Background: Ventilator associated pneumonia (VAP) in the intensive care unit (ICU) has been shown to be associated with significant morbidity and mortality.(1-3) It has been reported to affect between 9 and 27% of intubated patients receiving mechanical ventilation.(4-6)Objective: A meta-analysis was undertaken to combine information from published studies of the effect of subglottic drainage of secretions on the incidence of ventilated associated pneumonia in adult ICU patients.Data sources: Studies were identified by searching MEDLINE (1966 to January 2011), EMBASE (1980-2011), and CINAHL (1982 to January 2011).Review methods: Randomized trials of subglottic drainage of secretions compared to usual care in adult mechanically ventilated ICU patients were included in the meta-analysis.Results: Subglottic drainage of secretions was estimated to reduced the risk of VAP by 48% (fixed-effect relative risk (RR) = 0.52, 95% confidence interval (CI), 0.42-0.65). When comparing subglottic drainage and control groups, the summary relative risk for ICU mortality was 1.05 (95% CI, 0.86-1.28) and for hospital mortality was 0.96(95% CI, 0.81-1.12). Overall subglottic drainage effect on days of mechanical ventilation was -1.04 days (95% CI, -2.79-0.71).Conclusion: This meta-analysis of published randomized control trials shows that almost one-half of cases of VAP may be prevented with the use of specialized endotracheal tubes designed to drain subglottic secretions. Time on mechanical ventilation may be reduced and time to development of VAP may be increased, but no reduction in ICU or hospital mortality has been observed in published trials. (C) 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

The practice of intensive care medicine is increasingly being seen as extending outside the four walls of the intensive care unit (ICU). Systems are operating for the detection and rapid resuscitation of patients at the earliest possible stage, before and after discharge from the ICU. And yet,current scoring systems used for evaluating intensive care outcomes assume the interventions occur only within the geographical boundaries of the unit. Broader indicators that measure the continuum of care for seriously ill patients across the entire hospital include deaths, cardiorespiratory arrests and unexpected admission to the ICU. Analysis of these indicators can identify potentially preventable cases, where early identification and resuscitation may have prevented their occurrence. Hospital deaths and cardiorespiratory arrests can be further categorized into unexpected events by excluding patients with 'do not resuscitate' orders. This, in itself, assists in changing the culture of a hospital to being more explicit about dying patients. Unless global measurements of care of the seriously ill occurs it is difficult to estimate the impact of care before and after ICU admission; to evaluate ICU admission and discharge policies; to estimate the need for high dependency beds; or to evaluate care of the seriously ill in sites other than the ICU. The system must also develop targeted methods of distributing the data in order to have a maximum impact. Indicators which estimate the quality of care of the seriously ill across the whole hospital are a critical part of any system designed to improve management.