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Care bundles for the prevention of IAP

This article covers ways to improve clinical and non-clinical practices for intubation-associated pneumonia (IAP) prevention

Antonella Agodi PhD

Martina Barchitta PhD

Annalisa Quattrocchi PhD

Department “GF Ingrassia”, 

University of Catania, Catania, Italy

GISIO-SItI, Italian Study Group of Hospital Hygiene – Italian Society of Hygiene, Preventive Medicine and Public Health, Italy

Andrea Maugeri MSc

Department “GF Ingrassia”, 

University of Catania, Catania, Italy

Pneumonia and other lower respiratory tract infections are the most frequent types of healthcare associated infections (HAIs) reported by the European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of HAIs and antimicrobial use (25.7% of all reported HAIs).1 Pneumonia occurs  especially in intensive care units (ICUs) where a significant proportion of patients are exposed to mechanical ventilation. 

The ECDC annual epidemiological report describes that in Europe pneumonia occurred in 7% of patients hospitalised for at least two days in the ICU and 91% of these infections are associated with the presence of an invasive device.2 In Italy, pneumonia occurred in 9.8% of patients admitted to the ICU and 96% of these infections are associated with intubation (intubation-associated pneumonia, IAP).3 The ECDC has estimated that about 20–30% of HAIs are preventable by appropriate control programmes (…). A recent European study has estimated that 52% of ventilator-associated pneumonia (VAP) are preventable.4

As recommended, the prevention and control of IAP or VAP needs the implementation of clinical interventions, best practice guidelines, together with non-clinical interventions to guarantee the compliance with these guidelines.5 Scientific evidence suggests that clinical interventions should be combined into a “care bundle”, which the Institute for Healthcare Improvement (IHI) has defined as a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually (….).

However, there is no universally accepted bundle since both the elements and the number of bundle elements can be variable and some prevention strategies are still controversial.5 Care bundles have been used in a number of clinical settings. The IHI ventilator bundle has four care steps: raising the head of the patient’s bed (30–40 degrees); giving the patient medication to prevent stomach ulcers; preventing blood clots and seeing if patients can breathe on their own without a ventilator ( Thus the key components of the IHI ventilator bundle are: (i) elevation of the head of the bed, (ii) daily sedation vacations and assessment of readiness to extubate, (iii) peptic ulcer disease prophylaxis, (iv) deep venous thrombosis prophylaxis and (v) daily oral care with chlorhexidine (….). 

Furthermore, a pan-European committee has developed a “European care bundle”.   Potential measures were identified as most appropriate for inclusion in VAP care bundle recommendations. Five clinical interventions were recognised: (i) not implementing ventilator circuit changes unless clinically indicated; (ii) the incorporation of sedation control protocols into patient care; (iii) the use of strict hand hygiene using alcohol-based antiseptic before manipulating the airways; (iv) oral care with chlorhexidine 0.12% every eight hours; and (v) intra-cuff pressure control to reduce leakage of oropharyngeal secretions to the lower airway tract.6

Prevention strategies, including prevention by bundle, have been widely adopted, but results are inconclusive. Several studies showed that compliance to the bundle is associated with a reduction of VAP rates.7,8

The first study conducted to validate the European care bundle for VAP prevention was a multicentre cohort study in five Spanish ICUs.8 The main aims were to assess the impact of implementing the care bundle on VAP rates and duration of mechanical ventilation and the compliance levels of each individual measure on the risk of VAP. Results confirmed that the implementation of the bundle is associated with a reduction in the incidence of such infections and of the ICU length of stay. However, it was difficult to maintain high levels of compliance with bundle guidelines and continuous education of healthcare workers, multidisciplinary efforts combining doctors and other healthcare workers are required.8

Compliance to the bundle is essential but further clinical interventions need to be added to the existing bundles. In addition to guidelines for VAP prevention, the “Zero-VAP Project”, an initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses, includes an integral patient safety programme and continuous online validation of the application of the bundle.9 Furthermore, it has been reported that the implementation of a six-item VAP care bundle, modified from that of the IHI, in surgical ICUs decreases the incidence of VAP and multidisciplinary teamwork, education and a comprehensive checklist to improve healthcare workers compliance have been demonstrated to be key factors to success.10 Interestingly, implementing bundle strategies also shows a significant decrease in the use of the ventilator.10

