title: The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence.
abstract: OBJECTIVE
  The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator-associated pneumonia (VAP) outcomes.
  
  
  BACKGROUND
  The VCB is a group of four evidence-based procedures, which when clustered together and implemented as an 'all or nothing' strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions.
  
  
  METHODS
  A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded.
  
  
  CONCLUSIONS
  Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four-element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes.
  
  
  CONCLUSIONS
  A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.
authors.affiliation: Nursing Research & Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia.
authors.forename: Petra
authors.initials: P
authors.lastname: Lawrence
authors.forename: Paul
authors.initials: P
authors.lastname: Fulbrook
mesh_terms: D000328:Adult; D019317:Evidence-Based Medicine; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control*; D012121:Respiration, Artificial / Q000379:methods*