Intensive and Critical Care Nursing (2013) 29, 261265

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/iccn

Reducing risk for ventilator associated pneumonia

through nursing sensitive interventions
Svatka Micik , Nihada Besic, Natalie Johnson, Matilda Han,
Stephen Hamlyn, Hayley Ball

Cardiothoracic Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia

Accepted 21 April 2013

KEYWORDS
Nursing sensitive
interventions;
Nursing sensitive
patient outcomes;
Ventilator associated
pneumonia
Summary The purpose of this paper is to describe an improvement initiative designed to
implement nurse sensitive interventions known to reduce patients risk for ventilator associ-
ated pneumonia (VAP), in cardiothoracic intensive care patients. This initiative is a part of
one Australian critical care units efforts to identify and measure compliance with key nursing
interventions known to improve cardiac surgical patients outcomes. The premise behind the
initiative is that improved nursing process and surveillance systems allow emerging trends to
catalyse action and motivate nurses to reduce patients risk for infection acquisition. At ve
and nine months following implementation of the initiative a > 70% compliance rate in 11 out of
the 15 nurse sensitive interventions known to reduce patients risks for VAP and a drop in VAP
incidence from 13.4% to 7.69% from per 1000 ventilator days was accomplished.
Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

Assists nurses to transition from task focused to outcome based care.

Promotes implementation of evidence based recommendations.
Represents a low cost, yet cost effective infection control measure.

Corresponding author. Tel.: +61 8 8222 2288.

E-mail address: svatka.micik@health.sa.gov.au (S. Micik).

