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Curicullum Vitae
bull Name Hindra Irawan Satari
bull Position
bull Chief Infection Control Committee RSCM
bull Chief Infectious Diseases and Tropical Pediatrics Child Health Dept FKUI-RSCM
bull Member Antimicrobal Resistance Watch Unit RSCM
bull Education
ndash General practitioner FK UNPAD 1981
ndash General Pediatrician FKUI 1992
ndash Master of Tropical Pediatrics School of Tropical Medicine Liverpool University United Kingdom 1995
ndash Infectious and Tropical Pediatrics Consultant Kolegium IDAI 2002
ndash PhD in Medical Science FKUI 2012
bull Course
bull Advance course in Hospital Infection Hong Kong 1994
Email hsatari54yahoocom
VAP BUNDLE IN INFECTION CONTROL
bull Hindra Irawan Satari
bull Infection Control Committee
Ciptomangunkusumo Hospital
Jakarta
OUTLINE
bull Health-care associated infection (HAIs)
bull Pneumonia
bull Ventilator associated event
bull Bundle
bull VAP in Ciptomangunkusumo Hospital
2011-2013
bull Conclusion
DEFINITION OF HAIs
CDC 2013
A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility
An infection is considered an HAI if all elements of a CDCNHSN site-specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1)
For an HAI an element of the infection criterion may be present during the first 2 hospital days as long as it is also present on or after day 3 All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between elements
Major and Specific types of HAIs
bull Bone and joint infection (BJ)
bull Bloodstream infection (BSI)
bull Central nervous system (CNS)
bull Cardiovascular system (CVS)
bull Eye ear nose throat or
mouth infection (EENT)
bull Gastrointestinal infection (GI)
bull Lower respiratory infection
other than pneumonia (LRI)
bull Pneumonia (PNEU)
bull Reproductive tract infection
(REPR)
bull Surgical site infection (SSI)
bull Skin and soft tissues (SSI)
bull Systemic infection (SYS)
bull Urinary tract infection (UTI)
bull Ventilator-asociated event
(VAE)
PNEU-Pneumonia
bull There are 3 specific types of pneumonia
ndash clinically-defined pneumonia (PNU1)
ndash pneumonia with specific laboratory findings
(PNU2)
ndash pneumonia in immunocompromised patients
(PNU3)
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
VAP BUNDLE IN INFECTION CONTROL
bull Hindra Irawan Satari
bull Infection Control Committee
Ciptomangunkusumo Hospital
Jakarta
OUTLINE
bull Health-care associated infection (HAIs)
bull Pneumonia
bull Ventilator associated event
bull Bundle
bull VAP in Ciptomangunkusumo Hospital
2011-2013
bull Conclusion
DEFINITION OF HAIs
CDC 2013
A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility
An infection is considered an HAI if all elements of a CDCNHSN site-specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1)
For an HAI an element of the infection criterion may be present during the first 2 hospital days as long as it is also present on or after day 3 All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between elements
Major and Specific types of HAIs
bull Bone and joint infection (BJ)
bull Bloodstream infection (BSI)
bull Central nervous system (CNS)
bull Cardiovascular system (CVS)
bull Eye ear nose throat or
mouth infection (EENT)
bull Gastrointestinal infection (GI)
bull Lower respiratory infection
other than pneumonia (LRI)
bull Pneumonia (PNEU)
bull Reproductive tract infection
(REPR)
bull Surgical site infection (SSI)
bull Skin and soft tissues (SSI)
bull Systemic infection (SYS)
bull Urinary tract infection (UTI)
bull Ventilator-asociated event
(VAE)
PNEU-Pneumonia
bull There are 3 specific types of pneumonia
ndash clinically-defined pneumonia (PNU1)
ndash pneumonia with specific laboratory findings
(PNU2)
ndash pneumonia in immunocompromised patients
(PNU3)
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
OUTLINE
bull Health-care associated infection (HAIs)
bull Pneumonia
bull Ventilator associated event
bull Bundle
bull VAP in Ciptomangunkusumo Hospital
2011-2013
bull Conclusion
DEFINITION OF HAIs
CDC 2013
A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility
An infection is considered an HAI if all elements of a CDCNHSN site-specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1)
For an HAI an element of the infection criterion may be present during the first 2 hospital days as long as it is also present on or after day 3 All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between elements
Major and Specific types of HAIs
bull Bone and joint infection (BJ)
bull Bloodstream infection (BSI)
bull Central nervous system (CNS)
bull Cardiovascular system (CVS)
bull Eye ear nose throat or
mouth infection (EENT)
bull Gastrointestinal infection (GI)
bull Lower respiratory infection
other than pneumonia (LRI)
bull Pneumonia (PNEU)
bull Reproductive tract infection
(REPR)
bull Surgical site infection (SSI)
bull Skin and soft tissues (SSI)
bull Systemic infection (SYS)
bull Urinary tract infection (UTI)
bull Ventilator-asociated event
(VAE)
PNEU-Pneumonia
bull There are 3 specific types of pneumonia
ndash clinically-defined pneumonia (PNU1)
ndash pneumonia with specific laboratory findings
(PNU2)
ndash pneumonia in immunocompromised patients
(PNU3)
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
DEFINITION OF HAIs
CDC 2013
A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility
