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The recent healthcare news is heart-
warming. The Institute for Healthcare Improvement’s (IHI) 100,000 Lives and 5 Million Lives Campaigns, Surgical Care Improvement Project (SCIP) and the Association for Professionals in Infection Control and Epidemiology’s (APIC) Zero Tolerance Campaign have galvanized healthcare administrators and clinicians around the country and the world into using "bundles" of evidenced-based practices to prevent HAIs and other iatrogenic events, saving many thousands of lives and hundreds of thousands of healthcare dollars in the bargain.7 Success stories abound about the phenomenal improvements seen when bundles of practices are used, but as Dr. Bonnie Zell of the Centers for Disease Control and Prevention (CDC) and IHI notes, there is a lot of confusion about bundles and why they make a difference.8 The patient care practices found in bundles are not new; they have received considerable study and review in the recent as well as distant past. What is new is the universal agreement and emphasis that there are certain practices that must be used either sequentially or concomitantly, and most important, consistently, in order to improve outcomes and prevent healthcare-associated adverse events, especially HAIs, from occurring.

Although the IHI VAP bundle, published in 2004 as part of the 100,000 Lives Campaign, has arguably received the most attention, it is by no means the only recognized or recommended group of evidence-based VAP prevention practices. The CDC’s 2003 Guidelines for preventing health-care-associated pneumonia3 is a compendium of HAP/VAP prevention strategies stratified by the quality and quantity of supporting clinical studies. The American Thoracic Society 2004 Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia9 has a succinct section on patient and treatment-related modifiable risk factors for HAP/VAP prevention which identifies both general and specific interventions which should be incorporated into the care of at-risk patient populations. APIC also published in 2004 a synopsis of VAP prevention strategies10 and the American Association of Critical Care Nurses 2005 - 5th edition of the AACN Procedure Manual for Critical Care11 delineated important patient monitoring and care practices for prevention of adverse events associated with endotracheal intubation, which reiterated those essential evidence-based strategies.

Not every healthcare facility’s VAP prevention bundle is exactly alike. For example, some institutions choose to follow only Category I recommendations from the CDC’s guidelines.3 Others only follow the IHI VAP prevention bundle12, while others may create their own unique practice and prevention bundles. The important point is that whichever bundle practices are adopted, that they be routinely monitored for consistent high level compliance and resultant VAP prevention improvement.

The surest way to prevent VAP is to avoid intubating patients unless absolutely necessary or to remove patients from mechanical ventilator support as soon as possible.3,9 Non-invasive airway management options, such as bilevel non-invasive ventilation (Bi-PAP) or continuous positive airway pressure (CPAP), are excellent alternatives to intubation in certain patient populations which may be underutilized in some facilities.13 Ways to ascertain this may be to benchmark the ICU ventilator utilization ratio with other similar units or to see whether all ventilator patients are given daily "sedation vacations"12 to assess for readiness to wean and extubate.

If a patient does require ventilatory support, careful endotracheal (ET) tube selection and placement are important, as the newer device variants offer important features which can help minimize the adverse consequences of intubation. ET tubes with high volume, low pressure cuffs may reduce the likelihood of tracheal ischemia, trauma and inadvertent extubation.14 Cuffed ET tubes that are anatomically correct and with proper depth markings are revolutionizing pediatric anesthesia practice.15 ET tubes with cuffs having specialized sealant properties to minimize subglottic fluid leakage or that continuously suction subglottic secretions have shown significant VAP reduction benefits.16,17 Making sure that ET tubes as well as gastric feeding tubes are placed orally rather nasally has been shown to reduce sinusitis, a common precursor and possible initiator of VAP.9

Patient positioning, specifically keeping the patient’s head elevated at least 30° unless medically contraindicated, is an essential strategy to minimize aspiration of oral and gastric secretions.18 All critically ill patients are at risk for aspiration, but intubated patients and/or patients receiving liquid tube feedings are at extremely high risk for gastric reflux and having contaminated secretions enter their lungs. The other essential technique to prevent aspiration is suctioning of the mouth and throat (oropharynx) around the ET tube and above the cuff, and suctioning of pulmonary secretions through the ET tube on an as-needed basis. ET tube suctioning can be performed using either an open suction, single-use sterile catheter or a closed-suction in-line catheter system which is exchanged every 24 or 72 hours. According to the American Association for Respiratory Care (AARC), the benefits of the closed system are that it allows ventilated patients to be suctioned without removal of ventilator support, decreasing the potential for complications associated with open suctioning such as "alveolar derecruitment" as well as environmental contamination and healthcare worker exposure from the patient’s microbially colonized secretions.19

Another strategy related to patient positioning is the use of kinetic, continuous oscillation or rotational beds to decrease lung atelectasis and improve mobilization and clearance of bronchopulmonary secretions.20 Five of six studies from a meta-analysis found VAP reduction benefit from the use of these beds, especially in surgical and/or neurological patients; however, concern has been voiced about the additional daily cost of approximately $100 for the specialized bed. Considering the much higher consequences of VAP in both dollars and lives may help put prevention costs in perspective.

Saline lavage, the instilling of saline into the ET tube prior to suctioning, is a practice that should be minimized. This used to be commonly performed with the rationale being that the fluid irrigation would help liquefy thick secretions and facilitate their removal. That practice has fallen into disrepute because it was found to cause oxygen desaturation as well as flush micro-organisms into the lungs from the biofilm-encrusted artificial airway, actually promoting the incidence of VAP.21,22

Back to basics has become a common rallying cry in our high tech healthcare world, and no where has it been shown to be more important than in VAP prevention with the renewed emphasis on consistent provision of comprehensive oral care.23 Here is a case where both technique and tools has been found to be critical and in some cases, wanting. In 2004, researchers from the University of Louisville Schools of Nursing and Dentistry surveyed more than 550 nurses working in more than 100 ICUs about their oral care knowledge and practices.24 Ninety-two percent of the nurses reported that they believed oral care to be important, but only 20 percent used toothbrushes and toothpaste when providing oral care. Almost half of those surveyed said they needed better oral care supplies and wanted more evidence-based education about oral care. What they were asking for were both the tools and the techniques for providing evidence-based care.

In the final analysis, the best medical products, devices or tools cannot make up for poor patient care practices and techniques. However, the best evidence-based patient care demands that the best tools available be provided to support and augment that care. Certainly there is a concern about the additional cost some of these tools and devices may add to the bottom line. But a truism of healthcare borrowed from education helps put these costs into perspective: "If you think prevention is expensive, take a look at the cost of disease."25