86. Ventilator-Associated Pneumonia in Trauma Intensive Care Unit, a Dilemma in Quality Metrics

Abstract Background Ventilator-associated pneumonia (VAP) definition remains controversial. Ventilator-associated event (VAE) and probable/possible VAPs are reported to the National Healthcare Network (NHSN). In trauma patients, VAPs are also reported to the Trauma Quality Improvement Project (TQIP) utilizing the National Trauma Data Bank (NTDB)’s definition. Methods We reviewed all VAPs reported to NHSN and TQIP in trauma patients at the University of Nebraska Medical Center between January 1, 2015 and June 30, 2018. The primary objective was to determine the discordance rates between NHSN and NTDB definitions. VAPs identified by both NHSN+NTDB considered concordant; if identified by only one definition, considered discordant. Secondary objectives were mortality, intensive care unit (ICU) length of stay (LOS), and ventilator (vent) days. Fisher’s exact test and the Kruskal–Wallis test were used where appropriate; P < 0.05 = statistical significance. Results In total, 998 patients had 5,624 days of vent support during the study period. One hundred and one patients were diagnosed with VAP. The median age was 43 years (range 2–92), median vent days were 14 days (range 3–128), and median ICU LOS was 16 days (range 6–47). Of the 101 patients, 28 (27%) met VAP definition by NHSN and 88 (87%) by NTDB. Of the 101 patients, 15 (15%) were concordant and 85 (85%) were discordant. Cumulative all-cause mortality was 23/101 (23%). Composite analysis showed mortality 5/15 (33%) in concordant group, 3/13 (23%) in NHSN group, and 15/73 (20%) in NTDB group (P = 0.52). Median vent days between concordant, NHSN, and NTDB groups were 14 days, 16 days, and 14 days, respectively (P = 0.71). Median ICU LOS was 17 days in concordant, 21 days in NHSN, and 14 days in NTDB group (P = 0.094). Similarly, comparison of NHSN VAE with NTDB VAP definition showed 67/101 (66%) were discordant. There was no statistically significant difference in mortality between concordant (NHSN VAE+NDTB VAP) 9/34 (26%), NHSN VAE 3/13 (23%), and NTDB VAP 11/54 (20%) (P = 0.84). Conclusion Our study showed very high discordant (85%) reporting of VAP to different agencies. No difference in mortality, ICU LOS, and vent days was noted. The high discordance of reported VAPs results in inconsistency in quality metrics and hinders initiatives to decrease VAPs depending on which definition is followed. Improved standardization is needed. Disclosures All Authors: No reported Disclosures.

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Microbial Air Contamination in an Intensive Care Unit

International Journal of Public Health Science (IJPHS) ◽

10.11591/.v4i3.4725 ◽

2015 ◽

Vol 4 (3) ◽

pp. 145

Author(s):

Chih-Yi Chang ◽

Liang Tseng ◽

Lung-Shih Yang

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Statistical Significance ◽

Incidence Density ◽

Air Contamination ◽

Care Services ◽

Air Sampler ◽

Significant Difference ◽

Central Taiwan

Unit layout affects every aspect of intensive care services, including patient safety. A previous study has shown that patients admitted to beds adjacent to the sink and to the door of a large bayroom had the highest number of positive blood cultures and the highest blood culture incidence density, respectively. The present study measures microbial air contamination in a medical intensive care unit of a medical center in central Taiwan. Of the 17 rooms, 8 rooms with distinct physical environmental characteristics were selected. Sampling tests were conducted between December 2013 and February 2014 with a microbial air sampler (MAS-100NT). TSA was used for bacteria collection and DG18 for fungi collection. The overall average bacterial and fungal concentrations were 83CFU/m3 and 69CFU/m3, respectively. The ranges were between 8-354 CFU/m3 and 0-1468 CFU/m3, respectively. A significant difference was found in the bacterial concentration (p=.005) between different room locations. The highest concentration was found in the rooms located at the front end of the circulation (99 CFU/m3), while the lowest was found in the rooms located at the rear end of the circulation (55CFU/m3). Differences in fungal concentrations for different room locations did not reach statistical significance. In addition, differences in bacterial and fungal concentrations for rooms with different sink locations did not reach statistical significance. Even though the microbial concentrations generally complied with standards, the results may help designers and hospital administrators develop a healthier environment for patients.

