Caserta et al.

BMC Infectious Diseases 2012, 12:234

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RESEARCH ARTICLE Open Access

A program for sustained improvement in

preventing ventilator associated pneumonia
in an intensive care setting
Raquel A Caserta1*, Alexandre R Marra1, Marcelino S Durão1, Cláudia Vallone Silva2,
Oscar Fernando Pavao dos Santos3, Henrique Sutton de Sousa Neves4, Michael B Edmond5
and Karina Tavares Timenetsky1

Abstract
Background: Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and
associated with a high mortality.
Methods: A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize
VAP prevention were performed from October 2008 to December 2010. All of these processes, including the
Institute for Healthcare Improvement’s (IHI) ventilator bundle plus oral decontamination with chlorhexidine and
continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation.
Results: We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate
of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero
incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%.
Conclusion: These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates,
but it requires a complex process involving multiple performance measures and interventions that must be
permanently monitored.
Keywords: Ventilator associated pneumonia, Prevention, Intensive care, VAP bundle

Background ventilation and increased hospital expenses [8-10], as

Ventilator-associated pneumonia (VAP) is a common in- well as excessive utilization of antimicrobials with cor-
fection in the ICU. [1] Recent studies describe a rate of respondingly higher costs [8,9].
1 to 4 cases per 1,000 ventilator-days, although this can As part of the 5 Million Lives campaign, endorsed by
reach up to 10 cases per 1,000 cases ventilator-days in leading US agencies and professional societies, The Insti-
neonates and surgical patients [2,3]. The improvement tute for Healthcare Improvement (IHI) recommends
in outcomes associated with recent initiatives suggest that all ICUs implement a ventilator bundle to reduce
that many cases of VAP can be prevented by adhering to the incidence of VAP to zero [11]. Since 2007, we have
bundles of infection prevention measures [4,5]. implemented the VAP bundle in our ICU, including oral
The attributable mortality of VAP is around 4% to 9% hygiene with 0.12% chlorhexidine and continuous aspir-
varying with definitions, case-mix, causative microorgan- ation of subglottic secretions (CASS) [4]. With these
isms, and treatment adequacy [6,7]. VAP is also asso- measures we were able to achieve zero incidence of VAP
ciated with considerable morbidity, due to increased during a few months when a higher than 95% compli-
length of hospital and ICU stay, prolonged mechanical ance rate with the VAP bundle was obtained [4]. How-
ever, to date there are no reports of sustained low
* Correspondence: [email protected] incidence of VAP [4] (near zero).
1
Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, The purpose of this quasi-experimental study was to
627/701 - 5º Andar – Bloco B, São Paulo CEP 05651-901, Brazil evaluate whether the sustained implementation of the
Full list of author information is available at the end of the article

