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Running head: VAP

Ventilator Associated Pneumonia

Alice Nsawi

Baptist College of Health Science

04/11/2018.
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Abstract

Ventilator-Associated Pneumonia (VAP) is a lung infection that occurs in people who are on
mechanical ventilation or were on mechanical ventilation during a hospital staying. VAP is
responsible for 90% of nosocomial infection in mechanical ventilated patients. Ventilator-
associated pneumonia causes morbidity and mortality rate is increase in critically ill/sick patients
who has been intubated for 3 to 4 days, this associated to oropharyngeal bacteria species. VAP
develops as a result of aspiration of secretions that are contaminated with pathogenic organisms,
which can be endogenously acquired through the presence of an endotracheal tube (ETT). The
purpose of this study is to compare the length of hospital stay for patients with VAP, Cost to
treat patients with VAP, reimbursement policy, measures taken to prevent VAP after the
initiation of pay-for performance bill by congress which panelized hospital that patients had
hospital acquire infections. Time was a great factor which limited the collection of data, despite
the limitation of this study; there is evidence that critically ill population, including those in the
intensive care Units who are receiving mechanical ventilation support have a higher risk of
getting VAP because patients develop VAP, within 48 hours of admission. VAP has drastically
reduce since the introduction of the pay-for service/ performance bill was passed in 2008 and
was implemented by many organization including hospital and insurance company as the
reimbursement program
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Introduction

Pneumonia is one of the most common hospital-acquired infection complications that occur in

about 10% to 65% of mechanical ventilated patients. Ventilator-Associated Pneumonia (VAP) is

a lung infection that occurs in people who are on mechanical ventilation or were on mechanical

ventilation during a hospital staying. VAP is responsible for 90% of nosocomial infection in

mechanical ventilated patients. It is also considered the second leading cause of infection and

death in the United States Of America (USA). VAP greatly increase the cost, length of hospital

staying, intensive unite (ICU), staying, and mortality rate. Data collected by Center for Disease

Control and Prevention (CDC) shows that VAP rated higher than trauma, burns, neurosurgical

and surgical patients. Although, patients who have undergo head, neck, thorax, or abdomen

surgeries have shown a special increase risk in the past years.

Ventilator-associated Pneumonia (VAP) is pneumonia that occurs in mechanical

ventilated patients during intubation. In order to clinically diagnose VAP, patient has to be

invasively or noninvasively receiving mechanical ventilation support for at least 48hours or more

during hospital admission. Ventilator-associated pneumonia causes morbidity and mortality rate

is increase in critically ill/sick patients who has been intubated for 3 to 4 days, this associated to

oropharyngeal bacteria species. The early pneumonia bacteria are called hemophilus influenza,

streptococcus pneumonia, strephyloccus aureus, and late onset VAP are aerobic gram-negative

bacteria like pseudomonas aeruginosa or acintobacter species. VAP is characterized by the

presence of a new or progressive infiltrate, signs of systemic infection that is; fever, altered white

blood cell count, changes in sputum characteristics, and detection of a contributory agent.

According to Centers for Disease and Prevention Control (CDC), the greatest risk of a patient to

develop VAP is during the first 5 days of mechanical ventilation (3 %) with the mean duration
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between intubation and development of VAP being 3.3 days. This risk declines to 2 %/day

between days 5 to 10 of ventilation support.

Pathologic process

Ventilator-associated Pneumonia (VAP) develops as a result of aspiration of secretions that

are contaminated with pathogenic organisms, which can be endogenously acquired through the

presence of an endotracheal tube (ETT). The presence of an endotracheal tube is considered a big

risk factor for development of VAP which results in violation of natural defense mechanisms

like, the cough reflex of glottis (ETT is a considered a foreign body in the airway, the presence

of the tube triggers the natural immune system to fight) and larynx against micro aspiration

around the cuff of the tube. Infectious bacteria obtain have direct access to the distal respiratory

tract due to micro aspiration, which can occur during intubation, development of Gram-negative

bacteria and fungal species within the endotracheal tube by pooling and trickling of secretions

around the cuff, and impairment of mucociliary clearance of secretions with gravity dependence

on mucus flow within the airways. Keeping in mind that not only intubated patient can develop

VAP according to a report by CDC, it stated that “the use of non-invasive positive pressure

ventilation has been associated with significantly lower VAP rates compare to invasive

ventilation….” Patients who are not intubated can also get infection due to the poor hygiene from

health care personnel who ignore hand hygiene, cleaning of their stethoscope, frequent changing

of the ventilator circuit and touching of contaminated surfaces without properly cleaning

ventilator before using on another patient. The diagram below shows how easy it is for a patient

to get infection while on the mechanical ventilator.

