Barriers to the adoption of ventilator-associated events surveillance and prevention

Abstract

The CDC expanded the purview of safety surveillance for ventilated patients from ventilator-associated pneumonia (VAP) to ventilator-associated events (VAE) in 2013. CDC created VAE definitions to simplify surveillance, increase objectivity, and broaden prevention efforts. Many U.S. hospitals are conducting VAE surveillance but uptake beyond the U.S. has been limited. Review of recent publications suggest three major barriers to the adoption of VAE surveillance and prevention: 1) ongoing uncertainty about VAE and concern about its limited overlap with clinically-defined VAP, 2) a paucity of studies defining risk factors for VAEs and how best to prevent VAEs, and 3) lack of emphasis on VAE surveillance and prevention by regulatory agencies. Emerging data partially address the first two points. Possible VAPs missed by VAE surveillance are associated with lower mortality rates than VAEs and have similar outcomes whether treated with 3 days of antibiotics or more conventional courses, suggesting VAE focuses surveillance on severe events. Potentially-modifiable VAE risk factors include deep sedation, positive fluid balance, blood transfusions, and mandatory modes of mechanical ventilation with high inspiratory pressures. Potential interventions to prevent VAEs include avoiding intubation, minimizing sedation, paired daily spontaneous awakening and breathing trials, conservative fluid management, conservative transfusion thresholds, low tidal volume ventilation, and early mobility. There are important limitations to all existing prevention studies, however, and no study has thus far has tested a VAE prevention bundle that includes all these interventions. Further work is needed to better define the clinical significance of VAPs missed by VAE surveillance, to rigorously evaluate the impact of an optimized VAE prevention bundle on VAEs and other outcomes, and to weigh whether these additional data provide adequate evidence to support mandating VAE surveillance and prevention.

A systematic scoping review of the cost-impact of ventilator-associated pneumonia (VAP) intervention bundles in intensive care

“…5,6 VAP results in increased duration of invasive mechanical ventilation, intensive care unit (ICU), and hospital length of stay (LOS), and demand on health care resources. 4,7 Although the Centers for Disease Control and Prevention (CDC) recommendations from 2013 have shifted the focus away from monitoring VAP to monitoring ventilator-associated events, 8,9 these updated surveillance targets have not been universally adopted internationally, 10 and published costing studies have continued to use VAP criteria. [11][12][13] VAP places significant demand on acute beds and is a key contributor to rising acute health care costs.…”

Caution, not causality: The limitations of risk factor and outcome research on ventilator-associated events

“…The VAE definition is significantly more objective due to relying upon distinct measures of oxygenation (fraction of inspired oxygen (Fi02) and positive endexpiratory pressure (PEEP)), as opposed to previously utilized clinical definitions but now encompasses a much broader group of disorders beyond pneumonia; including pulmonary edema, atelectasis, mucus plugging, abdominal disorders and sepsis which may impact lung function, pulmonary embolism, and transfusion-related lung injury. 1,2 Discordance between clinical VAP and VAE-has been well-described, wherein VAE surveillance has not correlated with traditionally defined VAP cases. 2,3 Additionally, recommended prevention strategies for VAP may not necessarily impact VAE and compliance with VAP bundles has not correlated with improvement in VAE rates.…”

“…1,2 Discordance between clinical VAP and VAE-has been well-described, wherein VAE surveillance has not correlated with traditionally defined VAP cases. 2,3 Additionally, recommended prevention strategies for VAP may not necessarily impact VAE and compliance with VAP bundles has not correlated with improvement in VAE rates. 4 Due to the above, questions have been raised regarding the value of VAE as a metric for patient care or outcomes.…”

“…Previous studies have described the impact of VAE as a clinical outcome, noting worse prognosis for patients with VAEs compared to those without. 1,2 Controversy regarding these results remains due to concerns over sample size, study design, and ability to control for confounders. Additional research is required to determine the impact of VAE on meaningful patient centered outcomes, to better define the risk factors for VAE, and then to identify practical and effective preventative measures.…”

“…Trials utilizing spontaneous awakening and breathing trials have demonstrated decreased time on the ventilator and decreased VAE rates. 2,[6][7][8] These strategies coupled with minimization of sedation, early mobility, use of low tidal ventilation, and conservative fluid and blood product have all shown some success in decreasing the conditions associated with VAE (pneumonia, atelectasis, acute respiratory distress syndrome (ARDS), pulmonary edema, and more). 1,7,8 The authors of this study suggest focusing on PVAPs rather than the entire VAE umbrella.…”