrieved From:
https://www.hanys.org/ihi_campaign/upload/VanAntwerpen%20Case_Stu
dies.pdf
Institute for Healthcare Improvement. (2017). How to improve. Retrieved
From: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
Shakeel, A. & Posner, D. (2015). Ventilator-associated pneumonia overview of
nosocomial pneumonias. Retrieved from:
https://emedicine.medscape.com/article/304836-overview#a1