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Microbial Air Contamination in an Intensive Care Unit

International Journal of Public Health Science (IJPHS) ◽

10.11591/ijphs.v4i3.4725 ◽

2015 ◽

Vol 4 (3) ◽

pp. 145

Author(s):

Chih-Yi Chang ◽

Liang Tseng ◽

Lung-Shih Yang

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Statistical Significance ◽

Incidence Density ◽

Air Contamination ◽

Care Services ◽

Air Sampler ◽

Significant Difference ◽

Central Taiwan

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Among Trauma Patients, Younger Men with Ventilator-Associated Pneumonia Have Worse Outcomes Compared to Older Men—An Exploratory Study

Healthcare ◽

10.3390/healthcare7020067 ◽

2019 ◽

Vol 7 (2) ◽

pp. 67

Author(s):

Duraid Younan ◽

Sarah Delozier ◽

Nathaniel McQuay ◽

John Adamski ◽

Aisha Violette ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Length Of Stay ◽

Older Men ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Ventilator Associated Pneumonia ◽

Icu Stay ◽

Younger Men

Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP). Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival. Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, (p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days (p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09). Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.

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Reduction in Inadequate Empiric Antibiotic Therapy for Ventilator-Associated Pneumonia: Impact of a Unit-Specific Treatment Pathway

The American Surgeon ◽

10.1177/000313480807400610 ◽

2008 ◽

Vol 74 (6) ◽

pp. 516-523 ◽

Cited By ~ 8

Author(s):

Louis J. Magnotti ◽

Thomas J. Schroeppel ◽

Timothy C. Fabian ◽

L. Paige Clement ◽

Joseph M. Swanson ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Antibiotic Therapy ◽

Injury Severity ◽

Specific Treatment ◽

Empiric Antibiotic Therapy ◽

Trauma Patients ◽

Ventilator Associated Pneumonia ◽

Empiric Antibiotic ◽

Specific Pathway

Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). Reported mortality rates for inadequate empiric antibiotic therapy (IEAT) for VAP range from 45 to 91 per cent. The purpose of this study was to determine the effect of a unit-specific pathway for the empiric management of VAP on reducing IEAT episodes and improving outcomes in trauma patients. Patients admitted with VAP over 36-months were identified and stratified by gender, age, severity of shock, and injury severity. Outcomes included number of IEAT episodes, ventilator days, intensive care unit days, hospital days, and mortality. Three hundred and ninety-three patients with 668 VAP episodes were identified. There were 144 (22%) IEAT episodes: significantly reduced compared with our previous study (39%) ( P < 0.001). Patients were classified by number of IEAT episodes: 0 (n = 271), 1 (n = 98) and ≥ 2 (n = 24). Mortality was 12 per cent, 13 per cent, and 38 per cent ( P < 0.001), respectively. Multivariable logistic regression identified multiple IEAT episodes as an independent predictor of mortality (odds ratio = 4.7; 95% confidence interval: 1.684–13.162). Multiple IEAT episodes were also associated with prolonged mechanical ventilation and intensive care unit stay ( P < 0.001). Trauma patients with multiple IEAT episodes for VAP have increased morbidity and mortality. Adherence to a unit-specific pathway for the empiric management of VAP reduces multiple IEAT episodes. By limiting IEAT episodes, resource utilization and hospital mortality are significantly decreased.

