Prevalence of Ventilator-Associated Pneumonia Among ICU Patients on VAP Bundles

The Prevalence Of Ventilator- Associated Pneumonia (VAP) Among Intensive Care Unit (ICU)
Patients On VAP Bundles Of Care at a Tertiary Hospital
THE PREVALENCE OF VENTILATOR- ASSOCIATED PNEUMONIA

(VAP) AMONG ICU PATIENTS ON VAP BUNDLES OF CARE AT A TERTIARY HOSPITAL
In Partial Fulfillment of the Training Program

Department of Internal Medicine Residency Program
Submitted By:
Geranyl P. Laguardia, MD
Medical Officer III
Author
Precious Mae A. Gomez, MD
Thea Pamela Cajulao, MD, FPCP, FPSMID, FPSMS
Dr. Jovy Nigos, MD, FPCP, FPCCP, FPSMS
Co-Author
Domingo Solimen, MD, FPCP, FPSG, FPSDE
Training Officer
Department of Internal Medicine
Marie Ellaine N. Velasquez, MD, FPCP, FPSG, FPSDE
Department Head
Angelita Go, MD, FPCP, FPCC
Research Coordinator
0
THE PREVALENCE OF VENTILATOR- ASSOCIATED PNEUMONIA (VAP) AMONG ICU

PATIENTS ON VAP BUNDLES OF CARE AT A TERTIARY HOSPITAL
Name: Geranyl P. Laguardia, MD

laguardiageranyl@yahoo.com
Department of Internal Medicine, Baguio General Hospital and Medical Center
SUMMARY OF PROTOCOL
Introduction: Ventilator-associated pneumonia (VAP) continues to be an important challenge and

dilemma to critical care physicians. VAP is defined as pneumonia that occurs 48–72 hours or thereafter
following endotracheal intubation.(1) It is the second most common nosocomial infection in the intensive
(1)
care unit (ICU) and the most common in mechanically ventilated patients thus, VAP poses grave
implications in endotracheally intubated adult patients in ICUs worldwide and leads to increased adverse
(2)
outcomes and healthcare costs. In the past year, several “VAP bundle” were developed which are
collectively and reliably performs a straightforward set of evidence-based practices proven to improve
(2)
patient outcome and became a standard of care in preventing VAP. The most widespread use VAP
bundle was developed by Institute for Healthcare Improvement (IHI) from 2004 to 2006 consists of five
evidence-based practices. In 2016, the Intensive Care Society (ICS) recommended a revised bundle of
interventions for the prevention of VAP which includes the following: elevation of head of bed 30- 45
degrees, daily sedation interruption and assessment of readiness to extubate, use of subglottic secretion
drainage and avoidance of scheduled ventilator circuit changes. (12)
Objective: This study aims to determine the prevalence of VAP among ICU patients on VAP
BUNDLES of care at tertiary hospital.
Methodology: This is a prospective observational study. The study will be conducted on a specific
period and data will be collected daily starting from the day the patient was intubated. Direct
observation of the intubated patient and a bedside VAP bundle quality-rounding checklist will be used
for each ventilated patient with standard care.
Keywords: ventilator- associated pneumonia, intensive care unit, bundles, intubated
TABLE OF CONTENTS
1
I. INTRODUCTION
2
A Background-------------------------------------------------------- 3
-----
B Review of Related 3
Literature---------------------------------------
C Significance of the 6
Study--------------------------------------------
D Scope of the 7
Study----------------------------------------------------
II. RESEARCH QUESTION
A Objective----------------------------------------------------------- 7
-----
B Specific 7
Objectives----------------------------------------------------
III. METHODS
A Research 8
Design-------------------------------------------------------
B Research 8
Population-------------------------------------------------
C Methodology------------------------------------------------------ 9
-----
D Statistical 10
Analysis----------------------------------------------------
E Ethical 10
Consideration-------------------------------------------------
F Time 11
Table--------------------------------------------------------------
G Expenses 11
Table--------------------------------------------------------
IV. REFERENCES 12
V. APPENDICES
A Consent Form 14
---------------------------------------------------------
B VAP bundle checklist 16
------------------------------------------------
C Clinical criteria in diagnosis of 17
VAP-------------------------------
D VAP rate 17
----------------------------------------------------------------
E Dummy
Table----------------------------------------------------------
VI. RESULTS AND INTERPRETATION
VII. ACKNOWLEDGEMENT
A. Background of the Study
Ventilator-associated pneumonia (VAP) continues to be an important challenge and dilemma to
critical care physicians. VAP is defined as pneumonia that occurs 48–72 hours or thereafter following
3
endotracheal intubation, characterized by the presence of a new or progressive infiltrate, signs of

(1)
systemic infection, changes in sputum characteristics, and detection of a causative agent. It is the
second most common nosocomial infection in the intensive care unit (ICU) and the most common in
(1)
mechanically ventilated patients. Thus, VAP poses grave implications in endotracheally intubated
adult patients in ICUs worldwide and leads to increased adverse outcomes and healthcare costs. (2)
In the past year, several “VAP bundle” were developed which are collectively and reliably
performs a straightforward set of evidence-based practices, which were proven to improve patient
(2)
outcome and became a standard of care in preventing VAP. The most widespread use VAP bundle
was developed by Institute for Healthcare Improvement (IHI) from 2004 to 2006 consists of five
evidence-based practices, elevation of the head of the bed to 30–45 degrees, daily ‘sedation vacation’
and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, deep venous thrombosis
(DVT) prophylaxis, and oral hygiene with Hexetidine. In 2016, the Intensive Care Society (ICS)
recommended a revised bundle of interventions for the prevention of ventilator-associated pneumonia
which includes the following: elevation of head of bed 30- 45 degrees, daily sedation interruption and
assessment of readiness to extubate, use of subglottic secretion drainage and avoidance of scheduled
ventilator circuit changes. (12)
In this study, we would like to determine the prevalence of Ventilator- associated Pneumonia
(VAP) using VAP prevention bundle checklist by the infection prevention and control committee to ICU
patients at tertiary hospital from September 2019 to October 2019.
B. Review of Related Literature
An estimated 157,000 healthcare-associated pneumonias occurred in acute care hospitals in U.S.

