Egyptian Journal of Chest Diseases and Tuberculosis (2017) 66, 81–86

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The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

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Impact of VAP bundle adherence among ventilated

critically ill patients and its effectiveness in adult
ICU
Saad Rabie Samra a,*, Doaa Mohammed Sherif b, Sherif Ahmaed Elokda c

a
Chest Department, Zagazig University, Faculty of Medicine, Egypt
b
Medical Microbiology and Immunology Department, Mansoura University, Faculty of Medicine, Egypt
c
Anesthesia Department, Ain Shams University, Faculty of Medicine, Egypt

Received 18 August 2016; accepted 30 August 2016

Available online 6 October 2016

KEYWORDS Abstract Ventilator-associated pneumonia (VAP) is the most prevalent infection in intensive care
Staff education; units (ICU). To reduce this rate, the application of bundles – groups of individual practices and
VAP bundle; adherence to the best nursing practices from Association for Professionals in Infection Control
Mechanical ventilation; and Epidemiology (APIC) guidelines (2009) is recommended.
Pneumonia; This study aimed: This study aimed to estimate the microbiology including; rate of VAP,
Microbiology; mortality rate attributed to VAP, among (ICU) critically ill patients and evaluate the effectiveness
Intervention of adherence to VAP bundle on elimination of infection, also cost effectiveness as reflection to
length of stay in ICU.
Subject and methods: A comparative interventional design was used to achieve the aim of the
study. It is conducted in 14 bedded Adult Medical-surgical ICU.VAP Bundle Program was
implemented by our multidisciplinary team (pulmonologist, microbiologist, intensivist and ICU
nurses). The VAP bundle team starting the program implementation in January 2014 till the
end of December 2015 (follow up prospective study), all those patients underwent daily 5 items
1- bed elevation, 2- DVT prophylaxis, 3- peptic ulcer prophylaxis, 4- oral hygiene and 5- sedation
break and weaning assessment. Surveillance reports from ICU for the year 2013 were reviewed
(retrospective study). Data were collected and analyzed for (VAP) and compared before and after
VAP bundle intervention.
Results: All ventilated patients who met the inclusion criteria were grouped in two groups,
group A (130) patients non bundle used and group B (250) patient vap bundle used, then sub
grouped to VAP and non VAP for statistical analysis, mean age in vap patients was higher in
both groups, VAP incidence in group A 18.5% that decreased significantly to half of 9% in group
B, p value <0.05, also VAP rate/1000 ventilated day showed a statistically significant difference
between group A 25/1000 day in 2013 to VAP rate in 2014 year, 8.5/1000 ventilator days, also to
VAP rate 6/1000 ventilator days in 2015, p value <0.007. Strong significant negative correlation
between compliance of VAP bundle and VAP rate was found, p < 0.0001, VAP bundle
* Corresponding author.
E-mail address: [email protected] (S.R. Samra).
Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.
http://dx.doi.org/10.1016/j.ejcdt.2016.08.010
0422-7638 Ó 2017 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
82 S.R. Samra et al.

compliance ranged from 94% to 100%. Male and medical patients were higher in both groups
more than 62%, outcome improved after bundle as the death rate decreased in group B in both
subgroups than that in group A, and length of stay in ICU was lowered significantly in group B
about 2 days subsequently lowering the cost.
Conclusion: The application of VAP bundle is a feasible reality that produces improvement in
microbiological measures and nosocomal infection rates resulting in lowering mortality, shortened
lengths of hospitalization and decreased medical care costs. However, education and periodic
training remain a fundamental process of improving health services. VAPs were reduced by
improving bundle compliance and ensuring the same standard of care to all ICU patients. Direct,
on-site observation was a more accurate method of monitoring.
Ó 2017 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and
Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction Thomas 2016 concluding that for preventing VAP, combining

