Results of a Quality Improvement Project to Decrease VAP Incidence in the ICU

Background: The goal of this quality improvement intervention was to lower VAP rates in an intensive care unit (ICU) population to 1.76 infections or lower per 1000 days of mechanical ventilation.

Objective: Opportunities for decreasing the VAP rate were noted at our hospital in 2007, leading to an evaluation of conformity with the VAP bundle recommendations and procedures, and efforts to enhance compliance.

Methods: A process improvement team was formed which consisted of charge nurses, unit coordinators, infection preventionists, directors of ICUs, and quality management to develop a plan to combat VAP infections.

The VAP bundle of care was re-assessed, and the ICU management team verified compliance with all VAP bundle elements daily, including spot checks q24h for accurate documentation. Pre-intervention compliance rates with oral care were noted to be approximately 30%.

The VAP bundle consisted of the following components:

1. Head of the bed elevation between 30° and 45°

2. “Sedative interruption” on a daily basis with daily assessment of readiness to extubate

3. Prophylaxis for peptic ulcer disease and deep venous thrombosis 

4. Q2h oral care protocol

In 2007, the antiseptic solution used q12h in the oral care protocol was 1.5% hydrogen peroxide. This was changed to chlorhexidine gluconate in January 2008.

The VAP bundle was implemented in 4 ICUs (49 beds) with staff education. In 2008, q12h antiseptic oral care solution was added to the medical administration record for additional compliance documentation. Patient headcount in the ICU on mechanical ventilation was made by the respiratory therapy department daily. Statistical analysis was performed for August 2007 through December 2007 (pre-intervention period) and February 2008 through August 2009 (post-intervention period). The chi-square test was used to assess the change in the VAP rate, and counts per device days were presented.

Results: The data analysis revealed a reduction in the VAP rate from 10.3 per 1000 ventilator days (39/3793) during the pre-period to 0.4 (4/11,187) during the post-period.  The decrease constituted a 96% relative reduction. This finding was statistically significant (test statistic = 97.5, P<0.001).

Post-intervention compliance rates with oral care averaged 95% throughout the intervention period.

Conclusions: Development of a multidisciplinary process-improvement team is helpful in the development of a successful quality improvement initiative. Thorough assessment of peer-reviewed literature and guidelines should be conducted to ensure best practices in prevention are adhered to. Caregiver compliance is an important aspect of VAP prevention, and extra measures should be incorporated into a quality improvement protocol to enhance compliance tracking. Staff education, documentation of VAP-bundle prevention, and regular monitoring of procedures are important to achieve high VAP bundle compliance rates averaging 95%.