(3)
last 2011; 39% of these pneumonias were VAP. In a local study conducted at Philippine General
Hospital, the prevalence of nosocomial pneumonia in different ICUs is 28% and intubated patients have
a 6 to 21-fold increased risk for VAP (4)
VAP was defined as per Centers for Disease Control (CDC), as a pneumonia that occurred in a
patient who has been intubated and hooked to mechanical ventilator for more than two calendar days
with day of ventilator placement being day one (1), and the ventilator was in place during the
(3)
development of Pneumonia or the day before. Key in the pathogenesis of VAP is colonization of the
upper respiratory tract (oropharynx and trachea) with potentially pathogenic microorganisms, such as
Enterobatericeaea, Staphylococcus aureus, and Pseudomonas aeruginosa. (15)
4
According to 2016 Infectious Diseases Society of America (IDSA) guidelines on management of

adults with VAP, using clinical criteria alone could be used to diagnose VAP and the decision to start
antibiotic therapy. (5) In a retrospective study done in Qatar, clinical diagnosis of pneumonia was defined
as the presence of a new or progressive pulmonary infiltrates or consolidation or cavitation in chest
radiography, associated with at least two of the following criteria: body temperature of > 38∘ C or <
36∘C with no other known cause, leucocytes count < 4000/mm 3 or > 12000/mm3, and purulent tracheal
secretion or a change in characteristics of an existing secretion plus laboratory examination of sputum
via endotracheal (ETA) gram stain and culture sensitivity (GSCS) or bronchial lavage. (6)
Perhaps the most concerning aspect of VAP is the high rate of associated mortality. In 2012,
according to IHI’s Revised VAP Bundle, hospital mortality of ventilated patients who develop VAP is
46%, compared to 32% for ventilated patients who do not develop VAP. A local study done at National
Kidney Transplant Institute (NKTI) revealed that the prevalence rate of VAP is 19 percent and mortality
(13)
rate is 71 percent. In addition to that, VAP prolongs time spent on the ventilator, length of ICU stay,
(7)
and length of hospital stay after discharge from the ICU. VAP rates range from 1.2 to 8.5 per 1,000
ventilator days and the risk for VAP is greatest during the first 5 days of mechanical ventilation (3 %)
with the mean duration between intubation and development of VAP being 3.3 days (1)
As taught in medicine, prevention is better than cure, which is probably more appropriate as
concerned to VAP. Preventing VAP is one of the essential care in critically ill patients receiving
(8)
mechanical ventilation. VAP is a well preventable disease and a proper approach decreases the
hospital stay, cost, morbidity and mortality. (9)
BUNDLES are evidenced-based practices that are grouped together to encourage the consistent
(12)
delivery of these practices. These bundles are common in the ICU and have been developed for the
prevention of VAP. The VAP prevention bundle checklist is a series of evidence- based interventions
that when implemented together will achieve significant outcomes of reducing VAP (10)
The most widespread use VAP bundle was developed by Institute for Healthcare Improvement
(IHI) from 2004 to 2006 consists of five evidence-based practices, elevation of the head of the bed to
30–45 degrees, daily ‘sedation vacation’ and daily assessment of readiness to extubate, peptic ulcer
disease prophylaxis, deep venous thrombosis (DVT) prophylaxis, and oral hygiene with Hexetidine. In
2016, the Intensive Care Society (ICS) recommended a revised bundle of interventions for the
prevention of ventilator-associated pneumonia which includes the following: elevation of head of bed
5
30- 45 degrees, daily sedation interruption and assessment of readiness to extubate, use of subglottic
secretion drainage and avoidance of scheduled ventilator circuit changes. (12)
The difference between IHI and ICS VAP bundle is that it does not recommend the use of oral
chlorhexidine outside of cardiac surgery patients. Furthermore, ICS recommended the consideration of
the risk profile of gastrointestinal (GI) bleeding in each patient with judicious use of GI stress ulcer
prophylaxis (SUP) in patients considered being at risk of GI bleeding. (12)
In a study conducted by Mohamed in 2013 revealed that adherence with the VAP-bundle
approach in ICU decreases the prevalence of VAP, more rapid ventilator weaning, fewer ICU days, and
shorter hospitalizations and it has also a great impact on patient outcomes.
The success of the bundle depends largely on the way it is implemented; therefore, performance
(14)
of these must always be under constant review with surveillance of compliance. In a quasi-
experimental study conducted by Marra et al., high compliance with interventions to prevent VAP was
needed to reflect an impact on infection rates. The potential 58% decrease in VAP rates found when
(16)
moving from no compliance to total compliance. In 2005, Resar et al. included 61-hospital
organizations that participated in a collaborative on improving care in the ICU, found that twenty-one
ICUs reported more than 95% compliance with the elements of bundle and in these ICUs, there was a
59% decrease in VAP rates. (17)
VAP is a common critical condition that is often difficult to diagnose. Accurate data on the
epidemiology of VAP are limited by the lack of standardized criteria for its diagnosis. In 2007, a local
prospective study conducted by J.Tan et.al in Philippine Heart Center, recommended that clinical criteria
(APPENDIX III) could be used as a tool in the diagnosis of ventilator associated pneumonia and
reassess on the third day if antibiotic could be withhold. (18)
Ventilator associated pneumonia is a common and serious ICU complication, that is associated
with a longer ventilation duration, ICU/hospital stay, and increased in-hospital morbidity and mortality
which may lead to higher treatment costs. Effective nursing care and application of VAP bundle should
be rigorously applied in developing countries for VAP prevention.
II. RESEARCH QUESTION
6
A. General Objective: The objective of this study is to determine the prevalence of Ventilator-
associated Pneumonia (VAP) among ICU patients on VAP prevention bundle checklist of care at a
Tertiary Hospital
B. Specific Objectives:
Specifically this study aims to:
1. Determine the proportion of ICU patients on VAP bundles who will develop VAP
2. Determine the association of developing of VAP among patients on VAP prevention bundle
checklist
3. Describe the demographic profile and clinical data of patients on VAP prevention bundle
checklist
4. Describe the clinical profile in line with a.) Diagnosis b.) length of ICU stay c.) days on
mechanical ventilator and d.) outcome among patients on VAP bundles
5. Determine the pathogens isolated in patients on VAP prevention bundle checklist who developed
VAP
C. Significance of the Study
VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after
(7)
discharge from the ICU. Identifying the prevalence of VAP or other health related characteristics
would be important in planning and allocating health resources especially in our institution where there
are only limited resources and where most patients rely on assistance given by the local government.
And perhaps to make VAP prevention bundle checklist as a part of standard of care to critical care unit
for all mechanically ventilated patients in preventing and decreasing the prevalence of VAP.
D. Scope and Delimitations of the Study
In this study, Ventilator Associated Pneumonia (VAP) Prevention Bundle Checklist by the
Infection Prevention and Control Committee will be used as a daily checklist guide which includes
perform hand hygiene before and after contact with the patient or any of the ventilator circuit, use of
endotracheal tube with subglottic drainage of secretions, provide deep vein thrombosis prophylaxis
7
(DVT) if not contraindicated, spontaneous awakening trials if sedated, spontaneous breathing trial,
maintain ventilator circuits and change when soiled or malfunctioning, endotracheal suctioning, perform
good oral hygiene, head of bed elevation between 30-45 degrees, this will serve as the dependent
variable. (12)
The Independent variable in this study are those intubated patients inside the MICU, CCU,
SICU, and Stroke Unit of BGHMC will be and only those who met the inclusion criteria will be
enrolled. The dependent variables are the ventilator associated pneumonia, ICU length of stay, and
duration of mechanical ventilation. A causal relationship cannot be inferred from these data, therefore a
successive surveys might be needed if there is a potential impact of the VAP prevention bundle checklist
in ventilated patients and the prevalence of VAP.
E. Limitations of the study
The limitation of this study is that subglottic-drainage type endotracheal tube is new in our
institution and stocks might be limited.
Other limitations of this study, comparing with young adult with intact host defenses compared
to elderly patients with advanced aged with known co-morbids such as Diabetes Mellitus who are more
susceptible in acquiring infections, patients who received vaccination (Pneumococcal vaccines), history
of antibiotic used for the past three months not related to pulmonary diseases, and patients with
concomitant infections such as bed sores and Urinary Tract Infections that might hematogenously spread
to pulmonary circulation and eventually will develop Pneumonia.
F. Conceptual Framework
EXPOSURE
OUTCOME
Patient Variables (Modifiable and Non-

