American Journal of Infection Control 42 (2014) 34-7

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American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

The impact of a ventilator bundle on preventing ventilator-associated pneumonia:

A multicenter study
Joong Sik Eom MD a, Mi-Suk Lee MD b, Hee-Kyung Chun RN b, Hee Jung Choi MD c, Sun-Young Jung RN c,
Yeon-Sook Kim MD d, Seon Jin Yoon RN d, Yee Gyung Kwak MD e, Gang-Bok Oh RN e, Min-Hyok Jeon MD f,
Sun-Young Park RN f, Hyun-Sook Koo RN, MPH g, Young-Su Ju MD h, Jin Seo Lee MD a, *
a
Division of Infectious Diseases, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
b
Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, South Korea
c
Division of Infectious Diseases, Department of Internal Medicine, Ewha Woman’s University School of Medicine, Seoul, South Korea
d
Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, South Korea
e
Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Ilsan, South Korea
f
Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, South Korea
g
Centers for Infectious Disease Surveillance and Response, Korea Centers for Disease Prevention and Control, Osong, South Korea
h
Department of Occupation & Environmental Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea

Key Words: Background: For prevention of ventilator-associated pneumonia (VAP), a bundle approach was applied
Lung diseases to patients receiving mechanical ventilation in intensive care units. The incidence of VAP and the pre-
Intensive care units ventive efficacy of the VAP bundle were investigated.
Infection control
Methods: A quasi-experimental study was conducted in adult intensive care units of 6 university hos-
pitals with similar VAP rates. We implemented the VAP bundle between March 2011 and June 2011, then
compared the rate of VAP after implementation of the VAP bundle with the rate in the previous 8
months. Our ventilator bundle included head of bed elevation, peptic ulcer disease prophylaxis, deep
venous thrombosis prophylaxis, and oral decontamination with chlorhexidine 0.12%. Continuous aspi-
ration of subglottic secretions was an option.
Results: Implementation of the VAP bundle reduced the VAP rate from a mean of 4.08 cases per 1,000
ventilator-days to 1.16 cases per 1,000 ventilator-days. The incidence density ratio (rate) was 0.28 (95%
confidence interval, 0.275-0.292).
Conclusions: Implementing the appropriate VAP bundle significantly decreased the incidence of VAP in
patients with mechanical ventilation.
Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Ventilator-associated pneumonia (VAP) is one of the most
important health careeassociated infections (HAIs), resulting in
high morbidity and mortality1 and substantial associated costs.2
Prevention of VAP has been highlighted as a priority,3 and clinical
practice guidelines aimed at reducing VAP have been available for
many years.4 However, there is little clear evidence to guide the
* Address correspondence to Jin Seo Lee, MD, Department of Internal Medicine,
Division of Infectious Diseases, Kangdong Sacred Heart Hospital, Hallym Univer-
sity College of Medicine, 150 Seongnae-gil, Gangdong-gu, Seoul 134-701, South
Korea.
E-mail address: rem324@naver.com (J.S. Lee).
Conflict of interest: None to report.
This study was supported by the Korean Centers for Disease Control and
Prevention.
choice of interventions aimed at decreasing the incidence of VAP,
and moreover, interventions differ among studies.5,6 Since 2004,
the Institute for Healthcare Improvement (IHI) has recommended
that all ICUs implement a ventilator bundle to reduce the VAP rate
as part of its 5 Million Lives campaign.7 The IHI bundle, comprising
4 key componentsdhead of bed elevation, peptic ulcer disease
prophylaxis, deep venous thrombosis prophylaxis, and daily
sedation-vacationdhas demonstrated effectiveness.8,9 However,
some components are not easy to accomplish in resource-limited
intensive care units (ICUs), and other effective strategies, such as
oropharyngeal care with chlorhexidine,10 are missing.
We have modified the components of the IHI bundle and
reconstructed a VAP bundle. The present study examined the rate
of VAP in ICUs after initiation of the VAP bundle compared with the
VAP rate in the preceding 8 months.

