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Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia.

* PURPOSE To examine critical care nurses' knowledge about the use of the ventilator bundle to prevent ventilator-associated pneumonia.

* METHOD Published reports were reviewed for current evidence on the use of the ventilator bundle to prevent ventilator-associated pneumonia, and education sessions were held to present the findings to 61 nurses in coronary care and surgical intensive care units. Changes in the nurses' knowledge were evaluated by using a 10-item test, given both before and after the sessions. Changes in the nurses 'practices related to ventilator-associated pneumonia, including elevation of the head of the bed to 30[degrees] to 45[degrees] were observed in 99 intubated patients.

* RESULTS After the education sessions, the nurses performed better on 8 of the 10 items tested (P from .03 to <.001). The areas of most significant improvement were elevation of the head of the bed (P < .001), charting of the elevation of the head of the bed (P = .009), oral care (P = .009), checking of the nasogastric tube for residual volume (P = .008), washing of hands before contact with patients (P <.001), and limiting the wearing of rings (P < .001) and nail polish (P = .04). Even after the education sessions, the nurses' compliance with hand-washing recommendations before contact with patients was low, though statistically some improvement was apparent. Contraindications to elevation of the head of the bed did not appear to affect the nurses 'practices (P = .38).

* CONCLUSION Education sessions designed to inform nurses about the ventilator bundle and its use to prevent ventilator-associated pneumonia have a significant effect on participants' knowledge and subsequent clinical practice.


Ventilator-associated pneumonia (VAP) is an important safety issue in critically ill patients and in patients receiving mechanical ventilation. The American Association of Critical-Care Nurses (AACN) recommended steps for reducing the incidence of VAP; these steps are based on the best-practice guidelines for patients receiving mechanical ventilation. Called the "ventilator bundle," these steps incorporate the following guidelines from the Centers for Disease Control and Prevention (CDC) for preventing nosocomial pneumonia (1,2):

* elevation of the head of the bed (HOB) to 30[degrees] to 45[degrees] unless medically contraindicated,

* continuous removal of subglottic secretions,

* change of ventilator circuit no more often than every 48 hours, and

* washing of hands before and after contact with each patient.

These steps are considered feasible, safe, and cost effective for preventing VAP.

The CDC has not offered any recommendations about oral care or about how often to check the residual volume in nasogastric tubes. Nor has it suggested modifications in tube feeding procedures to prevent VAP, such as suspending feedings while patients are being repositioned or turning patients supine before commencing feedings. Research is still needed to ascertain at what level gastric residual volume increases aspiration risk and at what level feedings should be withheld. More research is needed on oral care and on procedures for checking residual volume in nasogastric tubes.

Current best practices for patients at risk of VAP can be established by conducting systematic literature reviews on the ventilator bundle and factors related to VAP and by communicating evidence-based findings through education sessions. Supported by current research and scientific evidence, this clinical project was aimed at examining critical care nurses' knowledge of the ventilator bundle and its applications for preventing VAP.

Current Evidence About the Ventilator Bundle and VAP

Most published studies have focused on the relationship between HOB elevation and the incidence of VAP. Table 1 presents current evidence on the prevention of VAE with respect to HOB elevation, hand washing, and oral care. A significant relationship between HOB elevation to 30[degrees] to 45[degrees] and a reduced incidence of VAP has been reported. (3,5,9)

Factors affecting the incidence of VAP include early, low back-rest elevation and severity of illness; backrest elevation alone has no relationship to the Clinical Pulmonary Infection Score. (6) In addition, high acuity levels with higher scores on the Acute Physiology and Chronic Health Evaluation II were directly associated with development of VAP, (3,4,6) and patients with VAP had higher mortality rates. (4) In a replication study, (8) the mean observed HOB position was 23[degrees] for intubated patients and 38[degrees] for nonintubated patients (P < .001). Kollef et al (5) reported that patients transported out of the intensive care unit (ICU) are at greater risk for development of VAE

Other researchers explored the barriers to using HOB elevation as a method of preventing VAP (14) and examined the relationship between VAP, days of mechanical ventilation, and ICU days, and thus hospital cost. (13) These researchers concluded with a recommendation that the HOB be elevated to 30[degrees] to 45[degrees] in patients receiving mechanical ventilation unless doing so is medically contraindicated. Babcock et al (10) reported a decrease in the rate of VAP after an educational intervention (from 8.75 cases per 1000 ventilator days before to 4.74 cases per 1000 ventilator days after; P<.001). Results of other studies (11,12) confirmed that staff education decreased the incidence of VAP (46% to 57.6%, P values from <.001 to .02).

