Stacked probability plots of the extended illness-death model using constant transition hazards - an easy to use shiny app.

BACKGROUND: Extended illness-death models (a specific class of multistate models) are a useful tool to analyse situations like hospital-acquired infections, ventilation-associated pneumonia, and transfers between hospitals. The main components of these models are hazard rates and transition probabilities. Calculation of different measures and their interpretation can be challenging due to their complexity. METHODS: By assuming time-constant hazards, the complexity of these models becomes manageable and closed mathematical forms for transition probabilities can be derived. Using these forms, we created a tool in R to visualize transition probabilities via stacked probability plots. RESULTS: In this article, we present this tool and give some insights into its theoretical background. Using published examples, we give guidelines on how this tool can be used. Our goal is to provide an instrument that helps obtain a deeper understanding of a complex multistate setting. CONCLUSION: While multistate models (in particular extended illness-death models), can be highly complex, this tool can be used in studies to both understand assumptions, which have been made during planning and as a first step in analysing complex data structures. An online version of this tool can be found at https://eidm.imbi.uni-freiburg.de/ .

Effect of propolis mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: a comparative randomized triple-blind clinical trial.

OBJECTIVES: Ventilator-associated pneumonia (VAP) increases the length of hospitalization and mortality rate. This study aimed to determine the effect of propolis mouthwash on the incidence of VAP in intensive care unit (ICU) patients. MATERIALS AND METHODS: Triple-blind, comparative randomized, controlled clinical trial was conducted over one year, with 110 ICU patients at Imam-Hossein and Bahar hospitals (Shahroud) and Kowsar Hospital (Semnan) in Iran. The intervention group used 15 cc of 0.06% propolis mouthwash solution twice daily at 8 AM and 4 PM for seven days. The control group used 15 cc of 0.2% chlorhexidine mouthwash at the same times and duration. Data were collected using a demographic questionnaire, APACHE II, Beck Oral Assessment Scale, and Modified Clinical Pulmonary Infection Score (MCPIS). RESULTS: There was no significant difference in demographic information, disease severity, and oral health between the two groups before and after intervention (P > 0.05). The incidence of VAP in the intervention group compared to the control group was 10.9% vs. 30.9% on the third day (P = 0.0166, 95% CI: 0.53-0.83 and RR = 0.35), 23.6% vs. 43.6% on the fifth day (P = 0.0325 and 95% CI: 0.31-0.95 and RR = 0.54), and 25.5% vs. 47.3% on the seventh day (P = 0.0224, 95% CI: 0.32-0.92, and RR = 0.54). The Mann-Whitney indicated the incidence of VAP was significantly lower in the intervention group on the third, fifth, and seventh days. CONCLUSION: Propolis mouthwash can be considered as an alternative to chlorhexidine mouthwash for ICU patients. CLINICAL RELEVANCE: Propolis mouthwash serves as a simple, economical intervention to potentially reduce incidence of VAP. TRIAL REGISTRATION: (IRCT20110427006318N12, date 02.04.2019).

The effectiveness of probiotics as an adjunct therapy in patients under mechanical ventilation: an umbrella systematic review and meta-analysis.

The literature regarding the role of probiotics in critically ill patients who have undergone mechanical ventilation (MV) is unclear; therefore, this umbrella systematic review and meta-analysis was carried out to clarify the effects of probiotics on the clinical outcomes of mechanically ventilated patients. The Scopus, PubMed/Medline, ISI Web of Science, and Google Scholar online databases were searched up to February 2023. All meta-analyses evaluating the impact of probiotics in patients under MV were considered eligible. The assessment of multiple systematic reviews (AMSTAR) questionnaire was used to evaluate the quality of the studies. Data were pooled using the random-effects approach. Thirty meta-analyses and nine clinical outcomes were re-analyzed. Probiotics significantly decreased ventilator-associated pneumonia (VAP) incidence, nosocomial infections, intensive care unit (ICU) length of stay, hospital length of stay, ICU mortality, hospital mortality, MV duration, duration of antibiotic use, and diarrhea. The obtained results of the current umbrella meta-analysis indicate that probiotic administration could be considered an adjunct therapy for critically ill patients; however, no specific probiotic treatment regimen can be recommended due to the diverse probiotics used in the included meta-analyses. The following microorganisms were used at various doses and combinations throughout the studies: Lacticaseibacillus casei, Lactiplantibacillus plantarum, L. acidophilus, L. delbrueckii, L. bulgaricus, Bifidobacterium longum, B. breve, B. salivarius, Pediococcus pentosaceus, Lactococcus raffinolactis, B. infantis, B. bifidum, Streptococcus thermophilus, Ligilactobacillus salivarius, L. lactis, B. lactis, Saccharomyces boulardii, L. rhamnosus GG, L. johnsonii, L. casei, S. faecalis, Clostridium butyricum, Bacillus mesentericus, L. sporogenes, S. boulardii, L. paracasei, B. subtilis, and Enterococcus faecium.

Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events.

INTRODUCTION: Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP. AREAS COVERED: This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles. EXPERT OPINION: Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.

Co-immobilization of Ciprofloxacin and Chlorhexidine as a Broad-Spectrum Antimicrobial Dual-Drug Coating for Poly(vinyl chloride) (PVC)-Based Endotracheal Tubes.

The endotracheal tube (ETT) affords support for intubated patients, but the increasing incidence of ventilator-associated pneumonia (VAP) is jeopardizing its application. ETT surfaces promote (poly)microbial colonization and biofilm formation, with a heavy burden for VAP. Devising safe, broad-spectrum antimicrobial materials to tackle the ETT bioburden is needful. Herein, we immobilized ciprofloxacin (CIP) and/or chlorhexidine (CHX), through polydopamine (pDA)-based functionalization, onto poly(vinyl chloride) (PVC) surfaces. These surfaces were characterized regarding physicochemical properties and challenged with single and polymicrobial cultures of VAP-relevant bacteria (Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis) and fungi (Candida albicans). The coatings imparted PVC surfaces with a homogeneous morphology, varied wettability, and low roughness. The antimicrobial immobilization via pDA chemistry was still evidenced by infrared spectroscopy. Coated surfaces exhibited sustained CIP/CHX release, retaining prolonged (10 days) activity. CIP/CHX-coated surfaces evidencing no A549 lung cell toxicity displayed better antibiofilm outcomes than CIP or CHX coatings, preventing bacterial attachment by 4.1-7.2 Log10 CFU/mL and modestly distressingC. albicans. Their antibiofilm effectiveness was endured toward polymicrobial consortia, substantially inhibiting the adhesion of the bacterial populations (up to 8 Log10 CFU/mL) within the consortia in dual- and even inP. aeruginosa/S. aureus/C. albicans triple-species biofilms while affecting fungal adhesion by 2.7 Log10 CFU/mL (dual consortia) and 1 Log10 CFU/mL (triple consortia). The potential of the dual-drug coating strategy in preventing triple-species adhesion and impairing bacterial viability was still strengthened by live/dead microscopy. The pDA-assisted CIP/CHX co-immobilization holds a safe and robust broad-spectrum antimicrobial coating strategy for PVC-ETTs, with the promise laying in reducing VAP incidence.

Probable Non-Ventilator-Associated Hospital-Acquired Pneumonia: A Case Report.