Modifiable risk factors)  Ventilator associated Pneumonia
 ICU length of stayMECHANICALLY

Age Co-morbidities
VENTILLATED 8
 Duration of mechanical
PATIENT
Gender GCS score ventilation
Confounding variables:
 comparing with young adult with intact host defenses compared to elderly patients with
advanced aged with known co-morbids such as Diabetes Mellitus who are more susceptible
in acquiring infections
 patients who received vaccination (Pneumococcal vaccines)
 history of antibiotic used for the past three months not related to pulmonary diseases
 patients with concomitant infections such as bed sores and Urinary Tract Infections that
might hematogenously spread to pulmonary circulation and eventually will develop
Pneumonia.
G. Operational Definition of terms
1. Ventilator Associated Pneumonia - is defined as pneumonia that occurs 48–72 hours or thereafter
following endotracheal intubation
2. VAP bundle - developed by Institute for Healthcare Improvement (IHI) from 2004 to 2006 consists of
five evidence-based practices, elevation of the head of the bed to 30–45 degrees, daily ‘sedation
9
vacation’ and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, deep venous
thrombosis (DVT) prophylaxis, and oral hygiene with Hexetidine.
3. Co-morbidities - is the presence of one or more additional conditions co-occurring with (that is,
concomitant or concurrent with) a primary condition; in the countable sense of the term,
a comorbidity (plural comorbidities) is each additional condition.
4. Glasgow Coma Scoring - The Glasgow coma scale is used to assess patients in a coma. The initial
score correlates with the severity of brain injury and prognosis. The Glasgow Coma Scale provides a
score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma.
III. METHODOLOGY
A. Research Design: This is an observational cross -sectional study. The study will be conducted on a
specific period and data will be collected daily starting from the day the patient was intubated. Direct
observation of the intubated patient and a bedside VAP bundle quality-rounding checklist will be used
for each ventilated patient with standard care.
10
B. Population of the Study: All intubated patients inside the ICU of Baguio General Hospital and
Medical Center will be and only those who met the inclusion criteria will be enrolled.
Inclusion Criteria:
1. Patients above 19 years old
2. Patients or those immediate family members of the patient who gave their informed consent of
the VAP prevention bundle checklist
3. Patients who are admitted at MICU, CCU, SICU, Stroke unit
4. Patients who are intubated and hooked to mechanical ventilator in less than 48 hours.
Exclusion Criteria:
1. Patients below 19 years of age
2. Patients who are intubated primarily due to Acute Respiratory failure secondary to Pulmonary
Infection like Community and Hospital- acquired Pneumonia, Pulmonary Abscess,
Bronchiectasis in acute infectious exacerbation, and Chronic Obstructive Pulmonary Disease
with concomitant pneumonia and those patients with active Pulmonary Tuberculosis.
3. Patients with unstable pelvic or spinal Cord Injury or/and any conditions that may be
contraindicated with head elevation more than 30 degrees
4. Patients hooked to mechanical ventilator outside ICU
5. Patients who are admitted more than 48 hours from other institution.
C. Sample size:
The study will include all intubated patients admitted in the ICU from September 2019 to
October 2019 who met the inclusion criteria. Sample size to calculate to assess VAP prevalence of 30%
with a precision of 5% and an alpha level of 95%. Initial computed population is 98 for this purpose. A
finite population correction will be applied where in: N=98 (initially computed population) and n=38
(total number of intubated patients for the months of September 2018 and October 2018). Computations
are as follows: Nfpc={N/1+ (98-1)}/n. The Computed total population is 28.
11
D. Materials and Methods
In order to make the staff (physicians, ICU and ward nurses, respiratory therapists) who will act
as research assistant should be aware of the general nature of the study, briefings and orientations will be
provided to key individuals. This information will be disseminated to care providers in the ICU and
regular ward. Additionally, all staff members will be informed of the study processes during the
educational intervention.
The study will be conducted on a specific period and data will be collected daily starting from
the day the patient was intubated. Direct observation of the intubated patient and a bedside VAP
prevention bundle quality rounding checklist will be used to assist the physicians, nurses, and respiratory
therapists in ICUs in complying with the daily protocol for each ventilated patient with standard care,
the details of which are shown in (Appendix II). The selected preventive interventions or the VAP
prevention bundle checklist will be presented to a panel of experts for content validation. Each expert
