Peter F. Drucker in 1954 : Management by
Advocated the use of:
Logic of SMART approach
• A grouping of best practices with respect to a
disease process that individually improve care,
but when applied together result in
substantially greater improvement.
• Compliance can be measured: yes/no
• The piecemeal application of proven
therapies in favour of an “all or none”
Kollef M 2008. Chest:134: 447-456.
Need For Such Approach
• At present there are recommendations given
by three groups on how to prevent VAP. ( ATS,
Joint Planning Group of Canadian Critical Care
group, and HICPAC).
• These guidelines are based on VAP
pathogenesis and aim to prevent bacterial
colonization of aero-digestive tract and
Non-adhernce to Guidelines
• Disagreement with
interpretation of clinical
• Lack of resources (31%)
• Costs (17%).
• Lack of resources (37%),
• Miscellaneous [overwork,
lack of time for hand
• Patient discomfort (8%)
• Disagreement with
reported study results (8%)
• Fear of potential adverse
Features of Existing Guidelines.
A. Effective Interventions
• Infection control program (eg, staff education)
• Monitor ICU infections
• Oral (nonnasal) intubation
• Avoidance of unnecessary reintubation
• Scheduled drainage of condensate from
• Enteral (not parenteral) nutrition
A. Effective Interventions
• Continuous subglottic suctioning
• Maintenance of adequate pressure in ETT cuff
• Hand hygiene between patient contacts
• Semi-recumbent positioning (30° to 45°).
B. Effective interventions for
selected (not routine) indications
• Antibiotic prophylaxis for patients with head
• Selective digestive decontamination for MDR
• Chlorhexidine mouth care(eg, coronary
C. Ineffective interventions
• Routine changes of ventilator circuit
• Daily changes of heat and moisture
• Chest physiotherapy
• Routine use of antibiotic prophylaxis, Selective
Digestive Decontamination, or chlorhexidine
D. Interventions of equivocal or
• Passive humidifier or heat-moisture exchanger
• Postural changes
• Sucralfate (vs histamine type-2 antagonist) to
prevent stress ulcer.
[ ATS Recommendations: Am J Respir Crit Care Med 2005;
Canadian Recommendations: Dodek P et al 2004. Ann Intern
Med ; 141:305–313.
HICPAC: Tablan OC et al 2004. MMWR Recomm Rep 2004;
• It is a package of evidence-based best
interventions that, when implemented
together for all patients on mechanical
ventilation, has resulted in dramatic
reductions in the incidence of ventilator-
associated pneumonia. (www.ihi.org)
• The science behind the bundle is so well
established that it should be considered
standard of care.
The VAP Bundle
• Not all possible therapies are included in a
particular bundle, as the bundle is not
intended to be a comprehensive list of all care
that should be provided
• Goal is to improve teamwork &
• Education based programmes with multiple
Effect of Interventions:
• Target Group: respiratory care practitioners
and ICU nurses. ( Study # 1 and 2)
• Educational interventions :Self-study module,
lectures, fact sheets, posters.
• Specific risk-reduction strategies: meticulous
hand hygiene, semi-recumbent positioning
( >30°), oral intubation, and regular drainage
of condensate from ventilator circuits.
Study # 1: Zack et al 2002. Crit Care Med; 30: 2407-12
No. of Infections /1000 ventilator days:
12.6 : Before Intervention
5.7: After intervention. Significance: p<0.001.
Study #2: Babcock et al 2004. Chest; 125: 2224-31.
8.8: Before intervention
4.7: After intervention. Significance: p<0.001.
Study# 3: Lai et al 2003. Infect Control Hosp Epidemiol;
• Implementation of stepwise strategies: (1)
elevating head of bed, (2) using sterile water
and enteral valves for nasogastric feeding, (3)
prolonging interval for changing in-line suction
Surgical ICU : 48% Reduction
Medical ICU : 38% Reduction
1. Daily awakening: “sedation vacation”
2. Daily assessment of readiness for weaning
3. DVT prophylaxis (unless contraindicated)
4. Stress bleeding prophylaxis.
5. Oral care with Chlorhexidine .
Rello J et al . Intensive Care Med. 2010. 36:773-80
Miller RS et al . J Trauma. 2010 Jan;68(1):23-31
What YOU Can Do? Start a
1. Is there a system in place now?
2. Know your baseline performance:
↳Randomly select 10/20 records of ventilated patient to
apply your measures to them.
↳Be sure to check compliance with the total bundle as
well, the “all or none” goal.
3. Educate ICU staff (using your own data).
Small Tests of Change
4. Move on to pilot test in one ICU:
↳ Refine the process
↳ Test on all shifts
↳ Test on all ventilated patients
5. Measure your results to know if a change was
“Most discussions of decision making assume that only senior
executives make decisions or that only senior executives'
decisions matter. This is a dangerous mistake.”
Calculate the Ventilator Associated
Numerator: number of ventilator
associated pneumonia cases.
Denominator: total ventilator days
*Multiply by 1000 to convert to a rate.
Measure # 2
• Identify the intervention measures you are
going to adopt in your ICU regarding VAP.
• Identify a modest number of measures: 4/5.
“The things included in the measurement become relevant; the
things omitted are out of sight and out of mind”. Peter F.
Calculate the compliance with the Ventilator
• Numerator: Number of vented patients receiving ALL
components of bundle
↳ please note that this is an ‘all or nothing’ measure: a
patient who had 4 out of 5 of the elements would count
as a ‘no’.
• Denominator: Total number of patients on ventilators for
the day of the prevalence sample.
Choose Specific objectives that precisely
define and quantify desired outcomes. ( e.g.
reducing the VAP rate by 25%). Avoid
unrealistic objectives, such as attempting
to completely eliminate VAP.
Measure the objective, monitor both staff
adherence to tactics and the infection rate
using predefined criteria,
Make objectives Achievable and relevant by
engaging stakeholders and empowering them
to select specific tactics and steps for
implementation. Nurses are in the best
position to identify the preventive tactics that
Objectives should also be Relevant to the
institution so that administrators provide
adequate staffing and other resources.
• Make objectives Time bound; set dates for
collecting baseline and periodic data, and a
completion date for evaluating the success of
“Can we achieve this idea? Or can we only talk
about it ?”
“Management by objective works - if you know the
objectives. Ninety percent of the time you don't”.
Peter F. Drucker