An infection is considered an HAI if all elements of a CDCNHSN site-specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1)
For an HAI an element of the infection criterion may be present during the first 2 hospital days as long as it is also present on or after day 3 All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between elements
Major and Specific types of HAIs
bull Bone and joint infection (BJ)
bull Bloodstream infection (BSI)
bull Central nervous system (CNS)
bull Cardiovascular system (CVS)
bull Eye ear nose throat or
mouth infection (EENT)
bull Gastrointestinal infection (GI)
bull Lower respiratory infection
other than pneumonia (LRI)
bull Pneumonia (PNEU)
bull Reproductive tract infection
(REPR)
bull Surgical site infection (SSI)
bull Skin and soft tissues (SSI)
bull Systemic infection (SYS)
bull Urinary tract infection (UTI)
bull Ventilator-asociated event
(VAE)
PNEU-Pneumonia
bull There are 3 specific types of pneumonia
ndash clinically-defined pneumonia (PNU1)
ndash pneumonia with specific laboratory findings
(PNU2)
ndash pneumonia in immunocompromised patients
(PNU3)
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
Major and Specific types of HAIs
bull Bone and joint infection (BJ)
bull Bloodstream infection (BSI)
bull Central nervous system (CNS)
bull Cardiovascular system (CVS)
bull Eye ear nose throat or
mouth infection (EENT)
bull Gastrointestinal infection (GI)
bull Lower respiratory infection
other than pneumonia (LRI)
bull Pneumonia (PNEU)
bull Reproductive tract infection
(REPR)
bull Surgical site infection (SSI)
bull Skin and soft tissues (SSI)
bull Systemic infection (SYS)
bull Urinary tract infection (UTI)
bull Ventilator-asociated event
(VAE)
PNEU-Pneumonia
bull There are 3 specific types of pneumonia
ndash clinically-defined pneumonia (PNU1)
ndash pneumonia with specific laboratory findings
(PNU2)
ndash pneumonia in immunocompromised patients
(PNU3)
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
PNEU-Pneumonia
bull There are 3 specific types of pneumonia
ndash clinically-defined pneumonia (PNU1)
ndash pneumonia with specific laboratory findings
(PNU2)
ndash pneumonia in immunocompromised patients
(PNU3)
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
PNEUMONIA BY ITS ONSET
bull Early
ndash During the first 4 days
of hospitalization
bull M catarrhalis
bull H influenzae
bull S pneumoniae
bull Viruses
ndash Influenza A and B
ndash Respiratory syncitial
virus
bull Late bull Gram negatice bacilli
bull S aureus including
methycillin-resistant S
aureus
bull Viruses
bull Yeast fungi
legionellae
bull Pneumocystis carinii
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
PNU1
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
PNU2
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
PNU3
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
THRESHOLD WHERES FOR CULTURED SPECIMENS
USED IN THE PNEUMONI CRITERIA
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
VAE ndash VENTILATOR-ASSOCIATED EVENT
bull VAC ndash Ventilator-Associated Condition
Patient has a baseline period of stability or improvement on the ventilator defined by ge2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
and
After a period of stability or improvement on the ventilator the patient has at least one of the following indicators of worsening oxygenation
1 Increase in daily minimum FiO2 of ge020 (20 points) over the daily minimum FiO2 in the baseline period sustained for ge2 calendar days
2 Increase in daily minimum PEEP values of ge3 cmH2O over the daily minimum PEEP in the baseline period sustained for ge2 calendar days
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
VAE ndash VENTILATOR-ASSOCIATED
EVENT
bull IVAC ndash Infection-related Ventilator-Associated Complication
Patient meets criteria for VAC
and
on or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation the patient meets both of the following criteria
1 Temperature gt38degC or lt36degC OR white blood cell count ge12000 cellsmm3 or le4000
cellsmm3
and
2 A new antimicrobial agent(s) is started and is continued for ge4 calendar days
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
What is a bundle
IHI developed the concept of ―bundles to help health care providers
more reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks
A bundle is a structured way of improving the processes of care and
patient outcomes a small straightforward set of evidence-based
practices mdash generally three to five mdash that when performed collectively
and reliably have been proven to improve patient outcomes
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
What makes a bundle so special
The power of a bundle comes from the body of science
behind it and the method of execution with complete
consistency Itrsquos not that the changes in a bundle are new
theyrsquore well established best practices but theyrsquore often not
performed uniformly making treatment unreliable at times
idiosyncratic A bundle ties the changes together into a
package of interventions that people know must be
followed for every patient every single time
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
So a bundle is a list of the right things to
do for a given patient
It resembles a list but a bundle is more than that A bundle
has specific elements that make it unique