had at least 3 years of experience in an intensive care unit (ICU), a master’s degree in nursing sciences
(or medicosocial sciences), and a particular interest in ICU-acquired infections. For content validity, the
experts will evaluate the VAP bundles of care by using a scale of 1 to 3, where 1 = not relevant, 2 =
relevant but not necessary, and 3 = absolutely necessary. The remarks of the panel will be collected and
to discuss and to revise the VAP bundles if there is any. After the revision, the experts will examine the
VAP prevention bundle checklist again; they unanimously declare the agreement with its content and
clarity.
Once patient is admitted at the ER who met the inclusion criteria, admitting physician should
inform the receiving resident physician at ICU or ward and will get the consent prior, during, or after
hooking the patient to Mechanical Ventilator.
The patient receiving medical care will be asked for consent at the ICU level once stabilized, so
not to compromise patient’s safety and urgency at the Emergency department level. If the patient is
incapable of providing consent (e.g. is unconscious or in the state of coma), the person’s legal
representative or next of kin assumes the responsibility. In the case where patient awakens or regains
decision making capacity during the study, a re-consent is necessary and will be obtain from the subject.
If a participant declines to continue in the study, the decision must be respected and withdrawal of the
subject from the study. Baseline clinical criteria should already be requested in the ER (initial chest x-
12
ray post intubation, CBC, Temperature, and ETA). After 48 hours from hooking to MV with concurrent
application of VAP bundles of care, a repeat clinical criteria should be requested as previously
mentioned for reassessment then every 72 hours thereafter. VAP prevention bundle checklist will be
initiated all throughout while participant is mechanically ventilated.
Study Procedure: Schematic Diagram/Algorithm of the Study
DATA
Inclusion Criteria: Exclusion Criteria:
ICU PATIENTS 1. Patients below 19 years of age

1. Patients above 19 years old
(date) 2. Patients who are intubated
2. Patients or those immediate primarily due to Acute Respiratory
family members of the failure secondary to Pulmonary
Infection like Community and
patient who gave their Hospital- acquired Pneumonia,
informed consent of the VAP VAP BUNDLES Pulmonary Abscess, Bronchiectasis in
acute infectious exacerbation, and
prevention bundle checklist Chronic Obstructive Pulmonary
Disease with concomitant pneumonia
3. Patients who are admitted at and those patients with active
MICU, CCU, SICU, Stroke Pulmonary Tuberculosis.
unit and regular ward 3. Patients with unstable pelvic or

spinal Cord Injury or/and any
4. Patients who are intubated conditions that may be 13
contraindicated with head elevation
and hooked to mechanical
more than 30 degrees
DAILY
VAP NOT DEVELOPED VAP DEVELOPED
STANDARD OF CARE
Initiation of appropriate
treatment based on
algorithm on VAP
D. Statistical Analysis:
Data are to be analyzed using SPSS. Descriptive statistics include mean and standard deviation
for the continuous variables and percentages for categorical data. The analysis of the difference between
groups of variables was done using the Analysis of Variance (ANOVA). A P-Value of 0.05 or less is
typically considered statistically significant.
E. Ethical Considerations:
The study will be reviewed and ethically approved by the Baguio General Hospital and Medical
Center, Ethics Board. The study will be performed in compliance with the written protocol. It was
initiated only after proper approval of the Ethics Board according to applicable local regulations.
14
Informed consent will be obtained from all eligible patients and watchers who will be included in
the study. Each patient and/or the consenting person will be informed that all data gathered in relation
with the study will be confidential and will be used exclusively for purposes of the study only.
In order to make the staff (physicians, ICU nurses, respiratory therapists) who will act as
research assistant should be aware of the general nature of the study, briefings and orientations will be
provided to key individuals. This information will be disseminated to care providers in the ICU.
Additionally, all staff members will be informed of the study processes during the educational
intervention.
Once VAP developed, a standard treatment procedure should be applied.
F. Time Table
ACTIVITY JAN FEB MARC APRIL MAY JUNE JULY AUGUST SEPT OCT NOV DEC
H
Conceptualizatio
n
TRB Submission
TRB Approval
ERC Submission
ERC Approval
Data Collection
Data Analysis
Formulation of
Discussion
Application for
Research
15
Completion
Evaluation of
Research
Completion
Public
Dissemination
RESEARCHER ______________________________________________
Approved by:
DEPARTMENT HEAD ______________________________________
TRAINING HEAD ___________________________________________
Noted by: __________________________________________________

