These evidenced-based practices should be implemented by frontline staff to help prevent Ventilator-Associated Pneumonia (VAP):
- Ensure that routine oral care is performed per hospital policy in order to prevent buildup of bacteria.
- Minimize ventilator exposure.
- Wean patients from the ventilator as early as possible.
- Conduct consistent weaning trials, daily sedation interruptions, and daily assessments of readiness to extubate.
- Ensure proper sedation levels for the patient by routinely assessing the patient’s cognitive function.
- Leverage subglottic suctioning tools and techniques as per hospital policy.
- Maintain effective hydration and nutrition.
- Ensure that the bed is kept at a proper angle, between 30 and 45 degrees, as much as possible.
- Throughout time of care, diligently monitor the patient for the following:
- Positive bacterial cultures
- Temperature changes
- Pharmacy reports of antimicrobial use
- Any changes in respiratory secretions
- Maintain a stable, effective airway.
- Maintain endotracheal tube cuff pressure between 20-30cm H2O.
- Rotate endotracheal tube position and re-secure following routine mouth care per protocol.
- Use continuous or intermittent subglottic suctioning.
- Conduct chest X-ray daily and/or evaluate with ultrasound.
- Provide nebulizer therapy as indicated.
- In case of an unplanned extubation, follow emergency ICU protocol.
- Coordinate peptic ulcer disease (PUD) prophylaxis.
- Tailor course of antibiotic to identified infectious agent and duration of mechanical ventilation.
- Ensure equipment sterilization and decontamination protocols prior to patient use.
- Use organizational screening tools to identify patients at risk for VAP.
- Implement early mobility management.
- Ensure that the primary care physician is informed of VAP diagnosis and treatments while in the hospital.
- Provide patients with information and supplies necessary for their continued care.
Discharge: Long-Term Facility
- In the event of transfer to a skilled nursing facility with ventilator, ensure handoff contains proper VAP prevention guidelines.
- Communicate risks for aspiration, antibiotics, and treatments to long-term care facilities.
- Ensure that the receiving facility is prepared to care for the patient and is equipped with the necessary tools and equipment.
- Ensure patients and family members are equipped with the information and knowledge needed about their experience in the hospital.
This guide outlines the steps that managers can follow to prevent Ventilator-Associated Pneumonia (VAP):
Managers’ Meeting Discussion Points:
- Acknowledge potential challenges in diagnosing and reporting VAP incidences.
- Emphasize the measurement and reporting of compliance with VAP prevention best practices monthly.
- Routinely reassess processes/procedures to identify reporting gaps, and ensure integrity of the data collected.
- Make sure VAP performance and progress are easily visible to frontline/bedside staff, including nurses, respiratory therapists, and environmental service workers.
- Post VAP longitudinal data prominently in staff areas in an easy-to-understand visual format. Discuss the results frequently and reward improvement.
- Ensure those on the frontline understand what intervention prompted the improvement.
- Post daily the amount of time since the last VAP incident.
- Review data reports at meetings and debriefs.
- Be transparent about data collection and reporting biases.
If you determine that a performance improvement project is necessary:
- Gather the right project team—multidisciplinary, engaged, frontline staff and patient/family representatives.
- Be sure to involve the right people on the team. You will want:
- An oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread.
- The actual project team that consists of 5–7 representatives who are most impacted by the process.
- Be sure to involve the right people on the team. You will want:
- Patients and family members, who should be involved in all improvement projects, as they can make important contributions to safer care.
- Understand what is currently happening and why.
- Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data, but the most important action here is to go to the point of care and observe.
- Even if team members work in the area daily, examining existing processes from every angle is frequently and unexpectedly an informative experience.
- The team should question all relevant caregivers and process participants during onsite observations to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
- Create a process map to identify opportunities for improvement and
- Illustrate each step and identify the gaps in best practices.
- Use a root cause analysis tool to identify why the gap exists/processes failed.
- Review the process map with the advisory team and invite frontline staff to validate accuracy.
- Prioritize required process changes and implement an accountable, time-limited action plan.
- Consider the cost effectiveness, time required, potential outcomes, and realistic possibilities of addressing each gap identified.
- Determine which are priorities for the organization to correct.
- Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers.
- Design an experiment to be trialed locally briefly; if successful, create an action plan for broader implementation.
- Be sure the action plan includes the following steps:
- Assess organizational cultural readiness to change and adopt appropriate strategies.
- Revise policies and procedures.
- Redesign forms and electronic record pages.
- Clarify patient and family education sources and content.
- Create a plan for changing documentation forms and systems.
