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Daily multidisciplinary rounds to implement the ventilator bundle decreases ventilator-associated pneumonia in trauma
Melvin E Stone1, David Snetman, Andrea O' Neill
1Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, New York 10461, USA. Melvin.Stone@NBHN.net
Insights
Daily goal rounds (GR) using the ventilator bundle (VAPB) checklist significantly reduced ventilator-associated pneumonia (VAP) in trauma patients. While VAP incidence decreased, mortality rates remained similar, suggesting VAP impacts length of stay but not survival in this cohort.
Area of Science:
- Critical Care Medicine
- Infectious Disease Prevention
- Trauma Patient Management
Background:
- Ventilator-associated pneumonia (VAP) remains a challenge in trauma patients, despite the implementation of the ventilator bundle (VAPB).
- High VAP rates persisted even after adopting the VAPB protocol.
- A multidisciplinary team approach was introduced to improve VAPB adherence.
Purpose of the Study:
- To evaluate the effectiveness of daily goal rounds (GR) focused on the VAPB in reducing VAP incidence in intubated trauma patients.
- To assess the impact of GR on VAP rates and patient outcomes.
Main Methods:
- A comparative study design was used, comparing a 10-month pre-GR period with a 10-month period of daily GR.
- VAP incidence was prospectively tracked using National Nosocomial Infection Surveillance criteria.
- Patient characteristics and outcomes were collected from trauma registry and medical records; patient groups were similar.
Main Results:
- VAP incidence decreased by 67% in the GR group compared to the pre-GR group (p=0.02).
- All-cause mortality rates were similar between the groups (16.5% vs. 21.3%; p=0.41).
- Patients with VAP experienced significantly longer mean ventilator, SICU, and hospital days (p=0.01 for all).
Conclusions:
- Daily multidisciplinary GRs focused on VAPB are effective in significantly decreasing VAP incidence in trauma patients.
- VAP is associated with increased length of mechanical ventilation, SICU stay, and hospital stay.
- The study lacked statistical power to determine the impact of GR or VAP on mortality due to a small number of deaths in the VAP cohort.
Background:
The incidence of ventilator-associated pneumonia (VAP) in trauma patients can be decreased with use of the ventilator bundle (VAPB). Our VAP rate remained high despite the adoption of the VAPB. To better implement the VAPB, a multidisciplinary team composed of the surgical intensive care unit (SICU) nursing staff, physician, and respiratory therapist reviewed briefly a checklist of VAPB goals for each patient before morning attending rounds. We hypothesized that such daily goal rounds (GR) focused on the VAPB would decrease the VAP rate.
Methods:
A pre-GR ten-month period (November 2006 to August 2007) was compared with the ten-month period (September 2007 to June 2008) with daily GRs. The occurrence of VAPs was tallied prospectively in all intubated trauma patients using the National Nosocomial Infection Surveillance criteria. Patient characteristics and outcome data were obtained from our trauma registry and medical records. Patient characteristics were similar in the 85 pre-GR patients and the 89 GR patients.
Results:
The number of VAPs decreased 67% in the GR patients (15 pre-GR vs. 5 GR; p=0.02); however, the all-cause mortality rate remained similar (16.5% vs. 21.3%; p=0.41). When patients were divided into those with and without VAP, there was a significant increase in mean ventilator, SICU, and hospital days in patients with VAP (p=0.01 for all). There were only two deaths among trauma patients with VAP.
Conclusion:
Daily multidisciplinary GRs focused on the VAPB can decrease the incidence of VAP significantly in trauma patients. Ventilator-associated pneumonia correlated with extended mean ventilator, SICU, and hospital days. Interestingly, despite a significant decrease in VAP, a decrease in the mortality rate was not observed. Given the small number of deaths in the VAP cohort, this study has insufficient statistical power to elucidate the true impact of GR intervention or VAP on the mortality rate in trauma patients.
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