a core set of prevention measures into a bundle is a practical
Ventilator-associated pneumonia (VAP) is an airways infec- way to enhance care [21].
tion that must have developed more than 48 h after the patient
was intubated. It accounts for up to 47% of all infections Aim of the work
among ICU patients [1]. It has been reported that VAP can
occur in 9–27% of all intubated patients [2] and accounts for The primary outcome of this current study was the evaluation
86% of nosocomial pneumonia [3]. of adherence to VAP bundle and its effect on VAP rates and
Systemic review on VAP in developing countries was mortality, while the secondary outcome was the cost saving
published in 2008 and found that VAP rates varied from resulting from implementation of VAP bundle.
10 to 41.7 per 1000 ventilator-days, which were generally
higher than the National Healthcare Safety Network (NHSN) Patients and method
rates [4].
VAP can result from either colonization of the aerodiges- Setting
tive tract with pathogenic bacteria or aspiration of gastric con-
tents that serve as reservoir of many organisms, aerobic gram
This study was conducted in open adult ICU, 14 bed, nurse to
negative bacilli are most frequently isolated including
Escherichia coli, Klebsiella pneumonia, Pseudomonas aerugi- bed 1:1 in which hand hygiene was applied since 2010 with a
nosa, Enterobacter spp, Serratia spp. and Acinetobacter compliance rate more than 95% in the last 3 years. All venti-
lated patients from January 2014 included in the prospective
spp., especially in patients with underlying serious disease [5].
When VAP occurs, it prolongs ICU length of stay, study until the end of December 2015; those patients were
increases medical care costs and increases morbidity and mor- studied and followed carefully by the team (pulmonologist,
tality [6], the cost of VAP can be explained by increased length intensivist, microbiologist and ICU nurses).
of stay in ICU by 5–7 days, also increased hospital stay length
2–3 folds among VAP patients [7], the higher mortality rates Design
among VAP patients explained by some authors as higher
antibiotic resistance 43% in causative agent isolated [8]. All patients who were mechanically ventilated for P48 h and
For reducing VAP mortality an organized process that 18 years of age, then we exclude those who were ventilated
guarantees early recognition of pneumonia and continuous due to severe pneumonia, or intubated outside our
application of evidence-based practice, so the Institute for hospital, and if there is any contraindication to one of the
Healthcare Improvement (IHI) developed a series of interven- VAP bundle items (hemorrhage, neck surgery and if allergic
tions related to ventilator care-VAP bundle- that should be to H2 blocker or chlorhexidine), in the period from January
implemented together to achieve the best outcome [9]. 2014 to the end of December 2015 and we compared them with
Although the optimal approach for reducing ventilator- the ventilated patient in our ICU in 2013 retrospectively. We
associated pneumonia is unclear, studies reported that educat- divided them into 2 main groups, group A that included
ing health care providers caring for patients on mechanical patients who were ventilated in 2013, and group B those
ventilation can decrease the rate of ventilator-associated who were ventilated with VAP bundle application in 2014
pneumonia [10]. and 2015.
A multidimensional strategy that included a bundle of All critical care nurses and staff were educated and made
infection control interventions, education process and outcome aware about VAP and the importance of the use of VAP bun-
surveillance then feedback on VAP rates was associated with a dle to decrease this nosocomial infection, VAP was diagnosed
significant reduction in VAP rate in ICUs in developing as per the Center of Disease Control (CDC) as a pneumonia
countries [11]. that occurs in a patient who was intubated and ventilated
VAP bundle was tried and applied to reduce VAP in ICUs within or more than 48 h according to the following criteria:
but has not been studied well in developing countries, also new or progressive infiltrates, consolidation or cavitations on
various bundle elements differ according to the medical team, chest X-ray with one of the following;
Impact of VAP bundle adherence among ventilated critically ill patients and its effectiveness in adult ICU 83

