Adherence to Ventilator-Associated Pneumonia Bundle and ...

PAPER 

Adherence to Ventilator-Associated Pneumonia 

Bundle and Incidence of Ventilator-Associated 

Pneumonia in the Surgical Intensive Care Unit 

Dorothy Bird, MD; Amanda Zambuto, NP; Charles O’Donnell, MS, RRT; Julie Silva, RRT; 

Cathy Korn, MPH, RN; Robert Burke, MA; Peter Burke, MD; Suresh Agarwal, MD 

Objective: To examine the impact of adherence to a 

ventilator-associated pneumonia (VAP) bundle on the 

incidence of VAP in our surgical intensive care units 

(SICUs). 

Design: Prospectively collected data were retrospectively 

examined from our Infection Control Committee 

surveillance database of SICU patients over a 38-month 

period. Cost of VAP was estimated at $30 000 per patient 

stay. 

Setting: Two SICUs at a tertiary care academic level I 

trauma center. 

Patients: Ventilated patients admitted to a SICU. 

Intervention: The Institute for Healthcare Improvement 

VAP bundle was instituted at the beginning of the 

study and included head-of-bed elevation, extubation assessment, 

sedation break, peptic ulcer prophylaxis, and 

deep vein thrombosis prophylaxis. A daily checklist was 

Author Affiliations: 

Departments of Surgery 

(Drs Bird, P. Burke, and Agarwal 

and Ms Zambuto), Respiratory 

Care (Mr O’Donnell and 

Ms Silva), and Infection Control 

(Ms Korn and Mr R. Burke), 

Boston Medical Center, Boston, 

Massachusetts. 

PREVENTION OF VENTILATORassociated-pneumonia 

(VAP) 

has become a priority for all 

intensive care units (ICUs) in 

the United States. 1,2 The critical 

importance of this issue reflects the high 

incidence (5.2 VAP cases/1000 ventilator 

days in surgical ICUs [SICUs] and 10.2 VAP 

cases/1000 ventilator days in trauma ICUs, 3 

making VAP among the most common infection 

in ICUs 4 ) and the high cost of treatment 

($11 000-$57 000). 5-7 Although increased 

attributable mortality in this group 

is controversial, 5,6,8-12 it is clear that those 

with VAP spend additional days on the 

ventilator, 6 additional days in the ICU, 5-9,11 

and additional days in the hospital. 5-8 

Adding to the pressure to eliminate VAP, 

the Centers for Medicare and Medicaid 

Services have announced that they may 

cease to reimburse hospitals for costs incurred 

as a result of VAP, 13 thus shifting 

this profound financial burden directly 

to hospitals. 

considered compliant if all 5 items were performed for 

each patient. 

Main Outcome Measures: Patients were assessed for 

VAP. Staff were assessed for compliance with the VAP 

bundle. 

Results: Prior to initiation of the bundle, VAP was seen 

at a rate of 10.2 cases/1000 ventilator days. Compliance 

with the VAP bundle increased over the study period from 

53% and 63% to 91% and 81% in each respective SICU. 

The rate of VAP decreased to 3.4 cases/1000 ventilator 

days. A cost savings of $1.08 million was estimated. 

Conclusions: Initiation of the VAP bundle is associated 

with a significantly reduced incidence of VAP in patients 

in the SICU and with cost savings. Initiation of a 

VAP bundle protocol is an effective method for VAP reduction 

when compliance is maintained. 

Arch Surg. 2010;145(5):465-470 

(REPRINTED) ARCH SURG/ VOL 145 (NO. 5), MAY 2010 WWW.ARCHSURG.COM 

465 

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www.archsurg.com by HoytBurdick, on June 24, 2010 

©2010 American Medical Association. All rights reserved. 

Evidence-based clinical practice guidelines 

aimed at reducing VAP have been 

available for many years 14,15 and include 

dozens of clear prevention strategies. Sadly, 

widely published guidelines often do not 

result in changed behaviors in the clinical 

setting, 16 and VAP prevention guidelines 

have proven no exception. 17 

Awareness of the gap between guideline 

dissemination and clinical practice has 

led to efforts by individual hospitals and 

health care systems to institute programs 

aimed at complying with VAP prevention 

guidelines to reduce the burden of this nosocomial 

infection. The bundle approach has 

been very successful at effecting evidencebased 

recommendations. 18-26 

When our institution’s SICUs revealed 

mediocre VAP rates in 2006, a bundle practicewasadoptedtoreducethiscomplication. 

