This document discusses strategies to prevent ventilator-associated pneumonia (VAP) in intensive care units. It outlines a prevention bundle with four elements: readiness to extubate assessed daily, keeping the head of the bed elevated 30-40 degrees, minimizing disruption of the ventilator circuit, and performing oral hygiene every 12 hours. VAP is a common and costly healthcare-associated infection, with estimated annual costs of over $40,000 per patient in the US due to increased length of stay. Implementing a multi-pronged prevention strategy can help reduce rates of VAP and lower financial burdens on the healthcare system.

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Ventilator Associated Pneumonia
−ICU Management Strategies−
Christopher L. Bosley BS, AAS, RRT-NPS, RCP
Neonatal-Pediatric Transport Clinical Specialist
Department of Anesthesia – Respiratory Care
Mayo Clinic-Eugenia Litta Children’s Hospital

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Conflict of Interest
• None

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Acknowledgement
 Deb Rowekamp, MS, RN
Nursing Education Specialist
Education and Professional Development
Assistant Professor in Nursing
Mayo Clinic - Rochester, MN.

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Objectives
• Recognize the significant financial implications
of Health Care Associated Infections (HAIs)
• Describe evidence based strategies to
decrease Ventilator-associated pneumonia

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What is VAP…?
• Ventilator-associated pneumonia (VAP) is a lung
infection that develops in a person who is on a
mechanical ventilator. 1
• An infection may occur if “germs” enter through the ETT
and get into the patient’s lungs. 1,2
• These germs can be spread in healthcare settings from
patient to patient on unclean hands of healthcare
personnel or through the improper use or reuse of
equipment.1,2
• VAP is a Healthcare-Associated Infection (HAIs). 1
1. www.cdc.gov/HAI/vap/vap.html#rphp
2. www.cdc.gov/HAI/patientSafety/patient-safety.html

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Healthcare-Associated Infections (HAIs)
• An estimated 1,737,125 Healthcare-associated
infections occur annually, the CDC reports inpatient
total costs upward of $35.7 to $45 Billion annually
(USA). 1
Types of HAIs:2
1. Ventilator-associated pneumonia (VAP)
2. Surgical Site Infection (SSI)
3. Central Line-associated Bloodstream Infection (CLABSI)
4. Catheter-associated Urinary Tract Infections (CAUTI)
1. Scott, R.D. The Direct Medical Costs of Healthcare
Associated Infections in U.S. hospitals and the Benefits of
prevention. U.S. Centers for Disease Control. March 2009.
2. www.cdc.gov/HAI/infectionTypes.html

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Financial Impact of HAIs
1. Surgical site infections (33.7% of the total $9.8B
cost)
2. Ventilator-associated pneumonia (31.6%)
3. Central line–associated bloodstream infections
(18.9%)
4. Clostridium difficile infections (15.4%)
5. Catheter-associated urinary tract infections (<1%)
Zimlichman E, Henderson D, Tamir O, et al. Health Care–
Associated Infections: A Meta-analysis of Costs and Financial
Impact on the US Health Care System. JAMA Intern Med. 2013.

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Financial Impact of VAP
• Ventilator-associated pneumonia accounted for
$40,144 per patient
• Length of Stay: (LOS: +8.4-13.1 days)
Zimlichman E, Henderson D, Tamir O, et al. Health Care–Associated
Infections: A Meta-analysis of Costs and Financial Impact on the US
Health Care System. JAMA Intern Med. 2013.

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Ventilator-associated pneumonia (VAP)
• VAP is the most deadly of the HAIs, with a
mean death rate of 35,967 per year1
• 52,543 cases of VAP occur annually, according
to the CDC estimates 2
1. Stone, P. Economic burden of healthcare-associated infections: an American
perspective. Expert Rev Pharmacoecon Outcomes Res. 2009 October; 9(5): 417–422.
2. Scott, R.D. The Direct Medical Costs of Healthcare Associated Infections in U.S.
hospitals and the Benefits of prevention. U.S. Centers for Disease Control. March 2009

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Solutions for Patient Safety Prevention Bundle
Ventilator-Associated Pneumonia (VAP) 1,2
1 Readiness to Extubate
2 Head of Bed Elevation
3 Minimize Disruption of the Circuit
4 Oral Hygiene
1. Children’s Hospitals’ Solutions for Patient Safety-national Children’s Network
2. www.solutionsforpatientsafety.org/for-hospitals/hospital-resources/

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Readiness to Extubate
 Assess readiness to extubate daily
• PICU Rounding Tool incorporates input from:
 Respiratory Therapy
 Nursing
 Physician

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Head of Bed Elevation
 Elevate head of bed to 30-40° for infants
and children
 Performed minimally once per day

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Head of Bed Elevation
Bed Angle

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Head of Bed Elevation
Crib Angle
http://www.hardmfg.comUse of a level attached to crib

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Minimize Disruption of the Circuit
 Inspect ventilator circuit for gross
contamination daily. If soiled, change circuit
 Performed minimally once per day

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Minimize Disruption of the Circuit
Closed Catheter Suction Devices

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Minimize Disruption of the Circuit
Ventilator Circuit Position
Notice how the vent circuit is draped over the head of the
bed, allowing condensation to drain toward the patient’s airway.

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Minimize Disruption of the Circuit
Ventilator Circuit Position
 Notice how the vent circuit is below the patient’s airway.
Having the circuit positioned along side the bed instead of behind the head of
the bed can help with draining condensation/secretions away from patient.

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Oral Hygiene
 Perform oral hygiene minimally every 12 hours
Challenges of Oral Hygiene:1,2
1. Bacterial colonization of the
oropharyngeal area
2. Aspiration of subglottic secretions
3. Colonization of dental plaque &
Respiratory Pathogens (Biofilms) 1. www.sageproducts.com
2. Schleder B. et al., J Advocate Health
Care 2002.

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Oral Hygiene
Suctioning
www.sageproducts.com

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Oral Hygiene
Brushing
www.sageproducts.com

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Oral Hygiene
Pastes, Rinses, Moisturizer
www.sageproducts.com

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Oral Hygiene
(No teeth)
www.sageproducts.com

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Oral Hygiene Assessment
www.sageproducts.com

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Prevention Bundle
Element
Recommended Approaches
Readiness to Extubate
(Performed minimally once per day)
• Ongoing assessment for extubation readiness every 24 hours.
• Daily health care team discussion to evaluate the need to remain
intubate and what steps are needed to work towards extubation.
Head of Bed Elevation
(Performed minimally once per day)
• Keep HOB elevated to 30-40° for all ventilated patient beyond
infancy.
• Consider use of colored or visual measurement device to ensure
proper angle
Minimize Disruption of the Circuit
(Performed minimally once per day)
• Perform circuit inspection every 8 hours for condensation &/or
gross contamination.
• Visually inspect ventilator for condensation or contamination
• Change circuit for gross contamination
• Drain circuit if fluid has accumulated
• Avoid changing the circuit on a routine basis
Oral Hygiene
(Performed minimally every 12
hours)
• Brushing teeth & gums with a soft bristle toothbrush & product
for plaque removal
• Use a gauze & sterile water for patients without teeth
• Consider performing oral care before repositioning patient

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Questions & Discussion