To the Editor—Ventilator-associated pneumonia (VAP) and central-line–associated bloodstream infection (CLABSI) are two common healthcare-associated infections (HAIs) that can result in increased mortality, morbidity, and length of hospital stay among critically ill patients.Reference Safdat, Dezfulian, Collard and Sain^1–Reference Higera, Rangel-Frausto and Rosenthal⁵ Recently, several prevention interventions have been divided into the two major care bundles by the Institute for Healthcare Improvement (IHI): the “ventilator bundle” and the “central line bundle.” Many studies have proven that the ventilator bundle and the central line bundle can significantly reduce the incidence of VAP and CLABSI, respectively. However, studies investigating the usefulness of concomitant implementations of these two bundles in the same unit are scarce. At our institution, we sequentially introduced the ventilator bundle and the central line bundle in an intensive care unit (ICU). We evaluated the clinical impact of sequential care bundles on HAI rates, including VAP and CLABSI, in a medical ICU.

This study was performed at a regional teaching hospital in a medical ICU that has 7 adult ICU beds and 1 intensivist. In 2011, we introduced the ventilator bundle, which includes (1) maintenance a semi-recumbent position (ie, 30°–45° elevation of the head to the bed), (2) daily interruption of sedation, (3) daily spontaneous breathing trials, (4) performance of oral care with an antiseptic solution (ie, 0.2% chlorhexidine gluconate), and (5) maintenance of endotracheal tube cuff pressure >20 cm H2O. In 2013, we further introduced the central line bundle, including (1) hand hygiene, (2) maximal sterile barriers, (3) chlorhexidine gluconate for skin preparation, and (4) avoidance of femoral vein as an access site. Our maintenance bundle includes (1) hand hygiene, (2) proper dressing change, (3) aseptic technique for accessing and changing needleless connector, and (4) daily catheter review. In addition, educational programs were arranged at the same time for the staff members in the ICU, including attending physicians, respiratory therapists, and nurse practitioners. Patient days, device days, and rates of VAPs, CLABSI, and catheter-associated urinary tract infections (CAUTI) were collected monthly by the infection-control practitioner from January 2011 to September 2013.

During this study period, 14 episodes of CLABSI and 8 episodes of VAP were recorded. The rate of CLABSI was 2.73 per 1,000 catheter days, and the rate of VAP was 1.72 per 1,000 ventilator days. In addition, 17 episodes of CAUTI were recorded, with a rate of CAUTI 2.5 per 1,000 catheter days. The data trends of VAP, CLABSI, and CAUTI are shown in Table 1. The rates of all 3 HAIs gradually declined over time, and the rates of CLABSI and VAP were zero during the last 9 months of the study period.

TABLE 1 Rates of VAP, CLABSI, and CAUTI in an Intensive Care Unit

NOTE. VAP, ventilator-associated pneumonia; CLABSI, central line-associated bloodstream infection; CAUTI, catheter-associated urinary tract infection.

^a Only from January to September, 2013.

From this midterm survey, we report several findings. First, sequential implementation of the ventilator bundle and the central line bundle reduced the development of CLABSI and VAP. Second, although the implementation of each care bundle may have increased the workload of all ICU members, we introduced these bundles gradually so that team members could effectively implement them without feeling overloaded. Finally, we have demonstrated the positive impact of these care bundles on HAI rates.

The rate of CLABSI gradually decreased from 2010 (after introduction of the ventilator bundle) to 2012 (before introduction of the central line bundle). During these 3 years, we implemented only 1 infection control measure, the ventilator bundle, and no other infection control policy was changed. The declining rate of CLABSI may have been due to the change of culture and clinical practice after the implementation of the ventilator bundle and its associated education. Thereafter, all of the team members better understood the clinical significance of the infection control policy and focused on preventing HAIs. In addition, the rate of CAUTI gradually declined over time after the introduction of the ventilator bundle and the central line bundle prior to the introduction of the CAUTI bundle. These findings and those of a previous studyReference Sulis, Walkey, Abadi, Campbell Reardon and Joyce-Brady⁶ indicate that the impact of the ventilator bundle and the central line bundle may not be limited to the rates of VAP and CLABSI; they may also have a positive impact on other types of HAIs.

Finally, we have also demonstrated that zero rates of VAP or CLABSI can be achieved by effective infection control measures. The implementation of these care bundles can eradicate HAIs. However, large-scale studies are needed to further confirm the long-term effects of these measures.

In conclusion, the sequential introduction of the ventilator bundle and the central line bundle can prevent the development of VAP and CLABSI. Each care bundle may have a positive impact on preventing other HAIs.