0964-3397/$ see front matter. Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.iccn.2013.04.005
262
Introduction
As a result of the economic and clinical burden of venti-
lator acquired pneumonia (VAP), it is important to reduce
patients risk of VAP acquisition. Although there are a myriad
of reasons why patients develop VAP and a multidisciplinary
approach is needed to reduce its incidence, nursing inter-
ventions play a vital role in VAP risk reduction. Establishing
nursing sensitive patient outcomes (NSPOs) for patients pre-
disposed to VAP provides measurable metrics that may be
used to design and or implement specic nursing interven-
tions.
Rationale for our QI project
Our unit is an eight bed cardiothoracic intensive care unit
(CTICU) in South Australia. Since our units inception we
have worked within a culture of nurse-led patient care. In
2008, having read the United States (US) Oncology Nursing
Society white paper on nursing sensitive patient outcomes
that promoted them as measurable effects of nursing care
and provided a guiding framework for developing NSPOs, we
considered how we might integrate this into our care (Given
and Sherwood, 2005). This has been an ongoing project for
the last four years and continues to be a work in progress.
The white paper prompted our nurses to ask two ques-
tions: what do we know about our performance and what
is in the literature about the development, implementation
and utilisation of NSPO initiatives? Upon considering these
questions we noted that although we had broad performance
measures such as quarterly infection control performance
indicator reports to help us understand our practice, we did
not have specic nursing intervention and patient outcome
measures to benchmark and inform and reafrm cardiotho-
racic intensive care nursing practice.
Development of our nurse sensitive outcomes
project
We reviewed the literature and learned for outcome meas-
ures to be meaningful, the chosen outcomes must be specic
to the setting, clinical context, patient population, type
of intervention, relevant to patient experiences and con-
sistent with the expected effects of the intervention and
supported by evidence (Doran and Pringle, 2011). When we
considered our CTICU patient group, we identied safety
(infections), post-operative symptom control (pain, immo-
bility and constipation) and psychological well-being as
important outcomes.
Once we determined the patient outcomes we believed
were relevant to our setting and could be improved by using
established evidence, the CTICU leadership group called for
expressions of interest from our nurses to join the NSPO
working party. Our aim was to create outcome teams led
by experienced clinical nurses working collaboratively with
less experienced nurses. This approach would engage the
whole team in the project.
Safety from preventable infections was one of the rst
patient outcomes identied by the NSPO working party
(Diagram 1). We looked to our own practice and searched the
S. Micik et al.
Safety from preventable infections
Care bundles
CRBSI SSI MRO VAP
Standard of care
Series of fundamental, interdependent and scientifically grounded nursing
steps grouped into care bundles aimed at controlling microorganisms on the
skin and in the oropharynx for which the CICU RN has sole responsibility to
implement
Nursing sensitive patient outcomes
CRBSI SSI MRO VAP acquisition rates
Nursing sensitive indicators
Specific nursing assessment indicators such as oral cavity assessment score
and intervention indicators such as 30 degree HOB elevation.
70% benchmark set to validate nursing compliance and performance
Quarterly surveillance/reporting of the indicators of each infection prevention
care bundle
Diagram 1 Categorisation of care bundles, standard of care,
nursing sensitive patient outcomes and nursing sensitive indica-
tors for preventable infections in the CTICU.
literature and found our patients were most at risk of devel-
oping catheter related blood stream infections (CRBSI),
surgical site infections (SSI), multi resistant organisms (MRO)
and ventilator associated pneumonia (VAP), all of which
are directly impacted by nursing care processes (Gil-Perotin
et al., 2012). Our next step was to develop a nursing
standard that promoted safety from preventable infections
with specic nursing interventions. We dened the nursing
standard as:
Series of fundamental, interdependent and scienti-
cally grounded nursing steps, grouped into care bundles
aimed at controlling micro-organisms on the skin and in
the oropharynx for which the CTICU registered nurse has
sole responsibility to implement. (CTICU NSPO working
party)
From our nursing standard we delineated catheter
related blood stream infections (CRBSI), surgical site infec-
tions (SSI), multi resistant organisms (MRO) and ventilator
associated pneumonia (VAP) care bundles aimed at reducing
preventable infections. Care bundles are sets of evidence
based practices, performed in a series of steps towards an
intended effect. They are ongoing processes that focus on
how to deliver the best care using a clear-cut method to
provide the best possible outcome for patients (NHMRC,
2010). Although we had already determined safety from pre-
ventable infections as the overall patient outcome, we also
needed to determine outcomes for each of the preventable
infection bundles. We were already reporting our CRBSI, SSI
and MRO to the National Nosocomial Infection Surveillance
Report. This data provided us with specic outcome meas-
ures for the CRBSI, SSI and MRO care bundles. We were not
yet collecting data on VAP rates.
To guide, direct and reach the desired infection free
outcomes for our patients we searched the literature for
nursing assessment and intervention indicators for each of
the four care bundles and chose indicators that were clini-
cally meaningful for the CTICU patient. Once we identied
