title: Ventilator-associated pneumonia bundled strategies: an evidence-based practice.
abstract: BACKGROUND
  Ventilator-associated pneumonia (VAP) is an ongoing challenge for critical care nurses as they use current evidence-based strategies to decrease its incidence and prevalence. Mechanical intubation negates effective cough reflexes and impedes mucociliary clearance of secretions, causing leakage and microaspiration of virulent bacteria into the lungs. VAP is responsible for 90% of nosocomial infections and occurs within 48 hours of intubation. VAP is a major health care burden in terms of mortality, escalating health care costs, increased length of ventilator days and length of hospital stay.
  
  
  OBJECTIVE
  (1) To provide a review of the literature on VAP bundle (VAPB) practices. (2) To describe the etiology and risk factors and define bundled practices. (3) To discuss an explanatory framework that promotes knowledge translation of VAPBs into clinical settings. (4) To identify areas for further research and implications for practice to decrease the incidence of VAP.
  
  
  METHODS
  Electronic searches in MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Collaboration were conducted using keywords specific to VAP. The inclusion criteria were: (1) Studies were original quantitative research published in an English peer-reviewed journal for the years 1997 to 2007. (2) Each study included an examination of bundled practices. (3) The clinical outcomes of critically ill adults with VAP were assessed. The studies were identified from the bibliographies of key references. Six studies were accepted based on the inclusion criteria. Each contributing author conducted the review and analysis of selected studies independently. The findings were compared and contrasted by all authors to establish consensus.
  
  
  RESULTS
  Evidence shows that VAPB practices decrease VAP rates. Bundled practices result in decreased ventilator days, intensive care unit length of stay, and mortality rates. A strong association was seen, with an increased clinician compliance with VAPB protocols with decreased VAP rates.
  
  
  CONCLUSIONS
  Methodologically robust randomized controlled trials are required to examine the efficacy of VAPBs and determine causality between VAPBs and clinical outcomes. Organizational commitment is needed to adopt a conceptual framework that promotes effective knowledge translation, incorporating factors of evidence, context, and facilitation of VAPBs into clinical settings. Instituting nurse-led intervention champion leaders to facilitate reliable and consistent implementation of VAPBs into practice is warranted.
authors.affiliation: CIHR/CHSF FUTURE Program for Cardiovascular Nurse Scientists, University of Toronto, Ontario, Canada. s.okeefe.mccarthy@utoronto.ca
authors.forename: Sheila
authors.initials: S
authors.lastname: O'Keefe-McCarthy
authors.forename: Cecilia
authors.initials: C
authors.lastname: Santiago
authors.forename: Gemma
authors.initials: G
authors.lastname: Lau
mesh_terms: D003422:Critical Care / Q000639:trends*; D055318:Evidence-Based Nursing / Q000379:methods / Q000458:organization & administration / Q000639:trends*; D006801:Humans; D015337:Multicenter Studies as Topic; D053717:Pneumonia, Ventilator-Associated / Q000209:etiology / Q000451:nursing / Q000517:prevention & control; D012307:Risk Factors