INTRODUCTION: Non-ventilator-associated hospital-acquired pneumonia is a preventable health care-associated infection accounting for 1 in 14 hospital deaths. Clinical factors influencing this condition include oral health and bacteria and oral care. This case report addresses diagnostics and clinical variables related to non-ventilator-associated hospital-acquired pneumonia and emphasizes the importance of prevention. CLINICAL FINDINGS: A 90-year-old woman was admitted to the hospital with shortness of breath and generalized weakness from new-onset atrial fibrillation and suspected heart failure exacerbation. During the hospitalization, her oral health status declined and oral bacterial colonization shifted, with Neisseria becoming the most common oral bacterial genus around the time of development of probable non-ventilator-associated hospital-acquired pneumonia. DIAGNOSIS: The patient had new respiratory symptoms and a chest radiograph positive for pneumonia on day 4 and was subsequently diagnosed with probable non-ventilator-associated hospital-acquired pneumonia. INTERVENTIONS: Intravenous antibiotic treatment was initiated. Oral care was completed on only 2 of 7 days. The patient received limited ambulation assistance and encouragement from staff and family members. No dysphagia screening was documented. OUTCOMES: On day 6, the patient was discharged with oral antibiotics to her independent living facility with home health care. CONCLUSIONS: Consistent oral care, early and frequent physical activity, and measures aimed to reduce aspiration risk are key interventions for all hospitalized patients to prevent non-ventilator-associated hospital-acquired pneumonia. Further research is warranted to assess shifts in oral bacteria and general oral health during hospitalization, which could provide clinically meaningful data on risk for non-ventilator-associated hospital-acquired pneumonia.

Nation-wide survey of oral care practice in Japanese intensive care units: A descriptive study.

Oral care for critically ill patients helps provide comfort and prevent ventilator-associated pneumonia. However, a standardized protocol for oral care in intensive care units is currently unavailable. Thus, this study aimed to determine the overall oral care practices, including those for intubated patients, in Japanese intensive care units. We also discuss the differences in oral care methods between Japanese ICUs and ICUs in other countries. This study included all Japanese intensive care units meeting the authorities' standard set criteria, with a minimum of 0.5 nurses per patient at all times and admission of adult patients requiring mechanical ventilation. An online survey was used to collect data. Survey responses were obtained from one representative nurse per intensive care unit. Frequency analysis was performed, and the percentage of each response was calculated. A total of 609 hospitals and 717 intensive care units nationwide participated; among these, responses were collected from 247 intensive care units (34.4%). Of these, 215 (87.0%) and 32 (13.0%) reported standardized and non-standardized oral care, respectively. Subsequently, the data from 215 intensive care units that provided standardized oral care were analyzed in detail. The most common frequency of practicing oral care was three times a day (68.8%). Moreover, many intensive care units provided care at unequal intervals (79.5%), mainly in the morning, daytime, and evening. Regarding oral care methods, 96 (44.7%) respondents used only a toothbrush, while 116 (54.0%) used both a toothbrush and a non-brushing method. The findings of our study reveal current oral care practices in ICUs in Japan. In particular, most ICUs provide oral care three times a day at unequal intervals, and almost all use toothbrushes as a common tool for oral care. The results suggest that some oral care practices in Japanese ICUs differ from those in ICUs in other countries.

Ceragenin-coated endotracheal tubes for the reduction of ventilator-associated pneumonia: a prospective, longitudinal, cross-over, interrupted time, implementation study protocol (CEASE VAP study).

