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Introduction  Ventilator-associated pneumonia (VAP) is the most frequent infection in patients admitted to intensive care units.  The efficacy of individual measures for the prevention of VAP is well documented, and data on the impact of implementing bundle measures have usually been reported from studies in which several measures are implemented simultaneously in the general intensive care unit (ICU).  The objective of our work was to evaluate the impact of four sequentially implemented measures for preventing VAP in a major heart surgery ICU. The measures were a specific training program, aspiration of subglottic secretions (ASSs), introduction of an inclinometer to improve the semirecumbent position, and reinforcement of oral care with chlorhexidine.    Methods  We compared rates of VAP, days on mechanical ventilation (MV), and cost of antimicrobial agents before and during implementation.    Results  We collected data from 401 patients before the intervention and from 1,534 patients during the intervention. Both groups were comparable. No significant differences in EuroSCORE were observed between the patients of both periods (6.4 versus 6.3;  P  = 0.7). The rates of VAP (episodes/1,000 days of ventilation) were, respectively, 23.9 versus 13.5 ( P  = 0.005). Mean number of days of MV/1,000 days of stay was 507 versus 375 ( P  = 0.001), and the cost of antimicrobial therapy (Euros/1,000 days of stay) was €70,612 versus €52,775 ( P  = 0.10). The main effect of sequential application of preventive measures in time achieved a relative-rate reduction of VAP of 41% (IRR, 0.41; 95% CI, 0.28 to 0.62). The mortality rate before and during the intervention was 13.0% and 10.2%, respectively.  VAP rate was most significantly reduced by training and the use of the inclinometer.    Conclusions  A sequentially applied bundle of four preventive measures reduces VAP rates, days of MV, and the cost of antimicrobial therapy in patients admitted to the major heart surgery ICU.    Trial registration  Clinical Trials.gov:  NCT02060045 . Registered 4 February 2014.

Impact of four sequential measures on the prevention of ventilator-associated pneumonia in cardiac surgery patients