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Performance of Prognostic Scoring Systems in Trauma Patients in the Intensive Care Unit of a Trauma Center

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17197226 ◽

2020 ◽

Vol 17 (19) ◽

pp. 7226

Author(s):

Shao-Chun Wu ◽

Sheng-En Chou ◽

Hang-Tsung Liu ◽

Ting-Min Hsieh ◽

Wei-Ti Su ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Organ Dysfunction ◽

Scoring Systems ◽

Predictive Performance ◽

Apache Ii ◽

Trauma Patients ◽

Saps Ii ◽

Significant Difference ◽

Prognostic Scoring Systems

Background: Prediction of mortality outcomes in trauma patients in the intensive care unit (ICU) is important for patient care and quality improvement. We aimed to measure the performance of 11 prognostic scoring systems for predicting mortality outcomes in trauma patients in the ICU. Methods: Prospectively registered data in the Trauma Registry System from 1 January 2016 to 31 December 2018 were used to extract scores from prognostic scoring systems for 1554 trauma patients in the ICU. The following systems were used: the Trauma and Injury Severity Score (TRISS); the Acute Physiology and Chronic Health Evaluation (APACHE II); the Simplified Acute Physiology Score (SAPS II); mortality prediction models (MPM II) at admission, 24, 48, and 72 h; the Multiple Organ Dysfunction Score (MODS); the Sequential Organ Failure Assessment (SOFA); the Logistic Organ Dysfunction Score (LODS); and the Three Days Recalibrated ICU Outcome Score (TRIOS). Predictive performance was determined according to the area under the receiver operator characteristic curve (AUC). Results: MPM II at 24 h had the highest AUC (0.9213), followed by MPM II at 48 h (AUC: 0.9105). MPM II at 24, 48, and 72 h (0.8956) had a significantly higher AUC than the TRISS (AUC: 0.8814), APACHE II (AUC: 0.8923), SAPS II (AUC: 0.9044), MPM II at admission (AUC: 0.9063), MODS (AUC: 0.8179), SOFA (AUC: 0.7073), LODS (AUC: 0.9013), and TRIOS (AUC: 0.8701). There was no significant difference in the predictive performance of MPM II at 24 and 48 h (p = 0.37) or at 72 h (p = 0.10). Conclusions: We compared 11 prognostic scoring systems and demonstrated that MPM II at 24 h had the best predictive performance for 1554 trauma patients in the ICU.

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Delirium in Trauma Patients: Prevalence and Predictors

Critical Care Nurse ◽

10.4037/ccn2017373 ◽

2017 ◽

Vol 37 (1) ◽

pp. 40-48 ◽

Cited By ~ 9

Author(s):

Kathryn T. Von Rueden ◽

Breighanna Wallizer ◽

Paul Thurman ◽

Karen McQuillan ◽

Tiffany Andrews ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Vision Loss ◽

Medical Center ◽

Academic Medical Center ◽

Hospital Costs ◽

Assessment Method ◽

Trauma Patients ◽

Intermediate Care

BACKGROUNDDelirium is associated with increased mortality, morbidity, hospital costs, and postdischarge cognitive dysfunction. Most research focuses on nontrauma patients receiving mechanical ventilation in the intensive care unit.OBJECTIVESTo determine the prevalence and predictors of delirium in trauma patients residing in intensive and intermediate care units of an academic medical center.METHODSTrauma patients were screened for delirium by using the Confusion Assessment Method for the Intensive Care Unit. Exclusion criteria included documented brain injury, history of psychosis or cognitive impairment, not speaking English, and hearing or vision loss.RESULTSOf the 215 study patients, 24% were positive for delirium; 36% of patients in the intensive care unit and 11% of patients in the intermediate care unit. Delirium-positive patients were older (mean age, 53.4 years) than patients who were not (mean age, 44 years; P = .004). Although mechanical ventilation (odds ratio, 4.73, P = .004) was the strongest independent risk factor for delirium, 12% of delirium-positive patients were not receiving mechanical ventilation. Other predictors of delirium were use of antipsychotic medications, higher scores on the Acute Physiology and Chronic Health Evaluation III, and lower scores on the Richmond Agitation-Sedation Scale.CONCLUSIONSPatients in both the intermediate and intensive care units, whether mechanical ventilation was used or not, were positive for delirium. Delirium prevention protocols may benefit trauma patients regardless of their inpatient location.

