title: Implementation and enforcement of ventilator-associated pneumonia prevention strategies in trauma patients.
abstract: BACKGROUND
  We hypothesized that strict enforcement of ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP and improve patient outcomes.
  
  
  METHODS
  This retrospective study examined 696 consecutive ventilated patients in a Level One trauma center. Three study groups were compared: Pre-VAPP, VAPP implementation, and VAPP enforcement. Ventilator days were compared with occurrences of VAP, defined by the U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to evaluate the effect of VAP on patient outcome. Fisher exact, Kruskal-Wallis, and chi-square analyses were used, and p < 0.05 was considered significant.
  
  
  RESULTS
  During the pre-VAPP protocol period, 5.2 cases of VAP occurred per 1,000 days of ventilator support. The number of cases of VAP decreased to 2.4/1,000 days (p = 0.172) and 1.2/1,000 days (p = 0.085) in the implementation and enforcement periods, respectively. However, when including all trauma patients, regardless of head Abbreviated Injury Score (AIS) score, the difference in the rate of VAP was statistically significant in the enforcement period, but not in the implementation period, compared with the pre-VAPP period (p = 0.014 and 0.062, respectively). A significant decrease was seen in the mortality rate (p = 0.024), total hospital days (p = 0.007), intensive care unit days (p = 0.002), ventilator days (p = 0.002), and hospital charges (p = 0.03) in patients without VAP compared with patients having VAP.
  
  
  CONCLUSIONS
  There was a statistically significant decrease in the occurrence of VAP with strict enforcement of a VAPP protocol, regardless of head AIS score. Although the difference in patients with a head AIS score <3 was not statistically significant, it was clinically meaningful, decreasing the already-low rate of VAP by half. Strict enforcement of VAPP protocols may be cost efficient for hospitals and prevent decreased reimbursement under the Medicare pay-for-performance strategies.
authors.affiliation: Department of Surgery, The University of Kansas Medical Center, Kansas City, Kansas 66160, USA. jheimes@kumc.edu
authors.forename: Jessica
authors.initials: J
authors.lastname: Heimes
authors.forename: Carla
authors.initials: C
authors.lastname: Braxton
authors.forename: Niaman
authors.initials: N
authors.lastname: Nazir
authors.forename: Nina
authors.initials: N
authors.lastname: Shik
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Carlton
authors.forename: Todd
authors.initials: T
authors.lastname: Lansford
authors.forename: John
authors.initials: J
authors.lastname: Alley
authors.forename: Jessica
authors.initials: J
authors.lastname: McDonnell
authors.forename: Tracy
authors.initials: T
authors.lastname: Rogers
authors.forename: Michael
authors.initials: M
authors.lastname: Moncure
mesh_terms: D006302:Health Services Research; D006801:Humans; D015994:Incidence; D017053:Infection Control / Q000379:methods*; D053717:Pneumonia, Ventilator-Associated / Q000453:epidemiology / Q000517:prevention & control*; D012189:Retrospective Studies; D014481:United States; D014947:Wounds and Injuries / Q000150:complications*