BACKGROUND: Critically ill patients are at high risk of acquiring ventilator-associated pneumonia (VAP), which occurs in approximately 20% of mechanically ventilated patients. VAP results either from aspiration of pathogen-contaminated oropharyngeal secretions or contaminated biofilms that form on endotracheal tubes (ETTs) after intubation. VAP results in increased duration of mechanical ventilation, increased intensive care unit and hospital length of stay, increased risk of death and increased healthcare costs. Because of its impact on patient outcomes and the healthcare system, VAP is regarded as an important patient safety issue and there is an urgent need for better evidence on the efficacy of prevention strategies. Modified ETTs that reduce aspiration of oropharyngeal secretions with subglottic secretion drainage or reduce the occurrence of biofilm with a coating of ceragenins (CSAs) are available for clinical use in Canada. In this implementation study, we will evaluate the efficacy of these two types of Health Canada-licensed ETTs on the occurrence of VAP, and impact on patient-centred outcomes. METHODS: In this ongoing, pragmatic, prospective, longitudinal, interrupted time, cross-over implementation study, we will compare the efficacy of a CSA-coated ETT (CeraShield N8 Pharma) with an ETT with subglottic secretion drainage (Taper Guard, Covidien). The study periods consist of four alternating time periods of 11 or 12 weeks or a total of 23 weeks for each ETT. All patients intubated with the study ETT in each time period will be included in an intention-to-treat analysis. Outcomes will include VAP incidence, mortality and health services utilisation including antibiotic use and length of stay. ETHICS AND DISSEMINATION: This study has been approved by the Health Sciences Research Ethics Board at Queen's University. The results of this study will be actively disseminated through manuscript publication and conference presentations. TRIAL REGISTRATION NUMBER: NCT05761613.

Efficacy of probiotics or synbiotics in critically ill patients: A systematic review and meta-analysis.

BACKGROUND: This latest systematic review and meta-analysis aim to examine the effects of probiotic and synbiotic supplementation in critically ill patients. METHODS: Relevant articles were retrieved from PubMed, Embase, the Cochrane Database, and the Web of Science. The primary output measure was the incident of ventilator-associated pneumonia, and the secondary outputs were diarrhea, Clostridium diffusion infection (CDI), incident of sepsis, incident of hospital acquired pneumonia, duration of mechanical exploitation, ICU mortality rate, length of ICU stay, in hospital mortality, and length of hospital stay. Data were pooled and expressed as Relative Risk(RR) and Standardized Mean Difference (SMD) with a 95 % confidence interval (CI). RESULTS: 33 studies were included in this systematic review and meta-analysis, with 4065 patients who received probiotics or synbiotics (treatment group) and 3821 patients who received standard care or placebo (control group). The pooled data from all included studies demonstrated that the treatment group has significantly reduced incidence of ventilation-associated pneumonia (VAP) (RR = 0.80; 95 % CI: 0.67-0.96; p = 0.021, I2 = 52.5 %) and sepsis (RR = 0.97; 95 % CI: 0.66-1.42; p = 0.032, I2 = 54.4 %), As well as significantly increased duration of mechanical exploitation (SMD = -0.47; 95 % CI: -0.74-0.20, p = 0.012, I2 = 63.4 %), ICU mobility (RR = 0.95; 95 % CI: 0.71-1.27; p = 0.004, I2 = 62.8 %), length of ICU stay (SMD = -0.29; 95 % CI: -0.58-0.01; p = 0.000, I2 = 82.3 %) and length of hospital stay (SMD = -0.33; 95 % CI: -0.57-0.08, p = 0.000, I2 = 74.2 %) than the control group. There were no significant differences in diarrhea, CDI, incidence of hospital acquired pneumonia, and in hospital mortality between the two groups. CONCLUSION: Our meta-analysis showed that probiotic and synbiotic supplements are beneficial for critically ill patients as they significantly reduce the incidence of ventilator associated pneumonia and sepsis, as well as the duration of mechanical exploitation, length of hospital stay, length of ICU stay, and ICU mortality. However, this intervention has minimal impact on diarrhea, CDI, incidence of hospital acquired pneumonia, and in hospital mortality in critically ill patients.

The next frontier of healthcare-associated infection (HAI) surveillance metrics: Beyond device-associated infections.