By complying with 4 VAP bundle elements 

describedbytheInstituteforHealthcareImprovement(IHI), 

17 webelievedthatwecould 

lessen our VAP burden.

Compliance, % 

100 

80 

60 

40 

20 

0 

TICU 

SICU 

2007 2008 2009 

Year 

Figure 1. Summary of total ventilator-associated pneumonia bundle 

compliance in 2 surgical intensive care units (SICUs) between January 1, 

2007, and April 30, 2009. TICU indicates trauma intensive care unit. 

METHODS 

SETTING 

Boston Medical Center is a 626-bed urban academic tertiary care 

center with a level I trauma designation. Our 2 SICUs include 

a closed 12-bed trauma/general surgery ICU (TICU) and an open 

16-bed surgical ICU where patients are admitted from general 

and subspecialty surgery services (SICU). Combined, our ICUs 

admit approximately 1600 critically ill patients annually. 

Daily assessment of bundle goals and order entry were performed 

by a multidisciplinary team including physicians, nurse 

practitioners, bedside SICU nurses, and pharmacists. Bedside SICU 

nurses were responsible for head-of-bed (HOB) elevation and for 

providing daily sedation breaks based on the Riker score. 

DESIGN 

Our VAP bundle initiative was assessed through retrospective 

review of prospectively collected data from infection control 

and trauma databases. The study period began March 1, 2006, 

when data on VAP incidence were collected prior to bundle initiation 

and includes data collected through May 31, 2009. 

The VAP bundle program began October 1, 2006. Compliance 

data were collected from then until May 31, 2009, a 31month 

period. Data were grouped by fiscal and calendar years. 

This study was performed using public databases and did 

not require institutional review board approval. 

VAP BUNDLE 

The VAP bundle adopted at our institution differed from the 

IHI bundle in that we teased apart “daily sedation vacations and 

assessment of readiness to extubate” into 2 individual components. 

Our bundle components were as follows: (1) HOB elevation 

greater than 30°, (2) daily sedation break, (3) daily assessment 

for extubation, (4) peptic ulcer prophylaxis, and (5) 

deep vein thrombosis prophylaxis. 

Compliance was assessed twice daily by the respiratory care 

service, who entered data into an electronic database. Compliance 

was recorded as yes or no for each bundle item. The entire 

bundle was considered compliant only if all 5 items were 

compliant. A bundle was considered noncompliant if any item 

was not performed, even if that item was contraindicated. The 

only exception was contraindication to deep vein thrombosis 


466 




prophylaxis in patients with head injury; the bundle was still 

considered compliant in this case. 

Compliance data were summarized on a weekly basis. These 

data were reviewed monthly by a multidisciplinary team including 

intensive care nursing managers who supplied feedback 

to the SICU nursing staff. 

OUTCOME MEASURES 

The primary outcome measure was the relationship between 

VAP bundle compliance and VAP incidence. Cases of VAP were 

identified by the infection control team during routine daily 

surveillance rounds through the ICUs using Centers for Disease 

Control and Prevention criteria. 27 All suspected VAP cases 

were reviewed thoroughly, including individual radiographs by 

the infection control team of nurses and physicians before a 

VAP diagnosis was confirmed. The members of the infection 

control team did not change during the study period. 

RatesofVAPweredefinedasthenumberofVAPcasesper1000 

ventilator days. Ventilator days were counted daily by the infection 

control team. A ventilator day was defined as a calendar day 

for which the patient was charged for mechanical ventilation. 

A secondary outcome of interest was the cost savings resulting 

from the VAP bundle program. At our institution, the 

cost to treat a VAP case was estimated to be $30 000 based on 

average costs documented in the literature. 5-7 

STATISTICAL ANALYSIS 

Differences in VAP rates were compared using the � 2 test. Summary 

statistics are provided as annual VAP rate (VAP cases per 

1000 ventilator days) with P value. Annual percentage of compliance 

was compared via 95% confidence intervals. 

RESULTS 

COMPLIANCE MEASURES 

Total bundle compliance increased every year in both 

SICUs throughout the study (Figure 1), from 53% to 

91% in the TICU and from 63% to 81% in the SICU. The 

TICU showed the greatest increase in total compliance. 

Both ICUs showed greater improvement in overall compliance 

between the first and second years of the study 

than between the second and third years of the study. 

Individual bundle items also showed improvement during 

the study period (Table). The HOB elevation and deep 

vein thrombosis prophylaxis bundle elements were initially 

the most deficient, but they improved greatly by 

the end of the study. Compliance with peptic ulcer prophylaxis, 

sedation break, and assessment for extubation 

were initially excellent and remained at or higher than 

92% throughout the study. 

VAP MEASURES 

The overall VAP rates in our 2 ICUs were similar prior 

to the bundle program (Figure 2) and were comparable 

to the 50th percentile reported by the 2004 National 

Nosocomial Infections Surveillance System 28 for 

SICUs and TICUs. 

The incidence of VAP decreased in each ICU during 

the study period. The TICU had a greater and more statistically 

significant reduction in VAP compared with the

Table. Ventilator-Associated Pneumonia Bundle Compliance 

SICU, which only approached statistical significance. The 

VAP incidence at the SICU increased slightly during the 

first year of the VAP bundle program but showed the greatest 

decrease during the second year. The TICU saw the 

greatest decrease in VAP during the third study year. 

Combined VAP rates decreased during the study period 

and were statistically significant in 2008 and 2009 

(Figure 2). This suggests a 67% risk reduction by the end 

of the study period. 

COST ANALYSIS 

The combined VAP incidence in our ICUs was 10.2 VAP 

cases/1000 ventilator days at the beginning of the study 

period. At that rate, 36 additional VAP cases would have 

been acquired by our patients during the study without 

the bundle. At an estimated expense of $30 000 (±$20 000)/ 

VAP case, $1 080 000 ($360 000-$1 800 000) was saved 

as a result of VAP prevention. 

COMMENT 

Our data show a correlation between VAP bundle compliance 

and reduction in VAP incidence. This effect was 

seen across 2 separate SICUs at our institution, it was sustained 

for 3 years, and it saw our VAP incidence decrease 

between the 10th and 25th national percentiles for 

SICUs and TICUs by the end of the study period. Prior 

to initiation of the VAP bundle, the VAP incidence was 

slightly higher at the TICU than at the SICU. We attribute 

this to the trauma population treated at the TICU 

and their higher risk of VAP. Overall compliance was proportional 

to the decrease in the VAP rate. The TICU experienced 

a higher level of compliance and a lower VAP 

rate at the end of 3 years than the SICU. This was likely 

because the VAP bundle project was initiated by TICU 

staff, although this does not explain why the first year 

saw better compliance at the SICU. 

Of the individual bundle elements, compliance with 

HOB elevation had the greatest impact on VAP reduction. 

Compliance with HOB elevation was initially very 

low in both ICUs but had the greatest improvement during 

the study period. Deep vein thrombolysis prophylaxis 

compliance, also initially poor, improved but does 

not contribute to VAP reduction. Other bundle elements 

had excellent compliance throughout the study 

Mean Compliance, % (95% CI) 

2007 2008 2009 

Bundle Item 

SICU TICU SICU TICU SICU TICU 

DVT prophylaxis 83 (77-88) 78 (73-84) 96 (94-98) 98 (97-99) 96 (91-100) 100 (100) 

HOB elevation 77 (73-82) 65 (57-72) 84 (80-89) 90 (86-93) 85 (77-94) 99 (98-100) 

Peptic ulcer prophylaxis 98 (96-99) 99 (98-100) 99 (98-100) 98 (97-99) 100 (99-100) 100 (99-100) 

Sedation break 98 (97-99) 97 (96-99) 97 (96-98) 99 (98-100) 95 (89-100) 98 (95-100) 

Assessment for extubation 96 (94-98) 92 (87-97) 97 (95-98) 97 (96-99) 99 (98-100) 94 (88-99) 

Total bundle compliance 63 (57-69) 53 (46-60) 78 (73-83) 85 (82-89) 81 (72-90) 91 (85-97) 

Abbreviations: CI, confidence interval; DVT, deep vein thrombosis; HOB, head-of-bed; SICU, surgical intensive care unit; TICU, trauma intensive care unit. 


