Implementation and enforcement of ventilator-associated pneumonia prevention strategies in trauma patients.

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.

Efficacy of a pneumonia prevention protocol in the reduction of ventilator-associated pneumonia in trauma patients.

BACKGROUND: We hypothesized that implementing evidence-based ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP, and that VAP affects patient outcomes. METHODS: A prospective study was performed with 331 consecutive ventilated trauma patients in a level one university teaching hospital. The VAPP protocol was modified to include elevation of the head of the bed more than 30 degrees , twice-daily chlorhexidine oral cleansing, a once-daily respiratory therapy-driven weaning attempt, and conversion from a nasogastric to an orogastric tube whenever possible. Ventilator days were compared with occurrences of nosocomial pneumonia, as defined by the U.S. Centers for Disease Control National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to discern the effect VAP has on outcome. RESULTS: In 2003, there were 1,600 days of ventilator support with 11 occurrences of VAP (6.9/1,000 ventilator days). In 2004, there were two occurrences of VAP in 703 days of ventilation (2.8/1,000 ventilator days). In the analysis of outcomes of the patients with and without VAP, there was a statistically significant difference in total hospital days (38.7 +/- 26.2 vs. 13.3 +/- 15.5), ICU days (27.8 +/- 12.6 vs. 7.5 +/- 9.7), ventilator days (21.1 +/- 9.8 vs. 6.0 +/- 10.3), Functional Independence Measures (7.25 +/- 2.3 vs. 10.8 +/- 1.8), and hospital charges ($371,416.70 +/- $227,774.31 vs. $138,317.39 +/- $208,346.64)(p < 0.05 for all). The mortality rate did not decrease significantly (20% vs. 7.5%; p = NS). The difference in the mean Injury Severity Score in the two groups was not significant (21.9 +/- 9.6 vs. 16.7 +/- 11.4 points) and thus could not account for the differences in outcomes. CONCLUSION: These data suggest that a VAPP protocol may reduce VAP in trauma patients. Ventilator-associated pneumonia may result in more hospital, ICU, and ventilator days and higher patient charges.