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Thapa D, Chair SY, Chong MS, Poudel RR, Melesse TG, Choi KC, Tam HL. Effects of ventilatory bundles on patient outcomes among ICU patients: A systematic review and meta-analysis. Heart Lung 2024; 63:98-107. [PMID: 37839229 DOI: 10.1016/j.hrtlng.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Ventilator bundles are suggested to prevent ventilator-associated pneumonia (VAP), but significant variations in the effects of the bundle on patient outcomes have been reported. OBJECTIVES To synthesize the evidence and evaluate the effects of the ventilator bundle on patient outcomes among critically ill adult patients. METHODS A broad search was performed in seven databases for relevant articles published from January 2002 to November 2022. Randomized controlled trials and quasi-experimental studies investigating the effects of implementing ventilator bundles in adult intensive care units (ICUs) were included. Two independent reviewers performed the study selection, data extraction, and risk of bias assessment. All data for meta-analysis were pooled using the random-effects model. RESULTS After screening, 19 studies were included in the meta-analysis. Evidence of low-to-moderate certainty showed that the ventilator bundle reduced the rate of VAP (risk ratio [RR] = 0.64; P = 0.003), length of ICU stay (mean difference [MD] = -2.57; P = 0.03), mechanical ventilation days (MD = -3.38; P < 0.001), and ICU mortality (RR = 0.76; P = 0.02). Ventilator bundle was associated with improved outcomes, except mortality. CONCLUSIONS The ventilator bundle, especially the IHI ventilator bundle, was effective in decreasing the incidence of VAP and improving most of the VAP-related outcomes. However, given the low-to-moderate certainty of evidence and high heterogeneity, these results should be interpreted with caution. A future study that adopts hybrid implementation trials with high methodological quality is needed to confirm the effects of the ventilator bundle on patient outcomes.
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Affiliation(s)
- Dejina Thapa
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Mei Sin Chong
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Rishi Ram Poudel
- Department of Orthopedics, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Tenaw Gualu Melesse
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Hon Lon Tam
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China.
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Martinez-Reviejo R, Tejada S, Jansson M, Ruiz-Spinelli A, Ramirez-Estrada S, Ege D, Vieceli T, Maertens B, Blot S, Rello J. Prevention of ventilator-associated pneumonia through care bundles: A systematic review and meta-analysis. JOURNAL OF INTENSIVE MEDICINE 2023; 3:352-364. [PMID: 38028633 PMCID: PMC10658042 DOI: 10.1016/j.jointm.2023.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 12/01/2023]
Abstract
Background Ventilator-associated pneumonia (VAP) represents a common hospital-acquired infection among mechanically ventilated patients. We summarized evidence concerning ventilator care bundles to prevent VAP. Methods A systematic review and meta-analysis were performed. Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation (MV) for at least 48 h were considered for inclusion. Outcomes of interest were the number of VAP episodes, duration of MV, hospital and intensive care unit (ICU) length of stay, and mortality. A systematic search was conducted in the MEDLINE, the Cochrane Library, and the Web of Science between 1985 and 2022. Results are reported as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). The PROSPERO registration number is CRD42022341780. Results Thirty-six studies including 116,873 MV participants met the inclusion criteria. A total of 84,031 participants underwent care bundles for VAP prevention. The most reported component of the ventilator bundle was head-of-bed elevation (n=83,146), followed by oral care (n=80,787). A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles, compared with the non-care bundle group (OR=0.42, 95% CI: 0.33, 0.54). Additionally, the implementation of care bundles decreased the duration of MV (MD=-0.59, 95% CI: -1.03, -0.15) and hospital length of stay (MD=-1.24, 95% CI: -2.30, -0.18) in studies where educational activities were part of the bundle. Data regarding mortality were inconclusive. Conclusions The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs. Their application in combination with educational activities seemed to improve clinical outcomes.
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Affiliation(s)
- Raquel Martinez-Reviejo
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Sofia Tejada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
- Clinical Research Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona 08035, Spain
| | - Miia Jansson
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, 90570, Finland
- RMIT University, Melbourne, 3010, Australia
| | - Alfonsina Ruiz-Spinelli
- Critical Care Department, Hospital de Clínicas Dr. Manuel Quintela, Montevideo, 11600, Uruguay
- Medicine Department, Universitat Internacional de Catalunya (UIC), Barcelona, 08017, Spain
| | | | - Duygu Ege
- Emergency Medicine Department, Adnan Menderes University, Aydin, 09010, Turkey
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, 90035-903, Brazil
| | - Bert Maertens
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, 9000, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, 9000, Belgium
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
- Clinical Research Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona 08035, Spain
- FOREVA Clinical Research, CHU Nimes, Université de Nîmes-Montpellier, Nîmes, 30012, France
- Medicine Department, Universitat Internacional de Catalunya (UIC), Barcelona, 08017, Spain
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Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review. Ann Surg 2021; 273:e239-e246. [PMID: 30985368 DOI: 10.1097/sla.0000000000003313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). BACKGROUND At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines. METHODS A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0. RESULTS Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report. CONCLUSIONS Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.
