title: Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years.
abstract: BACKGROUND
  Several studies showed that the implementation of the Institute for Healthcare Improvement (IHI) ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia (VAP) rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization.
  
  
  METHODS
  The study was conducted at the adult medical-surgical intensive care unit (ICU) at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) methodology while bundle data were collected by a cross-sectional design as per IHI methodology.
  
  
  RESULTS
  Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 (P for trend < 0.001). On the other hand, VAP rate decreased from 3.6 (per 1000 ventilator days) in 2010 to 1.0 in 2013 (P for trend = 0.054) and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 (P for trend < 0.001). There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate (cross-correlation coefficients -0.63 to 0.07) and ventilator utilization (cross-correlation coefficients -0.18 to -0.63).
  
  
  CONCLUSIONS
  More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link.
authors.affiliation: Infection Prevention and Control Department, King Abdulaziz Medical City, Jeddah and Riyadh, Saudi Arabia.
authors.forename: Majid S
authors.initials: MS
authors.lastname: Al-Thaqafy
authors.affiliation: Infection Prevention and Control Department, King Abdulaziz Medical City, Jeddah and Riyadh, Saudi Arabia ; Community Medicine Department, Faculty of Medicine, Mansoura University, Egypt.
authors.forename: Aiman
authors.initials: A
authors.lastname: El-Saed
authors.affiliation: Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: Yaseen M
authors.initials: YM
authors.lastname: Arabi
authors.affiliation: Infection Prevention and Control Department, King Abdulaziz Medical City, Jeddah and Riyadh, Saudi Arabia.
authors.forename: Hanan H
authors.initials: HH
authors.lastname: Balkhy
keywords: Bundle; Institute for Healthcare Improvement; health-care-associated infection; quality improvement; ventilator utilization; ventilator-associated pneumonia