|Year : 2017 | Volume
| Issue : 1 | Page : 50-57
Effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients at a selected private healthcare sector
Mohamed Abd Elmonem El-Sharkawy1, Warda Youssif Mohamed2, Nahla Shaban Ali3
1 Department of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Giza, Egypt
2 Professor of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Giza, Egypt
3 Assistant Professor of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Giza, Egypt
|Date of Submission||15-Jan-2017|
|Date of Acceptance||02-Feb-2017|
|Date of Web Publication||13-Jun-2017|
Mohamed Abd Elmonem El-Sharkawy
Department of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Giza
Source of Support: None, Conflict of Interest: None
Mechanical ventilator (MV) has serious complications; thus, the ultimate goal of MV is ventilator discontinuation. Ventilator bundle is a group of practices aimed to improve the patient outcomes.
The aim of this study was to examine the effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients.
A quasiexperimental design was utilized.
A purposive sample of 60 mechanically ventilated patients was enrolled. Patients were matched for age, sex, and medical characteristics and then randomly assigned to two groups. The study group included patients for whom all elements of the ventilator bundle were applied completely, whereas the control group included patients for whom the ventilator bundle elements were not applied completely.
This study was conducted in the ICUs of a selected private hospital in Cairo.
Tools of data collection
Three tools were utilized: sociodemographic and medical data sheet, ventilator bundle compliance checklist, and Burns’ Wean Assessment Program checklist.
There was a significant statistical difference between the compliant (study group) and the noncompliant (control) group as regards weaning indicator scores (t=4.20; P=0.001). There was a significant difference between patients of the two groups as regards the compliance with individual ventilator bundle elements with respect to head-of-bed elevation (χ2=4.85, P=0.046), sedation interruption (χ2=6.4, P=0.03), and assessment of readiness to extubate (χ2=5.2, P=0.02).
Implementation of ventilator bundle plays a pivotal role in weaning from a MV.
Applying the ventilator bundle practices with focusing on the head-of-bed elevation, daily sedation interruption, and assessment of readiness to extubate is highly recommended. Moreover, the use of a structured tool to assess readiness for weaning can help in managing the mechanically ventilated patients. Furthermore, replication of the study on a larger probability sample from different geographical locations in Egypt ensures generalizability of the study.
Keywords: mechanically ventilated patients, ventilator bundle, weaning, weaning indicator
|How to cite this article:|
El-Sharkawy MA, Mohamed WY, Ali NS. Effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients at a selected private healthcare sector. Egypt Nurs J 2017;14:50-7
|How to cite this URL:|
El-Sharkawy MA, Mohamed WY, Ali NS. Effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients at a selected private healthcare sector. Egypt Nurs J [serial online] 2017 [cited 2018 Aug 15];14:50-7. Available from: http://www.enj.eg.net/text.asp?2017/14/1/50/206937
| Introduction|| |
Mechanical ventilation (MV) may be indicated for many reasons. These reasons may include controlling the patient’s respirations during surgical procedures or during treatment of severe traumatic brain injury, to oxygenate the blood when the patient’s ventilatory efforts are inadequate, and to rest the respiratory muscles (Suzanne and Bare, 2010). Although the majority of the patients require MV for a short duration, ∼30% of those patients may require MV support for more than a week, and this prolongation of the MV period may increase the risk for serious complications (Figueroa-Casas et al., 2015).
Although MV is a lifesaving procedure, there are many complications that should be considered in the mechanically ventilated patients; these complications include barotrauma, volutrauma, aspiration and ventilator-associated pneumonia (VAP), tracheoesophageal fistula, stress ulcer and gastrointestinal bleeding, deep venous thrombosis, and other problems related to immobility (Jones and Fix, 2014). Thus, the main challenge of nurses in critical care units is mechanically ventilated patients and the failure to wean them from machine support (Grap, 2009). This is related to the high occupancy rate of ventilated patients, which constitutes one-fourth to one-half of critically ill patients who require MV (Blackwood et al., 2009; Grap, 2009). Weaning is a process that aims to discontinue the support that patient receives to start breathing spontaneously (Epstein and Walkey, 2013). It is the removal of patients from ventilatory support to breathe without the assistance from ventilation (Hemant et al., 2006; Epstein and Parsons, 2013)
Many risk factors affect the weaning process. Over the past several years, there has been controversy about the timing and role of tracheostomy in the ICU in reducing the development of VAP and delayed weaning (Möller et al., 2005). Placing mechanically ventilated patients in a semirecumbent body position (45°) has been demonstrated to reduce the incidence of VAP to more than 75% compared with those placed in a completely horizontal position (0°) (Drakulovic et al., 1999).
In a study carried out by Ibrahim et al. (2002) comparing early and late enteral feeding in medical ICU patients receiving MV, there was no mortality difference between the early and late enteral feeding groups. However, the group of patients who were fed earlier had a greater incidence of VAP and longer ICU stay.
Readiness for weaning from MV may include many criteria that ensure the willingness to liberate the patient from the ventilator. These criteria include the following: resolution of the critical condition for which the patient was subjected to MV, adequate respiratory efforts and cough reflex, and absence of excessive tracheobronchial secretion; stabilization of the cardiovascular status; stabilization of metabolic and respiratory functions; adequate oxygenation; and absence of sedation to ensure the cooperation of the patient (Pu et al., 2015).
The Institute for Healthcare Improvement (IHI) developed the bundle practices, including ventilator bundle, to enable the implementation of evidence-based preventive approaches for healthcare-associated infection (Evans, 2005).
The Ventilator Bundle comprises head-of-the bed elevation 30°–45°, oral care with chlorhexidine, daily sedation interruption and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis, aimed to improve outcome in mechanically ventilated patients. Daily spontaneous awakening and breathing trials are associated with early weaning from MV and VAP reduction. Thus, ventilator bundle application enhanced early weaning, decreased the length of stay in the ICU, and improved patient outcome (O’Keefe-McCarthy et al., 2008).
The IHI had defined the ventilator bundle compliance as the percentage of intensive care patients on MV for whom all elements of the ventilator bundle are documented on daily goal sheets and/or elsewhere in the medical record, with a target compliance of 95% (Resar et al., 2005).
Many studies have shown that implementation of the elements of IHI bundle alone or with other preventive measures are associated with reduced VAP rates. Moreover, a relatively fewer number of studies emphasized on investigating the relationship between the ventilator bundle compliance and ventilator utilization with differing results (Al-Thaqafy et al., 2014).
Significance of the study
Through empirical observations, literature review, and clinical experience in the ICUs for many years, it is noticed that many of ICU patients were connected to the MV, and weaning trials from MV are associated with many complications to the patient and increase the cost of care.
Many studies were conducted in the USA to assess the ventilator use and revealed that 33% of the admitted patients were receiving MV for a mean±SD duration of 5.9±7.2 days (Esteban et al., 2002). However, in Egypt the average duration of MV was 12.8±4.9 days (Mohamed, 2014).
Failed weaning trials result in respiratory muscle fatigue, VAP, and lung injury that result in delayed extubation. Few research studies were conducted nationally on the ventilator bundle practices and its effect on weaning from mechanical, and their findings revealed that implementation of evidenced ventilator bundle practices may reduce the incidence of such complications and improve the quality of patient care. In addition, compliance with evidence based guidelines on weaning among nurses is not valued within the variety of clinical settings.
Therefore, the investigator aimed to test the relationship between implementation of ventilator bundle practices and weaning from MV, which may improve the prognosis of those patients, and this in turn would decrease the average length of ICU stay and hence decrease the cost of care. Moreover, the application of ventilator bundle practices by the nurses would improve their performance and enhance their systematic approach of thinking while dealing with the critically ill patients. Eventually, this research might generate an attention and motivation for further studies in this area.
| Aim|| |
The aim of this study was to examine the effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients.
To fulfill the aim of this study, the following research hypothesis was formulated:
The study group of patients for whom all elements of the ventilator bundle was applied completely would get higher weaning scores compared with the control group of patients for whom the ventilator bundle elements were not applied completely.
| Patients and methods|| |
A quasiexperimental design was utilized.
The current study was carried out at different ICUs affiliated to a selected private healthcare sector in Cairo, Egypt, which implemented the ventilator bundle practices, but the compliance is variable. There are about 55 ICU beds in the hospital distributed between medical intensive care, surgical intensive care, neurocritical, chest pain unit, and coronary care units. The nurse : patient ratio is usually 1 : 1.