TRB Chairperson
G. Expense Table
Budget Item Budget Requirement
Supplies 1000.00 php
Printing 500.00 php
Posters 1,000 php
Medications 2,500 php
Operational 10,000 php

Expenses
TOTAL 15, 000 php
16
IV. REFERENCES
(1) Atul Ashok Kalanuria et. al. Ventilator-associated pneumonia in the ICU.
http://ccforum.com/content/18/2/208
(2) Kim-Peng Lim et. al. Efficacy of ventilator-associated pneumonia care bundle for prevention of
ventilator-associated pneumonia in the surgical intensive care units of a medical center. Immunology
and Infection (2015) 48, 316e321. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24183990
(3) CDC. Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU])

Event. January 2017. Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf
(4) Berba,et al.Incidence, risk factors, and outcome of HAP in critically Ill patients at the Philippine
General Hospital.Philippine Journal of Microbiology and Infectious Dis.1999. Available from:
http://philchest.org/v3/wp-content/uploads/2013/05/PJCD-Volume-15-Number-1.pdf
(5) Andre C. Kalil et. al. Management of Adults With Hospital-acquired and Ventilator-associated
Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the
American Thoracic Society. March 2016. Available from:
https://www.thoracic.org/statements/resources/tb-opi/hap-vap-guidelines-2016.pdf
17
(6) Husain Shabbir Ali et. al. Epidemiology and Outcome of Ventilator-Associated Pneumonia
in a Heterogeneous ICU Population in Qatar. March 2016. Available from:
https://www.hindawi.com/journals/bmri/2016/8231787/
(7) How-to Guide: Prevent Ventilator-Associated Pneumonia . Cambridge, MA: Institute for Healthcare
Improvement; 2012. (Available at www.ihi.org)
(8) Charity Wip and Lena Napolitano. Bundles to prevent ventilator-associated pneumonia: How
valuable are they? 0951-7375 ! 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
(9) Hina Gadani, Arun Vyas, and Akhya Kumar Kar. A study of ventilator-associated pneumonia:
Incidence, outcome, risk factors and measures to be taken for prevention Indian J Anaesth. 2010 Nov-
Dec; 54(6): 535–54010.4103/0019-5049.72643. Available at http://www.ijaweb.org/article.asp?
issn=0019-5049;year=2010;volume=54;issue=6;spage=535;epage=540;aulast=Gadani
(10) Guidelines for the prevention of ventilator associated pneumonia, 1st edition. April 2013
(11) Dr Arlene F Tolentino- Delos Reyes et. al. Evidence-Based Practice: Use Of The Ventilator Bundle
To Prevent Ventilator-Associated Pneumonia. American Journal Of Critical Care, January 2007,
Volume 16, No. 1. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17192523
(12) Thomas P Hellyer et. al., The Intensive Care Society recommended bundle of interventions for the
prevention of ventilator-associated pneumonia. 2016, Vol. 17(3) 238–243. Available at
https://journals.sagepub.com/doi/full/10.1177/1751143716644461
(13) Lyn Bonifacio and Renato Dantes. Ventilator-Associated Pneumonia in Critically Ill Patients
Admitted at National Kidney and Transplant Institute. Philippines Journal of Internal Medicine volume
26 No.6 2008. Available from: https://www.researchgate.net/journal/0119-
9641_Philippine_Journal_of_Internal_Medicine
(14) Gene Ambrocio et. al. Quality of Implementation of the Ventilator Associated Pneumonia Bundles
of Care in the University of the Philippines - Philippine General Hospital Central Intensive Care Unit
18
and Medical Intensive Care Unit: A Two Month Prospective Survey. October 2014. Available at:
https://journal.chestnet.org/article/S0012-3692(16)49754-0/fulltext
(15) Marc J. M. Bontem. Ventilator-Associated Pneumonia: Preventing the Inevitable. Healthcare

Epidemiology CID 2011:52 (1 January). Available at: https://www.ncbi.nlm.nih.gov/pubmed/21148529
(16) Marra AR et. al, Successful prevention of ventilator-associated pneumonia in an intensive care
setting. October 2009. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19559503
(17) Resar R et al., Using a Bundle Approach to Improve Ventilator Care Process and Reduce
Ventilator-Associated Pneumonia. May 2005. Available at
https://www.ncbi.nlm.nih.gov/pubmed/15960014
19
V. APPENDICES
APPENDIX I
Consent Form
(ENGLISH FORMAT)
Study Title: The Prevalence of Ventilator- associated Pneumonia (VAP) among ICU patients on
VAP BUNDLES of care at a Tertiary Hospital
Principal Investigator: Dr. Geranyl P. Laguardia