Studies on hand-washing practices focused on comparing bacterial counts before and after hands were washed with an alcohol-based solution (15-18) and on comparing the incidence of VAP when chlorhexidine was used and when an alcohol-based solution was used. (19) In one study, (20) researchers observed a decrease in bacterial contamination after hand washing. In another study, (17) wearing at least one ring during contact with a patient was directly associated with increased frequency of hand contamination with S aureus, gram-negative bacilli, or Candida species. Thus, regular hand washing with an alcohol-based solution and limited wearing of rings are directly related to a decreased rate of VAP. Based on these results, Trick et al (17) recommended that hands be washed with an alcohol-based solution and rings be removed before contact with a patient.

Although the CDC has not recommended strategies for oral care, a literature search revealed that the use of chlorhexidine oral rinse is directly associated with reduced rates of respiratory infection (3% with chlorhexidine vs 10% with placebo; P< .05). (23) Studies have addressed the use of chlorhexidine before intubation, (23) in patients scheduled for elective cardiac surgery, (23,26) and in patients with respiratory infections such as tracheobronchitis and pneumonia. (23) Two randomized controlled trials (21,22) showed that tracheobronchial colonization causing VAP occurred less often in patients whose mouths had been decontaminated with topical antibiotics than in those who were given a placebo (P < .001 to .04). Topical prophylaxis using antibiotics eradicated oropharyngeal bacterial colonies on admission (75%, P < .001) and prevented bacterial colonization of the trachea (52%, P = .03). (21) The documented mean frequency of oral care for nonintubated patients was 1.8 (SD 1.5) times, and nurses' self-reported mean frequency was 3.3 (SD 1.8) times. The documented mean frequency for the intubated patients was 3.3 (SD 1.8) times, and nurses' self-reported mean frequency was 4.2 (SD 2.1) times (P<.001). (8) Implementation of an oral care protocol and provision of appropriate oral hygiene tools increased the frequency and comprehensiveness of oral care (oral cavity assessment P =. 001, all types of oral care P < .001 ). (25)

Oral aspiration could be a factor that contributes to VAP. Current recommendations for general practice in tube-fed patients include routine checking of gastric residual volume every 4 to 6 hours and withholding of feeding for 1 hour if gastric residual volume is more than 1 to 1.5 times the amount provided in an hour, or more than 150 mL before bolus feeding. (27) These practices, however, have not been specifically studied in relation to VAP. In one study, (24) elevated gastric residual volume and vomiting were associated with an increased incidence of VAP. In another study, (9) the supine position and the length of time the patient stayed in that position were risk factors for gastric aspiration. In a study by McClave and colleagues, (28) the occurrence of regurgitation, regardless of its frequency or whether aspiration had occurred, was not associated with a higher incidence of pneumonia. More recently, an association was found between the occurrence of aspiration and the development of pneumonia. In that study, (7) pneumonia rates increased from 24% on day 1 to 48% on day 4. On day 4, the mean percentage of pepsin-positive tracheal secretions was twice as high for patients with pneumonia as for patients without pneumonia.


We conducted a clinical education project to assess nurses' knowledge about use of the ventilator bundle to prevent VAP and the related practice patterns in a coronary care unit (CCU) and surgical ICU (SICU) at a large hospital based in a medical center in a major metropolitan city. Changes in knowledge and nursing practices related to the ventilator bundle and VAP prevention were examined before and after education sessions about current evidence-based interventions. A total of 8 sessions were conducted to include most of the nurses working in the 2 units. These sessions included a 30-minute presentation, a pretest, and a posttest. An educational poster containing a copy of the presentation was placed in each unit after the education sessions for those nurses who were unable to attend. The 30-minute PowerPoint and poster presentation included materials from AACN's VAP practice alert, information from the literature obtained through Internet research, and the guidelines from the CDC.

