Rawat Nishi, Yang Ting, Ali Kisha J, Catanzaro Mary, Cohen Mariah D, Farley Donna O, Lubomski Lisa H, Thompson David A, Winters Bradford D, Cosgrove Sara E, Klompas Michael, Speck Kathleen A, Berenholtz Sean M
1Armstrong Institute, Johns Hopkins School of Medicine, Baltimore, MD.2Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.3The Hospital and Healthsystem Association of Pennsylvania, Harrisburg, PA.4Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD.5Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.6Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, MA.7Department of Medicine, Brigham and Women's Hospital, Boston, MA.8Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Crit Care Med. 2017 Jul;45(7):1208-1215. doi: 10.1097/CCM.0000000000002463.
Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs.
Longitudinal quasi-experimental study.
Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015.
We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal.
ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively.
A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.
呼吸机相关性事件与死亡率增加、机械通气时间延长以及重症监护病房（ICU）住院时间延长相关。鉴于国家对改善机械通气患者护理的高度关注，美国国立卫生研究院和医疗保健研究与质量局资助了一项两州合作项目，以减少呼吸机相关性事件。我们描述了该合作项目对56个ICU中呼吸机相关性事件发生率的影响。
纵向准实验研究。
2012年10月至2015年3月期间，马里兰州和宾夕法尼亚州38家医院的56个ICU。
我们组织了多方面的干预措施，以提高对循证实践、科室团队合作和安全文化的依从性。该合作项目推广的循证干预措施包括床头抬高、使用声门下分泌物引流气管插管、口腔护理、洗必泰口腔护理以及每日自主唤醒和呼吸试验。每个科室都成立了一个多学科质量改进团队。我们通过每月的电话会议指导各团队建立全面的基于科室的安全项目。使用通用工具在查房时收集数据，并录入基于网络的门户。
ICU报告了69417个机械通气患者日的干预依从性观察数据以及1022个科室月的呼吸机相关性事件数据。在合作过程中，对所有循证干预措施的依从性均有所提高。实施24个月后，每1000个呼吸机日的季度平均呼吸机相关性事件发生率从7.34例显著降至4.58例（p = 0.007）。在同一时期，与感染相关的呼吸机相关性并发症以及可能和很可能的呼吸机相关性肺炎发生率分别从每1000个呼吸机日3.15例降至1.56例以及从1.41例降至0.31例（p = 0.018，p = 0.012）。
多方面的干预措施与循证干预措施依从性的提高以及呼吸机相关性事件、与感染相关的呼吸机相关性并发症和很可能的呼吸机相关性肺炎的减少相关。我们的研究是迄今为止规模最大的一项研究，证实了最佳实践可以预防呼吸机相关性事件。