467 




Annual VAP Cases/1000 Ventilator Days, No. 

12 

10 

8 

6 

4 

2 

0 

2006 2007 2008 2009 

Year 

Total 

TICU 

SICU 

Figure 2. Summary of annual ventilator-associated pneumonia (VAP) cases 

in 2 surgical intensive care units (SICUs) between March 1, 2006, and April 

30, 2009. TICU indicates trauma intensive care unit. *P=.01; †P=.06; and 

‡P=.004. 

period. Head-of-bed elevation was the single element associated 

with reducing VAP risk that improved during 

the study period. 

Evidence-based guidelines for the prevention of nosocomial 

pneumonia have been published and revised by 

the Centers for Disease Control and Prevention since the 

1980s. 13,14,29,30 Since the publication of these guidelines, 

a decrease in the VAP rate has been appreciated by the 

National Nosocomial Infections Surveillance System. The 

SICU VAP rate was 25 VAP cases/1000 ventilator days 

in 1987 and decreased to 15 by 1991, 31 to 9.3 by 2004, 28 

and to 5.2 in 2006. 3 

Manangan et al 31 described compliance data obtained 

in 1995 via mailed self-report surveys regarding 

recommendations for management of ventilator equipment. 

This group found that compliance with timing of 

breathing circuit change (category 1A recommendation) 

had increased from 65% to 98% and that compliance 

with routine changing of the hygroscopic condenser-humidifiers 

or heat-moisture exchangers 

(category 1B recommendation) increased from 62% to 

93% since guideline publication. Most other recommended 

practices were not as well heeded or showed 

little change in behavior. 

In 1999, Cabana et al 16 reviewed 76 studies that examined 

guideline compliance and concluded that al- 

∗ 

† 

‡ 

∗

though the guidelines are widely distributed, they have 

only a small impact on changing physician practice. Rello 

et al 17 confirmed this disappointing reality for VAP guidelines 

as well. In this international study, critical care physicians 

deemed “opinion leaders” in the field of VAP were 

surveyed about evidence-based guidelines described by 

Kollef. 14 Rello and colleagues discovered a 25.2% noncompliance 

rate for recommended guidelines; noncompliance 

rates of 41.3% and 35.7% were seen for grade A 

and B recommendations, respectively. While Rello and 

colleagues found “disagreement with interpretation of reported 

trials” 17 and “lack of resources” 17 to be the main 

factors for noncompliance, Cabana and colleagues reported 

“lack of awareness, lack of familiarity, lack of selfefficacy, 

lack of outcome expectance, and inertia of previous 

practice” 16 as important barriers to implementing 

guidelines. 

Acknowledgment of widespread guideline noncompliance 

led to speculation by Sinuff et al 32 into methods for 

improving knowledge translation relevant to VAP prevention 

in ICUs. This group suggested that a multifaceted approach 

would yield the greatest success. An active educational 

strategy combined with reminders, audit, and 

feedback led by a guidance implementation team was recommended 

for further study. Craven 4 similarly advised that 

a cure for poor compliance with VAP guidelines should involve 

a multidisciplinary team that sets prevention benchmarks, 

establishes goals and timelines, and provides education, 

training, audits, and feedback. 

An enormous amount of effort has been spent overcoming 

barriers to guideline implementation. The earliest 

programs aimed at reducing VAP by complying with 

established recommendations were described in the mid- 

1990s. 

