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National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: does it really work?
Martin A Croce1, Karen J Brasel, Raul Coimbra
1Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA. mcroce@uthsc.edu
Insights
The ventilator bundle (VB) did not prevent ventilator-associated pneumonia (VAP) in trauma patients. VAP risk is linked to patient factors like sex and injury severity, not VB adherence.
Area of Science:
- Critical Care Medicine
- Trauma Surgery
- Infectious Disease Prevention
Background:
- The ventilator bundle (VB) is widely adopted for reducing ventilator-associated pneumonia (VAP).
- Evidence supporting the VB's efficacy is limited, despite its acceptance and implications for healthcare reimbursement.
- A multi-institutional trial was conducted to rigorously evaluate the VB's effectiveness in trauma patients.
Purpose of the Study:
- To assess the association between ventilator bundle compliance and the incidence of ventilator-associated pneumonia (VAP) in critically ill trauma patients.
- To identify independent predictors of VAP and mortality in this patient population.
- To determine if the VB is an effective strategy for VAP prevention in trauma ICUs.
Main Methods:
- A prospective, multi-institutional observational study involving six Level I trauma centers.
- Inclusion criteria: trauma patients requiring at least two days of mechanical ventilation in the ICU.
- Analysis utilized Cox regression with the VB as a time-dependent covariate to evaluate its impact on VAP and mortality.
Main Results:
- The study enrolled 630 trauma patients; 36% developed VAP, and 15% died.
- Logistic regression identified male sex and pulmonary contusion as predictors of VAP.
- Cox regression analysis found no association between VB compliance and VAP prevention.
Conclusions:
- Ventilator-associated pneumonia in trauma patients is independently predicted by male sex and chest injury severity.
- The Institute for Healthcare Improvement's ventilator bundle is not effective in preventing VAP in this population.
- Financial penalties for VAP should not be based on VB noncompliance, and alternative prevention strategies are needed.
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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