a- New onset purulent bronchial secretions. were older than those without VAP in both groups without
b- Leucopenia (white blood cell < 1500/mm3) or leukocy- statistically significant difference between them. Age distribu-
tosis (>12,000/mm3). tion among patients with VAP was 65 ± 26 years in group A
c- Core temperature >38 °C or <36 °C without other versus 69 ± 24 years in group B while it was 50 ± 25 years
cause. in group A versus 48 ± 33 in group B among non VAP
d- Positive culture from blood, bronchoalveolar lavage or patients Table 2. The result of the current study showed that
endotracheal aspirate. male patients represent a higher percentage in both study
groups either with Vap or without VAP and also, mechanical
Prospective study from January 2014 to the end of Decem- ventilation due to medical causes was higher than surgical
ber 2015, all patients on mechanical ventilations underwent by causes without statistically significant difference in both
the team in the following steps: groups in the same category Table 3. As regards mortality, this
study documented that death rate was decreased among VAP
1- VAP bundle items application. patients from 38% in group A to 30% in group B, also it was
2- Daily clinical examination by pulmonologist. decreased in non VAP patients from 9% in group A to 4% in
3- Fever chart 4 times daily. group B, without statistically significant difference, Table 3.
4- Chest X-ray before intubation then daily. Length of stay (LOS) was low among VAP patients in group
5- Tracheal aspirate (sputum) chart daily. B, (12.2 ± 4.6 day) when compared with group A(14
6- VAP rate monitoring as the number of infections per ± 6.2 day) while it was(10.4 ± 5.5 day) among non VAP
1,000 ventilator-day and ranking on monthly basis patients in group A versus (8.6 ± 4.4 day)in group B with sta-
through the study period. tistically significant difference with p value < 0.05 Table 3. In
7- Measurement of VAP bundle compliance daily and our study the mean VAP rate was 25/1000 ventilator days in
ranking it monthly; 2013 before VAP bundle application then decreased to
8.5/1000 ventilator days after bundle application in 2014,
No:receiving all bundle components0 down to 6/1000 day in 2015 with statistically significant differ-
compliance ¼
No:of patients on ventilator of the day of sample ence between group A (2013) and group B (2014–2015) with
p = 0.007 and 0.001 respectively Table 4. VAP rate Zero
8- Daily complete blood count (CBC). was recorded during some months especially in 2015 Table 4
9- Microbiological culture of tracheal aspirate and bron- Compliance of VAP bundle was measured for total items daily
choalveolar lavage as ordered. and recorded in a prospective manner, in group B compliance
rate was achieved between 94% and 100% Table 5. In group B
VAP bundle items were chosen as recommended by CDC there is a statistically significant negative correlation between
2010, during our study of CDC in 2014 the same items were compliance and VAP rate/1000 ventilator days through 2014
continued so we did not change anything, these implemented and 2015 on monthly bases, r = 0.86, p = 0.0001, Fig. 1.
bundles included:
Discussion
1- Bed elevation greater than 30° up to 45°.
2- Dvt prophylaxis.
Ventilator associated pneumonia is the most common infection
3- Peptic ulcer prophylaxis (H2 blocker).
in ICUs. VAP incidence ranges from 10% to 40% of patients
4- Oral hygiene with chlorhexidine (15 ml twice daily until
receiving mechanical ventilator [1]. VAP is a serious complica-
24 h after extubation).
tion of invasive mechanical ventilation and is associated with
5- Daily sedation break and assessment of weaning.
significant morbidity and mortality, so prevention of nosoco-
mial infections, including VAP was identified as a priority area
VAP rate expressed as:
for national action by the institute of medicine [12].
Total No:of VAP cases  1000 Center for Disease Control and Prevention (CDC) started a
Ventilator days long time ago to publish guidelines for the prevention of noso-
comial pneumonia as in 1983 it was focused on preoperative
prevention measures, then those guidelines were revised at
Result
1997 and included measures to decrease aspiration, prevent
cross-contamination or colonization of health care workers’
This study was conducted on three hundred and eighty hand and reduction of oropharyngeal and gastric colonization
patients, two hundred and fifty were prospectively observed of pathogenic microorganisms [13].
through two years (group B), while a hundred and thirty In 2003, guidelines were updated, expanded and focused in
patients were retrospectively reviewed over one year (group preventing health care associated pneumonia, especially VAP
A). All patients were ventilated with invasive mechanical ven- [14] and the definition of VAP was done depending on
tilation that lasting 48 h and more. Each group was sub-
classed into VAP and non VAP. In group A, the number of
patients who have VAP was 24(18.5%) and the non VAP
Table 1 Cumulative VAP incidence between both groups.
was 106(81.5%), while in group B, the number of patients with
VAP was 23(9%) and those non VAP was 227(91%) with sta- Group A (n = 130) Group B (n = 250) p
tistically significant difference in between both groups p value Vap incidence 24 (18.5%) 23 (9%) <0.05
<0.05 Table 1. Regarding age distribution, patients with VAP
84 S.R. Samra et al.

Table 2 Age distribution between study groups.

Group A (n = 130) Group B (n = 250) p
VAP (n = 24) Non VAP (n = 106) VAP (n = 23) Non vap (n = 227)
Age 65 ± 26 50 ± 25 69 ± 24 48 ± 33 0.76

Table 3 Patients’ characteristics in both study groups.