0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2013.06.023
 J.S. Eom et al. / American Journal of Infection Control 42 (2014) 34-7
Fig 1. Individual item compliance. HOB, head of bed elevation; PUD, peptic ulcer disease; DVT, deep vein thrombosis; CHG, chlorhexidine gargle; CASS, continuous aspiration of
subglottic secretions.
Table 1
VAP incidence before and after intervention
Before intervention After intervention
(July 2010-February 2011) (March 2011-June 2011)
VAP cases 57 7 follow the protocol for each bundle element. After the first month,
Ventilator-days 13,937 6,025
VAP incidence rate 4.08 1.16
Incidence density rate, 0.28; 95% CI, 0.275-0.292.
METHODS
Setting and study design
This study was conducted in 6 Korean university hospitals with
similar VAP rates. All of the hospitals were participants in the
Korean Nosocomial Infections Surveillance System (KONIS), and
thus had been conducting VAP surveillance before study initiation.
This surveillance was maintained throughout the study. A total of
196 ICU beds were involved.
Although the VAP bundle was not implemented in any hospital
at the start of the study, some of the elements were already in use
the ICUs, albeit not as a part of a bundle. Thus, we first investigated
the performance of the separate VAP bundle interventions over the
month before implementation of the VAP bundle.
Our VAP bundle comprised head of bed elevation, peptic ulcer
disease prophylaxis, deep venous thrombosis prophylaxis, and oral
decontamination with chlorhexidine 0.12%. Continuous aspiration
of subglottic secretions (CASS) was an option, because it requires a
specific endotracheal tube that is expensive and in short supply in
Korea.
An infection control practitioner evaluated each patient in each
ICU daily to check compliance with each bundle component. Head
of the bed elevation was checked every 4 hours and considered
done if checked “yes” all 6 times. Peptic ulcer disease prophylaxis
was considered done if an H1 blocker, proton pump inhibitor, or
sucralfate was given daily. Deep venous thrombosis prophylaxis
was considered done if low-dose heparin, compression stocking
application, or pneumatic compression was provided daily. Oral
decontamination with chlorhexidine 0.12% was verified every 8
hours and considered done if checked “yes” all 3 times. CASS was
35
considered done if the specialized endotracheal tube was used and
suction was performed appropriately.
We educated all of the ICU teams, including 23 doctors and 318
nurses, on VAP, the importance of the VAP bundle, and need to
the VAP bundle was implemented for 4 more months. Compliance
with bundle elements was recorded daily using a checklist, and all
interventions were monitored by infection control practitioners.
Nurses intervened in this process at the time of monitoring if
noncompliance with a bundle element was detected. Regular
feedback on compliance was provided to the ICU teams. Given the
time limitations of the study period, the VAP rate after imple-
mentation of the VAP bundle was compared with the rate in the
previous 8 months. All study procedures were approved by the
Institutional Review Board of each hospital.
Definitions
VAP surveillance was performed by trained infection control
professionals using the previous US Centers for Disease Control and
Prevention (CDC) definition,11 because this study was performed in
early 2011. VAP was defined by the presence of new or progressive
infiltrates on chest X-ray with no other obvious cause in patients
receiving mechanical ventilation for more than 48 hours in the ICU,
along with at least 2 of the following: temperature 38 C or 35 C,
leukocytosis (white blood cell count [WBC] >12,000/mm3) or
leukopenia (WBC <4,000/mm3), purulent endotracheal secretions,
potentially pathogenic bacteria isolated from the endotracheal
aspirate, and increasing oxygen requirement. Data on the devel-
opment of VAP were collected by the same infection control prac-
titioner throughout the study, and the incidence of VAP was
expressed as cases of VAP per 1,000 ventilator-days. VAP surveil-
lance had been performed in all 6 hospitals years before starting the
study, and was continued throughout the study in the same way.
Statistical analysis
The effects of the VAP bundle were analyzed based on the
incidence density ratio (rate). Baseline characteristics were
compared using the c2 or Fisher’s exact test for categorical variables
36 J.S. Eom et al. / American Journal of Infection Control 42 (2014) 34-7
and the t-test for continuous variables. A P value <.05 was
