This study aimed to measure compliance with ventilator-associated pneumonia (VAP) bundle components in an intensive care unit (ICU) in Saudi Arabia. An audit of 88 mechanically ventilated patients found high compliance (87.5-100%) with hand hygiene, mouth care, and avoiding routine ventilator tubing changes. Compliance was lower for head-of-bed elevation (95.2%) and daily sedation vacations (65.5%). No patients received endotracheal tubes with subglottic suction ports due to unavailability. The authors recommend increasing education, minimizing provider workload, improving equipment maintenance, and ensuring access to recommended ventilation equipment.

1. VAP bundle compliance in ICU
Authors
A. Al-Harthy , A. F. Mady , H. Al-Hanafy , W. Al-Etreby , M. Asim Rana
Department of Intensive Care Medicine,
King Saud Medical City, Riyadh, Kingdom of Saudi Arabia.
Corresponding Author
Waleed Tharwat Hashim Al-Etreby
Kingdom of Saudi Arabia, Riyadh, P.O. Box 331140 ZIP code 11373 Al-Shemaisi
Anesth_71@yahoo.com
Lead Consultant
Abdul Rahman Mishal Al-Harthy
King Saud Medical City, Critical Care Department
Riyadh, Kingdom of Saudi Arabia
The Online Journal of Clinical Audits. 2014; Vol 6(2).
Published June 2014.
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2. ISSN 2042-4779 ClinicalAudits.com
Abstract: Healthcare associated infection is a major concern worldwide, and ventilator associated
pneumonia (VAP) is the leading cause of mortality among them, VAP is also associated with increased
length of stay in ICU, and increased cost of treatment. Authorities all over the world have issued
guidelines and recommendations for the prevention of VAP in an effort to decrease its incidence.
Aims – To measure the compliance of healthcare providers in ICU with VAP bundle.
Methods – Concurrent snapshot review of the medical files of 88 adults ventilated patients took place,
during April 2014, for evidence of compliance with components of VAP bundle, namely: Hand hygiene,
mouth wash, elevation of head of bed (HOB), sedation vacation, non-routine changing of the ventilator
tubing, and the use of Endotracheal tube (ETT) with subglottic suction port.
Results – compliance with mouth wash and non-routine tubing change was 100%, while compliance with
hand hygiene was 87.5%, compliance with the elevation of HOB was 95.2%, compliance with sedation
vacation was 65.5%, no patients were intubated with ETT with subglottic suction port, so the compliance
was 0%
Conclusions – Awareness and education are required for the VAP bundle, every effort must be made to
minimize load of work on physicians and nurses, periodic preventive maintenance needs to be more
effective, and administration of the ICU will be addressed to provide ETT with subglottic suction ports.
Introduction
Healthcare-associated infection (HAI) is a major patient safety concern all over the
world 1
. The leading cause of death among (HAI) is ventilator associated pneumonia
(VAP), exceeding deaths due to central line infections, severe sepsis, and respiratory
tract infections in non-intubated patients 2
. With mortality rates ranging from 15% to
70% depending on the patient population 1
. And approximately 60% of deaths among
patients with hospital-acquired pneumonia 3
. Studies have also shown higher hospital
mortality rates of ventilated patients who develop VAP (about 46%) compared to
mortality rates of 32% of ventilated patients who do not develop VAP 4
. VAP is not only
associated with high mortality rates, but accounts also to increasing the length of stay
in ICU by an average of 4 to 9 days 3
. And consequently increasing directly
hospitalization costs to up to $40,000 per patient 5
. As well as increasing the duration of
mechanical ventilation, and making it more difficult to wean the patient from the
ventilator 6
.
Because of the seriousness of VAP and its morbid effect on patients’ outcome, many
authorities around the globe, like The Center for Disease Control (CDC), Joint
Commission, and the Leapfrog Group, have identified VAP rates as a measure of the
quality of care provided by an institution 7,8
. Several organizations have recommended
approaches, interventions, and evidence-based guidelines to address that issue 9
. And
many hospitals worldwide implemented a group of patient care practices, to be carried
out by the care team to standardize treatment, named the ventilator bundle or the VAP
bundle 10
. Including King Saud Medical City, Riyadh, KSA. Where this audit was carried
out.