A 10-item test was constructed to examine nurses' knowledge about VAP and its prevention by using interventions that are based on the ventilator bundle. The questions on the 10-item test contained information from the PowerPoint presentation. The project director conducted all the education sessions in the CCU and the SICU. Additionally, the project director created the PowerPoint and poster presentations as well as the 10-item test, all of which were reviewed by 2 critical care nursing experts and educators to establish content validity. The test included 10 questions on such topics as best-practice guidelines, microorganisms that cause VAR hand washing, supine positioning, enteral feeding, factors related to VAR definition of VAP, and diagnosis of pneumonia.

Participants included 14 night-shift nurses and 14 day-shift nurses from the SICU and 15 day-shift nurses and 18 night-shift nurses from the CCU. These participants comprised approximately 65% to 70% of all the nurses in each unit. Pretests and posttests were administered immediately before and after the in-service education sessions. In addition, the practice patterns of nurses were observed during the 1 month preceding and the 1 month following the education sessions. Practice patterns were assessed both before and after the education sessions by observing the care rendered to 30 patients in the SICU and 69 patients in the CCU, all of whom were receiving mechanical ventilation. HOB elevation was measured by checking the beds that were equipped with angle measurement to specify the degrees of elevation.

Practice was observed during shift reports at 7 AM and 7 PM. Factors assessed included whether HOB elevation was addressed during shift reports; the hand-washing practices of nurses; and whether nurses had artificial nails, wore nail polish, or wore rings (with the number of rings noted) during contacts with patients. Records in the computer information system were used to audit patients' charts for HOB elevation, frequency of oral care, and frequency of nasogastric tube checking in the preceding 12 hours. All data were collected and analyzed by the project director and reviewed by 2 critical care nursing experts who were project team members. Project implementation and evaluation took 6 months.


Demographic data for the nurses showed a range of ages, educational levels, years of experience in critical care, and total hospital experience (Table 2). Most nurses in the CCU (79%) and the SICU (86%) were female. Most (57%) were between 31 and 50 years of age; 13 CCU nurses (39%) were 41 to 50 years old, and 11 SICU nurses (39%) were 31 to 40 years old. Most nurses in both the CCU (61%) and the SICU (79%) had a bachelor of science degree in nursing. Hospital experience for most CCU (64%) and SICU (64%) nurses was 5 years or more. Similarly, most CCU (64%) and SICU (68%) nurses had 5 years or more of critical care experience.

Nurses' scores on the pretests and posttests are compared in Table 3. The changes in test scores indicate that the 30-minute education session increased the knowledge gained by the nurses about VAP and the ventilator bundle (independent t test, P < .001). Scores changed significantly ([chi square] tests, P < .05) from pretests to posttests for 8 of the 10 questions. The 2 questions that did not show improvements in scores were 2 true-false choice items regarding best-practice guidelines and hand washing (98%-100% correct on both the pretest and the posttest).

As for changes in practice patterns, nurses elevated the HOB to 30[degrees] or higher for 74% of the patients after the education sessions as compared with only 44% before the sessions (P < .001, Table 4). After the education sessions, significantly more nurses washed their hands before contact with a patient and significantly fewer nurses wore nail polish and tings (P < .05). However, even before the education sessions, most nurses washed their hands after contact with a patient (96%) and very few nurses wore artificial nails (1%). Additionally, although compliance with hand washing before contact with a patient increased significantly after the education sessions, compliance was still low (11% before education vs 45% after education). Possible contraindications to HOB elevation at 30[degrees] to 45[degrees] included decubitus ulcers, hemodialysis, continuous renal replacement therapy, intra-aortic balloon pump, emergency invasive procedures, hypotensive episodes, hemodynamic monitoring, and postoperative procedure(s) that may require the patient to be positioned supine or the HOB to be set at a lower elevation. Presence of possible contraindications to HOB elevation did not change from before to after the education sessions (P > .05).

Examination of patients' charts for practices related to the ventilator bundle showed significant improvement in HOB elevation, from 51% before the education sessions to 69% after the education sessions (P = .009, Table 5). The frequency of oral care increased significantly (P = .009). After the education sessions, 35% of the audited records showed documented oral care 3 times per shift, whereas only 16% showed the same frequency of care before the sessions. Residual volume in the nasogastric tube was also checked more frequently after the education sessions; 18% of patients were checked 3 times per shift, whereas only 3% of patients were checked that often before the sessions.


