Efficacy of VAP Care Bundle in Adult ICU Patients: A Literature Review

Running head: LITERATURE REVIEW
Literature review
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1LITERATURE REVIEW
Introduction:
Patients in the intensive care units (ICU) are at risk of mortality not only due to critical
illness, but also because of secondary complication caused due to occurrence of ventilator
associated pneumonia (VAP) in ICU. VAP is a type of pneumonia that is diagnosed after 48
hours of endotracheal intubation and patients receiving VAP has high likelihood of developing
mechanical ventilation. It is a common cause of hospital morbidity and mortality despite
development of advanced diagnostic techniques (Othman and Abdelazim 2017). The common
symptoms of VAP include signs related to pulmonary infection such as fever, purulent secretions
and bacteriological evidence of pulmonary infection. The main burden for ICU staffs is that
diagnosis of VAP prolongs length of stay in the ICU and has huge implications on medical care
and cost (Ranjan et al. 2014). Hence, in response to this issue, finding the best intervention to
prevent and control VAP events in ICU setting is critical.
In response to the high incidence of VAP in ICU, the Institute for Healthcare
Improvement (IHI) recommended the use of bundle of care such as oral care with chlorhexidine,
head of bed elevation, stress ulcer prophylaxis, daily sedation assessment and breathing trials to
reduce the incidence of VAP (Kalanuria, Zai and Mirski 2014). Currently in my practice setting,
individual interventions like head of bed elevation and stress ulcer prophylaxis is being used to
manage VAP. However, the VAP care bundle is a new component and it is not sure whether it
can provide desired outcomes or not. Hence, a literature review has been undertaken to evaluate
the feasibility and effectiveness of VAP care bundles in preventing risk of VAP in adult ICU
patients.

2LITERATURE REVIEW
Methods:
The search for relevant research literatures related to the research topic was done using
the databases like CINAHL, PubMed and Medline. The search terms that were used to retrieve
articles from the above mentioned databases included Ventilator associated pneumonia (VAP)/
VAP care bundle/ventilator care bundles, VAP prevention bundle; efficacy/effectiveness/impact;
intensive care units (ICU)/ICU patients/surgical ICU. After entering the search terms, the
suitability of the articles for the research topic was evaluated first by reading abstract and title of
the research articles. Additional articles related to VAP bundle in ICU were also obtained after
reviewing reference list of many articles. Apart from search terms, the search process was
guided by certain inclusion and exclusion criteria. The main inclusion criteria were that all
research articles must be full-text articles published within 2009 and it must have VAP care
bundle as the main intervention for the research. Articles that reported about the use of VAP
bundle in care settings other than ICU were excluded. The age of research participants was also a
primary inclusion criteria as the main purpose of the literature review was to evaluate outcomes
in ICU patients. Thematic approach has been taken to summarize outcome of various research
studies and group them under common themes.
Literature review (Establishing the efficacy of VAP care bundle in ICU patients):
With the IHI ‘s recommendation of using VAP prevention bundle rather than single
intervention to prevent VAP in ICU setting, there is a need to conduct rigorous analysis of
research literatures to assess the efficacy of the new intervention and its suitability for
implementation in the clinical setting.

3LITERATURE REVIEW
Based on search criteria, several studies were found to report about the impact of VAP
care bundles on preventing VAP in ICU setting. Lim et al. (2015) used a modified six item care
bundle compared to IHI’s five item bundle to analyse ventilator utilization and VAP incidence in
five surgical ICUs in a hospital. The study revealed the reduction in ventilator utilization post the
VAP bundle intervention and remarkable reduction in VAP cases. The VAP bundle design can
be regarded as the main factor that influenced patient’s outcome. The strength of the study was
that it included detailed interventions like hand hygiene before and after intubation procedure,
adequate cuff pressure, oral cavity secretion, defined intubation indication and device rinsed with
water to prevent the risk of infection. Inclusion of these additional interventions like hand
hygiene is considered to be effective an interventional study revealed the effectiveness of hand
hygiene in reducing VAP incidence (Saramma et al. 2011). However, one factor that limits
applicability of the findings by Lim et al. (2015) in all ICU setting is that the modified bundle
had several components and all of these interventions may not work for patients with multiple
co-morbidities before intubation. This point is also important because research evidence shows
the efficacy of simplified VAP bundles too. For example, Su et al. (2017) revealed decrease in
VAP rate by including a simplified three component bundle and the advantage of these bundles
were that it had minimum compliance related issues in implementing it in ICU setting. Despite
the challenges in using multiple components in VAP bundles, the research literatures confirms
that strategies like multi-disciplinary team work and continuous education and bundle promotion
can promote use of VAP bundle for the safety of adult ICU patients. Educational programs on
infection control and other bundle preventive measures can enhance outcome of ICU patients
(Meadows 2018).