Impact of a ventilator care bundle on critically ill mechanically ventilated patients at a tertiary care center in northern India

  1. Rajesh Harsvardhan
  2. Pallavi Mehra
  3. Richa Misra
  4. Afzal Azim
  5. Rupali Patnaik

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Abstract

Introduction Effective implementation of a care bundle is proven to decrease the occurrence of VAE, duration of mechanical ventilation, and length of stay in any ICU. Hypothesis/Gap statement There are few studies from India on the compliance rate of the ventilator care bundle and its impact on Ventilator Associated Event (VAE) rate as well as ICU course. Aim We assessed the compliance rate to six components of the ventilator care bundle and its impact on the rate of VAE and ICU course of patients admitted to the Critical Care Medicine ward at our centre. Methodology This prospective, observational, single-center cohort study included 68 patients who received mechanical ventilation in a 20-bed, adult mixed medical-surgical ICU at a tertiary care institute. Results The median duration of mechanical ventilation was 9 days. The compliance to the ventilator care bundle was partial (<6 components) among 52 patients while full compliance was observed in only 16 patients. The overall percentage compliance to six ventilator care bundle components was 99% for PUD-P followed by 98% for Assessment of Sedation (AS), 94% for Head of Bed Elevation (HoBE), 86% for Daily Oral Care with Chlorhexidine(O-CHX), 82% for Subglottic Suction Drainage (SSD) and 72% for Deep Venous Thrombosis Prophylaxis (DVT-P). The median duration of mechanical ventilation & length of stay in ICU decreased to 6 & 11 days respectively among patients with full bundle compliance. The baseline VAE rate was 11.3/1000 ventilator-days which decreased to 9.2/1000 ventilator-days during the study. Acinetobacter baumannii was the most common isolate (n= 37) out of which 90% were carbapenem resistant. Conclusion Full bundle compliance was observed to be associated with a reduction in VAE rate as well as the duration of mechanical ventilation and length of stay in the ICU.

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  2. Access Microbiology

    Comments to Author

    1. Methodological rigour, reproducibility and availability of underlying data - Inclusion and exclusion criteria to be mentioned under study participants. - Title of the article to be modified : "Impact of a ventilator care bundle on critically ill mechanically ventilated patients at suggestion: Impact of ventilator care bundle on mechanically ventilated patients in intensive care unit at a tertiary care centre in northern India - the research objectives to be stated clearly stated in aims and objectives. study on imapct of bundle care approach on duration of mechanical ventilation and length of stay to be specifically mentioned. - Review of literature is adequate. - - the methods are described in enough detail to permit someone to reproduce the experiments. The methods employed for ensuring compliance and recording of data to be detailed in methods section. Discussion should only discuss the result and its impact. - Methods appropriate to the research - statistical tools used to address the findings are appropriate. Statistical findings of all elements to be discussed under discussion - pre bundle, post bundle and also literature. - the authors have followed relevant ethical guidelines. 2. Presentation of results The results to be written in third person. Line 136 delete: As can be seen. Line140-141- to be written in third person. Line 136-137 & line 141-143 are regarding most common comorbidities. There is repetition and difference in comorbidities mentioned in these places. May please be corrected and written only once. Line 150 withHoBE&AS - spacing between different elements Line 166-167:spacing between micro organism generic and species name - the findings described in the article are significant and they provide knowledge and scientific evidence about impact of implementation of bundle care approach in mechanically ventilated patients in Indian setup. - The results been interpreted properly. - The conclusions to be rewritten in third person with reference to the published literature. 3. How the style and organization of the paper communicates and represents key findings The manuscript to be written in third person. The style and organization of paper 4. Literature analysis or discussion Literature has been analysed well. Discussion to be written in third person. Discussion on baseline characteristics not discussed with respect to literature.Only results of the present study are mentioned. Each element should be discussed with respect to literature. Line 199 - 202 "We ensured head-of-the-bed elevation by creating an environment ……………..below a 30-degree angle.- to be written in third person. Results of Head of bed elevation in the present study to be discussed here. Statistical analysis of impact of full bundle care approach with pre bundle care approach in respect of duration of mechanical ventilation and average length of stay too be discussed to assess and emphasize the effect of complete implementation of bundle care approach. Similar statistical analysis for all elements to be mentioned in discussion. 5. Any other relevant comments Overall the manuscript to be rewritten in third person. Page 3 L24 VAE should be written in expanded form and abbreviations in brackets as it is being mentioned for the first time in tis article, L34 median duration of length of stay also should be mentioned so that results can be compared on both terms on full bundle compliance which is mentioned in L40-41 " the median duration of mechanical ventilation & length of stay in ICU decreased to 6 & 11 days respectively among patients with full bundle compliance". L37- PUD-P to be written in expanded form with abbreviation in brackets Page 4 Introduction L 51-53- rephrase this sentence to convey full meaning "Ventilator-associated pneumonia (VAP) or VAEs for surveillance purposes since 2013, is a major complication of mechanical ventilation and one of the most important device-associated infections" L57- " the application of best" should be written as application of the best practices Page 5 Line 71 -72 "Though all measures for the prevention of VAEs were being used 72 before the introduction of the bundle, we lacked a structured approach" . Sentenced to be rephrased in third person viz. Though all measures for the prevention of VAEs were being used before the introduction of the bundle, a structured approach was lacking. Study participants Line 77- adult word to be deleted or above 18 years of age to be deleted and rewitten as All mechanically ventilated patients who were more than 18 years of age were included in the study. Or All mechanically ventilated adult patients were included in the study Other Inclusion and exclusion criteria of study participants to be enumerated. Baseline data collection and ICU course/outcomes Line 80-89 : paragraph under this heading to be written in third person. Inclusion and exclusion criteria to be enumerated under study participants Detection of VAE Paragraph to be written in third person. Line 98-99: "The rate of VAE was calculated by the following formula: VAE rate per 1000 ventilator 99 days = number of VAEs/ number of ventilator days *1000." The formula to be written in numerator and denominator format. Care bundle compliance Paragraph to be written in third person. Combine Line 103-104 with Line 105-106 to form one complete sentence. The following elements were measured : head-of-bed elevation (HoBE) 106 30-45 degrees, daily assessment of sedation (AS), peptic ulcer dise………….S-SD) Line 104-105 Statement in these lines "and each variable was recorded every 8 hours as a dichotomous yes/no and results were transferred to an electronic database" to be written after measurement of elements as "each variable was recorded every 8 hours as a dichotomous yes/no and results were transferred to an electronic database" Line 112-115: formula for calculation to written in numerator & denominator format - table of microbiology data also to be given as it is mentioned in results and discussion section.

