Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit

doi:10.1016/j.ajic.2008.05.010

American Journal of Infection Control

Volume 37, Issue 2, March 2009, Pages 172-175

https://doi.org/10.1016/j.ajic.2008.05.010 Get rights and content

The ventilator bundle (VB) includes a group of clinical maneuvers (head-of-bed elevation, “sedation vacation,” deep vein thrombosis prophylaxis, and peptic ulcer disease prophylaxis) to improve outcomes in patients undergoing mechanical ventilation. We modified the standard VB in our medical intensive care unit to include a group of respiratory therapist–driven protocols and, postimplementation, observed a statistically significant (P = .0006) reduction in ventilator-associated pneumonia (VAP), from a median of 14.1 cases/10³ ventilator-days (interquartile range [IQR] = 12.1 to 20.6) to 0 cases/10³ ventilator-days (IQR = 0 to 1.1).

Section snippets

Setting

This study was conducted in the 18-bed adult MICU at St Joseph's Regional Medical Center, a 750-bed teaching hospital in northern New Jersey, which admitted a median of 15,277 adult patients (range, 15,133 to 15,538) during the years of this study. Between January 1, 2003 and December 31, 2007, the MICU admitted a median of 1056 patients/year (interquartile range [IQR] = 1001 to 1133), of whom roughly 35% underwent mechanical ventilation. All patients were age ≥ 18 years, with no upper age

Results

We used 2 approaches to examine the change in the rate of VAP before and after intervention. First, we compared the overall rate during the historical period with the rate for the postintervention observation period. These data, shown in Figure 1, demonstrate a statistically significant (P = .006) decrease from a median value of 14.1 cases/10³ ventilator-days (IQR = 12.1 to 20.6; 95% confidence interval [CI] = 10.9 to 20.3) to a median of 0 cases/10³ ventilator-days (IQR = 0 to 1.1; 95% CI = 0

Discussion

Spurred in part by the Institute for Healthcare Improvement's “100,000 Lives Campaign,” the medical community undertook the development of practice guidelines to improve outcomes related to a core group of preventable clinical conditions. Among these, VAP has attracted considerable attention, with the publication of at least 15 randomized controlled trials and 7 integrative systematic reviews and meta-analyses directed toward the goal of preventing this complication.9, 10

Fox¹¹ has proposed a

References (12)

P. Youngquist et al.
Implementing a ventilator bundle in a community hospital
Joint Comm J Qual Patient Saf
(2007)
R. Resar et al.
Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia
Joint Comm J Qual Patient Saf
(2005)
P. Gastmeier et al.
Prevention of ventilator-associated pneumonia: analysis of studies published since 2004
J Hosp Infect
(2007)
C.D. Burger et al.
Ventilator bundle” approach to prevention of ventilator-associated pneumonia
Mayo Clin Proc
(2006)
M. Rumbak
VAP: strategies for prevention and treatment
J Respir Dis
(2000)
D.J. Cook et al.
Risk factors for ICU-acquired pneumonia
JAMA
(1998)

There are more references available in the full text version of this article.

Cited by (62)

