National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients

Does it really work?

Martin Croce, Karen J. Brasel, Raul Coimbra, Charles A. Adams, Preston R. Miller, Michael D. Pasquale, Chanchai S. McDonald, Somchan Vuthipadadon, Timothy Fabian, Elizabeth Tolley

Research output: Contribution to journalArticle

34 Citations (Scopus)

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 timedependent covariate using Cox regression as it relates to outcomes. RESULTS: Atotal 630 patientswere 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.

Original languageEnglish (US)
Pages (from-to)354-362
Number of pages9
JournalJournal of Trauma and Acute Care Surgery
Volume74
Issue number2
DOIs
StatePublished - Feb 1 2013

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Ventilator-Associated Pneumonia
Mechanical Ventilators
Wounds and Injuries
Intensive Care Units
Injury Severity Score
Compliance
Delivery of Health Care
Medical Errors
Thoracic Injuries
Nonpenetrating Wounds
Glasgow Coma Scale
APACHE
Contusions
Trauma Centers
Medicaid
Quality Improvement
Weaning
Artificial Respiration
Venous Thrombosis
Ulcer

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients : Does it really work? / Croce, Martin; Brasel, Karen J.; Coimbra, Raul; Adams, Charles A.; Miller, Preston R.; Pasquale, Michael D.; McDonald, Chanchai S.; Vuthipadadon, Somchan; Fabian, Timothy; Tolley, Elizabeth.

In: Journal of Trauma and Acute Care Surgery, Vol. 74, No. 2, 01.02.2013, p. 354-362.

Research output: Contribution to journalArticle

Croce, M, Brasel, KJ, Coimbra, R, Adams, CA, Miller, PR, Pasquale, MD, McDonald, CS, Vuthipadadon, S, Fabian, T & Tolley, E 2013, 'National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: Does it really work?', Journal of Trauma and Acute Care Surgery, vol. 74, no. 2, pp. 354-362. https://doi.org/10.1097/TA.0b013e31827a0c65
Croce, Martin ; Brasel, Karen J. ; Coimbra, Raul ; Adams, Charles A. ; Miller, Preston R. ; Pasquale, Michael D. ; McDonald, Chanchai S. ; Vuthipadadon, Somchan ; Fabian, Timothy ; Tolley, Elizabeth. / National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients : Does it really work?. In: Journal of Trauma and Acute Care Surgery. 2013 ; Vol. 74, No. 2. pp. 354-362.
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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 timedependent covariate using Cox regression as it relates to outcomes. RESULTS: Atotal 630 patientswere 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.",
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AU - Brasel, Karen J.

AU - Coimbra, Raul

AU - Adams, Charles A.

AU - Miller, Preston R.

AU - Pasquale, Michael D.

AU - McDonald, Chanchai S.

AU - Vuthipadadon, Somchan

AU - Fabian, Timothy

AU - Tolley, Elizabeth

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N2 - 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 timedependent covariate using Cox regression as it relates to outcomes. RESULTS: Atotal 630 patientswere 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.

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