In recent years, it has become increasingly evident that surveillance metrics for invasive device-associated infections (ie, central-line-associated bloodstream infections, ventilator-associated pneumonias, and catheter-associated urinary tract infections) do not capture all harms; they capture only a subset of healthcare-associated infections (HAIs). Although prevention of device-associated infections remains critical, we need to address the full spectrum of potential harms from device use and non-device-associated infections. These include complications associated with additional devices, such as peripheral venous and arterial catheters, non-device-associated infections such as nonventilator hospital-acquired pneumonia, and noninfectious device complications such as trauma, thrombosis, and acute lung injury. As authors of the device-associated infection sections in the SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, we highlight catheter-associated urinary tract infection as an example of the strengths and limitations of the current emphasis on device-associated infection surveillance, suggest performance metrics that present a more comprehensive picture of patient harm, and provide a high-level overview of similar issues with other infection surveillance measures.

Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial.

BACKGROUND: Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation. METHODS: PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406. FINDINGS: From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone. INTERPRETATION: In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation. FUNDING: French Ministry of Social Affairs and Health.

Clinical effect of pulmonary rehabilitation in patients with mechanical ventilation: A meta-analysis.

OBJECTIVE: To systematically evaluate the clinical efficacy of pulmonary rehabilitation in patients with mechanical ventilation in an intensive care unit (ICU). METHODS: Relevant studies were identified in the PubMed, Web of Science, National Library of Medicine, China National Knowledge Infrastructure and Wanfang databases. A meta-analysis was performed after screening based on the inclusion and exclusion criteria, data extraction and literature quality evaluation. RESULTS: In total, 19 studies involving 2181 participants were included. The results of the meta-analysis revealed that compared with patients with conventional rehabilitation measures, patients with pulmonary rehabilitation measures had a higher offline success rate (relative risk (RR) = 1.16; 95% confidence interval (CI): 1.09, 1.24; p < 0.00001) and higher arterial oxygen partial pressure levels (mean difference (MD) = 8.96; 95%CI: 5.98, 11.94; p < 0.0001) and these measures significantly shortened the duration of mechanical ventilation (standardised MD (SMD) = -1.08; 95%CI: -1.58, -0.59; p < 0.0001) and ICU stay (SMD = -1.41; 95%CI: -1.94, -0.88; p < 0.0001). Aspiration significantly reduced the incidence of ventilator-associated pneumonia (RR = 0.35; 95%CI: 0.24, 0.51; p < 0.00001) and deep vein thrombosis (RR = 0.32; 95%CI: 0.13, 0.76; p = 0.01) in ICU patients with mechanical ventilation. CONCLUSION: Pulmonary rehabilitation measures can improve the success rate of weaning from mechanical ventilation in ICU patients, shorten the time of mechanical ventilation and ICU hospitalisation and reduce the incidence of related adverse reactions, but the impact on mortality requires further study.

Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses.

Many meta-analyses have assessed the efficacy of preventive interventions against ventilator-associated pneumonia (VAP) in critically ill patients. However, there has been no comprehensive analysis of the strength and quality of evidence to date. Systematic reviews of randomized and quasi-randomized controlled trials, which evaluated the effect of preventive strategies on the incidence of VAP in critically ill patients receiving mechanical ventilation for at least 48 h, were included in this article. We identified a total of 34 interventions derived from 31 studies. Among these interventions, 19 resulted in a significantly reduced incidence of VAP. Among numerous strategies, only selective decontamination of the digestive tract (SDD) was supported by highly suggestive (Class II) evidence (risk ratio (RR)=0.439, 95% CI: 0.362-0.532). Based on data from the sensitivity analysis, the evidence for the efficacy of non-invasive ventilation in weaning from mechanical ventilation (NIV) was upgraded from weak (Class IV) to highly suggestive (Class II) (RR=0.32, 95% CI: 0.22-0.46). All preventive interventions were not supported by robust evidence for reducing mortality. Early mobilization exhibited suggestive (Class III) evidence in shortening both intensive length of stay (LOS) in the intensive care unit (ICU) (mean difference (MD)=-0.85, 95% CI: -1.21 to -0.49) and duration of mechanical ventilation (MD=-1.02, 95% CI: -1.41 to -0.63). In conclusion, SDD and NIV are supported by robust evidence for prevention against VAP, while early mobilization has been shown to significantly shorten the LOS in the ICU and the duration of mechanical ventilation. These three strategies are recommendable for inclusion in the ventilator bundle to lower the risk of VAP and improve the prognosis of critically ill patients.

Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention.

Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units.

BACKGROUND: Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate. AIM: To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. METHODS: A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. RESULTS: The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. CONCLUSION: Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

Effects of ventilatory bundles on patient outcomes among ICU patients: A systematic review and meta-analysis.

BACKGROUND: Ventilator bundles are suggested to prevent ventilator-associated pneumonia (VAP), but significant variations in the effects of the bundle on patient outcomes have been reported. OBJECTIVES: To synthesize the evidence and evaluate the effects of the ventilator bundle on patient outcomes among critically ill adult patients. METHODS: A broad search was performed in seven databases for relevant articles published from January 2002 to November 2022. Randomized controlled trials and quasi-experimental studies investigating the effects of implementing ventilator bundles in adult intensive care units (ICUs) were included. Two independent reviewers performed the study selection, data extraction, and risk of bias assessment. All data for meta-analysis were pooled using the random-effects model. RESULTS: After screening, 19 studies were included in the meta-analysis. Evidence of low-to-moderate certainty showed that the ventilator bundle reduced the rate of VAP (risk ratio [RR] = 0.64; P = 0.003), length of ICU stay (mean difference [MD] = -2.57; P = 0.03), mechanical ventilation days (MD = -3.38; P < 0.001), and ICU mortality (RR = 0.76; P = 0.02). Ventilator bundle was associated with improved outcomes, except mortality. CONCLUSIONS: The ventilator bundle, especially the IHI ventilator bundle, was effective in decreasing the incidence of VAP and improving most of the VAP-related outcomes. However, given the low-to-moderate certainty of evidence and high heterogeneity, these results should be interpreted with caution. A future study that adopts hybrid implementation trials with high methodological quality is needed to confirm the effects of the ventilator bundle on patient outcomes.

Identifying the barriers and facilitators to implementation of ventilator bundle in the nepalese intensive care unit: A descriptive qualitative study.

BACKGROUND: A ventilator bundle is an effective preventive strategy against the development of ventilator-associated pneumonia (VAP). However, in clinical practice ventilator bundle implementation is poor. Understanding the barriers to ventilator bundle implementation in low- and middle-income countries can inform the development of effective implementation strategies to reduce the burden of VAP. OBJECTIVES: The primary objective of this study was to explore the barriers and facilitators of ventilator bundle implementation perceived by healthcare professionals (HCPs) working in intensive care units (ICU) in Nepal. The secondary objective was to prioritise the barriers when developing implementation strategies. METHODS: This study used a pragmatic approach comprising a series of methods to identify the implementation strategies: (i) Barriers and facilitators were explored using a qualitative study design. Twenty-one HCPs selected using the maximum variation sampling technique from a large tertiary hospital, completed semistructured interviews. All the interviews were recorded, transcribed word-by-word, and uploaded into NVivo for analysis using the thematic analysis approach. (ii) After analysis, nine participants were selecteded to determine the priority order of the barriers using a barrier identification and mitigation tool. RESULTS: The data analysis revealed five main themes and 19 subthemes that affected ventilator bundle implementation. The main themes were provider-related factors, organisational and practice-related factors, performances of work, environmental conditions, and patient-related factors. The common barriers were job insecurity, poor knowledge, negative attitude, insufficient equipment, and severity of patient disease. Common facilitators were educational training, equipment functioning, adequate staff, strong leadership, and organisational support. Finally, eight main barriers were prioritised to target the change. CONCLUSION: The barriers to implementing ventilator bundles in ICUs were identified. Focussing on addressing the prioritised barriers may aid in improving patient care and safety in ICUs. Results may guide HCPs in the development of implementation strategies to reduce the burden of VAP.