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Nursing's Focal Points

February 2009 If this e-mail has been forwarded from a friend and you want to be placed on the mailing list, or if you wish to remove yourself from the mailing list, please send an e-mail to [email protected]

Ventilator-Associated Pneumonia Bundled Strategies: An Evidence-Based Practice

Adapted from Worldviews on Evidence-Based Nursing, Fourth Quarter 2008


Ventilator-associated pneumonia (VAP) is an ongoing challenge for critical care nurses as they use current evidence-based strategies to decrease its incidence and prevalence. Mechanical intubation negates effective cough reflexes and impedes mucociliary clearance of secretions, causing leakage and microaspiration of virulent bacteria into the lungs. VAP is responsible for 90% of nosocomial infections and occurs within 48 hours of intubation. VAP is a major health care burden in terms of mortality, escalating health care costs, increased length of ventilator days and length of hospital stay.

unit length of stay, and mortality rates. A strong association was seen, with an increased clinician compliance with VAPB proto-

Conclusions and Implications


(1) To provide a review of the literature on VAP bundle (VAPB) practices. (2) To describe the etiology and risk factors and define bundled practices. (3) To discuss an explanatory framework that promotes knowledge translation of VAPBs into clinical settings. (4) To identify areas for further research and implications for practice to decrease the incidence of VAP.

Methodologically robust randomized controlled trials are required to examine the efficacy of VAPBs and determine causality between VAPBs and clinical outcomes. Organizational commitment is needed to adopt a conceptual framework that promotes effective knowledge translation, incorporating factors of evidence, context, and facilitation of VAPBs into clinical settings. Instituting nurse-led intervention champion leaders to facilitate reliable and consistent implementation of VAPBs into practice is warranted.

About the authors


Electronic searches in MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Collaboration were conducted using keywords specific to VAP. The inclusion criteria were: (1) Studies were original quantitative research published in an English peer-reviewed journal for the years 1997 to 2007. (2) Each study included an examination of bundled practices. (3) The clinical outcomes of critically ill adults with VAP were assessed. The studies were identified from the bibliographies of key references. Six studies were accepted based on the inclusion criteria. Each contributing author conducted the review and analysis of selected studies independently. The findings were compared and contrasted by all authors to establish consensus.

Sheila O'Keefe-McCarthy, Strategic PhD Training Fellow, CIHR/CHSF FUTURE Program for Cardiovascular Nurse Scientists, Adjunct Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Cecilia Santiago, Clinical Nurse Specialist, MSICU, St. Michael's Hospital, Toronto, Ontario, Canada; Gemma Lau, Staff RN, RA, NICU, North York General, Toronto, Ontario, Canada. Address correspondence to Sheila O'Keefe-McCarthy, 155 College St., Suite 130, Toronto, Ontario, Canada M5T 1P8; E-mail: [email protected]

Figure: Risk Factors of VAP

Treatment regimes--gastric alkalinization Prolonged antibiotic use Endotracheal intubation Ineffective hand washing Supine positioning Invasive procedures Impaired mental status Nasogastric tubes Length of mechanical ventilation Preexisting comorbidities Hospital environment and equipment Continual or over sedation Contact with other patients/hospital staff Enteral feeding tubes


Evidence shows that VAPB practices decrease VAP rates. Bundled practices result in decreased ventilator days, intensive care

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