Cusp for vap evap on boarding call 5 evidence review
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CUSP for VAP: EVAP On Boarding Call #5: Evidence Review. Sean Berenholtz M.D., MHS Nishi Rawat , M.D. September 18 th , 2012 2:00 pm EST/ 11:00 am PST . On Boarding Call Schedule – Tuesdays 8/21–9/25 @ 2:00. Presentation Objectives.

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CUSP for VAP: EVAP On Boarding Call #5: Evidence Review

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Cusp for vap evap on boarding call 5 evidence review

CUSP for VAP: EVAPOn Boarding Call #5:Evidence Review

Sean Berenholtz M.D., MHS

Nishi Rawat, M.D.

September 18th, 2012

2:00 pm EST/ 11:00 am PST


On boarding call schedule tuesdays 8 21 9 25 @ 2 00

On Boarding Call Schedule –Tuesdays 8/21–9/25 @ 2:00


Presentation objectives

Presentation Objectives

To review the evidence to support the implementation of:

  • Head of Bed Elevation (HOB) ≥ 30 degrees

  • Spontaneous Awakening and Breathing Trials (SAT & SBT)

  • Oral Care with Chlorhexidine

  • Subglottic Suctioning


What data will teams need to collect

What data will teams need to collect?

  • Monthly VAE data using new CDC NHSN definitions

    • Numerator and denominator

    • Will work with you to collect baseline ‘VAE’ data

  • Daily process measure data

  • Quarterly implementation data and semi-annual structural measures

    • Brief survey and structured interview

  • Annual teamwork/culture data using the AHRQ Hospital Survey of Patient Safety (HSOPS)

  • Will work with HENS to ensure data reporting meets their needs


Process measures daily evaluation

Process measures: Daily evaluation

  • Head of Bed Elevation (HOB)

    • Use of a semi-recumbent position ( ≥ 30 degrees).

  • Spontaneous Awakening and Breathing Trials (SAT & SBT)

    • Make a daily assessment of readiness to wean with the use of the SAT and SBT.

  • Oral Care

    • At least 6 times per day

  • Oral Care with Chlorhexidine

    • Should be included in the oral care regimen 2 times per day

  • Subglottic Suctioning

    • Use subglottic suctioning ETTs in patients expected to be mechanically ventilated for >72 hours


Policy based structural measures

Policy Based Structural Measures :

  • Use a closed ETT suctioning system

  • Change close suctioning catheters only as needed

  • Change ventilator circuits only if damaged or soiled

  • Change HME every 5-7 days and as clinically indicated

  • Provide easy access to NIVV equipment and institute protocols to promote use

  • Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient

  • Use early mobility protocol

    ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation


Policy based structural measures1

Policy Based Structural Measures :

  • Perform hand hygiene

  • Avoid supine position

  • Use standard precautions while suctioning respiratory tract secretions

  • Use orotracheal intubation instead of nasotracheal

  • Avoid use of prophylactic systemic antimicrobials

  • Avoid non-essential tracheal suctioning

  • Avoid gastric over-distention

    ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation


Cusp for vap evap on boarding call 5 evidence review

Head of Bed Elevation


Head of bed elevation vap prevention guidelines

Head of Bed Elevation : VAP Prevention Guidelines

  • Recommends head of bed elevation at an angle of 30–45 degrees for patients with a high risk for aspiration (e.g., a person receiving mechanically assisted ventilation) in the absence of medical contraindication.

    • CDC; MMWR Recomm Rep. 2004;53:1-36

  • Recommends that patients should be kept in a semi-recumbent position (30-45 degrees) rather than supine to prevent aspiration.

    • ATS/IDSA; AJRCCM 2005;171(4):388-416.


  • Head of bed elevation vap prevention guidelines1

    Head of Bed Elevation : VAP Prevention Guidelines

    • Recommends the head of bed elevation to be 45 degrees, as long as not contraindicated.

      • Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

  • Recommends the use semi-recumbent position (30-45 degrees) as a strategy to prevent aspiration.

    • SHEA; ICHE 2008;29:S31-S40.


  • Hob elevation 2009 meta analysis

    HOB elevation: 2009 Meta-Analysis

    • 3 RCTs evaluating 337 patients receiving mechanical ventilation

    • Randomized to semi-recumbent 45 degrees or supine position

    • Odds of developing VAP significantly lower among patients positioned semi-recumbently

      • OR ,0.47,95% CI, 0.27-0.82

    Alexiou J Crit Care 2009;24(4):515-522


    Hob elevation 2009 meta analysis1

    HOB Elevation: 2009 Meta-Analysis

    Alexiou et al. J Crit Care 2009; 24(4):515-522


    Hob elevation

    HOB Elevation

    Population

    • Patients receiving mechanical ventilation in medical and respiratory ICUs

      Intervention (RCT)

    • Patients were randomly assigned the supine (N= 47)vs semi-recumbent at 45 degrees (N=39) positions

    Drakulovic et al. Lancet 1999; 354:1851-58.


    Hob elevation1

    HOB Elevation

    Outcomes

    • Frequency of clinically suspected pneumonia lower in semi-recumbent vs supine

      • 3 /39 [8%] vs 16/47 [34%]; CI 10.0–42.0, p=0·003

    • Frequency of microbiologically confirmed pneumonia lower in semi-recumbent vs supine

      • 2/39 [5%] vs11/47 [23%]; CI 4.2–31.8, p=0.018

    • Independent risk factors:

      • Supine body position (OR 6.8 [1.7–26.7], p=0.006)

      • Enteral nutrition (OR 5.7 [1.5–22.8], p=0.013)

    Drakulovic et al. Lancet 1999; 354:1851-58.


    Hob elevation2

    HOB Elevation

    Population

    • Patients receiving mechanical ventilation at 4 university ICUs

      Intervention (RCT)

    • Patients were randomly assigned to usual care (N= 109)vs semi-recumbent at 45 degrees (N=112) positions

    van Nieuwenhoven et al. CCM 2006;34(2)396-402.


    Hob elevation3

    HOB Elevation

    Outcomes

    • Target semi-recumbent position of 45 was not achieved for 85% of the study time

    • Frequency of clinically suspected pneumonia:

      • 16/112[14.3%] semi-recumbent vs 20/109 [18.3%] supine

    • Frequency of microbiologically confirmed pneumonia

      • 13/112 [11.6%] semi-recumbent vs8/109 [7.3%] supine

    • Achieved difference in treatment position (28 vs 10 degrees) did not prevent the development of VAP

    van Nieuwenhoven et al. CCM 2006;34(2)396-402.


    Cusp for vap evap on boarding call 5 evidence review

    Spontaneous Awakening and Breathing Trials (SAT &SBT)


    Spontaneous awakening and breathing trials vap prevention guidelines

    Spontaneous Awakening and Breathing Trials : VAP Prevention Guidelines

    • Does not specifically address SAT and SBT, however supports weaning.

      • CDC; MMWR Recomm Rep. 2004;53:1-36

  • Recommends use of daily interruption or lightening of sedation to avoid constant heavy sedation and to facilitate and accelerate weaning.

  • Does not specifically address SBT.

    • ATS/IDSA; AJRCCM 2005;171(4):388-416.


  • Spontaneous awakening and breathing trials vap prevention guidelines1

    Spontaneous Awakening and Breathing Trials : VAP Prevention Guidelines

    • Guideline excluded studies that evaluated SAT and SBT.

      • Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

  • Recommends the use of combining a daily assessment of readiness wean and daily sedation interruption.

    • SHEA; ICHE 2008;29:S31-S40.


  • Spontaneous awakening trials

    Spontaneous Awakening Trials

    Population

    • Medical ICU patients on mechanical ventilation

      Intervention(RCT)

    • Control group: no interruption (N= 68)

    • Rx group: daily interruption (N= 60) sedation held daily until the patients were awake and could follow instructions or uncomfortable or agitated.

    • All patients received an infusion of morphine for analgesia.

    Kress et al. NEJM 2000; 342:1471-77


    Spontaneous awakening trials1

    Spontaneous Awakening Trials

    Outcomes

    • 2.4 day reduction duration mechanical ventilation

      • 33% relative risk reduction

    • 3.5 day reduction ICU length of stay

      • 35% relative risk reduction

    • Hospital length of stay unchanged: control group 16.9 days (8.5-26.6 days) compared to rxgroup 13.3 days (7.3-20.0 days).

    Kress et al. NEJM 2000; 342:1471-77


    Spontaneous breathing trials

    Spontaneous Breathing Trials

    Population

    • Adult medical and coronary ICU patients on mechanical ventilation (n=300)

      Intervention (RCT)

    • Control group: daily screening (RSBI*) (n=151)

    • Experimental group: daily screening (RSBI) followed by 2-hour SBT (n=149) if they passed the screening test

    • Physicians were notified when their patients successfully completed the trial of spontaneous breathing.

    *RSBI: rapid shallow breathing index

    Ely et al. NEJM 1996; 335:1864-69.


    Spontaneous breathing t rial sbt

    Spontaneous Breathing Trial (SBT)

    • Patient passes SBT safety screen

    • Ventilatorysupport is removed and the patient is allowed to breathe through either a T-tube circuit or a ventilatory circuit using “flow triggering” (rather than triggering by pressure) with a continuous positive airway pressure of 5 cm of water.

    • No changes are required in the fraction of inspired oxygen or the level of positive end-expiratory pressure.


    Spontaneous breathing trials1

    Spontaneous Breathing Trials

    Outcomes

    • 1.5 day reduction duration mechanical ventilation

      • 25% relative risk reduction

    • 1.0 day reduction ICU length of stay

      • Not statistically significant

    • Reductions total ICU costs

    • Reductions in complications including reintubation

    Ely et al. NEJM 1996; 335:1864-69.


    Treatment protocol

    Treatment protocol

    Girard et al. Lancet 2008; 371: 126–34


    Abc trial awakening and breathing controlled trial

    ABC Trial: Awakening and Breathing Controlled trial

    Population

    • 336 ICU patients on mechanical ventilation

    • Four tertiary-care hospitals

      Intervention(RCT)

    • Control group: sedation per usual plus daily SBT (n=168)

    • Rx group: daily SAT followed by SBT (n=168) All patients received an infusion of morphine for analgesia.

    Girard et al. Lancet 2008; 371: 126–34


    Abc trial awakening and breathing controlled trial1

    ABC Trial: Awakening and Breathing Controlled trial

    • 3.1 increased days without mechanical ventilation

      • 21% relative risk increase

    • 3.8 day reduction ICU length of stay

      • 29% relative risk reduction

    • 4.3 day reduction hospital length of stay

      • 22% relative risk reduction

    • Number needed to treat (NNT) = 7.4 for one life saved

    Girard et al. Lancet 2008; 371: 126–34


    Cusp for vap evap on boarding call 5 evidence review

    Oral Care with Chlorhexidine


    Use chlorhexidine when performing oral care vap prevention guidelines

    Use Chlorhexidine when performing oral care: VAP Prevention Guidelines

    • No specific recommendation can be made for the routine use of an oral chlorhexidine rinse. (Unresolved issue)

      • CDC; MMWR Recomm Rep. 2004;53:1-36

  • Recommends regular oral care. CHG effective in specific populations (ie: CABG); routine use is not recommended until more data is available.

    • ATS/IDSA; AJRCCM 2005;171(4):388-416.


  • Chlorhexidine when performing oral care vap prevention guidelines

    Chlorhexidine when performing oral care: VAP Prevention Guidelines

    • Oral antiseptic CHG should be considered. Based on 1 level 1 and 2 level 2 trials, use of oral antiseptic CHG may decrease VAP. Safety, feasibility, and cost considerations are all very favorable.

      • Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

  • Perform regular oral care with an antiseptic solution. While the use of CHG is not specifically addressed, the 3 studies cited by the guideline all focused on cardiovascular surgery and demonstrated the efficacy of CHG.

    • SHEA; ICHE 2008;29:S31-S40.


  • Chg oral care evidence

    CHG Oral Care: Evidence

    • Gingival and dental plaque rapidly becomes colonized with bacteria in intubated patients due to poor oral hygiene and lack of mechanical elimination

    • Meticulous oral care reduces microbial burden in upper airway

    • Safety and feasibility of CHG oral care are favorable

    DeRiso A. Chest. 1996;109:1556.

    Chan E. BMJ. 2007;10:1136.

    Chlebicki M Crit Care Med 2007;35:595.


    Oral antiseptics 2011 systematic review and meta analysis

    Oral Antiseptics: 2011 Systematic Review and Meta-Analysis

    • 12 RCTs evaluating CHG (2341 patients)

    • Overall 38% VAP reduction

      • RR 0.72, 95%CI 0.55-0.94

    • Results varied by CHG concentration

      • 2% > 0.2% > 0.12%

    Labeau Lancet Infect Dis 2011;11:845-54


    Oral antiseptics a systematic review and meta analysis

    Oral Antiseptics: A Systematic Review and Meta-Analysis

    Labeau Lancet Infect Dis 2011;11:845-54


    Oral antiseptics a systematic review and meta analysis1

    Oral Antiseptics: A Systematic Review and Meta-Analysis

    • Variation by ICU Type

    • Cardiac Surgery only (n=2, 914 patients)

      • RR 0.41, 95% CI 0.17-0.98

    • Mixed ICUs (n=10, 1294 patients)

      • RR 0.77, 95% CI 0.58-1.02

    • Surgery or Trauma (n=2, 273 patients)

      • RR 0.67, 95% CI 0.50-0.88

    Labeau Lancet Infect Dis 2011;11:845-54


    Chg oral care recommendations

    CHG Oral Care: Recommendations

    • Chlorhexidine 0.12% oral solution (15 ml bid until 24 hours after extubation) for all intubated patients

      • Contraindications

        • Hypersensitivity to component of solution

        • <2 months of age

        • There is the possibility of direct contact with meninges

  • Brush patients’ teeth bid with soft toothbrush to remove dental plaque prior to using CHG

  • Oral Care should be performed q4;

  • Oral Care with CHG should be performed q12.


  • Cusp for vap evap on boarding call 5 evidence review

    Subglottic suctioning ETTs in patients mechanically ventilated for >72 hours


    Subglottic suctioning etts vap prevention guidelines

    Subglottic suctioning ETTs: VAP Prevention Guidelines

    • Recommend ETTs with a dorsal lumen above the cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions.

      • CDC; MMWR Recomm Rep. 2004;53:1-36

  • Recommend specially designed endotracheal tube (dorsal lumen) for continuous aspiration of subglottic secretions

    • ATS/IDSA; AJRCCM 2005;171(4):388-416.


  • Subglottic suctioning etts vap prevention guidelines1

    Subglottic suctioning ETTs: VAP Prevention Guidelines

    • Recommended subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours.

      • Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

  • Recommend the use of cuffed ETT with in line or subglottic suctioning.

    • SHEA; ICHE 2008;29:S31-S40.


  • Subglottic suctioning etts evidence

    Subglottic suctioning ETTs: Evidence

    • Drainage of subglottic secretions lessens the risk of aspiration

    • Specially designed endotracheal tubes have been developed to provide continuous or intermittent subglottic secretion removal

    Kollef M. Chest. 1999;116:1339.

    Smulders K. Chest 2002;121:858.


    Subglottic suctioning etts

    Subglottic Suctioning ETTs


    Subglottic suctioning etts evidence1

    Subglottic Suctioning ETTs: Evidence

    • 13 RCTs evaluating subglottic secretion drainage (2442 patients)

    • Overall 45% VAP reduction

      • RR 0.55 (95% CI 0.46–0.66)

      • NNT = 11

    • 1.5 day ICU LOS reduction

    • 1.1 day duration of MV reduction

    Muscedere J. Crit Care Med. 2011;39:1985.


    Subglottic suctioning etts a systematic review and meta analysis

    Subglottic Suctioning ETTs: A Systematic Review and Meta-Analysis

    Muscedere J. Crit Care Med. 2011;39:1985.


    Subglottic suctioning etts a systematic review and meta analysis1

    Subglottic Suctioning ETTs: A Systematic Review and Meta-Analysis

    Similar results if limited to studies of high methodologic quality

    Muscedere J. Crit Care Med. 2011;39:1985.


    Subglottic suctioning etts a cost effectiveness analysis

    Subglottic Suctioning ETTs: A Cost Effectiveness Analysis

    Conclusion:

    Regular utilization of CSS-ETs may produce significant cost savings, irrespective of the increased costs of CSS-ETs.