© 2012 Caserta et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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VAP bundle in our ICU could effectively reduce the inci- oral decontamination with chlorhexidine 0.12% + con-
dence of ventilator-associated pneumonia (VAP). tinuous aspiration of subglottic secretions (CASS) endo-
tracheal tube (phase 3). We then decided to analyze our
Methods performance after almost two years of all these interven-
Setting and study design tions (including the VAP bundle) to determine whether
An interrupted time series study was conducted in a 38- this was a sustainable program for controlling ventilator
bed medical-surgical intensive care unit (ICU) of a ter- associated pneumonia. We decided to extend data col-
tiary care, private hospital in São Paulo, Brazil. This is lection in phase 3 (VAP bundle + oral decontamination
an open staffing model ICU where approximately 2,200 with chlorhexidine 0.12% + continuous aspiration of
patients are admitted annually. This study was a quality subglottic secretions (CASS) endotracheal tube) to
improvement study that was approved by the Institu- evaluate this assumption (Figure 1). In summary, phases
tional Review Board of Hospital Israelita Albert Einstein 1, 2 and 3 (from April 2007 to September 2008) are
(IRB). The requirement for informed consent was a consequence of our previous publication [4]. We
waived by our IRB in accordance with the Code of Fed- extended data collection in this present manuscript
eral Regulations and the Privacy Rule. This project was (from October 2008 to December 2010) in phase 3.
carried out after our previously published study from We provided monthly feedback on compliance with the
April 2007 to September 2008 [4]. Herein we report bundle components to the ICU team (doctors, nurses
our observations for the period from October 2008 to and respiratory therapists). We also displayed posters
December 2010 to evaluate whether the sustained imple- in the ICU with bar charts showing compliance with
mentation of the VAP bundle in our ICU could effect- the recommended procedures. These posters also
ively reduce the incidence of VAP. All these hospital showed the VAP rate as determined in surveys con-
epidemiology data was analysed anonymously. ducted by the Department of Infection Control and Hos-
The VAP bundle included elevation of the head of the pital Epidemiology.
bed (HOB) (30–45 degrees); daily “sedation vacations”
and assessment of readiness to extubate; peptic ulcer Definitions
disease prophylaxis; and deep venous thrombosis/ VAP surveillance was performed by trained infection
pulmonary thromboembolism (DVT/PE) prophylaxis control specialists using the US Center for Disease
for all ICU patients requiring mechanical ventilation. Control and Prevention/National Healthcare Safety Net-
This ventilator bundle was monitored each weekday work (CDC/NHSN) definition [12] in an independence
by an ICU nurse. She intervened in this process while way from the treating ICU team, the incidence of VAP
performance monitoring was taking place at the bed- was expressed as cases of VAP per 1,000 ventilator-days
side if non-compliance with an element of the bundle and the incidence of ventilator associated tracheobron-
was detected (e.g., sedation was not stopped). We also chitis (VAT) was expressed as cases of VAT per 1,000
intervened in other CDC evidence-based practices ventilator-days.
for prevention of ventilator associated pneumonia [3] in- VAP was defined as the sum of the clinical criteria as
cluding: 1) no routine changing of humidified ventilator described the presence of fever (temperature >38°C),
circuits, 2) periodically draining and discarding conden- new or increased sputum production, in combination
sate collecting in the ventilator tubing and, 3) changing with radiologic evidence of a new or progressive
the heat-and-moisture exchangers (HMEs) when they
showed mechanical malfunction or became visibly
soiled. These CDC process measures were audited twice
yearly in a small sample of mechanically ventilated
patients at random intervals.
Other interventions to control VAP in the ICU were
implemented in October 2007 when oral decontamin-
ation with chlorhexidine 0.12% was introduced for all
mechanically ventilated ICU patients [4]. In February
2008, the continuous aspiration of subglottic secretions
(CASS) endotracheal tube was implemented for patients
requiring mechanical ventilation and expected to require
ventilation for longer than 24 hours [4]. Figure 1 Study design. *Phases 1, 2 and 3 (from April 2007 to
Previously [4] we had compared the VAP bundle alone September 2008) are a consequence of our previous publication [4].
We extended data collection in this present manuscript (from
(phase 1), with the VAP bundle + oral decontamination
October 2008 to December 2010) in phase 3.
with chlorhexidine 0.12% (phase 2), and the VAP bundle +
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pulmonary infiltrate, leukocytosis, a suggestive Gram’s compliance), 611 ventilator circuits without changes
stain, and grow of bacteria (not necessarily) in cultures (99.8% compliance) and 611 observations of HMEs
of sputum, tracheal aspirate, pleural fluid, bronchoal- changes (95% compliance). Also included in the analysis
veolar lavage (BAL), or blood [12]. Per the CDC/NHSN were 2,396 daily sedation vacations, gastric prophylaxis
definition, microbiological data are not necessary for opportunities and DVT/PE prevention opportunities
the diagnosis. with 98%, 99% and 98% compliance, respectively. There
VAT was defined as the presence of fever (temperature were also 611 observations of ventilator-circuit-tubing
>38°C), new or increased sputum production, a micro- condensate with 92% compliance. CASS was performed
biologically positive respiratory sample, and the absence in 342 patients since October 2008, and all patients