Education sessions were presented to most nurses in the CCU and SICU. After the nurses completed the sessions, their knowledge increased and their use of evidence-based practice improved. Thus the goals of the project were successfully met, as shown by the significant improvement in the nurses' test scores and in the number of patients who received the level of care recommended in the ventilator bundle. These results show that targeted intervention with a 30-minute education session can influence nurses' knowledge and clinical practice.

Significant changes were noted in the nurses' hand-washing practices before contact with a patient and in their use of nail polish and wearing of rings. The actual HOB elevation used, notation of HOB elevation in patients' charts, oral care, and checking of residual volume in the nasogastric tube also improved significantly. The observed practices also indicated some level of professionalism and awareness among the nurses regarding proper hand washing after contact with patients as well as the problems associated with wearing artificial nails. Such practices should be positively reinforced.

Findings of this project further support results of earlier studies about educating hospital staff about VAP and the ventilator bundle. (9,11,12) Evidence-based practices, including those addressed in the ventilator bundle, should be a driving force in shaping nursing practice. The ultimate goal of evidence-based practice is high-quality healthcare with beneficial outcomes. Reinforcement of education can help ensure that the education improves nursing practices in a sustained manner. Consistent and accurate documentation of HOB elevation at 30[degrees] or higher, oral care, and checking of residual volume in the nasogastric tube, along with surveillance of proper hand-washing practice among nurses, should be recommended.

Use of the ventilator bundle includes elevating the HOB to 30[degrees] to 45[degrees] to prevent VAP among ICU patients who are receiving mechanical ventilation. Patients in the ICU, who are frequently positioned supine because of the presence of decubitus ulcers, for hemodynamic monitoring, or for particular bedside procedures, should be consistently returned to a semi-recumbent position. If HOB elevation at 30[degrees] to 45[degrees] is a factor in the formation of decubitus ulcers, then the patient could still be placed in the semi-Fowler's position but turned from side to side at least every 2 hours.

The limitations of this project included the fact that not all the nurses in the CCU and SICU were able to participate in the live education sessions; for those who could not attend, the information was provided through an educational poster that was posted in the unit. In some cases, nurses who attended the sessions shared the information with those who did not attend. Because of the nature of the project and the scheduling of staff, no comparisons were made between nurses who attended the sessions and those who did not.

One factor that may have affected the results was the nurses' awareness of being observed before and after the education sessions, which may have led to more conscientious practice. Moreover, few patients received feedings via a nasogastric tube. Most patients receiving mechanical ventilation were receiving total parenteral nutrition, which meant that the number of patients with nasogastric tubes to be checked was limited. As with all chart audits, data are limited to the entries that were made; practices may have occurred without being documented. Finally, other limitations of the clinical project included absence of a control group against which to compare findings, the unknown reliability of the test questions, and the use of documentation as a proxy for actual practice.

Future studies should focus on high-risk and higher acuity patients and those patients receiving mechanical ventilation who are admitted to chronic care facilities, which would involve a longer period of observation. Future studies are needed to examine nursing practices, including oral care and nasogastric tube feedings, as related to prevention of VAR Studies that would establish a direct relationship between oral care, checking of residual volume in the nasogastric tube, and the development of VAP are essential to formulating evidence-based protocols for these practices. Scientific inquiries are needed to determine whether continuous pump or drip feedings via a nasogastric tube should be turned off while patients are being repositioned or placed supine for procedures. The ventilator bundle should be used to implement practice changes for patients, with specification of a safe gastric residual volume and recommendation of a frequency for checking residual volume in the nasogastric tube to prevent pulmonary aspiration.


The authors thank Patricia S. Lewis, RN, MS, CNAA, associate chief of nursing, and Lisa Hanna, RN, BSN, director of nursing at The Methodist Hospital, Houston, Tex, for their contributions to the implementation of this study. The authors also thank the nurses in the coronary care unit and the surgical intensive care unit at The Methodist Hospital for their participation in the project.


None reported.

