# VAP/VAE Resident Rounds Handout

**Applies to:** adult intubated trauma/SICU patients.
**Rule:** every intubated patient, every day, with exception documentation.

## Core Bundle Requirements (Daily)

| Element | Protocol Target | Required Charting |
|---|---|---|
| HOB elevation | 30-45 degrees | Angle or specific contraindication + alternative |
| Sedation strategy | Target RASS -1 to 0 when clinically feasible; prefer non-benzodiazepines | RASS target, agent(s), why deeper sedation if needed |
| SAT | Daily attempt unless contraindicated | Pass/fail/contraindicated + reason |
| SBT | Daily attempt unless contraindicated | SBT method (PS 5-8/PEEP 5 or T-piece), pass/fail/contraindicated + reason |
| Mobility | Progressive pathway: passive ROM -> active ROM -> dangle -> stand -> ambulate | Highest level achieved + barriers + next goal |
| Oral care | Toothbrushing q12h + oropharyngeal suction q4h and PRN | Both elements documented |
| Enteral nutrition | Start within 24-48h when feasible; gastric first, post-pyloric if aspiration risk/intolerance | Route + initiation status + reason for delay |
| Vent circuit | No scheduled changes; change only if soiled/malfunctioning | Circuit check + condensate drained away from patient |
| Liberation planning | Daily extubation-readiness statement | Ready/not ready + limiting factor |

## If a Bundle Element Cannot Be Done

- HOB contraindicated (e.g., spine/facial trauma): use reverse Trendelenburg and document rationale.
- SAT/SBT contraindicated: document specific reason (e.g., active seizures, elevated ICP), then reassess daily.
- Mobility limited: perform passive ROM minimum and document barriers.

## Additional Approaches (Case-Selected)

- If expected ventilation >48-72h: consider subglottic secretion drainage ETT.
- Consider early tracheostomy (<=7 days) for likely prolonged ventilation after multidisciplinary review.
- Post-extubation high-risk patients: consider HFNC or NIV to reduce reintubation risk.
- High aspiration risk: consider post-pyloric feeds and prokinetics.

## Practices Not Recommended for Routine VAP Prevention

- Routine oral chlorhexidine.
- Scheduled ventilator circuit changes.
- Probiotics for VAP prevention.
- Silver-coated ETT for routine use.
- Stress-ulcer prophylaxis solely for VAP prevention (only if GI bleed risk exists).

## Trauma/SICU Special Situations

### Spine or unstable facial trauma
- Reverse Trendelenburg if HOB target not possible.
- Continue oral care/suctioning regardless of position restrictions.

### Severe TBI
- Keep sedation as light as ICP/neuro status allows.
- Continue SAT/SBT when feasible per neuro constraints.
- Consider early tracheostomy based on trajectory.

### ARDS, open abdomen, or high vent settings
- Continue oral care bundle.
- Continue SAT/SBT when feasible.
- Emphasize lung-protective ventilation and fluid strategy.

## Daily Rounds Checklist

- [ ] HOB 30-45 degrees or documented exception
- [ ] RASS target documented; sedation strategy reviewed
- [ ] SAT outcome documented
- [ ] SBT outcome documented + extubation readiness plan
- [ ] Oral care documented (q12h brush, q4h suction)
- [ ] Mobility level/barriers documented
- [ ] Enteral nutrition route/status documented
- [ ] Vent circuit/condensate check completed
- [ ] DVT prophylaxis status documented
- [ ] Stress-ulcer prophylaxis indication reviewed

## Hard Stops

- Do not skip SAT/SBT without explicit contraindication.
- Do not document bundle completion without matching bedside execution.
- Do not use chlorhexidine rinse as routine VAP prevention.
- Do not perform scheduled circuit changes.

## Unit Targets (PIPS)

### Outcome tracking
- VAE (VAC/IVAC/PVAP) rate per 1,000 ventilator-days.
- Ventilator days.
- Reintubation within 48-72h.

### Process reliability (target >=90%)
- HOB compliance (or valid exception).
- Daily SAT compliance.
- Daily SBT compliance.
- Oral care compliance.
- Mobility documentation compliance.
- Enteral nutrition initiation within 24-48h.

## Source Basis

Condensed from active internal VAP bundle + VAP/VAE prevention guideline (effective November 2025).