Creating and Implementing a Bundle to Reduce VAP in the NICU

Central DuPage Hospital
Winfield, Illinois, USA



Rita Brennan, RNC, MS, Outcomes Manger, Women and Children’s Services
Jeffrey Loughead, MD, Medical Director, Neonatal Intensive Care Unit
Patricia DeJulio, BS, RRT, NPS, Clinical Practice Specialist, Respiratory Care
Susan Leston, RN, BSN, Interim Manager, Neonatal Intensive Care Unit
Jean Sosin, RN, Clinical Educator, Neonatal Intensive Care Unit



Decrease the ventilator-associated pneumonia (VAP) in the neonatal intensive care unit (NICU) to less than the 50th percentile (median) of the National Nosocomial Infections Surveillance System (NNIS).





Focus Number One: Endotracheal Tube Care (ETT)

  • A modified umbilical cord clamp method was used for ETT stabilization.
  • Emergent extubations and reintubations were discouraged with revised evaluation procedures for patients in distress to minimize the number of intubations/reintubations.
  • A continuously closed, in-line suctioning system was instituted, in which the suction tubing and patient care apparatus were never disconnected or broken.
Focus Number Two: Oral Care
  • The RN initiates the patient assessment by evaluating the ETT and completing oral care.
  • Bulb syringes were discontinued on ventilated patients for oral or nasal care.
  • All oral care products were changed to single use products.
  • Sterile water and gauze were used to wipe lips and gums; oral care was given every 3 to 4 hours.
  • Good handwashing and glove use prior to ETT, oral or suction care was emphasized.
  • Protocol for the mouth to be suctioned prior to the nose in all instances was created.
Focus Number Three: Respiratory Equipment Care
  • Ventilators circuits and oxygen therapy equipment were changed on an as needed basis for mechanical malfunctioning or when visibly soiled, rather than routinely, to reduce frequency of breaks in the system.
  • Oxygen therapy equipment was cleaned, rinsed, and allowed to completely air dry.
  • CPAP systems were allowed to remain on stand-by for no longer than 12 hours with flow and heater remaining on.
  • Resuscitation bags no longer were laid in the bed and were hung outside of the isolette or bed.
  • Resuscitation bags were replaced once per week.
Focus Number Four: Minimally Invasive Ventilatory Support
  • Enhanced use of minimally invasive ventilatory support techniques such as bubble continuous positive airway pressure (bCPAP) was used preferentially as appropriate.






Summary of Results / Lessons Learned / Next Steps 

Implementation of the neonatal ventilator bundle resulted in an immediate reduction in VAP. Prior to implementing the bundle there were 4/9 (44.4 percent) patients with VAP in 2004, only 1/4 (25 percent) patient develop VAP in 2004 after implementation. In 2005, 2/8 (25 percent) patients developed VAP with an annual rate of 5.43 infections/100 ventilator days.


Although the NICU has yet to achieve the VAP rate goal of less than 3.5 infections/100 ventilator days, the unit is making significant progress. Considering the fewer number of intubated patients and population changes unique to the unit, the NICU is now charting time between infections with the current goal of 225 days between infections. Further, the NICU has reduced the incidence of accidental extubations to zero. CDH has already agreed to be a mentor hospital for IHI's 100,000 Lives Campaign.
Lessons Learned

  • Allow your research and scope of project to include all facets that may affect outcome. The care issues leading to neonatal VAP are multifactorial with no single or prevailing cause.
  • Reducing accidental extubations to zero incidences is possible; however, this too is not solely responsible for eliminating VAP.
  • Implementing mandatory and enforced, enhanced, and programmed oral care in neonates is an important component in reducing accidental extubations and VAP.
  • Creating a uniform procedure for securing endotracheal tubes and uniform care of respiratory equipment are likely important components in reducing neonatal VAP.
  • Supporting respiratory function without the use of an endotracheal tube is critical in reducing hospital-acquired pneumonia.
  • Gain a strong commitment from the staff in order to enhance compliance and hold individual caretakers accountable. Enforce mandatory education as necessary to implement new processes as this is key to success at the individual patient level.
  • Celebrate success and praise the employees that consistently support your initiatives! Print and post graphs that show success create posters to keep staff informed, reword staff for favorable outcomes.

Contact Information
Rita Brennan
Outcomes Manager, Women and Children’s Services
Central DuPage Hospital


[Storyboard presentation at IHI's 2nd Annual International Summit on Redesigning Hospital Care, June 2006]

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