of pulmonary infiltrates on chest radiography. requiring mechanical ventilation received oral decon-
tamination with chlorhexidine 0.12% (Table 1).
Microbiological methods In 2010, the analysis included 2,260 HOB elevation
All isolates were identified by manual or automated observations (91% compliance), 390 ventilator circuits
methods and confirmed using the Vitek 2 system (bio- without changes (99% compliance) and 390 observations
Merieux Vitek, Inc., Hazelwood, MO). of HMEs changes (94% compliance). Daily sedation
vacations, gastric prophylaxis opportunities and DVT/PE
Statistical analysis prevention opportunities had 2,486 observations with
The variables of interest were those that indicated com- 91% of compliance in all measurements (Table 1).
pliance with the VAP prevention measures. We used
segmented regression analysis of interrupted time series Incidence density of VAP and in-hospital mortality
[13] to assess the changes in VAP before and after im- of VAP patients
plementation of the ventilator bundle, oral decontamin- The incidence density of VAP per 1,000 ventilator days
ation with chlorhexidine 0.12%, and CASS endotracheal in the ICU was 1.3 in 2009 (10,889 patient-days) and in
tube for patients requiring mechanical ventilation, 2010 the incidence was 2 (11,095 patients-days). The
according to the interventional phases (Figure 1). incidence density of VAT per 1,000 ventilator days in the
We adjusted a segmented regression model that ICU was 1.0 (10,889 patient-days) in 2009 and in 2010
allowed us to analyze a reduction (or an increase) in the incidence was 2 (11,095 patient-days).
VAP rate at each study phase separately: (1) ventilator Mechanical ventilation days, ICU length of stay, venti-
bundle only, April 2007 to October 2007; (2) ventilator lator utilization ratio, number of VAPs, number of VATs,
bundle + chlorhexidine, November 2007 to February ventilator-days, ventilator-free days, in-hospital mortality
2008; (3) ventilator bundle + chlorhexidine + CASS of VAP patients and in-hospital mortality ICU patients
endotracheal tube, March 2008 to December 2010 are shown in Table 1.
(Figure 1). Getting to zero VAP for one or more months has
The intercept and slope are the two parameters which occurred since 2009 when there was greater than 95%
define each segment of a time series. The intercept is compliance with the ventilator bundle, oral decontamin-
the value of the series at the beginning of a given time ation with chlorhexidine 0.12% and continuous aspir-
interval, the slope is the change of the measure (VAP ation of subglottic secretions (CASS) (Figure 2). In
rate) over a certain period (e.g., a month). A change in addition to this we continued to evaluate ventilator
slope (β) is defined by an increase or decrease in the circuits without changes, HMEs changes and ventilator-
slope of the time step after the intervention, compared circuit-tubing condensate.
with the time step preceding the intervention. It is Segmented regression analysis (Figure 3) showed a sta-
important to mention that this is not the same as tistically significant increase in VAP rate (β11 = +2.59;
constructing three models of simple linear regression, p < 0.001) in the first segment (ventilator bundle). The
because the third partition parameters depend on the transition from the first segment (ventilator bundle) to
previous partitions’ parameters. the second segment (ventilator bundle + chlorhexidine)
All tests of statistical significance were 2-sided with a showed a significant decrease in VAP rate (β20 = −11.24;
significance level set at 0.05. All the data analyses were p < 0.001). The slope (β21) in the second segment was
performed using SPSS 16.0 and SAS 9.1; SAS Institute negative, indicating a reduction in VAP rate upon imple-
Inc, Cary, NC, USA. mentation of oral decontamination with chlorhexidine
(β21 = −2.30 with p = 0.272). The transition from the sec-
Results ond segment (ventilator bundle + chlorhexidine) to the
Compliance with process measures in each phase third segment (ventilator bundle + chlorhexidine +
In 2009, the process measures subject to analysis CASS endotracheal tube) was not significant in VAP rate
included 2,396 HOB elevation observations (98.6% (β30 = −2.67 with p = 0.682). In the third segment the
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Table 1 Characteristics of the sustained period of “getting to zero” VAP prevention program in the ICU
2009 2010
Patient-days (total) 10,889 11,095
Number of patients 2,705 2,717
Age, mean ± SD (in years) 67±19 66±18
Male, n (%) 1,571 (58.1%) 1,587 (58.4%)
APACHE, mean ± SD 18±6 18±7
Ventilator-days (total) 3,009 3,043
Ventilator utilization ratio 0.28 0.27
MV days – median (IQR) 4 (1–22) 3.7 (1–23)
Ventilator-free days 7,880 8,052
ICU LOS days – mean ± SD 3.9±0.4 4.0±0.3
Compliance with process measures, n (%)
HOB observations 2362/2396 (98.6%) 2260/2486 (90.9%)
Daily “sedation interruptions” 2358/2396 (98.4%) 2273/2486 (91.4%)
Gastric prophylaxis 2393/2396 (99.9%) 2276/2486 (91.5%)
DVT/PE prevention 2363/2396 (98.6%) 2266/2486 (91.1%)
Ventilator circuits without changes 610/611 (99.8%) 387/390 (99.2%)
HMEs changed 584/611 (95.5%) 368/390 (94.3%)
Ventilator-circuit-tubing condensate 564/611 (92.3%) 360/390 (92.3%)
CASS endotracheal tube - n 342 311
Number of VAPs 4 6
Number of VATs 3 6
VAP rate per 1,000 ventilator-days 1.3 2.0
VAT rate per 1,000 ventilator-days 1.0 2.0
In-hospital mortality in VAP patients, n (%) 4/4 (100) 5/6 (83)
In-hospital mortality in ICU patients, n 196 220
In-hospital mortality in ICU patients per 10,000 patient days 180 198
CASS Continuous Aspiration of Subglottic Secretions.
DVT/PE Deep Venous Thrombosis/Pulmonary Embolism.
ICU LOS Intensive Care – Length of Stay.
HMEs Heat-and-Moisture Exchanges.
HOB Head of the Bed.
MV Mechanical Ventilation.
SD Standard Deviation.
VAP Ventilator Associated Pneumonia.
VAT Ventilator Associated Tracheobronchitis.

slope (β31) was practically zero, indicating that there pathogens overall were Pseudomonas aeruginosa and
was no reduction in VAP rate, which was maintained Acinetobacter baumannii. The majority of the pathogens
along the segment (β31 = 0.03 with p = 0.610). were identified by tracheal aspiration. Only 25% of VAP
patients (1/4) were investigate by BAL (Table 2).
Microbiological features The mortality rate was 100% for the patients with VAP
As seen in Table 2, we had 10 cases of VAP, 4 in 2009 in 2009 and 83.3% in 2010.
and 6 in 2010. Most patients were male (70%), with a
median age of 58 years old (range 20 to 85 years), the
median mechanical ventilation time was 9 days (range 5 Mechanical ventilation
to 33 days). Eighty percent of all the microorganisms The total time of mechanical ventilation was 6,052 days,
identified were gram-negative, followed by viruses (10%), with a utilization rate of 28% in 2009 and 27% in 2010
and 10% unidentified microorganisms. (Table 1). As seen in Figure 4, our mechanical ventila-
Pseudomonas aeruginosa accounted for over 40% tion utilization rates have been reduced since 2000, with
of the gram-negative pathogens. The most prevalent a 17% drop from 2000 to 2010.
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Bundle compliance (%)

VAP/1,000 ventilator-days September 2008 to December 2010
100 –Sustained Implementation 30
Previously published (4)
90
25
80
70
20
60
50 15
40
10
30
20
5
10
0 0
ju 07
au 07

oc 007

de 07

b/ 0
ap 008

ju 08
au 08

oc 008
de 008

fe 008
ap 09

ju 09
au 09

oc 009
de 009

fe 009
ap 010

ju 10
au 10

0c 010
de 010

10
20
0
n/

0
n/

20

0
n/

0
n/

20
r/2

2
t/2

c/

2
r/2

2
t/2

r/2

2
t/2

2
2
r/2

2
t/2
g/

g/

c/
b/

g/

c/
b/

g/

c/
ap

fe

Figure 2 Bundle compliance and VAP (ventilator associated pneumonia) rate from April 2007 to December 2010. This chart shows
extended data from the study published in AJIC 2009 (reference number 4). Oral decontamination with chlorhexidine 0.12% (since October/2007).
Continuous aspiration of subglottic secretions (CASS) endotracheal tube (since February/2008).

Discussion Many hospitals have achieved the goal of getting VAP

Since 2007, we have set as a priority in our hospital the to zero [14,15], while others have managed to substan-
eradication of nosocomial infections. To this end, we tially reduce VAP rates, but believe that eliminating VAP
have developed a set of best practices for prevention of in the intensive care unit may be an unrealistic goal [16].
ventilator associated pneumonia (VAP). In order to In a previous publication [4], we have shown that this
achieve a reduction in VAP rates, we have applied the was only possible when the compliance with the VAP
Institute for Healthcare Improvement bundle model and prevention bundle exceeded 95%, the CASS endo-
also implemented other preventive measures (oral chlor- tracheal tube was incorporated in daily practices and
hexidine 0.12% and CASS endotracheal tube). Our VAP [17,18] oral hygiene with chlorhexidine was implemen-
rates are discussed on a monthly basis at a multidiscip- ted [19]. In a recent systematic review and meta-analysis
linary meeting with our hospital’s chief executive officer of patients at risk for ventilator-associated pneumonia,
(CEO) and other senior management representatives re- the use of endotracheal tubes with subglottic secretion
sponsible for ensuring that healthcare practices support drainage was shown to effectively prevent ventilator-
a program for infection prevention and control that ef- associated pneumonia and to be possibly associated with
fectively prevents VAP. reduced duration of mechanical ventilation and length

Figure 3 Segmented regression of ventilator associated pneumonia (VAP) rate per 1,000 ventilator days from April 2007 to December
2010. Segmented 1: β10 = +6.08 p = 0.004; CI 95%: [(2.06 - 10.12)]. Segmented 1 (the slope): β11 = +2.59 p <0.001; CI 95%: [(1.47 - 3.71)].
Segmented 2: β20 = −11.24 p = 0.004; CI 95%: [(−18.60) - (−3.89)]. Segmented 2 (the slope): β21 = −2.30 p = 0.272; CI 95%: [(−6.48) - 1.88)].
Segmented 3: β30 = −2.67 p = 0.682; CI 95%: [(−15.83) - 10.47)]. Segmented 3 (the slope): β31 = +0.03 p = 0.610; CI 95%: [(−0.08) - 0.13)].
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Table 2 Characteristics of infections causing VAP during the sustained period of “getting to zero” VAP prevention
program
N Year Age Gender Diagnostic MV time Respiratory specimen Pathogen Clinical outcome
(days)
1 2009 85 Male DLOC/Hyponatremia 16 Tracheal aspirate P.aeruginosa Death
2 2009 65 Female Hypereosinophilia/ Myelopathy 5 BAL + Tracheal aspirate Acinetobacter baumannii Death
3 2009 20 Male Correction of GERD 19 Tracheal aspirate P.aeruginosa Death
4 2009 23 Female Liver failure/ liver transplant 5 Tracheal aspirate Acinetobacter lwoffii Death
5 2010 56 Male Respiratory failure/ BCP 16 Tracheal aspirate P.aeruginosa Death
6 2010 62 Male Carotid stenosis/ Endarterectomy 8 Tracheal aspirate S.marcescens Hospital discharge
7 2010 59 Male Chagas cardiomyopathy 10 Tracheal aspirate E.cloacae Death
8 2010 55 Female Hepatic encephalopathy 8 Nasopharyngeal swab RSV Death
9 2010 61 Male Acute respiratory failure/ BCP 33 Tracheal aspirate K.pneumoniae + P.aeruginosa Death
10 2010 58 Male Cranial trauma 7 Tracheal aspirate E.aerogenes + A.baumannii Death
MV Mechanical Ventilation.
DLOC Decreased Level Of Consciousness.
GERD Gastroenteral Reflux Disease.
RSV Respiratory Syncytial Virus.
BCP Bronchopneumonia.
BAL Bronchoalveolar lavage.

of ICU stay [18]. We believe this might be the reason for consider it important to report VAP rates, we believe we
our reduced time and utilization rate of mechanical ven- should continuously report our compliance to the pre-
tilation, together with the daily sedation vacation vention measures (VAP bundle) and the adverse events
included in the VAP bundle. We also believe that obtain- associated with mechanical ventilation in ICU patients
ing the commitment of all members of the ICU team [23]. However, we were able to show that the procedures
was ultimately a factor in our success in the implemen- implemented since 2007 have contributed to a signifi-
tation of these procedures over the years. cant reduction in our infection rates (Figure 5) and to a
Klompas et al. [20] have called attention to the pro- decrease in the use of mechanical ventilation in recent
blems that may arise when we use VAP as a quality indi- years (Figure 4). It is important to note that our VAP
cator, including difficulties with the subjectivity implied surveillance was performed by trained infection control
by the current VAP definition. Moreover, Edmond has practitioners using the US Centers for Disease Control
pointed out that the “getting to zero” approach may be and Prevention/National Healthcare Safety Network
associated with adverse unintended consequences [21]. (CDC/NHSN) definition [12] throughout the study
Moreover, the CDC/NHSN definition has been shown period. Even though we have failed to demonstrate a sta-
to have lower sensitivity than the American College tistically significant result using the segmented regres-
of Chest Physicians definition [22]. Even though we sion analysis of VAP prevention, we have achieved a

Mechanical Ventilation Utilization Rate

60

50

40

30
%

20

10

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Figure 4 Secular trends of mechanical ventilation utilization rate in ICU.

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Incidence Density Rate ( IDR) of VAP/1,000 MV-days

2004-2010
20.0 18.8

15.0
14.1
15.0
10.6
10.0

5.0 3.4
1.3 2.0
1.9
0.0
2004 2005 2006 2007 2008 2009 2010
Anual IDR in theICU NHSN 2009

Figure 5 Incidence density rate (IDR) of VAP/1000 ventilator-days from 2004 to 2010 in the ICU.

zero infection rate by applying all the VAP prevention Abbreviations

measures recommended in the literature [8,9]. VAP: Ventilator-associated pneumonia; VAT: Ventilator associated
tracheobronchitis; ICU: Intensive Care Unit; IHI: Institute for Healthcare
There are several limitations to this study. This is not Improvement; IRB: Institutional Review Board of Hospital Israelita Albert
a randomized trial but a quasi-experimental, interrupted Einstein; NNISS: National Nosocomial Infectious Surveillance System;
time series study. Quasi-experimental study designs are HOB: Elevation of the head of the bed; DVT/PE: Deep venous thrombosis/
pulmonary thromboembolism; CDC/NHSN: Center for Disease Control and
frequently used when it is not logistically feasible to con- Prevention/National Healthcare Safety Network; CASS: Continuous aspiration
duct a controlled trial. Thus, other unmeasured factors of subglottic secretions endotracheal tube; HMEs: Heat-and-moisture
might have coincided with the interventions effective exchangers; BAL: Bronchoalveolar lavage; CEO: Chief executive officer.
since April 2007 (implementation of the ventilator bun-
Competing interests
dle), resulting in a decrease in VAP rates in our ICU. The authors have declared that no competing interests exist.
However, this seems unlikely because there had been no
decrease in VAP rates over the previous several years Authors’ contributions
(Figure 5). Data from our ICU in 2011 and in the first RCE, MSD, CVS, KTT participated in the data collected and data analysis. AM,
OFPS, MBE and KTT participated in the design and coordination. RCE, AM,
quarter of 2012 have shown that the VAP rate continues CVS, HSSN, KTT and MBE helped to draft the manuscript and to provide
low (1.5 and 1.9, respectively). Finally, as this interven- critical review of the manuscript. All authors read and approved the final
tion was performed at a single medical center, it might manuscript.