*********************************************************************
Patient __________________________________
Date:
You are invited to participate in this study entitled The Prevalence of Ventilator- associated
Pneumonia (VAP) among ICU patients on VAP BUNDLES of care at a Tertiary Hospital
This research is being conducted in in-patients at INTENSIVE CARE UNIT of Baguio General
Hospital and Medical Center.
This study is conducted to find out the prevalence of ventilator- associated Pneumonia (VAP)
among ICU patients on VAP BUNDLES
The study coordinator will ask for your consent to participate in the study. Once you have agreed
to participate, a doctor or an ICU staff will apply VAP bundles daily to the patient in a span of time.
Participation in this study will benefit our patient since we prevent development of VAP which
can cause prolong time spent on the ventilator, length of ICU stay hence will lengthen hospital stay
and needed expenses.
Participation in this study is purely voluntary. You and your patient’s decision to join or not join
should not affect the care you will continue to receive at the ICU. There will be no form of money
All information gathered will be kept confidential by the researchers. The result of this paper
may be presented in conferences and publications. The authors have no conflict of interest.
20
Please do not hesitate to ask any questions at this point. Should you have any other comments or
questions, please call or send a message to: Dr. Geranyl P. Laguardia 09163640759. I am also
available at the department of MEDICINE – 6 th floor Flavier building to gladly answer your
questions.
You can also contact the BGHMC Ethics review thru Dr. Celestrell May O. Macalingay at this
number 24109 local 217. We appreciate your positive decision to participate in this study.
CERTIFICATE OF CONSENT
I have read the foregoing information, or it has been read to me. I have had the opportunity to ask
questions about it and any questions that I have asked have been answered to my satisfaction. I
understand what was explained to me and will voluntarily consent to participate as a participant in this
___________________________________ ______________________________
Name and Signature of Patient Date Signed
_________________________________ ______________________________
Name and Signature of Witness Name and Signature of Witness
Informed Consent Obtained By:

_________________________________ ______________________________
Name and Signature Date Signed
21
Consent Form
(Filipino format)
VAP BUNDLES of care at a Tertiary Hospital
Pangunahing may akda: Dr. Geranyl P. Laguardia

*********************************************************************
Pasyente: __________________________________
Petsa:_______________
Ang iyong partisipasyon ay inaanyayahan para sumali sa pananaliksik na ito na pinamagatang

The Prevalence of Ventilator- associated Pneumonia (VAP) among ICU patients on VAP
BUNDLES of care at a Tertiary Hospital
Ang pananaliksisk na ito ay isisasagawa sa INTENSIVE CARE UNIT ng Baguio General
Hospital and Medical Center.
Ang pananaliksisk na ito ay isinagawa upang matukoy ang insidente ng ventilator- associated
Pneumonia (VAP) sa pasyenteng nasa ICU na ginagamitan ng VAP BUNDLES.
Ang coordinator ng pananaliksik ay kukuha ng pahintulot sa inyo na kayo na lalahok sa
aktibidad na ito. Kung kayo ay pumayag na sumali, ang mga ICU staff ay mag-aaplay ng VAP
bundles araw-araw sa pasyente.
Ang benepisyong maibibigay nito sa iyong pagsali ay mga sumusunod: malalaman natin ang
mga ibat-ibang aspeto ng pagkakaron ng VAP, upang maiwasan ito, mabawasan ang araw ng
pananatili ng mga pasyente dito sa hospital, at upang mabawasan ang mga gastusin.
Ang pagsali sa pananaliksik na ito ay boluntaryo. Ang pagsali o hindi sa pag-aaral na ito ay hindi
makakaapekto sa paggaling o panggagamot sa pasyente. Wala pong sisingilin o ibibigay na pera
kapag kayo ay sumali dito. Ang siyang pangunahing imbestigador ang gagastos sa abot ng kanyang
makakaya.
Ang lahat ng impormasyon na makakalap ay kumpidensyal na itatago ng mananaliksik. Ang mga

makakalap na impormasyon ay maaaring iprisinta sa mga pagpupulong o publikasyon. Ang may
akda ay walang salungatan ng interes.
22
Huwag po kayong mahihiyang matanong. Kung mayroon mang karagdagang katanungan, maaari
ninyo akong itext o tawagan Dr. Geranyl P. Laguardia sa numerong 09163640759. Ako din po ay
mahahanap sa departamento ng Medisina, Flavier bldg., 6th floor at ako ay lugod na sasagot sa
inyong mga karagdagang katanungan. Maari ninyo rin pong ikontak ang BGHMC Ethics review sa
pamamagitan ni Dr. Celestrell May O. Macalingay sa numerong 24109 lokal 217. Kami po ay
nagagalak sa positibong desisyon ng inyong pagsali sa pananaliksik na ito.
Nabasa ko o ipinaliwanag sa akin ang lahat ng impormasyon n adapt kong malaman. Ako ay binigyan ng
oportunidad na magtanong at ako ay kombinsido sa kanilang mga sagot. Naiintindihan ko at klaro lahat ng
kanilang pagpapaliwanag sa akin at ako ay boluntaryong sasali sa pananaliksik na ito.
___________________________________ ______________________________
Pangalan at lagda ng pasyente Petsa
_________________________________ ______________________________
Pangalan at lagda ng saksi Pangalan at lagda ng saksi
Ang kumuha ng pahintulot:

_________________________________ ______________________________
Pangalan at lagda Petsa
23
Consent Form
(Ilocano format)
VAP BUNDLES of care at a Tertiaty Hospital
Principal Investigator: Dr. Geranyl P. Laguardia

