Multimodal Strategies for Ventilator-Associated Pneumonia Reduction in a Level 1 Trauma Center

Background: Ventilator-associated pneumonia (VAP) is a preventable complication among patients with trauma who require mechanical ventilation and is relevant in patients with traumatic brain injury (TBI), who are at increased risk for prolonged ventilation and impaired airway protection. With the goal of decreasing our VAP rates, we developed an interdisciplinary multimodal VAP reduction initiative. We hypothesized that a multimodal quality improvement approach targeting VAP prevention would decrease VAP rates in patients with trauma. Patients and Methods: We performed a pre-post quality improvement study of patients with trauma who underwent intubation before and after implementation of an evidence-informed VAP reduction bundle. The intervention included single-dose ceftriaxone prophylaxis within 12 h of intubation for eligible patients with TBI, standardized early tracheostomy (within 8 d) for patients with severe TBI failing extubation, standardized sedation vacation and spontaneous breathing trial parameters, providing education to improve subglottic suctioning compliance, and a respiratory care pathway for high-risk patients because of spinal cord injury. Outcomes measured included VAP incidence, tracheostomy use, time to tracheostomy, and Trauma Quality Improvement Program (TQIP) benchmark performance. Results: A total of 118 patients with trauma who underwent intubation were included in the study, with 61 in the pre-implementation cohort and 57 in the post-implementation cohort. Baseline demographic and injury characteristics were similar between groups. VAP decreased from 15/61 (24.6%) patients pre-implementation to 7/57 (12.3%) patients post-implementation. Among patients diagnosed with VAP, performance of tracheostomy increased from 40.0% to 100% (p = 0.017), and median time to tracheostomy decreased from 14 days (interquartile range [IQR], 7.25–17) to 8 days (IQR: 5–10) (p = 0.047). Institutional TQIP VAP performance improved from the 10th to 6th decile. Conclusion: Implementation of an interdisciplinary, multimodal VAP reduction initiative was associated with decreased VAP incidence and improved benchmarked trauma performance. Earlier tracheostomy among patients with VAP likely reflects improved adherence to the institutional care pathway; however, the independent contribution of this bundle component cannot be determined.