    Please rate the manuscript for methodological rigour

    Good

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  3. Access Microbiology

    Comments to Author

    * The authors describe their study as a prospective, observational cohort study, but the overall insight of the paper looks like an international study where the investigators have introduced a structural approach to the already available procedures. * The given aim of the research is to assess the compliance rate to six components of the ventilator care bundle and its impact on the rate of VAE and ICU course of patients admitted to the Critical Care Medicine. But the results and discussion section describes number of details regarding other variables they have assessed. ( eg: microbiological findings ) * The authors report an improvement of the compliance as well as outcome of patients towards the end of the study period. Which means a the study itself has become an intervention for the improvement of the compliance, in such case ethics approval and institutional approval would have been obtained. ( The study seems excepted from by ethics review committee because of the anonymous nature of the study), . Though it is anonymous in patients point of view, an 'intervention' of any ind may warrant prior review and approval. * The discussion section describes and discusses lots of details regarding the components of ventilator care bundle and does not discuss about their results in detail. The discussion would have been more focused and organized, rather than a description of available literature. * According to Lines 111 and 112 : the nurses in the same ICU has contributed to the data collection , which may have given rise to some bias during the reporting

    Please rate the manuscript for methodological rigour

    Poor

    Please rate the quality of the presentation and structure of the manuscript

    Satisfactory

    To what extent are the conclusions supported by the data?

    Partially support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  4. Access Microbiology

    Comments to Author

    Hello, It's an interesting work whose main teaching aims to reduce, in a simple and successful way, the VAE. It's just a notice, but according to the main result, don't you want to publish in a critical care journal than a microbiology one? -Line 163: 74 tracheal aspirate sample only ? No sputum or broncho-alveolar liquid? What is the average time between mechanical ventilation and tracheal aspirate sampling? - Lines 171 et 172: what are the mechanisms of carbapenems resistance: carbapenemase for all, efflux, high-level cephalosporin, etc…? Same question for the mechanism of resistance to colistin (plasmid mcr-1?) - You interestingly say that epidemiology is similar to several surveillance studies from India and that your study confirm multi-drug resistant organisms (lines 269-270), the resistance rate is extremely high! Therefore, do you know if the patients were already infected or colonized by multi-drug resistant organisms (Enterobacterales, P. aeruginosa, A. baumanii) before they arrived in ICU? - Have you shown an (positive) impact between the implementation of prevention bundles and antibiotic resistance rate? In my opinion, it would be interesting to investigate the impact of these measures on this point or at least evoke it according to the scientific literature.

    Please rate the manuscript for methodological rigour

    Good

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  5. Version published to 10.1099/acmi.0.000688.v1 on Access Microbiology