bull The changes are all necessary and all sufficient so if
yoursquove got four changes in the bundle and you remove
any one of them you wouldnrsquot get the same results mdash
meaning the patient wonrsquot have as high a chance of
getting better Itrsquos a cohesive unit of steps that must all
be completed to succeed
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
So a bundle is a list of the right things to
do for a given patient
bull The changes are all based on randomized controlled
trials what we call Level 1 evidence Theyrsquove been
proven in scientific tests and are accepted well-
established There should be no controversy involved
no debate or discussion of bundle elements A bundle
focuses on how to deliver the best care mdash not what the
care should be We want providers to get right to work
on the how on completing steps x y and z for every
patient
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
So a bundle is a list of the right things to
do for a given patient
bull The changes in a bundle are clear-cut and straightforward they
involve all-or-nothing measurement
bull Successfully completing each step is a simple and straightforward
process Itrsquos a ―yes or ―no answer ―Yes I did this step and that
one no I did not yet do this last one
bull Successfully implementing a bundle is clear-cut ―Yes I completed
the ENTIRE bundle or no I did not complete the ENTIRE
bundle There is no in between no partial ―credit for doing some of
the steps some of the time
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
So a bundle is a list of the right things to
do for a given patient
bull Bundle changes also occur in the same time and
space continuum at a specific time and in a
specific place no matter what
bull This might be during morning rounds every day
or every six hours at the patientrsquos bedside for
instance
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
Ventilator Bundle
ndash The Ventilator Bundle has four care steps
bull raising the head of the patientrsquos bed between 30 and 40
degrees
bull giving the patient medication to prevent stomach ulcers
bull preventing blood clots when patients are inactive
bull seeing if patients can breathe on their own without a
ventilator
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
2220
1576
1909 1734
374 193
2722
1953
804
1999
511 383
000
500
1000
1500
2000
2500
3000
JU
MLA
H H
AR
I P
EM
AS
AN
GA
N
VEN
TILA
TO
R
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED
PNEUMONIA (VAP) DI RSCM TAHUN 2011
Insiden rate
Target lt10permil
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
INCIDENCE RATE VAP
CIPTOMANGUNKUSUMO HOSPITAL 2012-2013
1272
336 311
122
465
704 608
383 305
860
476 551
000
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11 12
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM TAHUN 2012
Insidenrate
397 445 416
000
200
400
600
800
1000
1200
1 2 3
JUM
LAH
HA
RI P
EMA
SAN
GA
N
VEN
TILA
TOR
10
00
INSIDEN RATE INFEKSI VENTILATOR ASSOCIATED PNEUMONIA (VAP) DI
RSCM PERIODE JANUARI-MARET 2013
Insidenrate
Target lt10permil
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
Ventilator-associated pneumonia bundled strategies
an evidence-based practice OKeefe-McCarthy S Santiago C Lau G
CIHRCHSF FUTURE Program for Cardiovascular Nurse Scientists University of Toronto Ontario Canada
bull METHODS
Electronic searches in MEDLINE EMBASE CINAHL PsycINFO
and Cochrane Collaboration were conducted using keywords
specific to VAP
bull RESULTS
Evidence shows that VAPB practices decrease VAP rates
Bundled practices result in decreased ventilator days intensive
care unit length of stay and mortality rates A strong association
was seen with an increased clinician compliance with VAPB
protocols with decreased VAP rates
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
Bundles to prevent ventilator-associated pneumonia
how valuable are they Wip C Napolitano L
Department of Surgery University of Michigan Health System University Hospital USA
The Ventilator Bundle is an effective method to reduce VAP rates
in ICUs The ventilator bundle should be modified and expanded
to include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
A European care bundle for prevention of
ventilator-associated pneumonia Rello J Lode H Cornaglia G Masterton R VAP Care Bundle Contributors
Critical Care Department Vall dHebroacuten University Hospital Institut de Recerca Vall dHebroacuten-
UAB CIBERES Barcelona Spain
The resulting VAP care bundles for prevention were non-
ventilatory circuit changes unless specifically indicated alcohol
hand hygiene appropriately educated and trained staff
incorporation of sedation control and weaning protocols into
patient care and oral care with clorhexidine
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
CONCLUSION
bull A bundle is a specific tool with clear parameters It has a small
number of elements that are all scientifically robust that when taken
together create much improved outcomes
bull The Ventilator Bundle is an effective method to reduce VAP rates in
ICUs The ventilator bundle should be modified and expanded to
include specific processes of care that have been definitively
demonstrated to be effective in VAP reduction or a specific VAP
bundle created to focus on VAP prevention
THANK YOU
THANK YOU