considered to indicate statistical significance.
RESULTS
Compliance with the VAP bundle
Overall compliance with the VAP bundle (except CASS)
improved after implementation of the intervention, from 41.1% to
71.8%. Individual bundle items also showed improvement during
the study period (Fig 1). Oral decontamination with chlorhexidine
0.12% was initially the most deficient (45.6%), but it improved
greatly by the end of the study (91.6%). Compliance with peptic
ulcer disease prophylaxis was initially high (83%) and decreased
slightly (81.1%) after bundle implementation. Compliance with
head of bed elevation (65.9%) improved slightly (72.9%), as did
compliance with deep venous thrombosis prophylaxis (from
65.6% to 77.3%). There was no data on CASS use before the
study, but compliance with CASS increased to 10% after bundle
implementation.
Incidence of VAP
Before study initiation, there were 57 cases of VAP during the
8-month period from July 2010 through February 2011, for an
incidence rate of 4.08 events/1,000 ventilator-days. After study
initiation, 7 cases of VAP were detected between March 2011 and
June 2011, for an incidence rate of 1.16 events/1,000 ventilator-days.
The incidence density ratio (rate) was 0.28 (95% CI, 0.275-0.292)
(Table 1).
DISCUSSION
Evidence-based guidelines for preventing nosocomial pneu-
monia have been published by the CDC since the 1980s12 and have
contributed to a reduced incidence of VAP.13 The use of a care
bundle, a set of key interventions based on the guidelines, can
facilitate guideline implementation. In a large multicenter study,
implementation of the VAP bundle, with a compliance rate of >95%,
was associated with a significant reduction in VAP.7 Other studies
have also reported a reduced VAP rate with the use of similar care
bundles.8,9,14,15 However, there is some discordance regarding
specific bundle components,16,17 and some investigators have
argued against the use of VAP bundles.18
The present study demonstrates a reduction in VAP incidence
after implementation of a VAP bundle. The VAP rate decreased from
4.08 events/1,000 ventilator-days in the 8 months before study
initiation to 1.16 events/1,000 ventilator-days after initiation. The
incidence density ratio (rate) was 0.28 (95% CI, 0.275-0.292), which
means that the VAP incidence decreased by 0.28-fold.
Compliance with the bundle generally increased throughout the
study period. Of the individual bundle elements, compliance with
oral decontamination with chlorhexidine 0.12% had the greatest
impact on VAP reduction. Compliance with this intervention was
initially very low, but demonstrated the greatest improvement
during the study. Previous studies have shown that using 0.12%
chlorhexidine solution reduced the incidence of nosocomial
pneumonia10,19,20; however, other studies failed to demonstrate a
positive effect of oral chlorhexidine.21-23 Our results potentially
support the use of chlorhexidine as a bundle component for pre-
venting VAP, but more evidence is needed. Generally, good
compliance was demonstrated for all other bundle elements except
CASS. Compliance with peptic ulcer prophylaxis actually decreased
slightly during the study period, but this decline apparently had no
effect on our results. Although our bundle did not include a daily
sedation vacation, which is recommended by the IHI, it was still
able to effect a significant reduction in VAP rate.
This study has some limitations. First, the study period was
relatively short compared with previous studies; however, the
multicenter design, with 6 university hospitals including 196 ICU
beds, helped compensate for this limitation. Second, compliance
with CASS was very low. CASS requires specialized, expensive
endotracheal tubes and more time for tube manipulation and
maintenance of suction lumen patency. For this reason, CASS was
an optional component of our VAP bundle, and compliance with
CASS was very low, as expected. Although the effect of CASS is very
limited in this study, previous studies have found an association
between CASS and a decreased VAP rate.24-26 Inclusion of CASS in
the VAP bundle may decrease the VAP rate even further.
CONCLUSION
Proper application of the VAP bundle can decrease the incidence
of VAP in patients receiving mechanical ventilation. This study is
the first Korean multicenter research to evaluate the effectiveness
of the VAP bundle.
Acknowledgment
We thank the ICU staff of each participating hospital for their
contributions to the VAP bundle intervention and to this study.
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