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Checklist for Early Recognition and Treatment of Acute Illness and Injury: An Exploratory Multicenter International Quality-Improvement Study in the ICUs With Variable Resources. Crit Care Med 2021; 49:e598-e612. [PMID: 33729718 PMCID: PMC8132910 DOI: 10.1097/ccm.0000000000004937] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To determine whether the “Checklist for Early Recognition and Treatment of Acute Illness and Injury” decision support tool during ICU admission and rounding is associated with improvements in nonadherence to evidence-based daily care processes and outcomes in variably resourced ICUs. DESIGN, SETTINGS, PATIENTS: This before-after study was performed in 34 ICUs (15 countries) from 2013 to 2017. Data were collected for 3 months before and 6 months after Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation. INTERVENTIONS: Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation using remote simulation training. MEASUREMENTS AND MAIN RESULTS: The coprimary outcomes, modified from the original protocol before data analysis, were nonadherence to 10 basic care processes and ICU and hospital length of stay. There were 1,447 patients in the preimplementation phase and 2,809 patients in the postimplementation phase. After adjusting for center effect, Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation was associated with reduced nonadherence to care processes (adjusted incidence rate ratio [95% CI]): deep vein thrombosis prophylaxis (0.74 [0.68–0.81), peptic ulcer prophylaxis (0.46 [0.38–0.57]), spontaneous breathing trial (0.81 [0.76–0.86]), family conferences (0.86 [0.81–0.92]), and daily assessment for the need of central venous catheters (0.85 [0.81–0.90]), urinary catheters (0.84 [0.80–0.88]), antimicrobials (0.66 [0.62–0.71]), and sedation (0.62 [0.57–0.67]). Analyses adjusted for baseline characteristics showed associations of Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation with decreased ICU length of stay (adjusted ratio of geometric means [95% CI]) 0.86 [0.80–0.92]), hospital length of stay (0.92 [0.85–0.97]), and hospital mortality (adjusted odds ratio [95% CI], 0.81 (0.69–0.95). CONCLUSIONS: A quality-improvement intervention with remote simulation training to implement a decision support tool was associated with decreased nonadherence to daily care processes, shorter length of stay, and decreased mortality.
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Abstract
OBJECTIVES To assess the effectiveness of the ventilator bundle in the reduction of mortality in ICU patients. DATA SOURCES PubMed, Scopus, Web of Science, Cochrane Library for studies published until June 2017. STUDY SELECTION Included studies: randomized controlled trials or any kind of nonrandomized intervention studies, made reference to a ventilator bundle approach, assessed mortality in ICU-ventilated adult patients. DATA EXTRACTION Items extracted: study characteristics, description of the bundle approach, number of patients in the comparison groups, hospital/ICU mortality, ventilator-associated pneumonia-related mortality, assessment of compliance to ventilator bundle and its score. DATA SYNTHESIS Thirteen articles were included. The implementation of a ventilator bundle significantly reduced mortality (odds ratio, 0.90; 95% CI, 0.84-0.97), with a stronger effect with a restriction to studies that reported mortality in ventilator-associated pneumonia patients (odds ratio, 0.71; 95% CI, 0.52-0.97), to studies that provided active educational activities was analyzed (odds ratio, 0.88; 95% CI, 0.78-0.99), and when the role of care procedures within the bundle (odds ratio, 0.87; 95% CI, 0.77-0.99). No survival benefit was associated with compliance to ventilator bundles. However, these results may have been confounded by the differential implementation of evidence-based procedures at baseline, which showed improved survival in the study subgroup that did not report implementation of these procedures at baseline (odds ratio, 0.82; 95% CI, 0.70-0.96). CONCLUSIONS Simple interventions in common clinical practice applied in a coordinated way as a part of a bundle care are effective in reducing mortality in ventilated ICU patients. More prospective controlled studies are needed to define the effect of ventilator bundles on survival outcomes.
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Leonard KL, Borst GM, Davies SW, Coogan M, Waibel BH, Poulin NR, Bard MR, Goettler CE, Rinehart SM, Toschlog EA. Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates. Surg Infect (Larchmt) 2016; 17:363-8. [PMID: 26938612 DOI: 10.1089/sur.2014.076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. METHODS A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. RESULTS Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). CONCLUSIONS The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.
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Affiliation(s)
- Kenji L Leonard
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Gregory M Borst
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Stephen W Davies
- 2 Department of Surgery, University of Virginia , School of Medicine, Charlottesville, Virginia
| | - Michael Coogan
- 3 Department of Infection Control, Vidant Medical Center , Greenville, North Carolina
| | - Brett H Waibel
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Nathaniel R Poulin
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Michael R Bard
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Claudia E Goettler
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Shane M Rinehart
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Eric A Toschlog
- 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina
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Croce MA, Brasel KJ, Coimbra R, Adams CA, Miller PR, Pasquale MD, McDonald CS, Vuthipadadon S, Fabian TC, Tolley EA. National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: does it really work? J Trauma Acute Care Surg 2013; 74:354-60; discussion 360-2. [PMID: 23354225 DOI: 10.1097/ta.0b013e31827a0c65] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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