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Assessment of the Implementation of a Protocol to Reduce Ventilator-Associated Pneumonia in Intensive Care Unit Trauma Patients

Journal of Trauma Nursing ◽

10.1097/jtn.0b013e3182a171e3 ◽

2013 ◽

Vol 20 (3) ◽

pp. 133-138 ◽

Cited By ~ 1

Author(s):

Sarah B. Ongstad ◽

Tiffany A. Frederickson ◽

Sandy M. Peno ◽

Julie A. Jackson ◽

Catherine Hackett Renner ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Trauma Patients ◽

Ventilator Associated Pneumonia

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Implementation and 1-year follow-up of the cardiovascular ICU standardised handover

BMJ Open Quality ◽

10.1136/bmjoq-2020-001063 ◽

2021 ◽

Vol 10 (3) ◽

pp. e001063

Author(s):

Monica Lupei ◽

Nishkruti Munshi ◽

Alexander M Kaizer ◽

Luke Patten ◽

Joyce Wahr

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Healthcare Provider ◽

Information Transfer ◽

Medical Information ◽

Partial Information ◽

Outcome Data ◽

Improvement Project ◽

Provider Satisfaction ◽

Significant Difference

BackgroundMiscommunication during clinical handover can lead to partial information transfer and healthcare provider dissatisfaction. We hypothesised that a quality improvement project to standardise the cardiovascular intensive care unit (CVICU) handover could improve healthcare provider satisfaction and reduce information omission.MethodsAfter institutional review board approval, the operating room (OR) to CVICU handover was audited prior, post and 1 year after standardisation implementation. The medical information transferred, healthcare provider participation and satisfaction, and patient outcome data were collected. Additionally, surveys were sent to the OR and CVICU staff by email.ResultsThere were 68 handover processes observed. The odds of greater satisfaction with handover for providers were 18 times higher with the process post implementation (p<0.0001) and 26 times higher 1 year after implementation (p<0.0001). There was statistically significant difference between intensive care unit resident presence (45% vs 76% vs 91%, p=0.004), surgical faculty presence (10% vs 36% vs 45%, p=0.034) and surgical fellow presence (15% vs 64% vs 62%, p=0.001) between the three time periods. More information related to the surgeon (5% vs 52% vs 27%, p=0.002), the medical history (65% vs 96% vs 91%, p=0.014) and the cardiopulmonary bypass (47% vs 88% vs 76%, p=0.017) was conveyed. The duration of mechanical ventilation was shorter after implementation (2.2±2.6 days vs 1.2±1.9 days vs 0.5±1.2 days, p=0.026).ConclusionsOne year after the OR to CVICU standardised handover implementation, the healthcare provider satisfaction remained increased, more team members participated and the information transfer increased. Although some clinical outcomes improved, further studies are recommended to prove causality.

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VENTILATOR ASSOCIATED PNEUMONIA IN TRAUMA PATIENTS; ASSOCIATED RISK FACTORS, MICROBIAL ETIOLOGY AND OUTCOME

Pakistan Armed Forces Medical Journal ◽

10.51253/pafmj.v71i4.6278 ◽

2021 ◽

Vol 71 (4) ◽

pp. 1476-80

Author(s):

Sohaima Manzoor ◽

Farzana Batool ◽

Muneeba Ahsan Sayeed ◽

Azizullah Khan Dhiloo ◽

Humera Muhammad Ismail ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Intensive Care ◽