these intervention or process measures for each of the care
Ventilator acquired pneumonia
bundles we could correlate these with the outcome data
which would provide us with a useful means of identifying
areas for improvement. We established audit tools that mir-
rored the chosen indicators and searched the literature for
numerical target goals for each indicator.
The literature yielded no nursing benchmark targets for
our selected interventions and eventually we adopted Hand
Hygiene Australias 70% hand hygiene compliance target
rate, believed to decrease incidence of nosocomial infec-
tions and new MRSA and VRE cases (SA Health, 2011).
Therefore it was reasonable to assume the same would apply
to other preventable infections. Setting a numerical goal
claried our aims to reduce the risk of infection, directed
our agreed upon quarterly measurements of each of the indi-
cators for each of the care bundles. Once the aim had been
established, the team could work towards raising the thresh-
old targets. This would help change the initial focus from
reducing preventable infections as a desirable practice to
reducing preventable infections as a mandatory procedure.
Although we followed the same process for establishing
outcome and process measures for all of the preventable
infections, here we report only on the nursing sensitive
care bundle for reducing the cardiothoracic patients VAP
risk.
Nursing sensitive care bundle for reduction of VAP
risk
What is VAP? The generally accepted denition of VAP is
a sub-type of hospital-acquired pneumonia (HAP) which
occurs in people who are mechanically ventilated via an
endotracheal or tracheostomy tube at the time the pneu-
monia is diagnosed or within 48 hours of having been
mechanically ventilated (Hess, 2012). The internationally
stated rate is between 10 and 41.7% per 1000 ventilator days
(Arabi et al., 2008).
VAP is identied by using a combination of radiologic,
clinical and laboratory criteria. VAP carries an increased pain
and suffering burden, prolongs length of stay and carries
with it a greater risk of mortality. For hospitals and health
care administrators it greatly increases the cost of hospitali-
sation. VAP, a common intensive care unit complication has a
reported incidence in Australia of 25% and a crude mortality
of up to 65% (NHMRC, 2010).
Understanding VAP pathogenesis is essential in order to
develop a standard of care and an associated care bun-
dle to reduce the risk of acquisition. Although optimal
patient outcomes are generally associated with interdisci-
plinary collaboration, reducing risk of VAP is responsive to
targeted nursing interventions, surveillance and infection
control performance feedback. The literature identies four
VAP pathogeneses in the critically ill as:
(a) colonisation of the oropharynx by dental plague with
subsequent migration of the bacteria to the lower air-
way (Milstone et al., 2008);
(b) exogenous acquisition from the hands of health care
workers and through contaminated respiratory equip-
ment (INICC, 2012);
263
Ventilator associated pneumonia
Care bundles
Limit use of mechanical ventilation
Prevent aspiration of secretions
Prevent nasal and oro pharyngeal colonisation
Prevent use of contaminated equipment
Early mobilisation
Standard of care
Series of fundamental, interdependent and scientifically grounded nursing steps grouped
into bundles aimed to control microorganisms in the oropharynx for which the CTICU RN
has sole responsibility
Nursing sensitive patient outcome
VAP acquisition rate
Nursing sensitive indicators
Specific nursing assessment indicators such as daily assessment of readiness to wean
and nursing intervention indicators such as the use of cuffed ETT with above cuff aspirate
70% benchmark set to validate nursing compliance and performance
Quarterly surveillance/reporting of the indicators of each VAP prevention bundle with
consideration of broader infection control dashboard indicators
Diagram 2 Categorisation of care bundles, standard of care,
nursing sensitive patient outcomes and nursing sensitive indica-
tors for reducing patients risk of developing ventilator acquired
pneumonia in the CTICU.
(c) aspiration of microbe laden oropharyngeal and gastric
secretions around the cuffed airway management tube
into the lower respiratory tract (Fields, 2008);
(d) patient positioning with the head of the bed not ele-
vated to 3045 , prolonged ventilation, advanced age
and malnutrition (NHMRC, 2010).
We reviewed all of the above sources and delineated care
bundles, standard of care, patient outcome and nurse sen-
sitive indicators for VAP (Diagram 2). The standard for VAP
prevention was dened as;
A series of fundamental, interdependent and scienti-
cally grounded nursing steps grouped into a care bundle
aimed to control micro-organisms in the oropharynx for
which the CTICU RN has sole responsibility. (CTICU NSPO
working party)
From the same literature (INICC, 2012; Milstone et al.,
2008; NHMRC, 2010), we identied ve care bundles for
reducing cardiothoracic patients risk of VAP:
(1) limiting the use of mechanical ventilation;
(2) preventing aspiration of secretions;
(3) preventing nasal and or pharyngeal colonisation;
(4) preventing use of contaminated respiratory equipment;
and,
(5) early mobilisation.
Finally we delineated several risk reducing nursing
assessment and intervention indicators for each of the 5
care bundles (Diagram 3) from which we created a VAP risk
reduction audit tool. Our compliance was to be measured
by quarterly surveillance of outcome and process measures.
The primary outcome measure was the relationship between
VAP bundle compliance and VAP incidence. In the absence of
data on the actual incidence of VAP in our unit we reached
a consensus with the Intensive care consultant to identify
patients with suspected VAP by the specic antibiotic regime
264 S. Micik et al.