- Develop the communication plan.
- Design the education plan.
- Clarify how and when people will be held accountable.
- Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
- Measure both process and outcome metrics.
- Compare your outcomes against other related metrics in your organization.
- Routinely review all metrics and trends.
- Identify barriers to completion of action plans.
Involve those doing the work in the improvement initiative:
- Ensure that VAP protocols are embedded in clinical workflows, whether electronic or on paper.
- Ensure there are enough staff to effectively manage necessary preventive care.
- Assess which frontline professionals are completing VAP prevention practices and if this responsibility could be more appropriately allocated.
- Ensure adequate training and documentation of VAP prevention competencies and skills.
- Understand the barriers to implementation and/or sustainment, such as awareness of the evidence-based practices, buy-in to the practices, ability to implement the intervention easily in their existing workflow, etc.
- Provide a centralized place for care team planning and communication.
- Standardize practice across the system (e.g., patient positioning protocols should be the same across each facility).
- Ensure current policies align with protocols and workflows on the frontline. For example, standardize and align policies, protocols, and procedures around:
- Use of noninvasive ventilation equipment
- Prevention of aspiration
- Early mobility
- Set up systems (e.g., interdisciplinary rounds) to minimize ventilator exposure.
Recommended VAP improvement team:
- Respiratory care practitioners
- Physical and occupational therapists
- Infection control specialists
- Clinical educators
- Dietary staff
- Environmental service staff
- Engineering staff
- Information technology
- Patient/family members
- Data analysts
- Reimbursement and coding personnel
- IT/EHR specialists
VAP processes to consider assessing:
- Organizational coordination
- Which groups receive reports/data of VAP prevention compliance, what is done with that data, how is the data analyzed, and with whom is it shared?
- Which professionals are reporting to which bodies?
- Coordination of post-discharge needs.
- Respiratory management
- Ventilator setting modification and monitoring.
- Intubation decision making.
- Weaning, sedation vacations, spontaneous awakening trials, and spontaneous breathing trials.
- Who is conducting, when and how often, what is their decision-making process, and how do they share information and work with other professionals?
- Endotracheal cuff, subglottic suctioning, and tube maintenance.
- Patient positioning.
- Use of antibiotics and prophylactic systemic antimicrobials for VAP prevention.
- Who is prescribing and what are their justifications for prescribing?
- Antibiotic surveillance.
VAP metrics to consider assessing:
- Antibiotic surveillance
- Total number of patients on a mechanical ventilator per unit per month
- Total number of episodes of mechanical ventilation per unit per month
- Total number of ventilator days per unit per month
- Hospital days
- Hand hygiene compliance
- Percent of patients achieving RASS/SAS target
- Percent of patient days mobilized out of bed
- Delirium assessment compliance rate
- Ventilator length of stay
- ICU length of stay
- Hold staff accountable for providing the standard of care and reward success. Nonfinancial incentives may include:
- Special titles for champions of the work.
- Sharing an individual’s or unit’s efforts with a large group.
- Highlighting efforts in an article or newsletter.
- Presenting efforts, and calling out individuals or units by name, at conferences or events.
- Ensure that staff have a simple process to oversee VAP improvement work.
- Consider how VAP improvement aligns with other initiatives across the organization.
This protocol outlines the steps that executives can follow to prevent Ventilator-Associated Pneumonia (VAP):
Ventilator-associated pneumonia is the leading cause of death among healthcare-associated infections. With 300,000 cases of VAP annually in the U.S., this preventable illness is estimated to cost $50,000 per patient. VAP mortality ranges between 20% and 60%, with an annual incidence of 4% to 48%. Patients who acquire VAP have a significantly longer and more complicated course of mechanical ventilation and a longer stay in the ICU. According to the Agency for Healthcare Research and Quality, approximately 10% to 20% of patients suffering from VAP are twice as likely to die from being hospitalized.
Mechanically ventilated hospital patients are usually critically ill and need to be treated in an ICU. The infections that develop after two or more days of mechanical ventilation are thought to be caused by pathogenic secretions entering the lower respiratory tract via the endotracheal tube or tracheostomy. Even when airways are properly maintained, intubation may allow for oral, nasal, and gastric secretions to enter the lower airway. VAP and pediatric ventilator associated pneumonia (PVAP in individuals aged 18 and younger) are among the most commonly occurring healthcare setting-acquired infections in the ICU.
Researchers predict that implementing system-wide changes and using technologies to reduce VAP can save up to $15 billion per year while significantly improving quality and safety. For patients in the hospital who acquire VAP, the average extended stay is 4 to 9 days.