Emergency Room ◽

Therapeutic Option ◽

Significant Risk ◽

Control Measures ◽

P Value ◽

Trauma Patients ◽

Ventilator Associated Pneumonia

Objective: To assess the incidence, risk factors and outcome of ventilator associated pneumonia in trauma patients. Study Design: Prospective observational study. Place and Duration of Study: Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, from Jul to Dec 2019. Methodology: All trauma patients, above 12 years, placed on mechanical ventilation in the emergency room or intensive care unit, were enrolled. Patients that developed a clinical pulmonary infection score of less than 6 were diagnosed with ventilator associated pneumonia. Results: A total of 113 patients were enrolled in this study. Mean age was 32.9 ± 14.4 years. Thirty eight (33.6%) developed ventilator associated pneumonia. Patients with ventilator associated pneumonia, compared to non-ventilator associated pneumonia, had a longer emergency room stay of 7.8 ± 10.1 vs. 4.7 ± 7.4 days (p-value=0.013), greater ventilator days of 18.5 ± 12.6 vs. 7.9 ± 5.5 (p-value=0.001), longer hospital stay of >14 days in 65.8% vs. 33.3% (p-value=0.001) and higher mortality of 65.8% vs. 56% (p-value=0.213). Nurse to patient ratio and infection control measures for prevention of ventilator associated pneumonia were significantly reduced in emergency room compared to intensive care unit (p-value=0.001). Out of 43 respiratory isolates in 38 ventilator associated pneumonia patients, 40 (93%) were gram negatives of which 23 (57.5%) were multidrug resistant with polymyxins as the only therapeutic option. Conclusion: There was a high incidence of ventilator associated pneumonia in patients with trauma. Prolonged retention in the emergency room is a significant risk factor for ventilator associated pneumonia, due to understaffing..................

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Procalcitonin-guided antibiotic therapy for suspected and confirmed sepsis of patients in a surgical-trauma ICU: a prospective, two-period cross-over, interventional study

10.21203/rs.2.15320/v1 ◽

2019 ◽

Author(s):

Rispah Chomba ◽

Maeyane Steve Moeng ◽

Warren Lowman

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hospital Mortality ◽

Antibiotic Treatment ◽

Intervention Group ◽

Control Group ◽

Surgical Trauma ◽

Trauma Patients ◽

Significant Difference ◽

Antibiotic Duration

Abstract Background: Biomarkers like procalcitonin (PCT) are an important antimicrobial stewardship tool for critically ill patients. The purpose of our study was to compare a procalcitonin guided antibiotic algorithm to standard antibiotic treatment in surgical trauma patients admitted to the intensive care unit (ICU).Methods: A prospective, two period cross-over study was conducted in a surgical trauma intensive care unit in South Africa. In the first period, 40 patients were recruited into the control group and antibiotics were discontinued as per standard of care. In the second period, 40 patients were recruited into the procalcitonin group and antibiotics were discontinued if the PCT decreased by ≥ 80% from the peak PCT level, or to an absolute value of less than 0.5 µg/L. Antibiotic duration of treatment was the primary outcome. Patients were followed up for 28 days from the first sepsis event.Results: For the first sepsis event the PCT group had a mean antibiotic duration of 9.3 days while the control group had a mean duration of 10.9 days (p=0.10). Patients in the intervention group had more antibiotic free days alive (mean 7.7±6.57 days) compared to the control group ﴾mean 3.8±5.22 days, (p=0.004﴿. The length of ICU stay and length of hospital stay for the two groups were similar. The in-hospital mortality was reduced in the intervention group (15%) compared to the control group (30%).Conclusion: There was no significant difference in duration of antibiotic treatment between the two groups. However, the PCT group had more antibiotic free days alive and lower in-hospital mortality compared to the control group.Trial registration: Pan African clinical trial registry, PACTR201909715467725, date of registration: 20.9.2019; retrospectively registered, https://pactr.samrc.ac.za/Search.aspx

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