*********************************************************************
Patient __________________________________
Date:
Maawis kayo nga makinayon ditoy research agnagan ti The Prevalence of Ventilator-
associated Pneumonia (VAP) among ICU patients on VAP BUNDLES of care at a Tertiary
Hospital
Daytoy nga research ket maaramid idtoy INTENSIVE CARE UNIT iti Baguio General Hospital
and Medical Center.
Daytoy nga research ket naaramid tapno Makita nu kasatnu kaado ti agka pneumonia nu
nakatubo idtoy pasyente idtoy ICU.
Agdawat kami iti consent nu ipalubos yo nga ag participar kayo ditoy nga research. Nu ipalubos
yo, ada iti staff nga agaramid ti VAP budles inaldaw iti pasyente.
Ti pagsayaatan na daytoy nga research ket tapno haan umatidug ti panaka tubo, ti panag biag
ditoy ICU, ken umado ti gasto.
Ti panag participar ditoy ay haan nga pinilit. Diyay desisyon mu ken diyay desisyon ti pasyente
nga agparticipar o haan nga ag participar ket haan nga maakpektaran ti panag-agas ditoy ICU. Awan
ti kwarta nga maited nu maki participar kayu ditoy. Diyay makin bagi ti research ti mangbayad ti
am-amin anggana kaya na.
Amamin nga inpormasyon ket agtalinaed nga seckreto kadagiti nag sukimat. Ti resulta laeng ti
research nga daytoy ti mai kalat iti conference ken surat. Dagiti mangidadaulo ket agtutunos da.
Haan kayo nga mabain nga agdamag tata. Nu ada ti damag, ag itawag kayo lang kini: Dr. Geranyl
Laguardia daytoy nga numero 09163640759. Ada ak met lang idyay department of MEDICINE – 6th
floor Flavier bldg tapno makasaritaan yu nu ada ti damag. Mabalin yu met lang nga tawagen ti
BGHMC Ethics review, Dr. Celestrell May O. Macalingay idtoy nga numero 24109 lokal 217. Dakel
nga pasalamat mi nga maki participar kayo ditoy nga research.
24
Nabasak ken inexplikar da kanyak amamin nga impormasyon. Inikkan dak ti oras nga agdamag
ket naawatak ken kayat ko ti bales da nga sao. Naawatak nu anya ti inexplikar da kenyak, agboluntaryo
ak nga agparticipar ditoy nga research.
___________________________________ ______________________________
Nagan ken pirma ti pasyente Petsa
_________________________________ ______________________________
Nagan ken pirma ti witness Nagan ken pirma ti witness
Nangala iti consent:

_________________________________ ______________________________
Nagan ken pirma Petsa
APPENDIX II
VENTILATOR ASSOCIATED PNEUMONIA (VAP) PREVENTION BUNDLE CHECKLIST
I. DEMOGRAPHIC PROFILE
Name of Patient: Hospital No.
Date of Intubation: Place of Intubation:
Date of Transfer at the ICU:
Name of the HCW who intubated the Signature:

patient:
II. CARE MAINTENANCE

Instruction: Please indicate ☑ if the care is done and ☒ if not.
DAY DAY DAY DAY DAY DAY DAY DAY DAY DAY DAY DAY DAY DAY DAY
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
PHYSICIAN:
Perform hand hygiene before and

after contact with the patient or
any of the ventilator circuit.
Use endotracheal tube with
subglottic drainage of secretions.
Provide peptic ulcer disease

prophylaxis (PUD)
Provide deep vein thrombosis
prophylaxis (DVT)
Spontaneous Awakening Trials
(If sedated)
25
Spontaneous Breathing Trial
RESPIRATORY THERAPIST

Maintain Ventilator circuits
>Change when soiled or
malfunctioning
Endotracheal suctioning
NURSE:

Perform good oral hygiene
Head of bed elevation between 30-

45 degrees
Remarks:
Accomplished by:
Name & Signature of NOD
To be filled out by the healthcare worker (nurse/physician) who removed the ET:
Name and Signature of ROD who

requested ET Removal :
Name and Signature of the Nurse
who removed the ET:
Date and Time of ET Removal:
26
A.
C.
A. Traditional Endotracheal Tube (ET)
C. A subglottic catheter-type of ET has a dorsal B.
B. In a traditional
opening above theETcuff
tube, secretionstopool
connected a suction
lumen. above the cuff and below the glottis area which
causes aspiration, which is the primarily the
cause of VAP
APPENDIX III
Criteria for Weaning
27
Readiness to Wean
• Improvement of respiratory inotropic support

failure • Clear Chest x-ray
• Absence of major organ • Afebrile, normal WBC, no other indications of
system failure infection present
• Appropriate level of • Requiring <30% FiO2 to achieve target
oxygenation saturation set
• Adequate ventilatory status • <20 cmH2O to achieve TV of 7-15 mL/kg of
• Intact airway protective preinjury
mechanism (needed for BW
extubation) • PEEP <5 cmH2O
• Hemodynamic stability without vasopressor • Unsupported VC > 150 m
or
APPENDIX IV
CLINICAL CRITERIA IN DIAGNOSIS OF VAP

