New Guidelines Revamp VAP Reporting

August 8, 2013

By Karin Lillis

New guidelines from the National Health Safety Network (NHSN) are changing the way hospitals report ventilator-associated events, including complications and pneumonia, says Linda R. Greene, RN, MPS, CIC, a member of the board for the Association for Professionals in Infection Control (APIC). She was also a member of the CDC working group that helped shape the current surveillance definition algorithm for reporting VAEs.

The NHSN is the Centers for Disease Control and Prevention (CDC)'s system for surveillance reporting of healthcare-associated infections (HAIs). More than 5,000 healthcare facilities participate in the program, according to NHSN, and most report data on device-assisted HAIs, including ventilator-associated pneumonia. While the CDC does not require healthcare facilities to participate, many states mandate that hospitals report HAIs through NHSN.

Greene emphasizes that the new definitions aren't meant for and don't replace clinical diagnosis. Currently, the new reporting definitions apply only to adult patients in acute care, long-term acute care and rehabilitation settings, according to the CDC. Among the most notable, Greene says: The new definition no longer requires a chest radiograph to confirm a case of VAP. Studies suggest that chest radiographs are not a reliable indicator of VAP, the CDC notes, because there is variation among ordering practices, technique, interpretation and reporting.

Was it really (a case of VAP), or a byproduct of how the X-ray was read? Greene asks.
Since NHSN has only been collecting data since the beginning of the year, it's too soon to tell whether the new definition can help hospitals more accurately report cases of ventilator-associated events, like VAP, Greene says. Experts will tell you that any interventions that decrease vent time lead to better patient outcomes and lower mortality rates, she explains. Hospitals are still trying to determine what will work and how many preventable conditions are present."

Since the new reporting requirements have been in place, Greene notes, What we did see at my facility, is on one or two ventilator-associated complications (there were) unpreventable events. We did identify at least one or two cases of potential preventability, Greene says. We will be looking at the data more closely.

The new definitions are a starting place that experts hope will offer the opportunity to alter the outcomes.

In the (old) VAP definition, there has certainly been evidence to show that it ventilator bundles have prevented many cases of VAP through 'before and after' trials, Greene notes. The problem is that most of those studies haven't (looked at) outcomes of care. Also, because the old definition leaves so much room for interpretation as in the case of chest X-rays   it's difficult to determine based on NHSN data exactly how effective ventilator bundles are in preventing pneumonia and other complications, she adds.
That is the issue studies suggested a decrease in VAP rates, but there are very few that follow patient outcomes, Greene notes. One might be able to say that exposure to an antibiotic puts patients at risk. A hospital's VAP rate might decrease by 50 percent after applying the VAP bundle, but it's hard to know what we're measuring because the (current) definition is so flawed.

Infection preventionists are asking themselves, 'How do I implement the changes?' and 'What interventions should the hospital make?' Greene says.  It's important to form a multidisciplinary team. As much as we say we're collaborated, healthcare has been siloed especially in infection prevention.

Respiratory is a key player in evaluating patients on ventilators and it's critical to get the intensivist on board, Greene says. But what about the role of the infection preventionist?
He or she is more than the person who enters data into the NHSN and pulls information from the database, Greene says. The infection preventionist has an early eye on the data and can help hospitals spot trends positive or negative and launch appropriate action. Data is a powerful drive in preventing patient harm, Greene says.

Most importantly, she notes, The infection preventionist is a coach and facilitator. She's the person most intimate with the (new NHSN) definition and the most knowledgeable about prevention. She's the spark that helps ignite the rest of the team.
Greene adds, What's interesting and too soon to tell is when we have some comparative data that can allow hospitals to measure their efforts against similar organizations. For instance, one facility might review its VAP rates on a surgical ICU and find its rates are higher than other units at similar hospitals.

As hospitals begin to follow the definitions and enter that information into the NHSN, she says, it will create a more rich database and a better experience on the whole.

Karin Lillis is a freelance writer.