Document Type : Original Article


1 Department of Clinical Pharmacy, Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

2 Iranian Evidence Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran

3 The Liver and Gastrointestinal Research Center, Tabriz University of Medical sciences, Tabriz, Iran

4 Student Research center committee, Tabriz University of Medical Sciences, Tabriz, Iran

5 Department of Nursing, Tabriz University of Medical Sciences, Tabriz, Iran

6 Department of Anesthesiology and critical care, Tabriz University of Medical Sciences, Tabriz, Iran


Objective: Ventilator‑associated pneumonia (VAP) described as a secondary and preventable 
consequence in mechanically ventilated patients, emerges 48 h or more after patients 
intubation. Considering the high morbidity and mortality rate of VAP and the fact that VAP 
is preventable, it seemed necessary to evaluate care bundle compliance rate and effect of 
education on its improvement.
Methods: This observational study was conducted on 10 Intensive Care Units (ICUs) of 
four university affiliated hospitals in three steps. In the first step, VAP care bundle compliance 
including head of bed (HOB) elevation, endotracheal cuff pressure (ETCP), mouthwash time, 
utilizing close suction systems, subglottic secretion drainage, type of suction package, and 
hand wash before suctioning was evaluated. In the second and third steps, ICU staffs were 
trained and its effect on VAP care bundle compliance was investigated. Finally, an inquiry 
from nurses was conducted to evaluate the obtained results.
Findings: A total of 552 checklists consisting of 294 observations in the pre‑education 
group and 258 observations in the posteducation group were filled. Mean VAP care 
bundle compliance in pre‑education and posteducation stages was 36.5% and 41.2%, 
respectively (P > 0.05). Except for patients’ mouth washing, there were no improvement 
in HOB elevation (>30°), hand washing and ETCP after education. Based on the results of 
questionnaire received from nurses at the end of study, more than 90% of nurses believed 
that lack of rigid monitoring of VAP care bundle is a main reason of low adherence for VAP 
care bundle compliance.
Conclusion: The adherence to VAP care bundle was inappropriate. Education seems to be 
ineffective on improving VAP care bundle compliance. Frequent recall of the necessity of 
the VAP care bundle and the continuous supervision of ICU staffs is highly recommended.


  1. Klompas M. Does this patient have ventilator‑associated 
    pneumonia? JAMA 2007;297:1583‑93.
    2. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, CDC, 
    et al. Guidelines for preventing health‑care - Associated 
    pneumonia, 2003: Recommendations of CDC and the 
    Healthcare Infection Control Practices Advisory Committee. 
    MMWR Recomm Rep 2004;53:1‑36.
    3. Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, 
    Heyland D, et al. Comprehensive evidence‑based clinical 
    practice guidelines for ventilator‑associated pneumonia: 
    Prevention. J Crit Care 2008;23:126‑37.
    4. Evans D. The use of position during critical illness: Current 
    practice and review of the literature. Aust Crit Care 
    5. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, 
    Ferrer M. Supine body position as a risk factor for nosocomial 
    pneumonia in mechanically ventilated patients: A randomised 
    trial. Lancet 1999;354:1851‑8.
    6. McMullin JP, Cook DJ, Meade MO, Weaver BR, Letelier LM, 
    Kahmamoui K, et al. Clinical estimation of trunk position 
    among mechanically ventilated patients. Intensive Care Med 
    7. Dodek P, Keenan S, Cook D, Heyland D, Jacka M, H and L, 
    et al. Evidence‑based clinical practice guideline for the 
    prevention of ventilator‑associated pneumonia. Ann Intern 
    Med 2004;141:305‑13.
    8. TorresA, Carlet J. Ventilator‑associated pneumonia. European 
    Task Force on ventilator‑associated pneumonia. Eur Respir J 
    9. Hess DR, Kallstrom TJ, Mottram CD, Myers TR, Sorenson HM, 
    Vines DL, et al. Care of the ventilator circuit and its relation to 
    ventilator‑associated pneumonia. Respir Care 2003;48:869‑79.
    10. Ramirez P, Ferrer M, Torres A. Prevention measures for 
    ventilator‑associated pneumonia: A new focus on the 
    endotracheal tube. Curr Opin Infect Dis 2007;20:190‑7.
    11. Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J. 
    Continuous aspiration of subglottic secretions in the prevention 
    of ventilator‑associated pneumonia in the postoperative 
    period of major heart surgery. Chest 2008;134:938‑46.
    12. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, 
    Saint S. Subglottic secretion drainage for preventing 
    ventilator‑associated pneumonia: A meta‑analysis. Am J Med 
  2. 13. BachA, Boehrer H, Schmidt H, Geiss HK. Nosocomial sinusitis 
    in ventilated patients. Nasotracheal versus orotracheal 
    intubation. Anaesthesia 1992;47:335‑9.
    14. Holzapfel L, Chastang C, Demingeon G, Bohe J, Piralla B, 
    Coupry A. A randomized study assessing the systematic 
    search for maxillary sinusitis in nasotracheally mechanically 
    ventilated patients. Influence of nosocomial maxillary sinusitis 
    on the occurrence of ventilator‑associated pneumonia. Am J 
    Respir Crit Care Med 1999;159:695‑701.
    15. Grap MJ, Munro CL. Ventilator‑associated pneumonia: 
    Clinical significance and implications for nursing. Heart Lung 
    16. Sole ML, Byers JF, Ludy JE, Zhang Y, Banta CM, Brummel K. 
    A multisite survey of suctioning techniques and airway 
    management practices. Am J Crit Care 2003;12:220‑30