be inappropriate to extrapolate our results (i.e. VAP

Acknowledgments
mortality) to other hospitals. Even considering some We gratefully acknowledge all the healthcare workers Hospital Israelita Albert
aspects as the attributable mortality of VAP, other Einstein who continue working in VAP prevention.
studies applying more sophisticated analysis such as
multistate model that appropriately handle VAP as a Funding
No external funding was received for this work.
time-dependent event or competing risk survival analysis
have shown rates of attributable mortality as low as 10% Author details
1
[6,24]. Despite these limitations, our study further sup- Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein,
627/701 - 5º Andar – Bloco B, São Paulo CEP 05651-901, Brazil. 2Infection
port the assumption that controlling VAP rates can be a Control Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil. 3Medical
sustained with the monitoring of multiple performance Practice Department, Hospital Israelita Albert Einstein, São Paulo, Brazil.
4
measures and quality improvement efforts. Hospital Israelita Albert Einstein, São Paulo, Brazil. 5Department of Internal
Medicine, Virginia Commonwealth University School of Medicine, Richmond,
Virginia, USA.

Conclusions Received: 18 March 2012 Accepted: 24 September 2012

Published: 29 September 2012
The process and the outcome measures for VAP pre-
sented here are derived from published guidelines and References
other relevant literature. While we recognize that the 1. Richards MJ, Edwards JR, Culver DH, Gaynes RP: Nosocomial infections in
VAP definition may be subject to criticism due to its combined medical-surgical intensive care units in the United States.
Infect Control Hosp Epidemiol 2000, 21:510–515.
many subjective aspects, we managed to keep the whole 2. American Thoracic Society, Infectious Diseases Society of America:
team’s commitment to preventive measures for over two Guidelines for the management of adults with hospital-acquired,
years, which demonstrates this is a sustainable program ventilator-associated, and healthcare-associated pneumonia. Am J
RespirCrit Care Med 2005, 171:388–416.
for preventing ventilator-associated pneumonia in the 3. Edwards JR, Peterson KD, Andrus ML, Tolson JS, Goulding JC, Dudeck MA,
intensive care unit. Mincey RB, Pollock DA, Horan TC, NHSN Facilities: National Healthcare
Caserta et al. BMC Infectious Diseases 2012, 12:234 Page 8 of 8
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SafetyNetwork (NHSN) report, data summary for 2006, issued June. Am J Safety Network and American College of Chest Physicians criteria.
Infect Control 2007, 35:290–301. Crit Care Med 2012, 40:281–284.
4. Marra AR, Cal RGR, Silva CV, Caserta RA, Paes AT, Moura DF Jr, dos Santos 23. Klompas M: Ventilator-associated pneumonia: is zero possible? Clin Infect
OF, Edmond MB, Durão MS: Successful prevention of ventilator associated Dis 2010, 51:1123–1126.
pneumonia in an intensive care unit setting. Am J Infect Control 2009, 24. Nguile-Makao M, Zahar JR, Français A, Tabah A, Garrouste-Orgeas M,
37:619–625. Allaouchiche B, Goldgran-Toledano D, Azoulay E, Adrie C, Jamali S, Clec'h C,
5. Assanasen S, Edmond MB, Bearman G: Impact of 2 different levels of Souweine B, Timsit JF: Attributable mortality of ventilator-associated
performance feedback on compliance with infection control process pneumonia: respective impact of main characteristics at ICU admission
measures in 2 intensive care units. Am J Infect Control 2008, 36:407–413. and VAP onset using conditional logistic regression and multi-state
6. Bekaert M, Timsit JF, Vansteelandt S, Depuydt P, Vésin A, Garrouste-Orgeas models. Intensive Care Med 2010, 36:781–789.
M, Decruyenaere J, Clec'h C, Azoulay E, Benoit D, Outcomerea Study Group:
Attributable mortality of ventilator-associated pneumonia: a reappraisal doi:10.1186/1471-2334-12-234
using causal analysis. Am J Respir Crit Care Med 2001, 184:1133–1139. Cite this article as: Caserta et al.: A program for sustained improvement