Nursing sensitive indicators for VAP prevention bundle

Limit use of mechanical ventilation

Daily sedation vacation followed by a readiness to wean assessment and spontaneous breathing trial
Use NIV
Wean ASAP
Nursing vigilance to avoid accidental extubation as re intubation carries increased risk of VAP
Education of health personnel who care for patients undergoing mechanical ventilation about VAP

Prevent aspiration of secretions

Maintain 30 degrees semi-recumbent position
Avoid gastric over distension
Use Cuffed ETT with above cuff aspirate
Minimal leak ETT technique
Maintain ETT cuff pressure at least 20cm H2O

Prevent nasal and oro pharyngeal colonisation

Mupirocin nasal ointment 5days
Reduce oral plague and bacterial count by comprehensive oral hygiene with tooth brushing and oral swabs
impregnated with chlorhexidine 0.12%
Simple activities such as oral cavity assessment performed during oral care allow for early identification and
score based interventions

Prevention of use of contaminated equipment

Greater than 75% hand hygiene and PPE compliance with performance feedback of infection control
practices
Closed system suction
Adherence to recommended frequency of equipment change (HME filter 48hrs, breathing circuit only if solid,
single use yankuer sucker, closed suction system 72hrs)
Criteria for humidification (only with tenacious secretion)

Early mobilisation
Adherence to recommended mobilisation regime (INICC, 201 2 )

Diagram 3 Specic nursing sensitive indicators for reducing patients risk of developing ventilator acquired pneumonia in the
CTICU.

ordered. Our pharmacist searched the dispensing data and
identied those patients who were prescribed this specic
treatment during the pre-initiative and rst post initiative
auditing period. We then did a retrospective chart audit to
exclude those patients whose antibiotic treatment was not
continued because the microbiology ndings did not conrm
the initial diagnosis. In the last auditing period VAP cases
were identied by the intensive care specialist and entered
onto a Nursing Sensitive Outcome data sheet. VAP rates were
dened as the percentage of VAP cases per 1000 ventilator
days. Nurses routinely count ventilator days for each patient
and this practice continued.
Our VAP bundle initiative started as a part of the safety
from preventable infection NSPOs on November 1st 2011.
Prior to bundle initiation, data was collected through a ret-
rospective review of VAP rates for April 1st to June 30th
2011. We created a nursing sensitive patient outcome board
that displayed our selected patient outcomes, standards,
bundles and their specic interventions and compliance
data. The team responsible for this NSPO held weekly edu-
cation sessions on the bundle and associated nurse sensitive
interventions in October 2011. Compliance data was col-
lected on April 2nd 2012 and August 31st 2012, ve and nine
months after the initiative started with VAP rates being col-
lected for the three months leading up to and including the
audit months of April 2012 and August 2012.The board was
updated with the nursing assessment and intervention indi-
cators audit ndings for each of the ve VAP prevention care
bundles as well as the VAP prevalence rates. Recommenda-
tions for practice for all nursing sensitive indicators with
an audit score of less than 70% were made via the display
board and communicated to all nurses via the units on line
communication forum and at handover.
Findings of our VAP project
A retrospective pre initiative VAP rate for the period start-
ing 1st April 2011 and ending 30th June 2011 revealed a rate
of 13.4% per 1000 ventilated days. A post initiative VAP rate
for the period starting February 1st 2012 to April 30th 2012
was 7.69% per 1000 ventilated days and remained steady at
7.69% per 1000 ventilated days for the period June 1st 2012
to August 31st 2012. In the period of February 1st 2012 to
April 30th 2012 the 7.69% incidence of VAP corresponded to a
70% or greater score for ten out of the fourteen VAP preven-
tion nursing sensitive indicators. Of the four indicators that
did not meet the 70% target score, two were related to doc-
umentation. The other two were related to inadequate head
of bed elevation and frequency of naso enteric tube place-
ment measures. In the second post initiative audit we added
eight hourly endo tracheal cuff checks to the care bundle,
bringing the nursing interventions number to fteen. For
this period the 7.69% incidence of VAP corresponded to a
70% or greater score for ten out of fteen VAP prevention
indicators. Of the ve indicators that did not meet the 70%
target score, two were related to documentation. The other
three were related to daily change of suction equipment and
frequency of nasogastric measures and endo tracheal cuff
checks.
Conclusion
The CTICU work with NSPOs builds on the work of inter-
national nursing colleagues. Our efforts describe the steps
CTICU nurses are taking to help move forward knowledge
and action related to nursing sensitive patient outcomes for
Ventilator acquired pneumonia
cardiac intensive care patients. Our preliminary data sug-
gests a positive trend in decreasing VAP. Furthermore, our
work is helping our CTICU nurses to transition to outcome
focused care. The outcomes inspire and drive the required
interventions and help CTICU nurses own that which is
purely nursing. Setting up NSPOs for specic patient groups
requires considerable time, drive, commitment and enthu-
siasm. Once established it is anticipated the NSPOs will
continue to evolve, but the process will be a lot less time
consuming. Despite the effort required, this group of nurses
believe the framework is a valuable tool for benchmarking
against recognised standards and validating local nursing
practice.
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