Few studies report that the implementation of a bundle of preventive measures itself does not guarantee improvements in decreasing VAP rate. A survey has estimated that the implementation of the standard ventilator bundle requires a median of 115 minutes (IQR: 74–182) for patient every day and that other patient care tasks were sometimes delayed because time was allocated to ventilator bundle activities.11

The objective of the care bundle is to improve patient outcomes by facilitating and promoting changes in healthcare and encouraging compliance with the guidelines.8

In Europe, the IMPLEMENT project (IMPLEmenting strategic bundles for infection prevention & manageMENT) was designed to spread and test knowledge on how to implement strategic bundles for HAI prevention and management in European ICUs, in order to investigate the effectiveness of strategies to implement bundled evidence-based preventive interventions on a large scale ( Recently, in the framework of the IMPLEMENT project, a survey was conducted using a web-based methodology and a questionnaire available in six languages (English, German, Italian, Spanish, Portuguese and French), with the aim of documenting the practices of prevention of VAP in ICUs (clinical practices and measurements) and the attitudes toward the implementation of a measurement system.5

The survey included a total of 1730 replies received from 77 European and non European countries. Although almost two thirds of respondents reported the existence of written VAP prevention guidelines in their ICU, ICU doctors in Europe and elsewhere reported a low compliance with VAP prevention practices and priorities for improvement were identified. Besides, the promotion of the implementation of VAP prevention guidelines together with the promotion of the measurement of compliance to these guidelines and measurement of outcomes are needed.5 In a recent ecological study based on responses to the online questionnaire completed by critical care physicians in the framework of the IMPLEMENT Project, two basic measures have been identified as positively associated with compliance with six well established VAP prevention measures: the existence of written standards for management of ICU mechanically ventilated patients and the presence of VAP surveillance systems that should be adopted on a policy level.12

In Italy, in 2005 the Italian nosocomial infections surveillance in ICUs network, Sorveglianza Prospettica delle Infezioni Nosocomiali nelle Unità di Terapia Intensiva (SPIN-UTI), was established by the Italian Study Group of Hospital Hygiene (GISIO) of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI).3  In the framework of the fourth edition (from 2012 to 2013) of this project, an online survey was conducted in order to document reported IAP prevention practices in ICUs and attitudes towards the implementation of a measurement system.13 Particularly, two questionnaires were designed. One questionnaire was filled out by physicians working in ICUs in order to collect data on characteristics of physicians and ICUs, on clinical and measurement practices for IAP prevention and on attitudes towards the implementation of a measurement system. The second questionnaire was filled out for each intubated patient in order to determine compliance with prevention practices during ICU stay. 

A total of 26 Italian ICUs participated in the survey and a total of 768 intubated patients were surveyed. The results showed that the components of the European bundle and the two components not included in the European bundle but considered important for the control of the IAP (head of bed elevation and selective digestive decontamination) are implemented, although to a different level, in the ICU participants. In general, a high level of compliance with bundle practices was found, except for the daily sedation vacation and weaning protocol (43.6%) and for the selective digestive decontamination (12%). Overall, the compliance to all five components of the European bundle has been reported in 21.1% of patients; this percentage is comparable with that reported at the European level (20%).8

The study has identified actions that would facilitate the implementation of a measurement system of infections in ICUs, such as the presence of dedicated software and information technology resources and staff training. Furthermore, although significant differences were reported in the comparison between results of the SPIN-UTI project and those of the IMPLEMENT project, large potential for improvement in clinical and non-clinical practices aimed at preventing IAP in ICUs were identified.5,13

The management of intubation procedures and of ventilated patients was identified as a potential target for infection control interventions and as such there is the need for implementation of strategic bundles in order to decrease the growing risk of HAI in the ICUs.3 Several controversies exists on the efficacy and cost effectiveness of the bundle in the control of the HAIs and IAP, which depend on the context of the institution, on the individual interventions of the bundle and on the compliance to these components. Furthermore, efforts should be concentrated in continuous education of healthcare workers since training and communication are crucial elements to maintain high levels of compliance.8,14


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  11. Alvarez Maldonado P et al. Changes observed in three quality indicators after the implementation of improvement strategies in the respiratory intensive care unit. Med Intensiva 2014. 
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  14. Gastmeier P. No, it is not cost effective and evidence based. 23rd European Congress of Clinical Microbiology and Infectious Diseases. Berlin 27-30 April 2013.