Kelleghan et al 33 described a 1989 quality improvement 

project at Kaiser Permanente in California that was 

modeled after the principles of continuous quality improvement 

described by W. Edwards Deming, PhD. This 

is among the earliest attempts at reducing VAP incidence 

by enforcing existent infection control and prevention 

guidelines. With a multipronged approach, a multidisciplinary 

infection prevention team established a 

checklist of respiratory guidelines for staff, addressed barriers 

to compliance, instituted a hand-washing surveillance 

program, held educational seminars, began prospective 

VAP surveillance, and gave compliance feedback. 

This institution had a 57% reduction in VAP in 1 year, 

estimating 15 VAP cases prevented, 3 lives saved, and 

$105 000 in cost savings. 

Joiner et al 34 described similar efforts in Ohio in 1992. 

Also borrowing from continuous quality improvement 

theory, which stipulates that outcome improvement stems 

from change in process, a multidisciplinary quality improvement 

team compared the institution’s process of ventilator 

care management with evidence-based best-care 

practices and created a protocol to eliminate the gap between 

current and best care. The VAP and process evaluation 

data were collected and reviewed monthly, and areas 

for improvement were addressed. This institution also 

saw a dramatic decrease in VAP incidence, from 26 to 

16 VAP cases/1000 ventilator days, saving approximately 

$126 000 over 3 years. 


468 




The VAP bundle concept grew from the IHI’s 100 000 

Lives Campaign to reduce VAP incidence. 1 The bundle is 

a “small set of evidence-based interventions for patients on 

mechanical ventilation.” 18 Created in 2002, the IHIdefined 

bundle included 4 elements: HOB elevation, daily 

sedation vacation, peptic ulcer prophylaxis, and deep vein 

thrombosis prophylaxis. Clinical evidence supports that 

each item reduces patient mortality and morbidity 18 and 

that patients on mechanical ventilation should receive these 

things, despite the fact that only HOB elevation and sedation 

vacation reduce VAP risk. 

In 2005, Resar et al 19 described the IHI Impact Network’s 

experience implementing the IHI VAP bundle at 

61 hospitals. The ICUs achieving greater than 95% compliance 

saw a 59% reduction in VAP rates. Resar and colleagues 

emphasized that while bundle use may improve 

clinical outcomes, its use would also improve process reliability. 

They speculated further that the multidisciplinary 

teams, daily goal-setting, and increased attention 

to detail stimulated by the bundle importantly 

contributed to improved clinical outcomes. 

Cocanour et al 21 described VAP bundle use in their 

Houston, Texas, TICU. On discovery of high VAP incidence, 

a bundle program that included elements of the 

IHI VAP bundle in addition to several other precautions 

was initiated. The initial improvements in VAP incidence 

were modest and unsustained. When a computerized 

audit tool was implemented to calculate weekly 

bundle compliance data, the VAP rate decreased below 

the National Nosocomial Infections Surveillance System’s 

25th percentile and was sustained for the remaining 

months of the study. This result reveals the importance 

of process quality evaluation and feedback in 

improving clinical outcome when using a bundle. 

A similar experience was described by Hawe et al 20 in 

Scotland. They implemented a similar VAP bundle by displaying 

copies of the protocol at every ICU bedside. Compliance, 

assessed only periodically, was dismal during this 

passive implementation phase and no VAP reduction was 

seen. An active implementation phase that included educational 

workshops, compliance reporting, addressing barriers 

to delivery, and discussion of bundle adherence on 

daily multidisciplinary rounds was initiated. Compliance 

improved from 0% to 54% and VAP rates decreased 

dramatically from 19.17 to 7.5 VAP cases/1000 

ventilator days. Here, the education, feedback, and daily 

goal-setting were key to clinical success. 

Zaydfudim et al 25 made compliance feedback the keystone 

of their VAP bundle program in Nashville, Tennessee. 

When implementation of a bundle program with 

intermittent compliance monitoring failed to reduce VAP 

incidence, a real-time VAP bundle compliance dashboard 

was installed on every SICU computer monitor. 

Daily compliance reports were reviewed by multidisciplinary 

rounding teams and by physician and nursing leaders. 

Real-time compliance feedback resulted in an increase 

in total bundle compliance from approximately 

20% to about 90% over 1 year. Compliance with individual 

bundle items increased in every parameter during 

the study period, and overall VAP rates improved. 