Corresponding author: Susan D. Ruppert, RN, PhD, APRN, BC, NP-C. The University of Texas Health Science Center at Houston, School of Nursing, 6901 Bertner Ave, Room 694, Houston, TX 77030 (e-mail:


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By Arlene F. Tolentino-DelosReyes, RN, MSN, ACNP, Susan D. Ruppert, RN, PhD, APRN, BC, NP-C, Shyang-Yun Pamela K. Shiao, RN, PhD. From the School of Nursing, The University of Texas Health Science Center at Houston, Houston, Tex (AFT-D, SDR), and School of Nursing, University of Houston Victoria and University of Houston System at Sugar Land, Sugar Land, Tex (S-YPKS).
Table 1 Current evidence on the prevention of VAP

Reference Year Design

HOB elevation

Drakulovic et al (3) 1999 Randomized
 controlled trial

Kollef (4) 1993 Inception cohort design

Kollef et al (5) 1997 Comparison studies,
 surveillance of patients,
 and data collection

Grap et al (6) 2005 Longitudinal, descriptive

Metheny et al (7) 2006 Prospective, descriptive

Hanneman and Gusick (8) 2005 Cross-sectional design,
 observational data

Torres et al (9) 1992 Comparison

Babcock et al (10) 2004 Before and after
Salahuddin et al (11) 2004 education
Zack et al (12) 2002

Warren et al (13) 2003 Association and multiple

Cook et al (14) 2002 Semistructured
 interviews and focus

Hand washing

Girou et al (15) 2002 Randomized controlled
Lucet et al (16) 2002 trial
Trick et al (17) 2003
Zaragosa et al (18) 1999

Trick et al (17) 2003 Randomized controlled

Doebbeling et al (19) 1992 Crossover trial

Pittet et al (20) 1999 Observation study

Oral care

Bergman et a1 (21) 2001 Randomized controlled
Pugin et al (22) 1991 trial

Bergman et al (21) 2001 Randomized controlled

DeRiso et al (23) 1996 Randomized controlled

Mentec et al (21) 2001 Randomized controlled

Cutler and Davis (25) 2005 Observation before
 and after education

Hanneman and Gusick (8) 2005 Cross-sectional survey

Reference Significant outcomes Suggested practice

HOB elevation

Drakulovic et al (3) HOB elevation and HOB elevation at
 VAP 30[degrees]-

Kollef (4) Mortality rate and

Kollef et al (5) Transport of
 patients and VAP

Grap et al (6) Height of back rest HOB elevation
 and VAP, comfort
 and skin integrity
 of patient

Metheny et al (7) HOB and outcomes; HOB elevation
 risk factors for >30[degrees]

Hanneman and Gusick (8) HOB and outcomes, HOB elevation
 supine and
 semiprone with
 head down

Torres et al (9) Comparison of HOB elevation at
 semirecumbent and least 45 [degrees]
 supine positions prophylactic
 measure for
 gastric aspiration

Babcock et al (10) Staff education Staff education on
Salahuddin et al (11) decreased VAP VAP
Zack et al (12) incidence

Warren et al (13) VAP and length of
 stay in intensive
 care unit,
 hospital stay,
 mortality rate,
 hospital cost

Cook et al (14) Barriers leading to
 underuse of HOB

Hand washing

Girou et al (15) Bacterial count for Use of alcohol-based
Lucet et al (16) alcohol-based solution for hand
Trick et al (17) solution and hand washing
Zaragosa et al (18) washing

Trick et al (17) Wearing rings and Refraining from
 hand contamination wearing rings
 during work

Doebbeling et al (19) Use of Use of
 chlorhexidine, chlorhexidine,
 soap, and alcohol soap, and alcohol
 and VAP incidence

Pittet et al (20) Hand washing and Hand washing before
 bacterial count and after contact
 with patient

Oral care

Bergman et a1 (21) Tracheobronchial
Pugin et al (22) colonization and
 VAP incidence

Bergman et al (21) Antibiotics and Prophylactic
 colonization antibiotics

DeRiso et al (23) Chlorhexidine Oral care

Mentec et al (21) Gastric residual Check gastric
 volume and residual volume
 vomiting increased
 incidence of VAP

Cutler and Davis (25) Implementation of Oral care protocol
 oral care protocol and provision of
 improved oral care appropriate tools

Hanneman and Gusick (8) Mean documented oral

Abbreviations: HOB, head of bed; VAP, ventilator-associated

Table 2 Demographic data for nurses in the study

 No. (%) or nurses

 Coronary intensive
 care unit care unit Total
Parameter (n = 33) (n = 28) (N = 61)

