Discussion
VAE, illness
COMPLICATIONS
Our study demonstrates that an improvement collaborative for the care of mechanically ventilated patients was associated with improvement in daily care processes, including subglottic suctioning, (monthly increase of 3.5%), SAT (monthly increase of 2.1%), SBT (monthly increase of 1.9%) and the use of neuromuscular blockers (monthly decrease by 2.5%). These changes were not associated with a reduction in VAEs but were associated with a reduction in mortality (monthly decrease of 1.6%).Our study also confirms what other studies have shown that the compliance with the daily ventilator care processes such as SAT and SBT, is often low [VAE surveillance has been designed to overcome the inaccuracy of VAP definition, enhance the detection of the complications of mechanical ventilation and serve as a possible quality measure. Using different surveillance methods, several studies have demonstrated that VAEs were associated with increased duration of mechanical ventilation, prolonged ICU and hospital length of stay, and increased mortality [There are several possible explanations for the lack of change in VAE rate despite improvement in evidence-based practices. First, there has been inconsistent evidence that VAEs are preventable [Our study demonstrated that the quality improvement collaborative was associated with a reduction in mortality. Several studies have evaluated the individual and collective impact of ventilator bundle elements. A systematic review of 13 studies showed that the implementation of a ventilator bundle significantly reduced mortality (odds ratio 0.90, 95%CI 0.84–0.97) [The strengths of this study include the large sample size and the multicenter participation. The statistical model, which is suitable for multi-level data, accounted for the heterogeneity across ICUs and hospitals. The standardization of the study month allowed for robust interpretation of the effect of the intervention over time. We used several approaches for improvement, including education, benchmarking and feedback. The use of multiple approaches is important because education alone has been shown to lead to small improvements. Limitations include the non-randomized design; raising the possibility that the association between the implementation of daily care processes and mortality may be due to unmeasured confounders, including changes in practice or measurement. Because of the COVID-19 pandemic, the study was shortened from a planned 18-month to 15-month period, resulting in a median center contribution of 8 months. A longer intervention would possibly have led to more improvement. Further work is needed to evaluate approaches for sustainability, including for example, automation of data collection and reporting. Given the design of the study, patient-level detailed data were not collected, therefore it was not possible to adjust for patient characteristics or severity of illness. We did not assess inter-rater differences in assessing compliance or in determining VAEs. Finally, we did not assess the relative effectiveness of the separate components of the intervention. Nevertheless, this collaborative initiative is probably among the largest initiatives that used VAE constructs as the primary outcome for improving the care of mechanically ventilated patients outside North America. These findings suggest the need for randomized clinical trials to examine the effect of this bundle of interventions on VAEs and mortality among mechanically ventilated patients.