Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events

Abstract

Objective Ventilator-associated events (VAE) are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the NIH and AHRQ funded a two-state collaborative to reduce VAEs. We describe the collaborative’s impact on VAE rates in 56 ICUs. Design Longitudinal quasi-experimental study. Setting 56 intensive care units (ICUs) at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. Interventions We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multi-disciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a web-based portal. Measurements and Results ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of VAE data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean VAE rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p=0.007). During the same time period, infection-related ventilator-associated complication (IVAC) and possible and probable ventilator-associated pneumonia (PVAP) rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p=0.018, p=0.012), respectively. Conclusions A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in VAE, IVAC and PVAP. Our study is the largest to date affirming that best practices can prevent VAEs.

Implementing the comprehensive unit-based safety program model to improve the management of mechanically ventilated patients in Saudi Arabia

“…This is similar to data published from 56 ICUs in Maryland and Pennsylvania with 69,417 ventilated patient-days in which compliance with SAT and SBT was 77.5% and 71%, respectively. 24 Our ICUs have a nurse-led sedation vacation protocol and target sedation scores for all sedated patients. Furthermore, we have an SBT protocol that is respiratory therapist driven.…”

Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

“…15,16 Nevertheless, the potential to decrease VAP rates using VAP prevention bundles has been demonstrated by many authors, [17][18][19][20][21][22] and the preventable proportion of VAP was estimated to be 52%-55%. 23,24 Effective implementation is as important as choosing the right bundle components.…”

Using Objective Fluid Balance Data to Identify Pulmonary Edema in Subjects With Ventilator-Associated Events

“…Furthermore, instead of merely being a tool for the surveillance of VAEs, the long-term goal of the VAE algorithm should be to improve outcomes of mechanically ventilated subjects through prevention of VAEs. 5 As shown by Rawat et al, 15 the incidence of VAEs was reduced by 37.6% after implementation of a multifaceted intervention, highlighting the substantial role of the VAE algorithm in improving patient outcomes. Accumulating evidence have shown the crucial need of the conservative fluid strategy in critically ill patients, 27 and we identified in other work the critical role of cumulative fluid balance in critically ill influenza subjects.…”

“…A number of studies have characterized the incidence rate of VAE, ranging from 5% to 10% in mechanically ventilated subjects or from 2 to 12 events per 1,000 ventilator days. 2,7,8,10 Rawat et al 15 conducted a longitudinal quasi-experimental study that included 38 hospitals in Maryland and Pennsylvania between 2012 and 2015 and reported that the incidence rate was approximately 5 events per 1,000 ventilator days after the implementation of bundle care consisting of head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. In our ICU, bundled care with head-of-bed elevation, oral mouth care using chlorhexidine, daily assessment of sedation status, and spontaneous breathing trials was implemented for all participants and checked daily during the study period, and the incidence of VAE was 7.7 events per 1,000 ventilator days, which is similar to the data reported by Rawat et al 15 (Fig.…”