The cuff at the lower end of the ET tube is used to seal the airway during mechanical ventilation and minimize aspiration into the lower respiratory tract. A routine part of airway care is to measure and monitor ET tube cuff pressure to assess for a tracheal seal. Cuff pressure should be maintained above 20 cm H2O to minimize the aspiration risk, but below the tracheal mucosal capillary perfusion pressure of 25 to 30 cm H2O to minimize tracheal erosion.
Elevating the head of the bed is a well-documented way to help reduce VAP. Maintaining an angle of 30 to 45 degrees at all times reduces the aspiration risk, whereas supine positioning has been shown to increase risk. AACN’s VAP practice alert recommends an elevation of 30 to 45 degrees (unless medically contraindicated) for all patients receiving mechanical ventilation or who are at a high risk for aspiration (for instance, those with an enteral tube and a decreased level of consciousness).
Colonization of dental plaque from organisms in the oral cavity has been linked to hospital-acquired infections and VAP in mechanically ventilated patients. Providing mouth care decolonizes the oral cavity. AACN’s practice alert recommends providing mouth care every 2 to 4 hours. According to this alert, critical-care and acute-care settings should develop and implement a comprehensive oral hygiene program. The latter should include protocols for brushing the patient’s teeth, gums, and tongue and moisturizing the oral mucosa and lips.
The Institute of Healthcare Improvement (IHI) defines bundling of interventions as the “grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.” The ventilator bundle recognized by IHI and the Joint Commission consists of a group of evidence-based practices that, when implemented together, dramatically reduce VAP incidence in mechanically ventilated patients. The bundle includes these interventions:
The IHI ventilator bundle is included in current national policies and quality-improvement initiatives aimed at improving ventilator care. Hospitals across the country are implementing it and collecting and reporting data on its key interventions.
Although the bundle has been documented to decrease mortality and minimize the aspiration risk, it lacks an intervention to decolonize the oral cavity. Thus, an opportunity exists to improve healthcare quality and redefine strategies for VAP prevention.
We know little about how the bundling of autonomous nurse-initiated interventions affects VAP incidence. An autonomous nursing intervention is one that nurses can implement independently, based on their education and knowledge. To date, literature on the three autonomous nursing interventions discussed in this article have been explored individually to reduce VAP.
The author’s dissertation study found that the optimal bundle for reducing VAP includes these three interventions:
The study found that the risk of developing VAP fell 97.6% and the expected time until VAP occurred was almost 3.5 times longer in patients who’d received the optimal intervention bundle than in those who hadn’t. Implementing an autonomous nursing-intervention bundle that minimizes both the risk of aspiration into the lower respiratory tract and oral-cavity colonization reduced VAP incidence by 55.4%. Bundling the three interventions achieved better patient outcomes than if these same interventions had been implemented individually. (See Nursing-intervention bundle to reduce VAP By clicking on PDF icon above.)
The autonomous nursing-intervention bundle described above interrupted transmission of microorganisms to the lower respiratory tract. This bundle matches interventions with the two processes known to cause VAP. Bundling the interventions significantly contributed to reducing VAP in critically ill patients, indicating that applying consistent interventions can reduce risk and improve patient outcomes.
The concept of matching interventions to the cause of a specific problem can be generalized to address other healthcare challenges. Once interventions are matched to the cause of the problem, nursing interventions can be bundled and evidence can be incorporated into nursing practice and policy.
Selected references
American Association of Critical Care Nursing. Practice alert: Oral care in the critically ill. ww.aacn.org/WD/Practice/Docs/Oral_Care_in_the_Critically_Ill.pdf. Accessed January 20, 2011.
American Association of Critical Care Nursing. Practice alert: Ventilator associated pneumonia. www.aacn.org/WD/Practice/Docs/Ventilator_Associated_Pneumonia_1-2008.pdf. Accessed January 20, 2011.
American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
Association for Professionals in Infection Control and Epidemiology (APIC). An APIC Guide: Guide to the Elimination of Ventilator-Associated Pneumonia. Washington, DC: APIC; 2009.
Centers for Disease Control and Prevention. Ventilator-associated pneumonia (VAP) event. www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf. Accessed January 20, 2010.
Curtin L. Nursing strategies in reducing ventilator-associated pneumonia: Program evaluation. Dissertation Abstracts International; 2007.
Green LR, Sposato K. Guide to the Elimination of Ventilator-Associated Nneumonia. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2009.
Institute for Healthcare Improvement. Implement the ventilator bundle. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx. Accessed January 20, 2011.
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation. Am J Crit Care. 2010;19(1):39-47.
Murray T, Goodyear-Bruch C. Ventilator-associated pneumonia improvement program. AACN Adv Crit Care. 2007;18(2):190-199.
Sole ML, Aragon D, Bennett M, Johnson RL. Continuous measurement of endotracheal tube cuff pressure: how difficult can it be? AACN Adv Crit Care. 2008;19(2):235-243.
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. www.cdc.gov/ncidod/dhqp/pdf/guidelines/CDCpneumo_guidelines.pdf. Accessed January 20, 2011.
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. March 26, 2004. Guidelines for preventing health-care-associated pneumonia, 2003. MMWR. 53(RR-03):1-36.
Linda J. Curtin is the director of Nursing Education and Research at Good Samaritan Medical Center in Brockton, Massachusetts.