    Shorr et al. Chest 2001;119:228-235


    Potential limitations

    Potential Limitations

    • Potential limitations of Shorr et al. study

    • Limited to patients requiring more than 48 hours of ventilation

    • Base case assumed 25% VAP incidence

    • Did not include costs of suction canisters

    Hallais et al. Infect Control HospEpidemiol 2011;32(2):131-135


    Subglottic suctioning etts a cost effectiveness analysis1

    Subglottic Suctioning ETTs: A Cost Effectiveness Analysis

    • Design: Cost-benefit analysis, based on hypothetical replacement of standard ETT with CSS ETT

    • Setting: all 416 patients receiving mechanical ventilation in tertiary-care SICU in France (2006)

    • Methods: base case 7.9 VAP per 100 ventilated patients; 29% reduction in VAP with CSS; included sensitivity analysis (lowest VAP rate 6.6%)

    • Conclusion: CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

    Hallais et al. Infect Control HospEpidemiol 2011;32(2):131-135


    Subglottic suctioning etts recommendations

    Subglottic Suctioning ETTs: Recommendations

    • Continuous subglottic suctioning system recommended for patients expected to be mechanically ventilated for >72 hours

    • Unanswered questions

      • How to identify pts that will require MV > 3 days; most studies used SDD ETTs for all patients undergoing major surgery

      • Should ETTs be changed if patients require MV > 3 days.


    Tools and resources

    Tools and Resources

    • Educational Resources

      • Fact sheets

      • Literature reviews

      • Powerpoint slides

      • Audio recordings

    • VAP and CUSP toolkits

    • Social networking

    http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/


    Science of safety

    Science of Safety

    • Safety is a property of systems

      • Standardize with protocols, create checklists, learn when things go wrong

      • We need lenses to see the system

  • Recognize these principles apply to technical and team work

  • Teams make wise decisions when there is diverse and independent input


  • Next steps

    Next Steps

    • Review evidence with CUSP team

    • Think about how best to educate staff

      • Use educational tools

      • Create ‘resource book’ in ICU

    • Make sure staff know who to contact in your ICU if questions or concerns

    • Review unit level policies and protocols and work toward alignment with recommendations

    • Develop and share policies and protocols


    Cusp for vap evap on boarding call 5 evidence review

    Questions

    • Karol G. Wicker, MHS

      Senior Director, Quality Policy & Advocacy

      Maryland Hospital Association

      [email protected]

    • Mary Catanzaro RN BSMT CIC

      Project Manager HAIs

      Hospital and Healthsystem Association of Pennsylvania

      [email protected]


    References

    References

    Slide 9, 18, 29, 37

    • CDC; MMWR Recomm Rep. 2004;53:1-36

    • ATS/IDSA; AJRCCM 2005;171(4):388-416.

      Slide 10, 19, 30, 38

    • Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

    • SHEA; ICHE 2008;29:S31-S40.

      Slide 11, 12

    • Alexiou VC, Vrettos Ierodiakonou V, Dimopoulos G, Falagas ME, Impact of patient position on the incidence of ventilator-associated pneumonia: A meta-analysis of randomized controlled trials J Crit Care 2009; 24(4):515-522


    References1

    References

    Slide 13, 14

    • Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. 1999; 354:1851-58.

      Slide 15, 16

    • Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel Frank FH, Joore HCA, Schijndel, RJ, Strack MD, Van derTweel I, Graham R, Bonten MJ Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: A randomized study. CCM 2006;34(2)396-402.

      Slide 20, 21

    • Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. NEJM 2000; 342:1471-77


    References2

    References

    Slide 22, 24

    • Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, Johnson MM, Browder RW, BowtonDL,Haponik EF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. NEJM 1996; 335:1864-69.

      Slide 25, 26, 27

    • Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 2008; 371: 126–34


    References3

    References

    Slide 31

    • DeRiso AJ, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidinegluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996; 109: 1556-1561.

    • Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ. 2007;10:1136

    • Chlebicki MP, Safdar N, Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2007;35:595.

      Slide 32, 33, 34

    • Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis 2011;11:845-54


    References4

    References

    Slide 39

    • Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999 Nov;116(5):1339-46.

    • Smulders K, van derHoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest. 2002 Mar;121(3):858-62.

      Slide 40

    • Vallés J, Artigas A, Rello J, Bonsoms N, Fontanals D, Blanch L, Fernández R, Baigorri F, Mestre J. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med. 1995 Feb 1;122(3):179-86.


    References5

    References

    Slide 41, 42, 43

    • Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med. 2011 Aug;39(8):1985-91.

      Slide 44

    • Shorr AF, O'Malley PG. Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia : potential economic implications. Chest. 2001 Jan;119(1):228-35.

      Slide 45, 46

    • Hallais C, Merle V, GuitardPG,Moreau A, Josset V, Thillard D, Haghighat S, Veber B, Czernichow P. Is continuous subglottic suctioning cost-effective for the prevention of ventilator-associated pneumonia? Infect Control Hosp Epidemiol. 2011 Feb;32(2):131-5.


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