Sex of nurse
 Female 26 (79) 24 (86) 50 (82)
 Male 7 (21) 4 (14) 11 (18)

Age, y
 20-30 9 (27) 7 (25) 16 (26)
 31-40 7 (21) 11 (39) 18 (30)
 41-50 13 (39) 4 (14) 17 (28)
 51-60 3 (9) 5 (18) 8 (13)
 [greater than or equal to] 61 1 (3) 1 (4) 2 (3)

Highest educational level in nursing
 Diploma 1 (3) 1 (4) 2 (3)
 Associate's degree 12 (36) 5 (18) 17 (28)
 Bachelor's degree 20 (61) 22 (79) 42 (69)
 Graduate degree 0 0 0

Nursing experience, y
 <1 6 (18) 3 (11) 9 (15)
 1-2 2 (6) 4 (14) 6 (10)
 3-4 4 (12) 3 (11) 7 (11)
 [greater than or equal to] 5 21 (64) 18 (64) 39 (64)

Critical care experience, y
 <1 6 (18) 2 (7) 8 (13)
 1-2 2 (6) 5 (18) 7 (11)
 3-4 4 (12) 2 (8) 6 (10)
 [greater than or equal to] 5 21 (64) 19 (68) 40 (66)

Shift worked
 7 AM-7 PM 15 (45) 14 (50) 29 (48)
 7 PM-7 AM 18 (55) 14 (50) 32 (52)

Table 3 Comparison of results from pretest and posttest
(N = 61)

 No. (%) correct

Subject of question Pretest Posttest P

 1. Ventilator bundle
 best-practice guidelines * 61 (100) 61 (100) >.99

 2. Microorganisms
 causing VAP 17 (28) 53 (87) <.001

 3. Poor hand washing 60 (98) 60 (98) >.99
 and VAP *

 4. Supine positioning and
 lung capacity 46 (75) 57 (93) .006

 5. Enteral feeding and VAP 32 (52) 54 (89) <.001

 6. Risk factors for VAP 44 (72) 57 (93) .002

 7. Treatment-related risk
 factor for VAP 12 (20) 46 (75) <.001

 8. Host-related risk factors
 for VAP 17 (28) 48 (79) <.001

 9. Pneumonia diagnoses * 54 (89) 60 (98) .03

10. Definition of VAP 53 (87) 61 (100) .003

Total score, mean, SD 6.31, 1.35 9.11, 1.36 <.001
 (range) (2-10) (5-10)

* True/false items.

Abbreviation: VAP, ventilator-associated pneumonia.

Table 4 Observations of practices (N = 99)

 No. (%) of nurses
 performing practice

 Before After
Practice education education P

Hands washed
 (before contact) 11 (11) 45 (45) <.001

Hands washed
 (after contact) 95 (96) 99 (100) .08

Nail polish 4 (4) 0 (0) .04

Artificial nails 1 (1) 0 (0) .32

Rings worn <.001
 0 39 (39) 65 (66)
 1 44 (44) 27 (27)
 2 14 (14) 4 (4)
 3 2 (2) 3 (3)

Actual head-of-bed
 elevation <.001
 <30[degrees] 55 (56) 26 (26)
 [greater than or equal to] 44 (44) 73 (74)

Contraindications 41 (41) 35 (35) .38

Table 5 Chart audit (N = 99)

 No. (%) of charts
 with practice noted

 Before After
Practice education education P

Head-of bed elevation .009
 Not recorded on chart 33 (33) 26 (26)
 <30[degrees] 16 (16) 5 (5)
 [greater than or equal to] 30[degrees] 50 (51) 68 (69)

Frequency of oral care .009
 in 12-hour shift
 0 45 (45) 27 (27)
 1 25 (25) 25 (25)
 2 13 (13) 12 (12)
 3 16 (16) 35 (35)

Frequency of checking .008
 residual volume in
 nasogastric tube during
 a 12-hour shift
 0 13 (13) 11 (11)
 1 12 (12) 6 (6)
 2 12 (12) 8 (8)
 3 3 (3) 18 (18)
 Not applicable 59 (60) 56 (57)
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Author:Shiao, Shyang-Yun Pamela K.
Publication:American Journal of Critical Care
Date:Jan 1, 2007
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