We attribute the success of our VAP bundle program 

to several of the factors described earlier. First, we used

a concise, well-established bundle described by the IHI 17,25 

where each component has a well-documented impact on 

morbidity. 18 Numerous other ICUs in the United States have 

had success in decreasing VAP incidence using the IHI 

bundle. 17 Second, our comprehensive approach to bundle 

implementation and its incorporation to daily rounds and 

goal-setting contributed to our success. 18 Daily multidisciplinary 

rounds with a checklist by a team including nurses, 

pharmacists, and physicians ensured that bundleappropriate 

orders were entered and completed. Our system 

of regular audit and feedback may have made the greatest 

impact on bundle compliance. The VAP compliance and 

incidence data were reviewed weekly, monthly, and quarterly. 

Weekly data were summarized in an electronic newsletter 

that included days since last VAP. Quarterly VAP data 

were posted in several locations throughout the hospitals 

and the ICUs. Nursing supervisors who attended monthly 

meetings discussed compliance data, comparing current and 

prior performance, and provided feedback to the ICU nursing 

staff. Presumably once the trend in reduced VAP incidence 

became apparent with improved bundle compliance, 

the staff became even more motivated to improve 

performance. These same feedback and reminder mechanisms 

continue presently. 

Strengths of our study include the large number of patients 

(approximately 4000) treated in our SICUs over 

2 1 ⁄2 years. The similar results achieved at both SICUs underscore 

the validity of our results. Another important 

strength is the measurement of our primary outcome (VAP 

incidence) by an experienced, unchanging infection control 

team. 

Among the weaknesses of this study, we did not compare 

our SICU populations between units or years. It is 

possible that healthier patients with fewer risk factors for 

VAP were admitted in 2009 than in 2006. We did not 

account for contraindications to VAP bundle items when 

scoring compliance. This may have led to underestimation 

of actual guideline compliance. Finally, the greatest 

weakness of our study is that it does not account for 

other ongoing programs at out institution aimed at reducing 

nosocomial infections, including a handwashing 

campaign, blood glucose control protocols, a 

chlorhexidine gluconate mouthwash protocol, and availability 

of an endotracheal tube that supports continuous 

aspiration of subglottic secretions. While we have 

documented improved compliance with hand washing, 

which may have had an impact on our VAP rates, compliance 

data are not available for the other interventions. Use 

of chlorhexidine mouthwash and of the endotracheal tube 

that supports continuous aspiration of subglottic secretions 

began in 2005 at our institution, 1 year prior to initiation 

of the bundle program. 

In summary, our study demonstrates the success of a 

VAP bundle in reducing the incidence of VAP and in cutting 

costs in 2 SICUs when excellent compliance is maintained. 

Compliance was achieved by incorporating the 

bundle into daily multidisciplinary rounds and through 

regular audit and feedback. This is a simple, inexpensive, 

effective method of reducing VAP in the SICU. 

Accepted for Publication: November 12, 2009. 

Correspondence: Dorothy Bird, MD, Department of Sur- 


469 




gery, Boston Medical Center, 88 E Newton St, Boston, 

MA 02118 (dorothy.bird@bmc.org). 

Author Contributions: Study concept and design: Zambuto, 

O’Donnell, and Agarwal. Acquisition of data: 

O’Donnell, Silva, Korn, and R. Burke. Analysis and interpretation 

of data: Bird, O’Donnell, R. Burke, P. Burke, and 

Agarwal. Drafting of the manuscript: Bird. Critical revision 

of the manuscript for important intellectual content: Bird, 

Zambuto, O’Donnell, Silva, Korn, R. Burke, P. Burke, and 

Agarwal. Statistical analysis: Bird. Administrative, technical, 

and material support: Zambuto, O’Donnell, Silva, Korn, 

R. Burke, and Agarwal. Study supervision: P. Burke and 

Agarwal. 

Financial Disclosure: None reported. 

Previous Presentation: This paper was presented at the 

90th Annual Meeting of the New England Surgical Society; 

September 11, 2009; Newport, Rhode Island; and 

is published after peer review and revision. 

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