Hospital executives can support their staff in VAP performance-improvement initiatives by:
- Reviewing patient outcome trends monthly.
- Engaging with relevant performance-improvement advisory teams.
- Removing barriers to approved action plan implementation.
- Ensuring transparency in reporting VAP data across the organization.
- Ensuring adequate staffing levels.
- Reviewing and approving relevant policies and procedures.
This guide outlines the steps that patients, family members, and caregivers can follow to prevent Ventilator Associated Pneumonia (VAP):
Ask your care team the following questions so that you are familiar with the process of putting a patient on a ventilator:
- What is the purpose of a ventilator?
- What are the risks of being on a ventilator?
- What does the care team do to mitigate these risks, such as VAP?
- How long will the patient be on a ventilator?
- How often is this device cleaned?
- How often is the patient’s mouth cleaned?
- Are you going to raise the head of the bed while the patient is on the ventilator? If so, why?
- Are there risks of stomach ulcers? And if so, how do you prevent them?
- What can patients and families do to help prevent VAP when at the hospital?
- Can the care team provide information about common post-pneumonia symptoms?
- Can the care team provide instructions on breathing exercises?
- How do you prevent blood clots?
- What are some methods to alleviate problems with sleeping and eating?
- When do I seek help if symptoms worsen?
- What steps can we take at home to prevent VAP?
- How would I know if oxygen therapy is needed at home? And if so, how do I make sure it’s being done properly?
- How do I know if monitoring is needed when the patient is discharged home? If needed, how do I make sure it’s being done properly?
- How do I know if nebulizer therapy is needed when the patient is discharged home? If needed, how do I make sure it’s being done properly?
- Where and how do I find help when the patient is discharged home?
- When can the patient try breathing on their own?
To become more familiar with how ventilators work, please review the following:
A ventilator is a machine that helps a person breathe. Ventilation gets oxygen to the blood to keep their organs healthy, even when their lungs are not working properly. A ventilator pushes air through the breathing tube to inflate the lungs. This device can give more oxygen to the lungs than is generally in the air. The ventilator then allows the air to come out of the lungs as it would during exhalation.
People can stay conscious while on a ventilator. However, they may take medicine to make them sleepy. Then, the ventilator does the work of breathing and allows the body to rest to heal. Also, people usually cannot eat while on a ventilator. They typically receive nutrition through a tube from their nose to their stomach.
A breathing tube, or endotracheal tube, is connected to a ventilator machine and goes through the mouth or nose into the airway to keep air flowing into the lungs. A breathing tube can help a person who cannot maintain their airway. The process of placing a breathing tube is intubation. Intubation is when doctors put an endotracheal, or breathing, tube into a person’s windpipe. It can help a person breathe during surgery or if they can’t breathe on their own. The beathing tube prevents the patient from speaking because it passes through the vocal cords. While you may speak to the individual, it is important not to ask questions that require more than a head nod. It is frustrating for the patient if you try to engage in a conversation, and it is more effective to provide information about home and friends than to ask questions. The healthcare team is always focused on patient assessment and ready to remove the tube as soon as possible.
Resources for the reader:
CDC. Frequently Asked Questions About Ventilator-associated Pneumonia. (2019)
CDC. Pneumonia (Ventilator-associated [VAP] and Non-ventilator-associated Pneumonia [PNEU]) Event. (2023).
File T.M., et al. Patient education: Pneumonia in adults (Beyond the Basics). (2022).
Luckraz H, et al. Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study. Intensive Care Society. (2018).
Torres A, et al. Summary of the international clinical guidelines for the management of hospital-acquired and ventilator-acquired pneumonia. European Respiratory Society Open Research. (2018).
Vyas, J. Pneumonia in adults – discharge. Mount Sinai. (2020)
What happens if you get pneumonia in the hospital? Institute for Quality and Efficiency in Health Care. (2018).
Klompas M, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and non-ventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infection Control & Hospital Epidemiology. (2022).
Modi A.R., et al. Hospital-acquired and ventilator-associated pneumonia: Diagnosis, management, and prevention. Cleveland Clinic Journal of Medicine. (2020).
Guillamet C.V., et al. Is Zero Ventilator-Associated Pneumonia Achievable?: Practical Approaches to Ventilator-Associated Pneumonia Prevention. Clin Chest Med. (2018)
Metersky M.L., et al. Management of Ventilator-Associated Pneumonia: Guidelines. Clin Chest Med. (2018)
Wicky P.H., et al. Ventilator-associated pneumonia in the era of COVID-19 pandemic: How common and what is the impact?