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The diagram above show how the ETT can contribute to VAP, the accumulation of colonization

with bacteria/contamination which can easily be aspired in to the lungs directly around the ETT

if accidentally deflated, this explain the reason why patient need to have their mouth rinse out

every two hours and suction as needed to prevent the contaminated fluid or secretion from get in

to the patients airway. Also frequent check of the ETT position everyday reposition reduces

tissue damage, which can lead to airway damage and cuff pressure will reduce the chances of

this to happen.

Purpose of the Study

The study is done to compare the rate of VAP before and after the initiation of guidelines to

prevent VAP as a result of increasing concern by the congress and health insurance companies.

Improve the quality of life for patient in the critically ill patients in the intensive care units, Cost
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of treating patient with ventilator-associated pneumonia, how to prevent the VAP and measures

taken so far.

According to the graph above, it shows that cost of treating a patient with ventilator-

associated pneumonia double the cost of another patient with the same underlying disease but

without VAP. Preventing VAP not only reduces cost but it also reduces the length of hospital

stay and risk of mortality /morbidity rate reported as follows “The mean hospital length of stay

(LOS) for VAP patients was 26.5 ± 13.1 days compared with 17.8 ± 4.7 days for non–VAP

patients (p = .032). The hospital LOS attributable to VAP was 8.7 days. The mean hospital costs

for VAP patients was $156,110 ± $80,688 compared with $104,953 ± $59,191 for non–VAP

patients (p = 0.026). The attributable facts about VAP costs were $51,157. After implementation

of the VAP prevention bundle, VAP rates decreased from 7.8 cases per 1,000 ventilator days in

fiscal year…”
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Reimbursements policies

Many insurance companies have set protocol to determine reimbursement for hospital and other

healthcare providers/facilities. The Centers for Medicare &Medicaid (CMS) and the Joint

commission play a front rule in setting some the reimbursement policies which many insurance

companies have been using in the past decade. According to the Centers for Medicare &

Medicaid (CMS), it uses the pay-for performance protocol through the Premier Demonstration

Project (PDP) that encourages hospitals to report the measures taking to improve patient safety.

This policy was initiated be by the congress in 2008 as a result of the government spending about

1.7 million dollars every year in hospital acquired infections which results in deaths. In order for

the reimbursement policy to be effective, Medicare implemented policy which penalizes any

hospital or healthcare provider if Medicare patient acquire any of the following condition during

their hospital staying or within 30 days of hospital discharge due to the following conditions, the

hospital will not be reimbursed for the care provided. Medicare conditions included; if infections

were not present during admission, infection like catheter-associated urinary tract infections and

vascular catheter-associated infections, c central line-associated bloodstream infections, catheter-

associated urinary tract infections, ventilator-associated pneumonia, Clostridium difficile, and

MRSA (methicillin-resistant staphylococcus aureus).

Prevention of VAP

The joint Commission center in 2008 put in place the hand hygiene project which target health

care personnel. This was done to sustain a high quality of patient care that has been so critical.

The joint Commission identifies the following as the causes of failure to clean hands.

 Ineffective placement of dispensers or sinks

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 Hand hygiene compliance data are not collected or reported accurately or frequently

 Lack of accountability and just-in-time coaching

 Safety culture does not stress hand hygiene at all levels

 Ineffective or insufficient education

 Wearing gloves interferes with process

 Perception that hand hygiene is not needed if wearing gloves

 Health care workers forget

 Distraction

Instead of health care personnel giving any of the above excuses for not properly performing

hand hygiene, some hospital has protocol in place to follow up with hand hygiene and prevent

VAP. These hospitals make sure before entering/existing any patient’s room, the clinician scrub

hands with alcohol base solution (hand sanitizer). On the part of the respiratory therapists, there

are protocols in each hospital, changing of the ventilator circuit after 7 days or only when it

visible soiled. Implementing this policy reduces the chances of contamination and introduction

of infection. Another way the respiratory department limits the introduction of VAP is by

changing out the suctioning ballards everyday, with this practice, not all the hospital do change

out their ballards every day. There is not research out to confirm that one of the practices is

better because one of the hospitals is collecting data to see if the practice is working.

