Document Detail


National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: does it really work?
MedLine Citation:
PMID:  23354225     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Since its introduction by the Institute for Healthcare Improvement, the ventilator bundle (VB) has been credited with a reduction in ventilator-associated pneumonia (VAP). The VB consists of stress ulcer prophylaxis, deep venous thrombosis prophylaxis, head-of-bed elevation, and daily sedation vacation with weaning assessment. While there is little compelling evidence that the VB is effective, it has been widely accepted. The Centers for Medical and Medicaid Services has suggested that VAP should be a "never event" and may reduce payment to providers. To provide evidence of its efficacy, the National Trauma Institute organized a prospective multi-institutional trial to evaluate the utility of the VB.
METHODS: This prospective observational multi-institutional study included six Level I trauma centers. Entry criteria required at least 2 days of mechanical ventilation of trauma patients in an intensive care unit (ICU). Patients were followed up daily in the ICU until the development of VAP, ICU discharge, or death. Compliance for each VB component was recorded daily, along with patient risk factors and injury specifics. Primary outcomes were VAP and death. VB compliance was analyzed as a time-dependent covariate using Cox regression as it relates to outcomes.
RESULTS: A total 630 patients were enrolled; 72% were male, predominately with blunt injury; and mean age, Injury Severity Score (ISS), and 24-hour Glasgow Coma Scale (GCS) score were 47, 24, and 8.7, respectively. VAP occurred in 36%; mortality was 15%. Logistic regression identified male sex and pulmonary contusion as independent predictors of VAP and age, ISS, and 24-hour Acute Physiology and Chronic Health Evaluation as independent predictors of death. Cox regression analysis demonstrated that the VB, as a time-dependent covariate, was not associated with VAP prevention.
CONCLUSION: In trauma patients, VAP is independently associated with male sex and chest injury severity and not the VB. While quality improvement activities should continue efforts toward VAP prevention, the Institute for Healthcare Improvement VB is not the answer. Financial penalties for VAP and VB noncompliance are not warranted.
LEVEL OF EVIDENCE: Therapeutic study, level III.
Authors:
Martin A Croce; Karen J Brasel; Raul Coimbra; Charles A Adams; Preston R Miller; Michael D Pasquale; Chanchai S McDonald; Somchan Vuthipadadon; Timothy C Fabian; Elizabeth A Tolley
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Publication Detail:
Type:  Clinical Trial; Journal Article; Multicenter Study; Research Support, Non-U.S. Gov't; Research Support, U.S. Gov't, Non-P.H.S.    
Journal Detail:
Title:  The journal of trauma and acute care surgery     Volume:  74     ISSN:  2163-0763     ISO Abbreviation:  J Trauma Acute Care Surg     Publication Date:  2013 Feb 
Date Detail:
Created Date:  2013-01-28     Completed Date:  2013-04-05     Revised Date:  2013-09-25    
Medline Journal Info:
Nlm Unique ID:  101570622     Medline TA:  J Trauma Acute Care Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  354-60; discussion 360-2     Citation Subset:  AIM; IM    
Affiliation:
Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA. mcroce@uthsc.edu
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MeSH Terms
Descriptor/Qualifier:
APACHE
Clinical Protocols
Female
Glasgow Coma Scale
Humans
Injury Severity Score
Intensive Care / methods*
Male
Middle Aged
Pneumonia, Ventilator-Associated / epidemiology,  prevention & control
Prospective Studies
Respiration, Artificial / methods*
Sex Factors
Thoracic Injuries / mortality,  therapy
Wounds and Injuries / mortality,  therapy*
Wounds, Nonpenetrating / mortality,  therapy

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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