A purposive convenience sample of 60 mechanically ventilated adult male and female patients were enrolled in the study. Patients were matched for age, sex, and medical characteristics, and then those patients were divided randomly into two groups. The first group (study) of patients received compliance with the VAP bundle more than or equal to 95%, whereas the second one group (control group) did not receive ventilator bundle practices or the compliance is less than 95% during the MV period.
These exclusion criteria include patients who have brain stem infarction, patients with neuromuscular disorder, patients with chronic debilitating and terminal diseases, patients with BMI less than 18 kg/m2 or more than 32 kg/m2, and patients younger than 18 years and older than 60 years of age.
Three tools for data collections were utilized:
- Tool 1: Background data sheet: It included patient’s age, sex, smoking status, current medical diagnosis, comorbidities, and the main reason for ICU admission.
- Tool 2: Ventilator bundle compliance checklist: It was adopted on the basis of the guidelines of IHI (Resaret al., 2005) to assess the compliance with ventilator bundle practices. This tool was examined by a panel of three medical and three nursing experts to assess its validity and reliability.
- The key components of the ventilator bundle checklist are as follows:
- Elevation of the head of the bed.
- Mouth care with chlorhexidine.
- Daily sedation interruption.
- Assessment of readiness to extubate.
- Peptic ulcer disease prophylaxis.
- Deep venous thrombosis prophylaxis.
This tool was reviewed by a panel of three medical and three nursing experts to assess its validity and reliability.
The compliance rate is calculated by dividing actual daily compliance with the number of days the patient has been receiving ventilation. This figure is multiplied by 100 to calculate percentage compliance (Beattie et al., 2012).
Calculation for ventilator-associated pneumonia bundle compliance
The final percentage of ventilator bundle compliance for the patient shall be calculated on the basis of the total percentage of nurses’ compliance with all ventilator bundle practices together throughout the ventilator days. Thereafter, the sample will be categorized on the basis of the cumulative compliance into two groups: the compliant group, whose total compliance percentage is more than or equal to 95%, and the noncompliant group, whose total compliance percentage is less than 95%.
Tool 3: Burns’ Wean Assessment Program checklist
This tool was developed by Burns (1990) and is used to systematically assess and track weaning progresses of the mechanically ventilated patients through general assessment and respiratory assessment. The Burns Weaning Assessment Program is a 26-factor scoring instrument. It is used to decrease variability in managing patients on MVs. The instrument consists of three components: general assessment, respiratory assessment, and arterial blood gas results. The response of each component of these subscales is yes, no, or not assessed. A cutoff point for the instrument is 50. If the score is more than 50 the patients are more likely to be weaned successfully. This means that a score more than 50 is a predictor for successful weaning. Further, if the score is less than 50 the patient is more likely to have unsuccessful weaning. The Burns’ Wean Assessment Program (BWAP) is an indicator for successful weaning process and is considered valid; the inter-rater reliability of the instrument is 95% (Epstein et al., 2002).
Validity and reliability of tools
Content validity was determined to identify the degree to which the used tools measure what was supposed to be measured. Tools were examined by a panel of three medical and three critical care nursing experts to determine whether the included items were clear and suitable to achieve the aim of the current study.
A pilot study was carried out on six patients to test the feasibility, objectivity, and the applicability of the study tools. Carrying out the pilot study gave the investigator experience to deal with the included participants and use the data collection tools. On the basis of the results of the pilot study, needed refinements and modifications were made and pilot study participants were excluded from the actual study sample.
Protection of human rights
The approval of the ethical committee boards of the affiliated university and the targeted hospital was granted before the study commenced. The confidentiality and anonymity of the information in the records were maintained using codes. The purpose and significance of the study were explained to all participants. All patients and their families were assured that their participation is voluntary and that they can withdraw at any time without compromising their care.
The current study was conducted in two phases: the designation phase and implementation phase.
It is concerned with the construction and preparation of different data collection tools (sociodemographic and medical data sheet, patient assessment sheet, ventilator bundle compliance checklist, and BWAP checklist). In addition, managerial arrangements were carried out and the investigator prepared formal requests to selected private hospitals. The purpose and nature of the study were explained to gain acceptance and support. This stage required about 2 months and ended by carrying out the pilot study.
Data were collected over a period of 18 months between March 2014 and September 2015. The researcher visited the assigned settings on a daily basis during the day and night shifts. The enrolled patients and their relatives were informed individually about the purpose and nature of the study. Thereafter, the researcher obtained written consent from those who accepted to participate in the study.
Later, sociodemographic and medical data (tool 1), were obtained from patients on the first day. Concerning the compliance of the healthcare professionals with the ventilator bundle practices, it was assessed using tool 2 on a daily basis until the patient was extubated or the patient was for more than 10 consecutive days on MV.
After 72 h of MV, the patient was started to be assessed for readiness of weaning on daily basis using BWAP checklist (tool 3) until extubation or for 10 consecutive days from initiation of MV.
| Results|| |
Demographic characteristics of the two groups of patients as regards compliance with ventilator bundle implementation are presented in [Table 1]. This table reveals that there was no significant difference between patients with compliance and those with noncompliance to VAP bundle application with regard to age (48.4±11.2 vs. 45.4±11.2 years, respectively, where t=1.03; P=0.4), sex (χ2=0.3; P=0.4), and smoking status (χ2=0.47; P=0.3).
Medical characteristics of the two groups of patients as regards compliance with ventilator bundle implementation are presented in [Table 2]. There was no significant difference between patients with compliance and those with noncompliance to VAP bundle implementation as regards current medical diagnosis, such as cardiac, respiratory, gastrointestinal, neurological, and renal diseases. Moreover, [Table 2] reveals that there was no significant difference between compliant and noncompliant patients as regards both length of MV days and comorbid signs and symptoms except the presence of edema (χ2=4.4; P=0.04).
|Table 2: Medical characteristics of patients by their compliance to ventilator-associated pneumonia bundle implementation|
Click here to view
The distribution frequency of the studied patients by their compliance to individual ventilator bundle elements is presented in [Table 3]. It reveals that there was a significant difference between patients of the two groups as regards the compliance with individual ventilator bundle elements with respect to head-of-bed elevation (χ2=4.85; P=0.046), sedation interruption (χ2=6.4; P=0.03), and assessment of readiness to extubate (χ2=5.2; P=0.02).
|Table 3: Frequency distribution of the studied patients by their compliance to individual ventilator-associated pneumonia bundles|
Click here to view
Comparison between the compliant and the noncompliant group to VAP bundle implementation with respect to their weaning scores is presented in [Table 4]. It revealed that there was a significant difference between patients with compliance and those with noncompliance as regards weaning scores (t=4.20; P=0.001).
|Table 4: Comparison between the compliant and the noncompliant group with ventilator-associated pneumonia bundle implementation by their weaning scores (n=60)|
Click here to view
Correlation between age and total BWAP score as a weaning indicator from MV is presented in [Table 5]. It reveals a positive correlation, and there was no statistical significance between age and total BWAP score as a weaning from MV (r=0.018; P=0.89).
|Table 5: Correlation between age and total Burns’ Wean Assessment Program score as a weaning indicator from mechanical ventilator (n=60)|
Click here to view
Correlation between length of MV and total BWAP score as a weaning indicator from MV is presented in [Table 6]. It reveals a negative correlation, and there was a highly statistically significant difference between length of MV and total BWAP score as a weaning from MV (r=−0.818; P=0.0001).
|Table 6: Correlation between length of mechanical ventilation, and total Burns’ Wean Assessment Program score as a weaning indicator from mechanical ventilator (n=60)|
Click here to view
| Discussion|| |
The current study aimed to compare compliance versus noncompliance with VAP bundle implementation and its effectiveness on weaning among mechanically ventilated patients at a selected private healthcare sector. Our study findings revealed that there were no significant differences between compliant and noncompliant patients with respect to their demographic characteristics such age, sex, and smoking status. This finding is partially congruent with a similar study by Mohamed (2014), who studied compliance with VAP bundle implementation and its effectiveness on surgical and medical subpopulation in adult ICU and revealed that the mean age of patients who were studied after VAP bundle initiation was nonsignificantly lower than those before VAP bundle implementation, and there was no significant difference in sex distribution in the studied population. Similarly, the current study finding is consistent with the findings of Montasser et al. (2015), who studied the incidence of VAP with incomplete or complete adherence to bundle of prevention; they revealed that there was no significant difference between cases with incomplete and those with complete VAP bundle application as regards age (49.57±6.39 vs. 49.42±5.35 years, respectively), sex distribution (male patients represented 71.4% of cases with incomplete VAP bundle application and 65.0% of cases with strict application of VAP bundle).
On comparing the compliant and noncompliant patients with VAP bundle implementation by their medical characteristics, our study findings revealed that there was no significant statistical difference between patients by their distribution of their diseases as regards respiratory, cardiovascular, neurological, and gastrointestinal diseases. This finding is consistent with Montasser et al. (2015), who found no significant statistical difference in cases with incomplete or complete VAP bundle application as regards cause of ICU admission: medical, postoperative, and traumatic (P=0.75). As regards comorbid signs and symptoms, there were only significant statistical differences between compliant and noncompliant patients with VAP bundle application as regards presence of lower limb edema (P=0.04) and pressure ulcer (P=0.01).
On the same line, the current study finding revealed that there was no significant difference between the compliant and noncompliant groups of patients as regards duration of connection to MV. Our study finding is contradictory to Mohamed (2014), who found that the total VAP bundle compliance rate steadily increased from 63 to 84% during the period of implementation and reduction of duration of MV from 12.8±4.9 to 8.5±4.3 days for patients with VAP bundle compliance at the end of the study. Furthermore, Hawe et al. (2009) reported that the decrease in the mean length of stay and mean duration of ventilation was statistically significant in their patients subjected to VAP bundle. However, another study evaluating these components of the bundle reported a 95% adherence with the bundle and an associated reduction in VAP, but investigators acknowledged that the reduction may have been related to a concurrent improvement program that focused on the care of the ventilated patients.
The current finding is in agreement with Montasser et al. (2015), who revealed a significant statistical difference between cases with incomplete or complete VAP bundle application as regards duration of MV (P<0.001). Furthermore, Chen et al. (2015) reported that multidisciplinary bundle care decreased the cases of ventilator days.
In the present study, we compared the compliant and noncompliant groups of patients with their compliance rates of individual elements of VAP bundle. It revealed that there was a statistical difference between the two groups as regards head-of-bed elevation (P=0.04).
Concerning the finding pertinent to maintaining of head-of-bed elevation at 30°, in this perspective, the current finding that was congruent with a recent study conducted by nurses in a Brazilian ICU found similar results, in which a head-of-bed elevation between 30° and 45° presented a 46.26–52% full compliance among different work shifts (Silva et al., 2011). However, Gonçalves et al. (2012) reported that the goal of keeping the head-of-bed elevation to 45° is difficult to achieve, as patients often change position. In the daily unit studied, patients on MV were frequently positioned between 10° and 30°, even though evidence recommends that patients with MV should not be held in positions lower than 30°.
As regards the individual VAP bundle rates pertinent to applying daily sedation interruption and assessing readiness to wean, our study finding revealed that there were significant differences between the compliant and noncompliant groups of patients. On the basis of this study, daily interruption of sedation as a part of the ventilator bundle for patients who were ready for weaning was safe and fundamental. The current finding is in agreement with that of Venkatram et al. (2010), entitled ‘safety of daily sedation interruptions in mechanically ventilated inner city patients − an alternative approach’, who concluded in their study that a regular assessment of weaning eligibility linked to daily sedation interruptions in weaning-eligible patients as a part of a ventilator bundle strategy is safe in an inner city medical ICU setting. This strategy does not result in increased unplanned extubations and premature weaning.
The current study compared the compliant and the noncompliant group of patients with VAP bundle implementation by their weaning scores. It revealed that there was a significant statistical difference between the two groups (where t=4.20; P=0.001), as the compliant group that utilized the full individual components of VAP bundle obtained higher weaning scores compared with the noncompliant group of patients who did not utilize all individual components together during the MV period. Such a result was supported by
Mohamed (2014), who concluded and highlighted that adherence with the VAP bundle approach in ICU leads to more rapid ventilator weaning, fewer ICU days, and shorter hospitalizations, and it has also a great impact on patient outcomes.
Applying the ventilator bundle practices with focusing on the head-of-bed elevation, daily sedation interruption, and assessment of readiness to extubate is highly recommended. The use of a structured tool to assess readiness for weaning can help in managing the mechanically ventilated patients. Moreover, replication of the study on a larger probability sample from different geographical locations in Egypt ensures generalizability of the study. 
