Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines

• Main Authors: Iqbal M, Lee S, Singarajah CU, Robbins RA, Pattee JJ, Padrnos L, Bui T, Whitmore EJ
• Format: Article
• Language: English
• Published: Arizona Thoracic Society 2011-08-01
• Series: Southwest Journal of Pulmonary and Critical Care
• Subjects: Institute of Healthcare Improvement; deep venous thrombosis prophylaxis; guidelines; head of bed elevation; readiness to extubate; readiness to wean; sedation vacation; stress ulcer diesase prophylaxis; ventilator-associated pneumonia
• Online Access: http://www.swjpcc.com/critical-care/2011/8/22/analysis-of-overall-level-of-evidence-behind-the-institute-o.html?SSScrollPosition=62

Background Clinical practice guidelines are developed to assist in patient care but the evidence basis for many guidelines has recently been called into question. Methods We conducted a literature review using PubMed and analyzed the overall quality of evidence and made strength of recommendation behind 6 Institute of Health Care (IHI) guidelines for prevention of ventilator associated pneumonia (VAP). Quality of evidence was assessed by the American Thoracic Society levels of evidence (levels I through III) with addition of level IV when evidence existed that the guideline increased VAP. We also examined our own intensive care units (ICUs) for evidence of a correlation between guideline compliance and the development of VAP. Results None of the guidelines could be given more than a moderate recommendation. Only one of the guidelines (head of bed elevation) was graded at level II and could be given a moderate recommendation. One was graded at level IV (stress ulcer disease prophylaxis). The remainder were graded level III and given weak recommendations. In our ICUs compliance with the guidelines did not correlate with a reduction in VAP (p<0.05). Conclusions Most of the IHI guidelines are based on level III evidence. Data from our ICUs did not support guideline compliance as a method of reducing VAP. Until more data from well-designed controlled clinical trials become available, physicians should remain cautious when using current IHI VAP guidelines to direct patient care decisions or as an assessment of the quality of care.