Division of Pulmonary and Critical Care Medicine, Mayo Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Intensive Care Unit, Qilu Hospital, Shandong University, Jinan, China.
Division of Pulmonary and Critical Care Medicine, Mayo Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN.
Chest. 2013 Nov;144(5):1461-1468. doi: 10.1378/chest.12-1675.
Recent changes in critical care delivery, including the widespread implementation of health-care bundles, were aimed at reducing complications of critical illness, in particular ventilator-associated pneumonia (VAP), but no population-based study evaluated its effectiveness.
Using a previously validated electronic medical record database, we identified adult (≥ 18 years old) critically ill patients from Olmsted County, Minnesota, requiring mechanical ventilation for ≥ 48 h from January 2003 to December 2009. Trained intensivists identified cases of VAP according to different established clinical definitions. The incidence and outcome of VAP was compared before and after implementation of the so-called "VAP bundle."
The median age, severity of illness, proportion of surgical patients, and patients with neurologic disease increased over time (P < .05 for trend in all). Regardless of the definition used, the VAP rate remained similar throughout the study period and did not change with the introduction of the VAP bundle. According to previous Centers for Disease Control and Prevention criteria, the yearly estimates of the VAP incidence ranged between 7.1 and 10.4 cases per 1,000 ventilator-days, with an age-adjusted incidence of 3.1 vs 5.6 per 100,000 population (P = .54 for trends). Standardized hospital mortality ratio of patients at high risk to develop VAP significantly decreased from 1.7 (95% CI, 0.8-3.0) to 0.7 (95% CI, 0.3-1.4; P = .0003 for trend).
The incidence of VAP was unaffected by the implementation of the VAP bundle. Secular changes in hospital mortality are unlikely to be attributed to the VAP bundle per se.
重症监护治疗的最近变化，包括广泛实施医疗保健捆绑包，旨在减少重症疾病的并发症，特别是呼吸机相关性肺炎（VAP），但没有基于人群的研究评估其有效性。
使用先前验证的电子病历数据库，我们从明尼苏达州奥姆斯特德县确定了需要机械通气≥48 小时的成年（≥18 岁）危重症患者，从 2003 年 1 月至 2009 年 12 月。经过培训的重症监护医生根据不同的既定临床定义确定 VAP 病例。比较了 VAP 捆绑包实施前后 VAP 的发生率和结局。
中位年龄、疾病严重程度、手术患者比例和神经系统疾病患者比例随时间推移而增加（趋势 P <.05）。无论使用何种定义，整个研究期间 VAP 发生率均保持相似，并且随着 VAP 捆绑包的引入并未改变。根据先前的疾病控制与预防中心标准，VAP 发病率的年估计值在每 1000 通气日 7.1 至 10.4 例之间，年龄调整后的发病率为每 10 万人 3.1 至 5.6 例（趋势 P =.54）。发生 VAP 高风险患者的标准化医院死亡率比值从 1.7（95%CI，0.8-3.0）显著降低至 0.7（95%CI，0.3-1.4；趋势 P =.0003）。
VAP 捆绑包的实施并未影响 VAP 的发生率。医院死亡率的季节性变化不太可能归因于 VAP 捆绑包本身。