Group A (n = 130) Group B (n = 250) p
Vap (n = 24) Non vap (n = 106) Vap (n = 23) Non vap (n = 227)
Male 18(75%) 70(66%) 16(70%) 154(68%) 0.6
Female 6(25%) 36(34%) 7(30%) 73(32%) 0.36
Medical 17(71%) 66(62%) 15(65%) 152(67%) 0.57
Surgical 7(29%) 40(38%) 8(35%) 75(33%) 0.43
Death 9(38%) 10(9%) 7(30%) 10(4%) 0.3
LOS 14 ± 6.2 10.4 ± 5.5 12.2 ± 4.6 8.6 ± 4.4 <0.05

Table 4 Vap rate/1000 days monthly distribution throughoutthe study.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean
2013 16 28 32 26 18 20 28 30 22 26 24 30 25
2014 16 14 12 0 0 18 10 8 0 12 12 0 8.5
2015 0 12 10 18 4 13 0 0 10 0 6 0 6
*
p 2013 vs 2014 = 0.007; *p 2013 vs 2015 = 0.001; *p 2014 vs 2015 = 0.33.

Table 5 Compliance of vap bundle.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2014 94 96 97 100 98 94 98 97 98 96 95 100
2015 98 96 97 95 99 96 98 98 97 98 99 100
P = 0.67.

Figure 1 Correlation between compliance and VAP rate/1000 ventilator days R = 0.8605; p < 0.0001.

microbiology, radiology and clinical diagnosis, also applica- In 2010 5 items were approved as VAP bundles that we used in
tion of VAP bundle as a collective preventive measure started our study aiming to evaluate its impact and efficacy on VAP
to be applied as protocols and known identified elements [14]. prevention or modification.
Impact of VAP bundle adherence among ventilated critically ill patients and its effectiveness in adult ICU 85

In this study we found cumulative incidence of VAP in our Outcome of ventilated patients in this study regarding
ICU was 18.5% in 2013 before the VAP bundle and decreased mortality and LOS in ICU was improved as mortality was
to 9% after bundle application with statistically significant dif- 38% in-between VAP patients group A, that come down to
ference, Kamel A.M (2014), found in his study a significant 30% in VAP patients group B, and from 9% to 4% in non
lowering in VAP incidence from 34% to 18% after his bundle VAP patients in groups A and B respectively with no statisti-
application [15]. Instead of that our results were more valuable cally significant difference, this result in our study after VAP
and at a lower rate compared to his results before and after bundle implementation, was lesser than that recorded by
bundle application as we applied strict hand hygiene policy American Thoracic Society (ATS) 2005 of VAP mortality,
in our ICU from 2010 with compliance of more than 95% and was between 33% and 50% [20]. LOS was decreased
monthly until the end of study. significantly among mechanically ventilated patients in our
In the current study we found that VAP was favorable with ICU in group B either VAP or non VAP subgroup after bundle
aging, mean age ± standard deviation (SD) was 65 ± 25 year application nearly 2 days less, this statistically significant low-
and 69 ± 24 year in VAP patients in group A and B respec- ering in LOS was recorded in many studies [15,19]. which was
tively, and in non-VAP it was 50 ± 25 years in group A versus reflected by decreased financial support and medical staff
48 ± 33 years in group B, in contrast with most of the studies effort, that result achieved our secondary goal that is decreased
that showed that mean age of VAP groups was less than non cost from nearly 2000 to 3000$ per case.
VAP groups, this may be due to that the age range in this study On conclusion, the application of the VAP bundle is a fea-
ranged from 18 to 105 years, also age is one of the most impor- sible reality that produces improvement in microbiological
tant risk factors for VAP especially if more than 70 years [16]. measures and nosocomial infection rates resulting in lowering
VAP rate was higher in group A in our ICU 25/1000 ventilator mortality, shortened lengths of hospitalization and decreased
days but in the range that was documented by Arabi et al. medical care costs. However, education and periodic training
(2008) in his systematic review as the VAP rate in developing remain a fundamental process of improving health services.
countries varied from 10 to 41.7/1000 ventilator days [3], VAPs were reduced by improving bundle compliance and
VAP rate was significantly decreased in group B to 8.5/1000 ensuring the same standard of care to all ICU patients. Direct,
ventilator days with a p value = 0.007 in the first year (2014) on-site observation was a more accurate method of
after bundle application, then more improvement was achieved monitoring.
in the second year (2015), as the VAP rate declined to 6/1000
ventilator days with a p value = 0.001. Achievement of Zero Conflict of interest
rate was done in some months but was not sustained due to
many factors like underlying diseases, Glasgow Coma Scale There is no conflict of interest.
(GCS) and resistant organisms. Zero VAP rate was doubtful
to be achieved by many experts [17], nevertheless more than
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