Another organization that is working hard to reduce the rate VAP is the centers for Disease

Control (CDC) which has also develop the following guidelines to limit VAP;

 Keep the head of the patient’s bed raised between 30 and 45 degrees unless other

medical conditions do not allow this to occur, by elevating the bed, it reduces the

incidence of gastric aspiration and bacteria from the stomach from entering the lungs.
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 Check the patient’s ability to breathe on his or her own every day so that the patient can

be taken off of the ventilator as soon as possible. This done through patient spontaneous

breathing trial (SBT) day or as tolerated by the patient. Some hospitals require the

physician order to do this but others follow a protocol which allows the respiratory

therapist to start the SBT without the Physician order if the patients meet the weaning

criteria.

 Caregivers should clean their hands with soap and water or an alcohol-based hand rub

before and after touching the patient or the ventilator. This very important, because hand

washing is not only protecting the patient but everybody involve in the care of the patient

by reducing the spray of germs and bacteria.

 Clean the inside of the patient’s mouth on a regular basis. Cleaning the patient mouth

regularly eliminate the accumulation of bacteria in the mouth that can go in to the lungs if

the cuff integrity is compromised during suctioning or checking of the cuff pressure.

 Clean or replace equipment between uses on different patients, cleaning equipment

between patients reduce the chance of getting another patient contaminated with bacteria

pick up from another patient, especially the stethoscope which is some time place directly

on the patient’s body.

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Looking at the two graphs above, Graph “A” shows infection in general and graph “B” shows

VAP only. The graphs showed the differences before the reimbursement program also known as

pay –for performance project was initiated. Between 2005 and 2007, the rate of VAP has started

decreasing but in the years 2012 and 2014, the number drop down to more the half the total

number in 2007, because hospitals has also put in place the guidelines and protocol to improve

patient care due to practice of clinical-based medicine.

Comments/limitations

The study was done alongside my other school work, clinical and classes. There was time limited

to collect data, information was also limited because most hospital I called the ask question like

the how many VAP patient they get every month/year were not willing to share that information

due to the hospital privacy policy. Another limitation was different hospital have different

strategies to prevent VAP so it hard to decides which strategy was best because most of these

strategies were just put in place and they are still collecting data to determine the success the

strategies. Another challenge for collecting accurate information was, not all the patients that

were treated for VAP in these hospitals were prior patient to the hospital, which makes it hard to

get the right number or know if the hospital strategy for preventing VAP is working or not. Most

of the information about the prevention of VAP was based on scholar article which did not

narrow their study on VAP alone but hospital-acquire infection in general.

Conclusion

Despite the limitation of this study, there is evidence that critically ill population, including

those in the intensive care Units who are receiving mechanical ventilation support have a higher

risk of getting VAP because patients develop VAP, within 48 hours of admission. This leaves
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little time for preventive efforts to become effective as clinicians who working hard to stabilize

the patient and running numerous tests to determine what is wrong with the patient. With that

been said, the rate VAP has drastically reduce since the introduction of the pay-for service/

performance bill was passed in 2008 and was implemented by many organization including

hospital and insurance company as the reimbursement program.

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References

Carol. M, Porth (2015). Essentials of Pathophysiology Concepts of Altered Health State. 2001

Market Street. Philadelphia, PA 19103 USA.

Facts about the Hand Hygiene Project (2008). The Joint Commission Center for Transforming

Healthcare

Grap, J. M. and Munro, L. C. (2016). Preventing Ventilator-associated Pneumonia; evidence-

based care. School of Nursing, Virginia Commonwealth University. Richmond Va

23298-0567 USA.

Luckraz, H. Manga, N. Senanayake, E. Abdelaziz, M. Gopal, S. Charman, S. Girri, R. Oppong,

R. Andrinis, L. (2017). Cost of Treating Ventilator-associated Pneumonia post Cardiac

Surgery in National Health Service. Centers for Disease Prevention and Control (CDC).

Timsit, J.-F., Esaied, W., Neuville, M., Bouadma, L., & Mourvillier, B. (2017). Update on

ventilator-associated pneumonia. F1000Research, 6, 2061.

Zarzaur, B. L., Bell, T., Croce, M. A., & Fabian, T. C. (2013). Geographic Variation in

Susceptibility to Ventilator-Associated Pneumonia after Traumatic Injury. The Journal

of Trauma and Acute Care Surgery, 75(2), 234–240.