Critical Path Network

Abstract & Commentary: Staff education cuts vent pneumonia rate in half

With a cost savings of more than $400,000

Source: Zack JE, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 2002; 11:2,407-2,412.

Abstract: A focused-education program was associated with a dramatic reduction in the incidence of ventilator-associated pneumonia.

The purpose of this pre- and post-intervention observation study was to evaluate the effect of an educational initiative on ventilator-associated pneumonia (VAP) rate. The educational program was directed toward respiratory therapists and critical care nurses. The patient population consisted of those developing VAP during a two-year period. A multidisciplinary task force developed policies and an educational initiative to reduce VAP rates. The educational program consisted of a self-study module, lectures, and pre- and post-testing. The focus of the self-study module was coverage of general topics related to VAP and specific emphasis on risk-reduction strategies. Successful completion of the program was required of all respiratory therapists and made available to critical care nurses on an elective basis.

Posters related to VAP were posted throughout the ICU. The pre-intervention period occurred from Oct. 1, 1999, to Sept. 30, 2000, and the post-intervention period occurred from Oct. 1, 2000, until Sept. 30, 2001. The diagnostic criteria for VAP were a modification of those established by the American College of Chest Physicians.

A total of 114 respiratory therapists completed the educational program. The average correct exam score increased from 80% to 91% (P < 0.001) after completing the educational module, and the average score six months after implementing the intervention was 85%. The educational module also was completed by 146 critical care nurses, and their scores increased from 81% to 91% (P < 0.001).

During the 12-month period before the intervention, the VAP rate was 12.6 per 1,000 ventilator days. Following the intervention, the VAP rate was 5.7 per 1,000 ventilator days — a decrease of 57.6% (P < 0.001). The cost saving associated with this intervention was calculated to be at least $424,000. Zack and colleagues concluded that an educational program focused on respiratory therapists and critical care nurses resulted in significant reductions in VAP rate.

Commentary by Dean R. Hess, PhD, RRT, assistant professor of anesthesia at Harvard Medical School and assistant director of respiratory care at Massachusetts General Hospital.

Nosocomial infections are an important cause of morbidity and mortality. Pneumonia is the most common nosocomial infection, and 86% of nosocomial pneumonia cases are associated with mechanical ventilation. Respiratory therapists and intensive care nurses are involved intimately in the care of mechanically ventilated patients and are, thus, uniquely positioned to affect VAP rates. Significant opportunities exist to improve VAP prevention practices.1-3 These include decreasing the frequency of ventilator circuit changes, increasing the use of noninvasive ventilation, and elevation of the head of the bed.

Despite considerable evidence that has emerged in recent years, approaches to the prevention of VAP remain archaic in many intensive care units.

Although there is considerable evidence of the benefit of the semirecumbent position for the prevention of VAP, I frequently observe mechanically ventilated patients who are not positioned accordingly.

Despite considerable evidence4 that changing ventilator circuits and in-line suction catheters at regular intervals does not decrease VAP rate (and a meta-analysis suggests that this might actually increase VAP rate), the practice of changing circuits at regular intervals continues in many hospitals. I know of instances where infection control departments blocked the plans of respiratory care staff to implement the practice of as-needed ventilator circuit changes because adopting such a practice "does not make sense!"

Unfortunately, what makes sense in the minds of some (dare I call this "expert" opinion?) still trumps high-level evidence in many hospitals. Despite evidence that it decreases intubation rate, increases survival, and decreases VAP rate, noninvasive ventilation in appropriately selected patients remains underused in many hospitals.

This study by Zack, et al. shows that an educational intervention directed primarily at respiratory therapists and critical care nurses can significantly reduce ventilator-associated pneumonia rates and associated costs.

However, the researchers have not reported whether this intervention affects other important outcomes such as antibiotic use, length of hospital stay, or mortality. In spite of these limitations, an education program such as the one described in this study should be considered — particularly for hospitals with a higher than expected ventilator-associated pneumonia rate.


1. Heyland DK, et al. Prevention of ventilator-associated pneumonia: Current practice in Canadian intensive care units. J Crit Care 2002; 17:161-167.

2. Cook D, et al. Influence of airway management on ventilator-associated pneumonia: Evidence from randomized trials. JAMA 1998; 279:781-787.

3. Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999; 340:627-634.

4. Hess DR. Response to Demers RR. Is the gastrointestinal tract the sole source of organisms in ventilator-associated pneumonia? Respir Care 2002; 47:696-699.