- Open Access
Value and price of ventilator-associated pneumonia surveillance as a quality indicator
Critical Care volume 14, Article number: 403 (2010)
Awareness of the importance of quality assurance in the ICU is growing but the methodology is still under development and subject to debate [1–3]. Ventilator-associated pneumonia (VAP) seemed to come close to being an important, valid, reliable, responsive, interpretable and feasible outcome parameter . We therefore decided to measure VAP incidence on a regular basis. A prospective study was carried out with yearly assessment of the incidence of VAP during a 3-month period. Definition of VAP was based on the recommendations of the Centers for Disease Control and Prevention . Overall, out of 550 patients ventilated for >48 hours, only two cases of definite VAP were observed . Because no further improvement could be achieved in this field, we turned our attention to other outcome parameters. A perceived rise in incidence of VAP led us to repeat our evaluation, despite growing concern about the importance, validity and reliability of VAP as a quality indicator .
With the same methodology we measured the incidence of VAP again. Compared to our previous research, we observed a significant (P < 0.001, chi-square test) increase in VAP in accordance with our impressions (Table 1).
The incidence of VAP in our unit is still below that reported in the literature . When used as a benchmark, we are performing well. However, when used as a quality indicator over time the results should lead to concern. Even if patients diagnosed with VAP do not have real VAP but colonization, atelectasis, or fluid overload, these conditions are also detrimental for the patient and should be avoided .
As a benchmark, VAP incidence might have limited value [1, 2]. This is mainly due to inappropriate case mix correction and to diagnostic inaccuracy. Fear of being judged on disputable quality indicators such as inter-hospital benchmarks is a serious threat to the probably valuable use of intra-hospital trend analysis of quality indicators. Used as a longitudinal quality indicator in a single centre, VAP is less threatened by case-mix differences and the limited sensitivity and specificity of the VAP diagnostic criteria. The price of this quality assessment is considerable. The workload of this 14-week evaluation resulted in an estimated cost of 20,000 euros.
In our view, measurement of VAP incidence has its value as an intra-hospital quality indicator but not as a benchmark.
Klompas M: Unintended consequences in the drive for zero. Thorax 2009, 64: 463-465. 10.1136/thx.2009.114165
Klompas M: The paradox of ventilator-associated pneumonia prevention measures. Crit Care 2009, 13: 315. 10.1186/cc8036
Curtis JR, Cook DJ, Wall RJ, Angus DC, Bion J, Kacmarek R, Kane-Gill SL, Kirchhoff KT, Levy M, Mitchell PH, Moreno R, Pronovost P, Puntillo K: Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team. Crit Care Med 2006, 34: 211-218. 10.1097/01.CCM.0000190617.76104.AC
Horan TC, Andrus M, Dudeck MA: CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008, 36: 309-332. 10.1016/j.ajic.2008.03.002
Tulleken JE, Zijlstra JG, Ligtenberg JJ, Spanjersberg R, Werf TS: Ventilator-associated pneumonia: caveats for benchmarking. Intensive Care Med 2004, 30: 996-997. 10.1007/s00134-004-2247-z
All participating physicians for the recording of data, Mr H van Assen for providing all APACHE-scores of included patients.
The authors declare that they have no competing interests.
About this article
Cite this article
Aardema, H., Dijkema, L., Lazonder, M.G. et al. Value and price of ventilator-associated pneumonia surveillance as a quality indicator. Crit Care 14, 403 (2010). https://doi.org/10.1186/cc8189
- Quality Indicator
- Trend Analysis
- Outcome Parameter
- Fluid Overload
- Limited Sensitivity