Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia

American Journal of Critical Care, Jan, 2007 by Arlene F. Tolentino-DelosReyes, Susan D Ruppert, Shyang-Yun Pamela K. Shiao

Table 1 Current evidence on the prevention of VAP

Reference                 Year             Design

HOB elevation

Drakulovic et al (3)      1999   Randomized
                                   controlled trial

Kollef (4)                1993   Inception cohort design

Kollef et al (5)          1997   Comparison studies,
                                   surveillance of patients,
                                   and data collection

Grap et al (6)            2005   Longitudinal, descriptive
                                   design

Metheny et al (7)         2006   Prospective, descriptive
                                   design

Hanneman and Gusick (8)   2005   Cross-sectional design,
                                   observational data

Torres et al (9)          1992   Comparison

Babcock et al (10)        2004   Before and after
Salahuddin et al (11)     2004     education
Zack et al (12)           2002

Warren et al (13)         2003   Association and multiple
                                   regression

Cook et al (14)           2002   Semistructured
                                   interviews and focus
                                   groups

Hand washing

Girou et al (15)          2002   Randomized controlled
Lucet et al (16)          2002     trial
Trick et al (17)          2003
Zaragosa et al (18)       1999

Trick et al (17)          2003   Randomized controlled
                                   trial

Doebbeling et al (19)     1992   Crossover trial

Pittet et al (20)         1999   Observation study

Oral care

Bergman et a1 (21)        2001   Randomized controlled
Pugin et al (22)          1991     trial

Bergman et al (21)        2001   Randomized controlled
                                   trial

DeRiso et al (23)         1996   Randomized controlled
                                   trial

Mentec et al (21)         2001   Randomized controlled
                                   trial

Cutler and Davis (25)     2005   Observation before
                                   and after education

Hanneman and Gusick (8)   2005   Cross-sectional survey

Reference                 Significant outcomes    Suggested practice

HOB elevation

Drakulovic et al (3)      HOB elevation and      HOB elevation at
                            VAP                    30[degrees]-
                                                   45[degrees]

Kollef (4)                Mortality rate and
                            VAP

Kollef et al (5)          Transport of
                            patients and VAP
                            rate

Grap et al (6)            Height of back rest    HOB elevation
                            and VAP, comfort
                            and skin integrity
                            of patient

Metheny et al (7)         HOB and outcomes;      HOB elevation
                            risk factors for       >30[degrees]
                            VAP

Hanneman and Gusick (8)   HOB and outcomes,      HOB elevation
                            supine and
                            30[degrees],
                            semiprone with
                            head down
                            15[degrees]-
                            20[degrees]

Torres et al (9)          Comparison of          HOB elevation at
                            semirecumbent and      least 45 [degrees]
                            supine positions       prophylactic
                                                   measure for
                                                   gastric aspiration

Babcock et al (10)        Staff education        Staff education on
Salahuddin et al (11)       decreased VAP          VAP
Zack et al (12)             incidence

Warren et al (13)         VAP and length of
                            stay in intensive
                            care unit,
                            hospital stay,
                            mortality rate,
                            hospital cost

Cook et al (14)           Barriers leading to
                            underuse of HOB
                            elevation

Hand washing

Girou et al (15)          Bacterial count for    Use of alcohol-based
Lucet et al (16)            alcohol-based          solution for hand
Trick et al (17)            solution and hand      washing
Zaragosa et al (18)         washing

Trick et al (17)          Wearing rings and      Refraining from
                            hand contamination     wearing rings
                                                   during work

Doebbeling et al (19)     Use of                 Use of
                            chlorhexidine,         chlorhexidine,
                            soap, and alcohol      soap, and alcohol
                            and VAP incidence

Pittet et al (20)         Hand washing and       Hand washing before
                            bacterial count        and after contact
                                                   with patient

Oral care

Bergman et a1 (21)        Tracheobronchial
Pugin et al (22)            colonization and
                            VAP incidence

Bergman et al (21)        Antibiotics and        Prophylactic
                            colonization           antibiotics

DeRiso et al (23)         Chlorhexidine          Oral care
                            reduced
                            respiratory
                            infection

Mentec et al (21)         Gastric residual       Check gastric
                            volume and             residual volume
                            vomiting increased
                            incidence of VAP

Cutler and Davis (25)     Implementation of      Oral care protocol
                            oral care protocol     and provision of
                            improved oral care     appropriate tools

Hanneman and Gusick (8)   Mean documented oral
                            care

Abbreviations: HOB, head of bed; VAP, ventilator-associated
pneumonia.

Table 2 Demographic data for nurses in the study

                                              No. (%) or nurses

                                                   Surgical
                                       Coronary    intensive
                                       care unit   care unit    Total
Parameter                              (n = 33)    (n = 28)    (N = 61)

Sex of nurse
  Female                                26 (79)     24 (86)    50 (82)
  Male                                   7 (21)      4 (14)    11 (18)

Age, y
  20-30                                  9 (27)      7 (25)    16 (26)
  31-40                                  7 (21)     11 (39)    18 (30)
  41-50                                 13 (39)      4 (14)    17 (28)
  51-60                                  3 (9)       5 (18)     8 (13)
  [greater than or equal to] 61          1 (3)       1 (4)      2 (3)

Highest educational level in nursing
  Diploma                                1 (3)       1 (4)      2 (3)
  Associate's degree                    12 (36)      5 (18)    17 (28)
  Bachelor's degree                     20 (61)     22 (79)    42 (69)
  Graduate degree                        0           0          0

Nursing experience, y
  <1                                     6 (18)      3 (11)     9 (15)
  1-2                                    2 (6)       4 (14)     6 (10)
  3-4                                    4 (12)      3 (11)     7 (11)
  [greater than or equal to] 5          21 (64)     18 (64)    39 (64)

Critical care experience, y
  <1                                     6 (18)      2 (7)      8 (13)
  1-2                                    2 (6)       5 (18)     7 (11)
  3-4                                    4 (12)      2 (8)      6 (10)
  [greater than or equal to] 5          21 (64)     19 (68)    40 (66)

Shift worked
  7 AM-7 PM                             15 (45)     14 (50)    29 (48)
  7 PM-7 AM                             18 (55)     14 (50)    32 (52)

Table 3 Comparison of results from pretest and posttest
(N = 61)

                                      No. (%) correct

Subject of question                Pretest       Posttest       P

 1. Ventilator bundle
    best-practice guidelines *     61 (100)      61 (100)      >.99

 2. Microorganisms
    causing VAP                    17 (28)       53 (87)      <.001

 3. Poor hand washing              60 (98)       60 (98)       >.99
    and VAP *

 4. Supine positioning and
    lung capacity                  46 (75)       57 (93)       .006

 5. Enteral feeding and VAP        32 (52)       54 (89)      <.001

 6. Risk factors for VAP           44 (72)       57 (93)       .002

 7. Treatment-related risk
    factor for VAP                 12 (20)       46 (75)      <.001

 8. Host-related risk factors
    for VAP                        17 (28)       48 (79)      <.001

 9. Pneumonia diagnoses *          54 (89)       60 (98)       .03

10. Definition of VAP              53 (87)       61 (100)      .003

Total score, mean, SD             6.31, 1.35    9.11, 1.36    <.001
  (range)                           (2-10)        (5-10)

* True/false items.

Abbreviation: VAP, ventilator-associated pneumonia.

Table 4 Observations of practices (N = 99)

                                  No. (%) of nurses
                                 performing practice

                                 Before        After
Practice                        education    education      P

Hands washed
  (before contact)               11 (11)     45 (45)      <.001

Hands washed
  (after contact)                95 (96)     99 (100)      .08

Nail polish                       4 (4)       0 (0)        .04

Artificial nails                  1 (1)       0 (0)        .32

Rings worn                                                <.001
  0                              39 (39)     65 (66)
  1                              44 (44)     27 (27)
  2                              14 (14)      4 (4)
  3                               2 (2)       3 (3)

Actual head-of-bed
  elevation                                               <.001
  <30[degrees]                   55 (56)     26 (26)
  [greater than or equal to]     44 (44)     73 (74)
    30[degrees]

Contraindications                41 (41)      35 (35)      .38

Table 5 Chart audit (N = 99)

                                             No. (%) of charts
                                            with practice noted

                                            Before       After
Practice                                   education   education    P

Head-of bed elevation                                              .009
  Not recorded on chart                     33 (33)     26 (26)
  <30[degrees]                              16 (16)      5 (5)
  [greater than or equal to] 30[degrees]    50 (51)     68 (69)

Frequency of oral care                                             .009
  in 12-hour shift
  0                                         45 (45)     27 (27)
  1                                         25 (25)     25 (25)
  2                                         13 (13)     12 (12)
  3                                         16 (16)     35 (35)

Frequency of checking                                              .008
  residual volume in
  nasogastric tube during
  a 12-hour shift
  0                                         13 (13)     11 (11)
  1                                         12 (12)      6 (6)
  2                                         12 (12)      8 (8)
  3                                          3 (3)      18 (18)
  Not applicable                            59 (60)     56 (57)