title: Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle.
abstract: OBJECTIVE
  Ventilator-associated pneumonia is the most common intensive care unit-acquired infection. Although there is widespread consensus that evidenced-based interventions reduce the risk of ventilator-associated pneumonia, controversy has surrounded the importance of implementing them as a "bundle" of care. This study aimed to determine the effects of implementing such a bundle while controlling for potential confounding variables seen in similar studies.
  
  
  METHODS
  A before-and-after study conducted within the context of an existing, independent, infection surveillance program.
  
  
  METHODS
  An 18-bed, mixed medical-surgical teaching hospital intensive care unit.
  
  
  METHODS
  All patients admitted to intensive care for 48 hrs or more during the periods before and after intervention.
  
  
  METHODS
  A four-element ventilator-associated pneumonia prevention bundle, consisting of head-of-bed elevation, oral chlorhexidine gel, sedation holds, and a weaning protocol implemented as part of the Scottish Patient Safety Program using Institute of Health Care Improvement methods.
  
  
  RESULTS
  Compliance with head-of-bed elevation and chlorhexidine gel were 95%-100%; documented compliance with "wake and wean" elements was 70%, giving overall bundle compliance rates of 70%. Compared to the preintervention period, there was a significant reduction in ventilator-associated pneumonia in the postintervention period (32 cases per 1,000 ventilator days to 12 cases per 1,000 ventilator days; p<.001). Statistical process control charts showed the decrease was most marked after bundle implementation. Patient cohorts staying ≥6 and ≥14 days had greater reduction in ventilator-associated pneumonia acquisition and also had reduced antibiotic use (reduced by 1 and 3 days; p=.008/.007, respectively). Rates of methicillin-resistant Staphylococcus aureus acquisition also decreased (10% to 3.6%; p<.001).
  
  
  CONCLUSIONS
  Implementation of a ventilator-associated pneumonia prevention bundle was associated with a statistically significant reduction in ventilator-associated pneumonia, which had not been achieved with earlier ad hoc ventilator-associated pneumonia prevention guidelines in our unit. This occurred despite an inability to meet bundle compliance targets of 95% for all elements. Our data support the systematic approach to achieving high rates of process compliance and suggest systematic introduction can decrease both infection incidence and antibiotic use, especially for patients requiring longer duration of ventilation.
authors.affiliation: Medical Research Council/University Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland. mozza@doctors.org.uk
authors.forename: Andrew Conway
authors.initials: AC
authors.lastname: Morris
authors.forename: Alasdair W
authors.initials: AW
authors.lastname: Hay
authors.forename: David G
authors.initials: DG
authors.lastname: Swann
authors.forename: Kirsty
authors.initials: K
authors.lastname: Everingham
authors.forename: Corrienne
authors.initials: C
authors.lastname: McCulloch
authors.forename: Jane
authors.initials: J
authors.lastname: McNulty
authors.forename: Odette
authors.initials: O
authors.lastname: Brooks
authors.forename: Ian F
authors.initials: IF
authors.lastname: Laurenson
authors.forename: Brian
authors.initials: B
authors.lastname: Cook
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Walsh
mesh_terms: D018806:APACHE; D000368:Aged; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D017053:Infection Control / Q000379:methods*; D007362:Intensive Care Units / Q000458:organization & administration*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control*; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D016896:Treatment Outcome