1. New infiltrate on chest radiograph (or radiographically confirmed worsening of pre-existing
28
infiltrate) and
2. At least two (2) of the following:
o Leukocytosis (>12,000/mm3)
o Leukopenia (<4,000/mm3)
o Fever (38 C)
o Hypothermia (<35 C)
o Purulent Tracheal secretions
APPENDIX V
The total number of cases of ventilator-associated pneumonia for a particular time period,
reported as a rate per 1,000 ventilator days. For example, if in September there were 12 cases of VAP,
the number of cases would be 12 for that month. We want to be able to understand that number as a
proportion of the total number of days that patients were on ventilators. Thus, if 25 patients were
ventilated during the month and each, for purposes of example, was on mechanical ventilation for 3
days, the number of ventilator days would be 25 x 3 = 75.
The Ventilator-Associated Pneumonia Rate per 1,000 ventilator days then would be 12/75 x
1000 = 160.
B. Ventilator Bundle Compliance
On a given day, select all the ventilated patients and assess them for compliance with the
Ventilator Bundle. If even one bundle component is missing, the case is not in compliance with the
bundle unless contraindicated to a patient. For example, if there are 7 ventilated patients, and 6 patients
have all 5 bundle elements completed, then 6/7 (86%) is the compliance with the Ventilator Bundle. If
all 7 ventilated patients had all 5 elements completed, compliance would be 100%. If all 7 were missing
even a single element, compliance would be 0%.
Compliance to the bundles was computed as follows: number of vented patients receiving all
components of bundle/total number of patients on ventilator for the day of the prevalence sample x100
Level of Reliability (compliance with all bundle Reduction in VAP Rate:
elements)
Unchanged STATUS 22 %
<95% COMPLIANCE 40%
>95% COMPLIANCE 61%
29
APPENDIX VI
DUMMY TABLE
Table1: Determine the proportion of Intubated ICU patients hooked to mechanical ventilator on
VAP bundles
N % P value
VAP
Total
Table 2: Determine the association of developing of VAP among patients on Non-VAP and on
VAP BUNDLES
N % P value
VAP
Non-VAP
Total
Table 3: Sociodemographic Data in relation of patients under VAP bundles who developed VAP
N %
AGE
19-30
31-40
41-50
51-60
61-70
>70
GENDER
Male
Female
MARITAL STATUS
Single
Married
Separated
Divorced
Widowed
PROVINCE
Abra
Apayao
Baguio City
Benguet
30
Ifugao
Kalinga
La Union
Mt. Province
Nueva Ecija
Nueva Vizcaya
Pangasinan
Others
Table 4: Clinical Profile of patients under VAP bundles who developed VAP
N %
Diagnosis
Cerebrovascular disease,
Infarct
Cerebrovascular disease,
bleed
Congestive Heart failure
COPD
Trauma/ Vehicular accident
CNS infection
Neuromuscular Disease
Malignancy
Days on Mechanical Ventilator (Length of mechanical ventilation depends on criteria of weaning)
Less than 10 days
More than 10 days, but less
than 20 days
More than 20 days
Length of ICU stay
Less than 7 days
7- 14 days
13- 21 days
21- 30 days
More than 30 days
OUTCOME
Improved/ Discharge
Death
Home against medical advise
Table 5: Determine the pathogens isolated in patients on VAP Bundles who developed VAP
Gram positive
Gram negative
31
Fungal
None
32

Prevalence of Ventilator-Associated Pneumonia Among ICU Patients on VAP Bundles

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Prevalence of Ventilator-Associated Pneumonia Among ICU Patients on VAP Bundles

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The Prevalence Of Ventilator- Associated Pneumonia (VAP) Among Intensive Care Unit (ICU)

Patients On VAP Bundles Of Care at a Tertiary Hospital

THE PREVALENCE OF VENTILATOR- ASSOCIATED PNEUMONIA

In Partial Fulfillment of the Training Program

Medical Officer III

Precious Mae A. Gomez, MD

Thea Pamela Cajulao, MD, FPCP, FPSMID, FPSMS

Dr. Jovy Nigos, MD, FPCP, FPCCP, FPSMS

Domingo Solimen, MD, FPCP, FPSG, FPSDE

Department of Internal Medicine

Marie Ellaine N. Velasquez, MD, FPCP, FPSG, FPSDE

Department of Internal Medicine

Angelita Go, MD, FPCP, FPCC

Department of Internal Medicine

THE PREVALENCE OF VENTILATOR- ASSOCIATED PNEUMONIA (VAP) AMONG ICU

Name: Geranyl P. Laguardia, MD

Introduction: Ventilator-associated pneumonia (VAP) continues to be an important challenge and

Keywords: ventilator- associated pneumonia, intensive care unit, bundles, intubated

endotracheal intubation, characterized by the presence of a new or progressive infiltrate, signs of

An estimated 157,000 healthcare-associated pneumonias occurred in acute care hospitals in U.S.

According to 2016 Infectious Diseases Society of America (IDSA) guidelines on management of

II. RESEARCH QUESTION

C. Significance of the Study

D. Scope and Delimitations of the Study

E. Limitations of the study

Patient Variables (Modifiable and Non-

 ICU length of stayMECHANICALLY

 patients who received vaccination (Pneumococcal vaccines)

G. Operational Definition of terms

1. Patients above 19 years old

3. Patients who are admitted at MICU, CCU, SICU, Stroke unit

1. Patients below 19 years of age

4. Patients hooked to mechanical ventilator outside ICU

D. Materials and Methods

Study Procedure: Schematic Diagram/Algorithm of the Study

Inclusion Criteria: Exclusion Criteria:

ICU PATIENTS 1. Patients below 19 years of age

unit and regular ward 3. Patients with unstable pelvic or

VAP NOT DEVELOPED VAP DEVELOPED

Once VAP developed, a standard treatment procedure should be applied.

DEPARTMENT HEAD ______________________________________

TRAINING HEAD ___________________________________________

Noted by: __________________________________________________

Posters 1,000 php

Medications 2,500 php

Operational 10,000 php

(3) CDC. Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU])

(15) Marc J. M. Bontem. Ventilator-Associated Pneumonia: Preventing the Inevitable. Healthcare

Principal Investigator: Dr. Geranyl P. Laguardia

Name and Signature of Witness Name and Signature of Witness

Informed Consent Obtained By:

Pangunahing may akda: Dr. Geranyl P. Laguardia

Ang iyong partisipasyon ay inaanyayahan para sumali sa pananaliksik na ito na pinamagatang

Ang lahat ng impormasyon na makakalap ay kumpidensyal na itatago ng mananaliksik. Ang mga

Ang kumuha ng pahintulot:

Principal Investigator: Dr. Geranyl P. Laguardia

Nangala iti consent:

Name of the HCW who intubated the Signature:

II. CARE MAINTENANCE

Perform hand hygiene before and

Provide peptic ulcer disease

Spontaneous Breathing Trial

Perform hand hygiene before and