Wheeler Derek S, Whitt John D, Lake Michael, Butcher John, Schulte Marion, Stalets Erika
1Division of Critical Care Medicine, Cincinnati Children's Hospital Medical 2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
Pediatr Crit Care Med. 2015 Jul;16(6):565-71. doi: 10.1097/PCC.0000000000000405.
Hospital-acquired infections increase morbidity, mortality, and charges in the PICU. We implemented a quality improvement bundle directed at ventilator-associated pneumonia in our PICU in 2005. We observed an increase in ventilator-associated tracheobronchitis coincident with the near-elimination of ventilator-associated pneumonia. The impact of ventilator-associated tracheobronchitis on critically ill children has not been previously described. Accordingly, we hypothesized that ventilator-associated tracheobronchitisis associated with increased length of stay, mortality, and hospital charge.
Retrospective case-control study.
Critically ill children admitted to a quaternary PICU at a free-standing academic children's hospital in the United States.
None.
We conducted a retrospective case control study, with institutional review board approval, of 77 consecutive cases of ventilator-associated tracheobronchitis admitted to our PICU from 2004-2010. We matched each case with a control based on the following criteria (in rank order): age range (< 30 d, 30 d to 24 mo, 24 mo to 12 yr, > 12 yr), admission Pediatric Risk of Mortality III score ± 10, number of ventilator days of control group (> 75% of days until development of ventilator-associated tracheobronchitis), primary diagnosis, underlying organ system dysfunction, surgical procedure, and gender. The primary outcome measured was PICU length of stay. Secondary outcomes included ventilator days, hospital length of stay, mortality, and PICU and hospital charges. Data was analyzed using chi square analysis and p less than 0.05 was considered significant. We successfully matched 45 of 77 ventilator-associated tracheobronchitis patients with controls. There were no significant differences in age, gender, diagnosis, or Pediatric Risk of Mortality III score between groups. Ventilator-associated tracheobronchitis patients had a longer PICU length of stay (median, 21.5 d, interquartile range, 24 d) compared to controls (median, 18 d; interquartile range, 17 d), although not statistically significant (p = 0.13). Ventilator days were also longer in the ventilator-associated tracheobronchitis patients (median, 17 d; IQR, 22 d) versus control (median, 10.5 d; interquartile range, 13 d) (p = 0.01). There was no significant difference in total hospital length of stay (54 d vs 36 d; p = 0.69). PICU mortality was higher in the ventilator-associated tracheobronchitis group (15% vs 5%; p = 0.14), although not statistically significant. There was an increase in both median PICU charges ($197,393 vs $172,344; p < 0.05) and hospital charges ($421,576 vs $350,649; p < 0.05) for ventilator-associated tracheobronchitis patients compared with controls.
Ventilator-associated tracheobronchitis is a clinically significant hospital-acquired infection in the PICU and is associated with longer duration of mechanical ventilation and healthcare costs, possibly through causing a longer PICU length of stay. Quality improvement efforts should be directed at reducing the incidence of ventilator-associated tracheobronchitis in the PICU.
医院获得性感染会增加儿科重症监护病房（PICU）的发病率、死亡率及费用。2005年我们在本PICU实施了一项针对呼吸机相关性肺炎的质量改进方案。我们观察到在呼吸机相关性肺炎近乎消除的同时，呼吸机相关性气管支气管炎有所增加。此前尚未描述过呼吸机相关性气管支气管炎对危重症儿童的影响。因此，我们推测呼吸机相关性气管支气管炎与住院时间延长、死亡率及住院费用增加有关。
回顾性病例对照研究。
在美国一家独立的学术儿童医院的四级PICU住院的危重症儿童。
无。
经机构审查委员会批准，我们对2004年至2010年期间连续收入本PICU的77例呼吸机相关性气管支气管炎病例进行了回顾性病例对照研究。我们根据以下标准（按优先顺序）为每个病例匹配一个对照：年龄范围（<30天、30天至24个月、24个月至12岁、>12岁）、入院时儿科死亡风险Ⅲ评分±10、对照组的呼吸机使用天数（至发生呼吸机相关性气管支气管炎前天数的>75%）、主要诊断、潜在器官系统功能障碍、外科手术及性别。所测量的主要结局指标是PICU住院时间。次要结局指标包括呼吸机使用天数、住院时间、死亡率以及PICU和住院费用。数据采用卡方分析，p<0.05被视为具有统计学意义。我们成功为77例呼吸机相关性气管支气管炎患者中的45例匹配了对照。两组在年龄、性别、诊断或儿科死亡风险Ⅲ评分方面无显著差异。与对照组（中位数18天；四分位间距17天）相比，呼吸机相关性气管支气管炎患者的PICU住院时间更长（中位数21.5天；四分位间距24天），尽管差异无统计学意义（p = 0.13）。呼吸机相关性气管支气管炎患者的呼吸机使用天数也比对照组更长（中位数17天；四分位间距22天），而对照组为（中位数10.5天；四分位间距13天）（p = 0.01）。总住院时间无显著差异（54天对vs 36天；p = 0.69）。呼吸机相关性气管支气管炎组的PICU死亡率更高（15%对5%；p = ），尽管差异无统计学意义。与对照组相比，呼吸机相关性气管支气管炎患者的PICU费用中位数（197,393美元对172,344美元；p<0.05）和住院费用（421,576美元对350,649美元；p<0.05）均有所增加。
呼吸机相关性气管支气管炎是PICU中一种具有临床意义的医院获得性感染，可能通过导致PICU住院时间延长而与机械通气时间延长及医疗费用增加有关。质量改进措施应致力于降低PICU中呼吸机相关性气管支气管炎的发生率。
