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B y K i m b e r l y H a i n e s , R N

It’s ironic when you think about it – a mechanism

designed to keep patients alive can actually make them

sicker and even kill them.

We’re talking about ventilators, or, more specically,

ventilator-associated pneumonia (VAP). Most surgical

patients undergo general anesthetic for their procedures

and are then extubated in the operating room at the end

of surgery. Critically ill patients, however, remain intubated

after being transported from the operating room to the ICU.

Stop and think for a second about how long those patients

might remain on ventilators. As hours and days tick by,

the risk of VAP grows exponentially.

VAP typically occurs after 48 hours of intubation and is

a leading cause of death among patients who contract

nosocomial infections. In addition to prolonging a patient’s

hospital stay, VAP also adds an estimated cost of $40,000

per admission. Ultimately, approximately 46 percent of 

patients who develop VAP will not survive. 1

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In an eort to reduce post-operative complications, the Surgical Care

Improvement Project (SCIP) has targeted post-operative VAP as one of four

areas requiring improvement. According to SCIP, sta education regarding

best practices and new technologies as well as eective communication leads

to quality improvement. The organization also states that standardized

processes lead to improved consistent care and better outcomes.2

 The prevention of ventilator-associated pneumonia is also a goal of the

Institute of Healthcare Improvement (IHI) 100,000 Lives Campaign.

 The organization has put together a how-to guide to prevent VAP. The

guide advocates the use of a ventilator bundle, which is a grouping of best

practices that result in signicant improvement in the prevention of VAP.

Some facilities have seen a 45 percent decrease in VAP using this bundled

approach. The IHI bundle was designed to increase adherence to basic

preventative measures, and includes the following therapies:1

Elevating the head of the bed

• Elevating the head of the hospital bed 30 degrees to 45 degrees

improves ventilation and reduces the likelihood of atelectasis and

aspiration of gastric contents.Deep vein thrombosis (DVT) prophylaxis

•  The rate of DVT increases in sedentary sedated patients.

Peptic ulcer prophylaxis

•  The mortality rate of patient’s increases ve times in documented

occurrences of gastrointestinal bleeding related to stress ulcerations.

Aspiration of gastric contents might precipitate pneumonia.

Sedation vacation

• Daily interruption of sedation allows assessment of the patient’s

readiness to be extubated. A reduced sedative state also allows

the patient to assist in extubation by controlling secretions and

coughing. Patient ventilation time decreased almost 50 percent

using this technique.

While the IHI acknowledges additional therapies such as subglottic suctioning

and oral care can also decrease the risk of VAP, these therapies were not

included in the IHI bundle. The bundle includes only therapies the IHI felt

could be implemented rapidly and were readily available at all facilities.1

 The prevention of ventilator-associated pneumonia requires a multidisciplinary

approach. The next time an intubated patient is transported to the ICU,

theses therapies should be considered. They might save the patient’s life.

References:1 Institute for Healthcare Improvement. Getting Started Kit: Prevent Ventilator Associated

Pneumonia. How-to Guide. Available at: http://www.ihi.org. Accessed May 24, 2007.2 Surgical Care Improvement Project. Respiratory. Available at: http://medqic.org/scip.

Accessed May 24, 2007.

About the author

Kimberly Haines, currently a clinical nurse consultant, has been

an RN for 13 years. Previously, she was a sta nurse at a number

of acute care facilities and ambulatory surgery centers.