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Aims
To measure the compliance of the care providers with the elements of the VAP bundle.
Audit Standards (table 1)
1- Intubated patients should be positioned with their upper body elevated (semi-
recumbent or sitting) for as much of the time as possible, unless contraindicated
like spine injury.
2- Oral antiseptics (for example, chlorhexidine) should be included as part of an
oral hygiene regimen for all patients who are intubated, unless contraindicated
due to oro-pharyngeal trauma.
3- Hand hygiene, in accordance with national hand hygiene guidelines, should be
part of the routine clinical care of mechanically ventilated patients, without
exception.
4- The ventilator circuit should be changed only if soiled or damaged, not on a
routine basis.
5- Sedation reviewed, and if appropriate stopped daily, and the patient is assessed
for weaning and extubation, unless contraindicated due to difficulty of ventilation,
refractory hypoxia, or HFO.
6- Use of subglottic secretion drainage ETT in patients likely to be ventilated for
more than 48 hours.
Table 1: Audit standards and criteria.
Evidence of quality of care or service
(criterion)
Standard
(% compliance)
Exception(s) Definitions and
instructions for data
collection
1 Elevation of head of bed 30 – 45 degrees 100% Spine injury All ventilated adult
patients in ICU
2 Oral hygiene with chlorhexidine 100% Oro-pharyngeal trauma All ventilated adult
patients in ICU
3 Hand Hygiene 100% NONE All ventilated adult
patients in ICU
4 Circuit change only when needed 100% NONE All ventilated adult
patients in ICU
5 Sedation review and vacation 100% HFO, high ICP, difficult
to ventilate
All ventilated adult
patients in ICU
6 Subglottic suction ETT 100% Not available All ventilated adult
patients in ICU
Methods
The study was carried out at King Saud Medical City (KSMC), Riyadh, Saudi Arabia.
KSMC has a 120 bed state of the art ICU, making it one of the largest ICUs in the
middle east, accepting both medical and surgical cases.
During the month of April 2014, 88 mechanically ventilated adult patients were included
in the study.
Concurrent snap shot data were collected from the patients’ medical records, in a
YES/NO tick box form, concerning the six audit standards stated above. Percentage of
compliance with each standard was calculated separately, by dividing the number of
patients who meet the standard, by the number of patients to whom the standard
applies minus exceptions, multiplied by 100.

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Results (table 2, figure 1)
1. Compliance with hand hygiene was observed in 77 cases out of 88 without
exceptions, with a percentage of 87.5%
2. Compliance with mouth wash with chlorhexidine was 100%, no patients were
excluded.
3. Compliance with elevation of head of bed was 81 out of 85 patients, with a
percentage of 95.2%, and 3 patients with unstable spine fracture were excluded.
4. Compliance with sedation vacation was documented in 57 patients out of 87,
with a percentage of 65.5%, while one patient on high frequency oscillation was
excluded.
5. Compliance with non-routine changing of the ventilator tubing was 100% without
exceptions.
6. Compliance with the use of subglottic suction ETT was 0%
Table 2: Summary of results.
Criteria Exception Compliance Percentage
Hand Hygiene zero 77/88 87.5 %
Mouthwash zero 88/88 100 %
HOB elevation 3 81/85 95.2 %
Sedation vacation 1 57/87 65.5 %
Changing tubing zero 88/88 100 %
Subglottic suction 88 0/88 0 %
Figure 1: Summary of results.
1- Hand hygiene, 2- Mouth wash, 3- HOB, 4- Sedation vacation, 5- change of tubes, 6- subglottic suction tube

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Discussion
Mouthwash with chlorhexidine for intubated patients is a part of the daily nursing care in
our ICU, and all patients audited received that intervention, resulting in a compliance
percentage of 100%.
It is also the routine practice of respiratory therapists in the ICU to change tubing only if
they become soiled with secretions or damaged, resulting in a 100% compliance.
Compliance with hand hygiene was 87.5 %, noncompliance was observed in eleven
patients. Out of those eleven episodes of non-compliance, five cases were related to
emergency situations, like sudden desaturation or accidental extubation. Non-
compliance was observed among physicians, either ICU or out of ICU physicians.
Sedation vacation and assessment of readiness of extubation had the lowest
compliance percentage of about 66%, 87 patients were included and one patient on
HFO was excluded.
As for the use of ETT with subglottic suction port, all of the patients were excluded,
resulting in a compliance percentage of zero%
Conclusions
Compliance with the nursing elements of VAP bundle (mouth wash, hand hygiene, and
non-routine changing of the ventilator tubing) is up to standards, while the
inconsistencies were observed from the physicians side. In part due to unawareness
and lack of education about the elements of the bundle, especially between physicians
from outside the ICU, and in part due to the concentration on resuscitation by ICU
physicians in emergency situations, on the expense of policies and recommendations.
The overload of work (be it paper work, or critically ill patients handled by the same
person) make it impossible sometimes for the ICU physician to consider holding
sedation for an intubated patient and start a trial of weaning, which requires his/her
undivided attention and concentration.
Compliance with the standard of elevation of the head of bed, that was breached four
times, was the result of a malfunctioning bed once, and forgetting to return the patient
to semi-sitting position after care three times, which could also be attributed to the
overload of work on the bedside nurse, with many responsibilities and tasks to be
performed.
The zero compliance with the standard of using ETT with subglottic suction port was
simply due to its unavailability in our institution.
Recommendations
• Education, awareness, and enlightening are a must for the successful
implementation of any advocated intervention or practice. A campaign of
awareness of the VAP bundle is required to educate healthcare providers, about
its importance. Different methods can be used like: posters, reminder (pocket)
cards, lectures, group discussions, one-on-one talks …etc.

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• Decreasing the load of work on the physician as well as the nurse is
recommended, so that the best care can be provided. Minimizing paper work is a
method, perhaps also recruitment of more personnel.
• Proper maintenance of all ICU equipment, and periodic checking. If a bed is not
functioning, it should not be available for patient admission.
• Administration of the ICU will be addressed to provide the ETT with subglottic
suction port.
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