Ventilator education program reduces VAP

Train respiratory care practitioners, ICU nurses

A multimodal education program to teach nursing and respiratory therapy staffs about improved techniques has led to a significant reduction in the incidence of ventilator-associated pneumonia (VAP).

The program was implemented at Barnes-Jewish Hospital, a 1,000-bed university-affiliated primary and tertiary care teaching hospital in St. Louis.

In the 12 months before the intervention, 191 episodes of VAP occurred in 15,094 ventilator days. That rate declined to 81 episodes following implementation, or a decrease of 57.6%. In addition, the estimated cost savings for the 12 months following the intervention were between $425,606 and $4.05 million.1

"VAP has such a high mortality rate, and the ICU [intensive care unit] is where a majority of people really get sick, so it is there that you have a greater opportunity to get infections," notes Jeanne E. Zack, BSN, of the Washington University School of Medicine, Department of Hospital Epidemiology and Infection Control and co-author of the study.

"Because we monitor certain indicators within our hospital, including VAP caused among people who were intubated, we saw our rate increasing. It was also higher than our national benchmark — the national nosocomial data from the Centers for Disease Control and Prevention [CDC], which they have collected since the 1980s," she explains

This benchmarking was important, she notes, for giving her department an accurate idea of where the hospital stood.

A quality issue

For Zack, VAP was a clear quality issue from day one. "The thing that really interests me in terms of health care quality is the whole concept of Six Sigma," she explains. "My dad did quality work at Ralston Purina, and I learned about it from him."

Ultimately, she became entrusted with Six Sigma at Barnes-Jewish Hospital. "When I took it on, I told one of our epidemiologists we could get the infection rate to zero," she notes. She recognizes that it’s more realistic to take a mechanical device and attempt to achieve an error rate of zero, "but you can strive for it with humans," she insists. "However, one should try to achieve it in a quality way."

Zack says she truly believes that one infection is a negative outcome. "That one person could be my best friend, my brother, my father, or my sister," she says. "That makes it more personal — that person in the bed with a tube in their throat is someone’s brother, sister, or friend."

Setting up the program

The intervention took place between Oct. 1, 1999, and Sept. 30, 2001, but before it could begin, the groundwork had to be laid. A multidisciplinary task force including two physicians and members of the Barnes-Jewish hospital infection control team was established in February 1999. Its charge: develop a hospital policy. The policy was drawn from existing literature and then compared to the latest CDC recommendations on VAP.

The task force included respiratory therapy, the critical care pulmonary director, infection control specialists, and nursing. "We ended up having task forces at the consortium level," Zack notes, explaining that BJC HealthCare, of which Barnes-Jewish is one facility, is a multisystem organization with 13 different hospitals under one umbrella. "All policies and procedures come out of there," she says. "They come down from the vice president as a prime directive."

The VAP education program, drawn from the new policies, was to target the ICU nursing staff, in addition to the respiratory care practitioners. "We targeted them because they are the primary caregivers to those on ventilators — as such, they have an impact on VAP," Zack explains. "They perform inline suctioning, they may drain the ventilator circuit of condensate, and so on." The program was mandatory for the respiratory care practitioners, and optional — but strongly encouraged — for the nurses.

The program included several different components, including a 10-page self-study module on risk factors and practice modifications; training at staff meetings; and formal lectures. Fact sheets and posters reinforcing the information were posted throughout the ICU and the department of respiratory care services.

The inservices were provided by one of the infection control staff. For the respiratory care practitioners, two one-hour lectures were taught on the pathogenesis and prevention of VAP.

"The key was to educate people," says Zack. "When I was a staff nurse in the ICU, we knew how take care of patients, but no one talked to us about VAP."

One of the key methods for measuring the effectiveness of the education program was a 20-question exam testing staff’s VAP prevention knowledge. The same test was given following the intervention, and test scores were compared. Anyone scoring less than 80% on the post-intervention test (in the case of the respiratory care practitioners, it was given six months after completing the self-study module) was required to repeat the self-study module. The average pre-intervention test score was 79.6; the average post-intervention score was 90.9.

Excitement a key to success

Generating excitement among staff was one of the keys to the program’s success, Zack notes. "You can have this great initiative, but it won’t be that effective if you don’t go out and get people excited. We posted fact sheets in bathrooms and lunchrooms to increase awareness; we didn’t just give the test and leave. We also hammered the message home with posters on VAP."

Then, when results started coming in, the excitement level was further reinforced. "After staff did the pre-test, the education, and the post-test, as rates started to drop — the first changes being in the surgical ICU — I mentioned it to my colleagues. They got so excited; they complained when we first gave them the test, but this was a good way of letting them know they had an impact."

The team continued to show personnel their dropping rates at QI meetings. "We told them they did a great job and talked about positive things," she notes. "To improve quality, lower lengths of stay, reduce mortality, and save the hospital [more than] $5000,000 is pretty exciting."

It was no less important, she notes, to have a leader who told the respiratory therapy staff that the program was mandatory. "Plus, the other exciting thing is that respiratory therapists receive CEU credits in the state of Missouri for programs like this," Zack adds.


1. Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 2002; 30:2,407-2,412.

Need More Information?

For more information, contact:

  • The Association for Professionals in Infection Control and Epidemiology (APIC), Washington, DC. Telephone: (888) 235-2074. Copies of the Barnes-Jewish program are available on CD-ROM from APIC ($75 for members and $95 for nonmembers). Call and ask for BJC Healthcare Presents: Educational Modules for the Prevention of Nosocomial Infections.
  • Jeanne E. Zack, BSN, Washington University School of Medicine, Department of Hospital Epidemiology and Infection Control, St. Louis. E-mail: