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Ventilator bundles not adequate in trauma ICU.

COLORADO SPRINGS -- Implementation of a widely advocated bundle of evidence-based practices aimed at reducing ventilator-associated pneumonia had the desired effect in a busy medical ICU but not in the same hospital's level I trauma/surgical ICU, Dr. Patrick J. Offner reported at the annual meeting of the Western Surgical Association.

"I think ventilator-associated pneumonia prevention is an important goal in our patients. However, the ventilator bundle as implemented by us was ineffective in reducing the ventilator-associated pneumonia rate in our trauma ICU," observed Dr. Offner of St. Anthony Central Hospital, Denver.

The explanation for the disparate outcomes is unclear. Compliance with all four elements of the ventilator bundle--elevation of the head of the bed to an angle of 30-45 degrees, daily interruption of sedation to assess readiness for extubation, deep vein thrombosis prophylaxis, and prophylaxis against peptic ulcer disease--was about 85% in both the medical and surgical ICUs in this prospective study, Dr. Offner said.

One thing is clear, however: If implementation of standardized ventilator bundles is going to be incorporated in pay-for-performance, as seems highly likely, then those bundles need to be revised and made more relevant to trauma/surgical patients so hospitals and surgeons aren't unfairly penalized, Dr. Offner said.

Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection and accounts for substantial morbidity, mortality, and health care cost. Numerous medical centers have reported success in sustaining extremely low VAP rates since introducing ventilator bundles. But these reports emanate from medical ICUs, not trauma/surgical ICUs, according to Dr. Offner.

St. Anthony is a busy urban tertiary referral center with just under 3,000 trauma admissions per year. The hospital has trauma surgeons and critical care medicine physicians on site 24/7, and they do rounds together. The hospital introduced the four-pronged ventilator bundle--the same as that advocated in the 5 Million Lives Campaign of the Institute for Healthcare Improvement--as a quality improvement initiative in August 2005. Prior to implementation, ICU nurses and respiratory therapists received several months of intensive education. Compliance with the ventilator bundle was tracked daily, and VAP diagnosis was based on the Centers for Disease Control and Prevention definition.

The VAP rate in the medical ICU fell from 7.8 cases/1,000 ventilator-days at baseline to 2.0/1,000 ventilator-days in the seventh quarter following introduction of the ventilator bundle. In contrast, the rate increased slightly in the trauma/surgical ICU from 10 to 11.9 cases.

When the study period was divided into two halves, the VAP rate dropped from 9.2 cases/1,000 ventilator-days in the first half to 1.4 in the latter months. In the trauma/surgical ICU, the VAP rate was 13.7 cases/1,000 ventilator-days in the first half and 11.6 in the second half, a nonsignificant difference. The VAP rate in the cardiac and pulmonary ICU went from 6.2 to 3.0 cases/1,000 ventilator-days.

Discussant Dr. Gregory J. Jurkovich said these results support the notion that the pneumonia commonly seen in trauma patients differs from that encountered in medical or coronary ICUs.

"Rather than calling it ventilator-associated pneumonia in these trauma patients, perhaps we should call it CTAP--chest trauma-associated pneumonia; or IAP--injury-associated pneumonia; or RAP--resuscitation-associated pneumonia," added Dr. Jurkovich, professor of surgery at the University of Washington and chief of the trauma service at Harborview Medical Center, Seattle.

"The four strategies in the ventilator bundle are advocated by the medicine-dominated critical care societies," he continued. "This type of work [by Dr. Offner] is important as we become more beholden to national norms and practice guidelines."

Asked which of the four bundle elements had the poorest compliance, Dr. Offner said it was, to his considerable surprise, elevating the head of the bed.

"I thought that would be the one that would be easiest to implement. But the nurses are concerned about elevating the head of the bed. They worry about pressure ulcers, the patient sliding out of the bed, things like that," he said.

Dr. Offher noted that the four elements of the 5 Million Lives ventilator bundle are but a small portion of a lengthy list of evidence-based interventions for VAP prevention. He and his surgical colleagues are considering incorporating into the St. Anthony ventilator bundle the following measures: a rigorous hand hygiene program, routine use of a secretory tube to suction fluids, and early tracheostomy in patients likely to be on mechanical ventilation for more than a week.


Denver Bureau
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Title Annotation:Infectious Diseases
Author:Jancin, Bruce
Publication:Internal Medicine News
Geographic Code:1USA
Date:Mar 1, 2008
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