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Effectiveness of a Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia at the PICU

A Systematic Review and Meta-Analysis

de Neef, Marjorie, MSc, RN1; Bakker, Leo, MSc, RN2; Dijkstra, Sandra, RN3; Raymakers-Janssen, Paulien, MSc, RN4; Vileito, Alicija, MSc, RN5; Ista, Erwin, PhD, RN6

Pediatric Critical Care Medicine: January 16, 2019 - Volume Online First - Issue - p
doi: 10.1097/PCC.0000000000001862
Review Article: PDF Only
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Objectives: Ventilator-associated pneumonia is one of the most frequent hospital-acquired infections in mechanically ventilated children. We reviewed the literature on the effectiveness of ventilator care bundles in critically ill children.

Data Sources: Embase, Medline OvidSP, Web-of-Science, Cochrane Library, and PubMed were searched from January 1990 until April 2017.

Study Selection: Studies were included if they met the following criteria: 1) implementation of a ventilator care bundle in PICU setting; 2) quality improvement or multicomponent approach with the (primary) objective to lower the ventilator-associated pneumonia rate (expressed as ventilator-associated pneumonia episodes/1,000 ventilator days); and 3) made a comparison, for example, with or without ventilator care bundle, using an experimental randomized or nonrandomized study design, or an interrupted-times series. Exclusion criteria were (systematic) reviews, guidelines, descriptive studies, editorials, or poster publications.

Data Extraction: The following data were collected from each study: design, setting, patient characteristics (if available), number of ventilator-associated pneumonia per 1,000 ventilator days, ventilator-associated pneumonia definitions used, elements of the ventilator care bundle, and implementation strategy. Ambiguities about data extraction were resolved after discussion and consulting a third reviewer (M.N., E.I.) when necessary. We quantitatively pooled the results of individual studies, where suitable. The primary outcome, reduction in ventilator-associated pneumonia per 1,000 ventilator days, was expressed as an incidence risk ratio with a 95% CI. All data for meta-analysis were pooled by using a DerSimonian and Laird random effect model.

Data Synthesis: Eleven articles were included. The median ventilator-associated pneumonia incidence decreased from 9.8 (interquartile range, 5.8–18.5) per 1,000 ventilator days to 4.6 (interquartile range, 1.2–8.6) per 1,000 ventilator days after implementation of a ventilator care bundle. The meta-analysis showed that the implementation of a ventilator care bundle resulted in significantly reduced ventilator-associated pneumonia incidences (incidence risk ratio = 0.45; 95% CI, 0.33–0.60; p < 0.0001; I 2 = 55%).

Conclusions: Implementation of a ventilator-associated pneumonia bundle has the potential to reduce the prevalence of ventilator-associated pneumonia in mechanically ventilated children.

1Intensive Care Unit, Department of Pediatrics, Amsterdam UMC – Emma Children’s Hospital, Amsterdam, The Netherlands.

2Intensive Care Unit, Department of Intensive care, Radboud University Medical Center, Nijmegen, The Netherlands.

3Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

4Intensive Care Unit, Department of Pediatrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, The Netherlands.

5Intensive Care Unit, Department of Pediatrics, VUMC, Amsterdam, The Netherlands.

6Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC – Sophia Children’s Hospital, University Medical Center, Rotterdam, The Netherlands.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: m.deneef@amc.uva.nl

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies