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National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: Does it really work?

Croce, Martin A. MD; Brasel, Karen J. MD, MPH; Coimbra, Raul MD, PhD; Adams, Charles A. Jr MD; Miller, Preston R. MD; Pasquale, Michael D. MD; McDonald, Chanchai S. PhD; Vuthipadadon, Somchan PhD; Fabian, Timothy C. MD; Tolley, Elizabeth A. PhD

Journal of Trauma and Acute Care Surgery: February 2013 - Volume 74 - Issue 2 - p 354–362
doi: 10.1097/TA.0b013e31827a0c65
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BACKGROUND Since its introduction by the Institute for Healthcare Improvement, the ventilator bundle (VB) has been credited with a reduction in ventilator-associated pneumonia (VAP). The VB consists of stress ulcer prophylaxis, deep venous thrombosis prophylaxis, head-of-bed elevation, and daily sedation vacation with weaning assessment. While there is little compelling evidence that the VB is effective, it has been widely accepted. The Centers for Medical and Medicaid Services has suggested that VAP should be a “never event” and may reduce payment to providers. To provide evidence of its efficacy, the National Trauma Institute organized a prospective multi-institutional trial to evaluate the utility of the VB.

METHODS This prospective observational multi-institutional study included six Level I trauma centers. Entry criteria required at least 2 days of mechanical ventilation of trauma patients in an intensive care unit (ICU). Patients were followed up daily in the ICU until the development of VAP, ICU discharge, or death. Compliance for each VB component was recorded daily, along with patient risk factors and injury specifics. Primary outcomes were VAP and death. VB compliance was analyzed as a time-dependent covariate using Cox regression as it relates to outcomes.

RESULTS A total 630 patients were enrolled; 72% were male, predominately with blunt injury; and mean age, Injury Severity Score (ISS), and 24-hour Glasgow Coma Scale (GCS) score were 47, 24, and 8.7, respectively. VAP occurred in 36%; mortality was 15%. Logistic regression identified male sex and pulmonary contusion as independent predictors of VAP and age, ISS, and 24-hour Acute Physiology and Chronic Health Evaluation as independent predictors of death. Cox regression analysis demonstrated that the VB, as a time-dependent covariate, was not associated with VAP prevention.

CONCLUSION In trauma patients, VAP is independently associated with male sex and chest injury severity and not the VB. While quality improvement activities should continue efforts toward VAP prevention, the Institute for Healthcare Improvement VB is not the answer. Financial penalties for VAP and VB noncompliance are not warranted.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Department of Surgery (M.A.C, T.C.F.), Biomedical Informatics (C.S.M., S.V.), and Biostatistics and Epidemiology (E.A.T.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (K.J.B.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (R.C.), University of California, San Diego, San Diego, California; Department of Surgery (C.A.A.), Brown University, Providence, Rhode Island; Department of Surgery (P.R.M.), Wake Forest University, Salem, North Carolina; Department of Surgery (M.D.P.), Lehigh Valley Hospital, Allentown, Pennsylvania.

Submitted: September 19, 2012, Revised: October 11, 2012, Accepted: October 12, 2012.

This study was presented at the 71st Annual Meeting of the American Association for the Surgery of Trauma September 12–15, 2012, in Kauai, Hawaii.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Address for reprints: Martin A. Croce, MD, Department of Surgery, University of Tennessee Health Science Center, 910 Madison, #220, Memphis, TN 38163; email:

© 2013 Lippincott Williams & Wilkins, Inc.