Financial support and sponsorship
Conflicts of interest
The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
| References|| |
Al-Thaqafy MS, El-Saeed A, Balkhy H (2014). Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years. Ann Thorac Med 9:221–226.
Blackwood B, Alderdice F, Burns KE, Cardwell CR, Lavery GG, O’Halloran P (2009). Protocolized vs. non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients: Cochrane review protocol. J Adv Nurs 65:957–964.
Beattie M, Shepherd A, Maher S, Grant J (2012). Continual improvement in ventilator acquired pneumonia bundle compliance: a retrospective case matched review. Intensive Crit Care Nurs 28:255–262.
Chen YR, Chang PC, Chen JJ (2015). The effect of central line insertion bundle on the rate of central line-associated bloodstream infection. J Microbiol Immunol Infect 48:S91.
Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M (1999). Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 354:1851–1858.
Epstein SK, Parsons P (2013). Weaning from mechanical ventilation: readiness testing. [Monografía en Internet]. Waltham, MA: UpToDate.
Epstein SK, Walkey A (2013). Methods of weaning from mechanical ventilation. UpToDate WolthersKluwer Amsterdam Niederlande. Empfangen 10.
Epstein CD, El-Mokadem N, Peerless JR (2002). Weaning older patients from long-term mechan ical ventilation: a pilot study. Am J Crit Care 11:369–377.
Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, Arroliga AC (2002). Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 287:345–355.
Evans B (2005). Best-practice protocols: VAP prevention. Nurs Manage 36:10–16.
Figueroa-Casas J, Dwivedi A, Connery S, Quansah R, Ellerbrook L, Galvis J (2015). Predictive models of prolonged mechanical ventilation yield moderate accuracy. J Crit Care 30:502–505.
Grap MJ (2009) Not-so-trivial pursuit: mechanical ventilation risk reduction. Am J Crit Care 18:299–309.
Gonçalves FAF, Brasil VV, Ribeiro LCM, Tipple AFV (2012). Nursing actions for the prevention of ventilator-associated pneumonia. Acta Paul Enferm 25:101–107.
Hawe SC, Ellis SK, Cairns JC, Longmate A (2009). Reduction of ventilator- associated pneumonia: active vs passive guideline implementation, Intensive Care Med 35:1180–1186.
Hemant R, Chacko J, Singh K (2006). Weaning from mechanical ventilator. Indian J Anesth 50:435–438.
Ibrahim HE, Mehringer L, Prentice D, Sherman G, Schaiff R, Fraser V, Kollef MH (2002). Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. J Parenter Enteral Nutr 26:174–181.
Jones J, Fix B (2014). Critical care notes: clinical pocket guide. 2nd ed. Philadelphia, PA: FA Davis.
Mohamed KAE (2014). Compliance with VAP bundle implementation and its effectiveness on surgical and medical sub-population in adult ICU. Egypt J Chest Dis Tuberc 63:9–14.
Montasser GM, Eita MS, Ayman S, Abd Elbadee M, EL Shanawany E (2015). The incidence of ventilator associated pneumonia with incomplete or complete adherence to bundle of Prevention. N Y Sci J 8:10.
Möller MG, Slaikeu JD, Bonelli P, Davis AT, Hoogeboom JE, Bonnell BW (2005). Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg 189:293–296.
O’Keefe-McCarthy S, Santiago C, Lau G (2008). Ventilator-associated pnemonia bundled strategies: an evedence − based practices. Worldviews Evid Based Nurs 5:193–194.
Pu L, Zhu B, Jiang L, Du B, Zhu X, Li A, Chen W (2015). Weaning critically ill patients from mechanical ventilation: a prospective cohort study. J Crit Care 30:862.e7–862.e13.
Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T (2005). Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 31:243–248.
Silva LT, Laus AM, Canini SR, Hayashida M (2011). Evaluation of prevention and control measures for ventilator-associated pneumonia. Rev Lat Am Enfermagem 19: 1329–1336.
Suzanne SC, Bare B (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia, United States: Lippincott Williams & Wilkins.
Venkatram S, Nayak J, Kanna J (2010). Safety of daily sedation interruptions in Mechanically ventilated inner city patients − an alternative approach. J Med Med Sci 1:242–247.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]