7. Nquile-Makao M, Zahar JR, Français A, Tabah A, Garrouste-Orgeas M, in preventing ventilator associated pneumonia in an intensive care
Allaouchiche B, Goldgran-Toledano D, Azoulay E, Adrie C, Jamali S, Clec'h C, setting. BMC Infectious Diseases 2012 12:234.
Souweine B, Timsit JF: Attributable mortality of ventilator-associated
pneumonia: respective impact of main characteristics at ICU admission
and VAP onset using conditional logistic regression and multi-state
models. Intensive Care Med 2010, 36:781–789.
8. Tejerina E, Frutos-Vivar F, Restrepo MI, Anzueto A, Abroug F, Palizas F,
González M, D'Empaire G, Apezteguía C, Esteban A, Internacional
Mechanical Ventilation Study Group: Incidence, risk factors, and outcome
of ventilator-associated pneumonia. J Crit Care 2006, 21:56–65.
9. Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH:
VAP outcomes scientific advisory group. Epidemiology and outcomes of
ventilator-associated pneumonia in a large US database. Chest 2002,
122:2115–2121.
10. Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Bruisson C: The
attributable morbidity and mortality of ventilator associated pneumonia
in the critically ill patient. Am J Respir Crit Care Med 1999, 159:1249–1256.
11. Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, Susag A:
Implementing a ventilator bundle in a community hospital. Jt Comm J
Qual Patient Saf 2007, 33:219–225.
12. Horan TC, Andrus M, Dudeck MA: CDC/NHSN surveillance definition of
health care-associated infection and criteria for specific types of
infectioins in the acute care setting. Am J Infect Control 2008, 36:309–332.
13. Safdar N, Dezfulian C, Collard HR, Saint S: Clinical and economic
consequences of ventilator-associated pneumonia: a systematic review.
Crit Care Med 2005, 33:2184–2193.
14. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T: Using a
bundle approach to improve ventilator care processes and reduce
ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005,
31:243–248.
15. Berriel-Cass D, Adkins FW, Jones P, Fakih MG: Eliminating nosocomial
infections at Ascension Health. Jt Comm J Qual Patient Saf 2006,
32:612–620.
16. Bouadma L, Deslandes E, Lolom I, Le Corre B, Mourvillier B, Regnier B,
Porcher R, Wolff M, Lucet JC: Long-term impact of a multifaceted
prevention program on ventilator-associated pneumonia in a medical
intensive care unit. Clin Infect Dis 2010, 51:1115–1122.
17. Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J: Continuous
Aspiration of Subglottic Secretions (CASS) in the prevention of
ventilator-associated pneumonia in the postoperative period of major
heart surgery. Chest 2008, 134:938–946.
18. Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK:
Subglottic secretion drainage for the prevention of ventilator-associated
pneumonia: a systematic review and meta-analysis. Crit Care Med 2011,
39:1985–1991. Submit your next manuscript to BioMed Central
19. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V: Randomized and take full advantage of:
controlled trial and meta-analysis of oral decontamination with 2%
chlorhexidine solution for the prevention of ventilator-associated
• Convenient online submission
pneumonia. Infect Control Hosp Epidemiol 2008, 29:131–136.
20. Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, Stevenson K, Samore M, • Thorough peer review
Platt R, CDC Prevention Epicenters Program: Multicenter evaluation of a • No space constraints or color figure charges
novel surveillance paradigm for complications of mechanical ventilation.
PLoS One 2011, 6(3):e18062. • Immediate publication on acceptance
21. Edmond MB: Getting to zero: is it safe? Infect Control Hosp Epidemiol 2009, • Inclusion in PubMed, CAS, Scopus and Google Scholar
30:74–76.
• Research which is freely available for redistribution
22. Skrupky LP, McConnell K, Dallas J, Kollef MH: A comparison of ventilator-
associated pneumonia rates as identified to the National Healthcare
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