The ongoing challenge of ventilator-associated pneumonia: epidemiology, prevention, and risk factors for mortality in a secondary care hospital intensive care unit
2023, Infection Prevention in Practice
Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality among intensive care unit infections. Despite various preventive measures, the incidence of VAP remains high.
This study aimed to explore the epidemiology and risk factors for VAP associated mortality in a secondary care hospital, comparing outcomes before and after implementing a VAP prevention bundle.
This retrospective study was conducted from July 1, 2021, to June 30, 2023, at a secondary care hospital. Patients over 18 years old who underwent mechanical ventilation for more than 48 hours were included. The study compared the incidence, microbiological etiology, and outcomes of VAP before and after implementing the VAP prevention bundle and analyzed risk factors for mortality from VAP.
A total of 83 patients diagnosed with VAP were included. Despite concerted efforts to implement the VAP prevention bundle, there was no significant decrease in the VAP rate per 1000 ventilator days, early-onset VAP, secondary bloodstream infections, acute respiratory distress syndrome, and 30-day mortality. The microbiological etiology of VAP remained consistent between the two periods. A decrease in lymphocyte count and albumin level were identified as independent risk factors for 30-day mortality.
Concerted efforts to implement a VAP prevention bundle did not significantly reduce the incidence or improve outcomes of VAP in this secondary care hospital setting. The microbiological etiology remained unchanged. Monitoring lymphocyte count and albumin level may help identify patients at high mortality risk. Further research is needed to develop more effective VAP prevention and management strategies.
The Impact of Initiation of an Intensivist-Led Patient Management Protocol on Outcomes After Cardiac Surgery
2021, Journal of Cardiothoracic and Vascular Anesthesia
Prolonged intensive care unit stay after cardiac surgery is associated with high mortality. The aim of this study was to evaluate the impact of the introduction of a quality improvement program under the supervision of an intensivist on the long-term mortality of high-risk patients with prolonged intensive care unit (ICU) stay after cardiac surgery.
Retrospective study of prospectively collected data.
Cardiac surgery ICU.
A total of 7,549 patients after cardiac surgery.
Patients were divided into two periods: 2004 to 2007, before introducing the quality improvement program (3,315 patients), and 2009 to 2014, after introduction of the program (4,234 patients). In the period from 2004 to 2007, patients were divided into group I (ICU stay ≥ seven days), which included 242 patients, and group III (ICU stay < seven days), which included 3,073 patients. Also, in the period from 2009 to 2014 patients, were divided into group II (ICU stay ≥seven days), which included 326 patients, and group IV (ICU stay < seven days), which included 3,908 patients. Patient outcomes were compared. Follow-up was five years for each group.
The European System for Cardiac Operative Risk Evaluation did not differ significantly among the groups. When comparing between group I and group II, 30-day mortality decreased significantly from 24.8% to 16.6%, six-month mortality from 27.3% to 19.3%, one-year mortality from 42.1% to 32.2%, 3-year mortality from 54.5% to 43.3%, and 5-year mortality from 61.2% to 51.8%. In comparing between group III and group IV, the authors did not observe a statistically significant decrease of mortality.
Intensivist-led patient management protocol is associated with decreased long-term mortality in high-risk patients with a prolonged ICU stay.
Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization
2017, Brazilian Journal of Infectious Diseases
The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p < 005). On average, VAP occurred 17.33 ± 21.09 days in the case group and 10.43 ± 7.83 days in the control group (p = 0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.
Impact and feasibility of an emergency department–based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department
2017, American Journal of Infection Control
Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates.
This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day.
PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ² = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11.
VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.
Prevention of ventilator-associated pneumonia: Use of the care bundle approach
2016, American Journal of Infection Control
Citation Excerpt :
Eom et al26 reported that implementation of the VAP bundle significantly reduced the VAP rates from 4.08/103-1.16/103 ventilator-days. In addition, several authors have reported that they eliminated VAP using care bundles.13,18,19 Youngquist et al13 demonstrated that they decreased the VAP rates from 2.66-0 per 103 ventilator-days in the ICU by achieving 100% compliance with the VAP bundle.
The ventilator-associated pneumonia (VAP) care bundle consists of evidence-based practices to improve the outcomes of patients receiving mechanical ventilatory therapy. This study aimed to investigate the implementation of the care bundle on VAP rates in this quasiexperimental study.
The protocol of this study consisted of 3 phases. In the initial phase, observations were made to determine the VAP care bundle adherence of intensive care unit (ICU) nurses. In the second phase, education was provided to ICU nurses on the subject of the VAP care bundle. For the third phase, the effect of VAP care bundle adherence on the VAP rates after education was investigated.
The nurses' VAP care bundle adherence improved after education from 10.8% (n = 152) to 89.8% (n = 1,324) and showed statistically significant improvement (P = .0001 and P < .05). In this study, the VAP rates were determined as 15.91/10³ ventilator-days before education and 8.50/10³ ventilator days after education. It was found that the VAP rates after the education period were significantly lower than the VAP rates before education.
VAP care bundle implementation with education prepared according to evidence-based guidelines decreased VAP rates. Thus, implementation of the VAP care bundle on mechanically ventilated patients care is recommended.
Ventilator-Associated Pneumonia
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition

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Brief ReportEfficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit

Section snippets

Setting

Results

Discussion

Joint Comm J Qual Patient Saf

Joint Comm J Qual Patient Saf

J Hosp Infect

Mayo Clin Proc

VAP: strategies for prevention and treatment

J Respir Dis

Risk factors for ICU-acquired pneumonia

JAMA

Brief Report
Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit