The Effects of Bundle Adherence on Ventilator-Associated Pneumonia: A Quality Improvement Project

Abstract

Ventilator-associated pneumonia (VAP) is a hospital-acquired infection that affects intubated patients on a ventilator. The risk of acquiring the infection increases the longer a patient stays on the ventilator. Complications from ventilator-associated pneumonia can impact the patient physically, financially, or emotionally. Evidence-based recommendations collectively implemented to prevent VAP are referred to as a care bundle. Despite rising VAP cases in a local hospital, adherence to all elements of the VAP prevention bundle remained low. Our quality improvement project aimed to provide training to staff to increase awareness and adherence to the VAP bundle and decrease the number of VAP cases. Levin’s Evidence-Based Practice Improvement Model served as a guiding framework for the project. The project leader delivered education to core staff in one Critical Care unit on all aspects of the VAP bundle. Concurrently, the process of performing Sedation Vacations and Spontaneous Breathing Trials was standardized and implemented.

There was an improvement in adherence to several VAP prevention bundle elements. Head of bed adherence improved from 67% to 68% (p = .805) for non-core staff and from 84% to 97% (p < .001) adherence for core staff. Oral care improved from 58% to 62% (p = .373) adherence for non-core staff and 84% to 93% (p < .001) for core staff. Suctioning adherence declined from 87% to 85% (p = .866) for non-core staff and improved from 85% to 89% (p = .471) for core staff. Chlorhexidine mouth cleaning adherence declined from 96% to 90% (p = .377) with non-core staff and remained at 90% (p = .922) pre- and post-intervention for core staff. Brushing the patient’s teeth adherence declined from 64% to 30% (p = .011) for non-core staff and from 64% to 36% (p < .001) for core staff. Performing a sedation vacation adherence improved from 11% to 35% (p = .026) for non-core staff and from 7% to 43% (p < .001) for core staff. Spontaneous breathing trial adherence improved from 8% to 56% (p = .002) non-core staff and from 5% to 51% (p < .001) in core staff. Overall adherence to all bundle elements went from 30% to 24% for non-core staff and improved from 70% to 76% (p = .022) for core staff. There was a decrease in VAP cases after the education despite increased ventilator days.

Keywords: Ventilator-associated pneumonia, VAP, bundle, adherence, hospital-acquired infection