Use of the ABC care bundle to standardize guideline implementation in a cardiac surgical population: a pilot study

Effect of feedback on ventilator care bundle compliance: before and after study

BACKGROUND

Care bundles cluster together several evidence-based practices and, in the intensive care setting, the ventilator care bundle (VCB) has been applied widely.

AIM

To determine the effect of monthly feedback on VCB compliance.

DESIGN

Before and after study: primary outcome measure VCB compliance.

METHODS

Data were collected for 1 year from two metropolitan general intensive care units (ICU) on one randomly allocated day per week. Baseline data from adult ventilated patients were collected during the first 6 months (phase 1). During the second 6 months (phase 2), monthly compliance data were provided to each ICU regarding both ICUs' performance.

RESULTS

Both 'all or nothing' compliance (when all four VCB elements were complied with) and overall compliance (the average compliance of the four elements) increased between the two phases. These increases were mostly small and statistically insignificant. Although both measures increased in ICU B, both fell in ICU A. ICU B's overall compliance increase was statistically significant (p = 0·005), but its 'all or nothing' compliance increase (19%), whilst arguably clinically significant, did not reach statistical significance. ICU B achieved increased compliance with all four VCB elements in phase 2, whereas ICU A achieved increases in two elements (deep vein thrombosis and gastric ulcer prophylaxis). Both ICUs achieved 100% compliance with gastric ulcer prophylaxis for all of phase 2. Head of bed elevation was the least complied with element in phase 1, and increased in ICU B only in phase 2.

CONCLUSIONS

Although the compliance rates with individual elements are encouraging, the results regarding the effect of feedback on VCB compliance were variable. The finding of relatively poor compliance with head of bed elevation is consistent with previous research.

RECOMMENDATIONS

Further research is needed to determine the effects of audit and feedback, and which strategies are most effective.

The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence

AIMS AND OBJECTIVES

The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator-associated pneumonia (VAP) outcomes.

BACKGROUND

The VCB is a group of four evidence-based procedures, which when clustered together and implemented as an 'all or nothing' strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions.

SEARCH STRATEGY

A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded.

CONCLUSIONS

Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four-element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes.

RELEVANCE TO CLINICAL PRACTICE

A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.