Background: Studies have shown the cost of VAP to equal or exceed $40,000 per patient

1. Efforts from The Institute for Healthcare Improvement to improve VAP outcomes have led to the initiation of "Ventilator Bundles"
2. In addition, ventilator circuits should be monitored regularly so that accumulated condensate in the tubing can be removed
3. It is a CDC category level (II)recommendation for the use of noninvasive positive pressure ventilation(NPPV) when medically indicated
4. In 2004 a multicenter/mutlidiciplinary team was put together in an effort to reduce VAP rates by initiating a bundle program, increase the use of NPPV, and make equipment changes that would lead to positive patient outcomes.

Methods: Our bundle protocol included: HOB >30 degrees; daily sedation vacation; assessment of readiness to extubate; PUD Prophlaxis; DVT Prophylaxis; and Q4 oral care. In addition, heated-wire circuits were used after 3 vent days or when a HME was contraindicated. In theory HME's can reduce incidence of VAP by reducing condensate within a vent circuit(5). However, HME's require frequent "breaking" of the circuit, which may contribute to infection and active humidification without a heated-wire circuit will accumulate condensation and require frequent draining. Additional NPPV devices and a variety of masks were obtained in an effort to increase usage. IC personnel and RT managers measured compliance by using daily check sheets for each ventilated patient.

Results: In Fiscal year 2007, our two facilities annually admitted 19,740 patients, respectively. Comparing a period from Jan-April 2007 & 2008, average NPPV/day had increased from 3.85 to 7.2 NPPV/day (P-value 0.00084), while Invasive Vents/day had decreased from 6.62 to 4.9 Invasive vents/day (P-value 0.035) Pt. admissions during that same period increased from 5829 in 2007 to 5896 in 2008. Using NNIS criteria to determine VAP, over a 3 year period has passed since the VAP program was implemented and this hospital has maintained a "0" VAP rate through April 2008.

Conclusion: Implementation of a comprehensive program that includes a VAP bundle, use of NPPV, and good ventilator circuit management may reduce VAP rates. The inclusion of both nursing and respiratory care teams into these initiatives builds a productive collaboration between the two disciplines. Regularly scheduled education and daily checks increases staff compliance and successful outcomes.