Bundle to reduce ventilator associated events

Nishi Rawat, Ting Yang,  Kisha J. Ali et el  published a two state multifaceted intervention study showing benefits of improved compliance with evidence based practices can reduce ventilator-associated event, infection-related ventilator- associated complication, and probable ventilator-associated pneumonia. It was a longitudinal quasi-experimental study involving 56 ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015.


In January 2013, the Centers for Disease Control and Prevention (CDC) released new surveillance
definitions for ventilator associated events(VAEs). Updated version of these definition is in the picture below.  VAEs are associated with prolonged mechanical ventilation, increased mortality, antimicrobial use, and ICU, and hospital lengths of stay.


All hospitals in
Maryland and Pennsylvania with an adult ICU were invited to participate to implement the following

  1. Head-of-bed elevation (HOB),
  2. Use of subglottic suctioning for endotracheal tubes (Sub-G ETTs),
  3. Oral care (OC) six times per day,
  4. Chlorhexidine mouth care (CHG) two times per day,
  5. Performance of spontaneous awakening trials (SATs), and
  6. Performance of spontaneous breathing trials (SBTs).


The quarterly mean VAE rate significantly decreased from 7.34 cases per 1,000 ventilator-days during the first study quarter to 4.58 cases after 24 months of implementation (p = 0.007).

A statistically significant decrease in VAE rates over time, with an average 6% (95%
CI, 2–9%; p = 0.002) quarterly decrease in the incidence rate


The future bundle would incorporate newer interventions based on emerging evidence, and these include the following

  1. Early mobility
  2. Low tidal volume interventions
  3. Conservative fluid and transfusion strategies


  1. Not a randomized study
  2. Duration of mechanical ventilation, ICU, and hospital length of stay, or mortality not studied
  3. Not able to compare participating ICUs with nonparticipating ICUs
  4. No validation of intervention compliance and VAE data
  5. Did not evaluate VAE rates pre- and postintervention


In this study, HOB compliance remained high and Sub-G ETT compliance remained low. By this measure, OC, CHG, SAT, and SBT had the most impact.


All these interventions are simple, and potentially without significant harm and should be employed by all ICUs.

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