+ Author Affiliations
(See the Major Article by Klompas et al, on pages 370–7.)
Healthcare providers have at their disposal
an arsenal of tools to prevent healthcare-associated infections (HAIs),
including
infection prevention bundles, provider education, hand
hygiene monitoring and feedback, and the ability to track HAI events
and provide feedback of HAI infection rates to
providers and hospital administration. Participation in long-term
surveillance
efforts as part of a regional or national program
provides critical data that healthcare facilities can use to develop and
implement local prevention efforts and achieve
reductions in infection rates [1–3].
Historically, many infections that met HAI surveillance definitions
were not considered by clinicians to be preventable,
and the consequences of their detection were limited
to debates among providers and healthcare epidemiology personnel within
the facility and internal decisions about how best to
use the data. These internal discussions often fueled improvements in
surveillance and situational awareness of the
preventability of HAIs within individual healthcare facilities. However,
the
consequences have changed with the advent of required
reporting of HAI data through the National Healthcare Safety Network
(NHSN). This reporting is necessary to comply with
state-based mandates for HAI reporting and public availability of
facility-specific
HAI data, as well as federal HAI reporting
requirements.
Beginning in January 2011, hospitals
participating in the Centers for Medicare and Medicaid Services (CMS)
Hospital Inpatient
Quality Reporting Program are required to use NHSN to
report central line–associated bloodstream infections (CLABSIs) among
adult, pediatric, and neonatal intensive care unit
(ICU) patients. The CLABSI data reported via NHSN to CMS for
approximately
3500 hospitals will be used to qualify hospitals for
their annual payment update and for public reporting on the Department
of Health and Human Services Hospital Compare Web
site. CMS reporting requirements for acute care hospitals will expand in
2012 to include catheter-associated urinary tract
infections among pediatric and adult ICU patients and surgical site
infections
following colon surgeries and abdominal
hysterectomies. In 2013 reporting will include methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile
infection rates. Whenever possible, CMS has looked to the National
Quality Forum (NQF) when choosing measures for its quality
reporting programs; NQF is now requesting that the
Centers for Disease Control and Prevention propose a new
ventilator-associated
pneumonia (VAP) measure for approval. In this current
landscape where data-driven performance incentives are used as tools
to influence healthcare quality, the question of
“whether” VAP will be included as a publicly reported metric in
pay-for-performance
programs may soon become questions of “when and how”
VAP will be included.
With this in mind, NHSN staff recognize that
methods and criteria considered sufficient for HAI surveillance and
performance
improvement within individual healthcare facilities
may be inadequate for interfacility comparisons and pay-for-reporting
and pay-for-performance programs. Therefore, any
changes to the NHSN VAP definitions must be made with performance
measurement
in mind. Ignoring the likelihood that any refined VAP
measure may be adopted by CMS for performance measurement purposes would
be irresponsible.
NHSN’s current pneumonia definitions,
implemented in 2002, are designed to be used for surveillance of all
healthcare-associated
pneumonia events, including (but not limited to) VAP.
As of January 2011, approximately 900 facilities were participating
in VAP surveillance through NHSN, including those from
3 states (Oklahoma, Washington, and Pennsylvania) with VAP reporting
mandates. There are currently 3 sets of criteria that
can be used to report a VAP event to NHSN; all require radiographic
evidence and signs and symptoms of pneumonia.
Microbiological evidence of pneumonia, obtained from a list of
acceptable specimen
types, is optional in 1 set of criteria and required
in the other 2. The requirement for radiographic evidence has been
identified
by infection prevention staff who perform VAP
surveillance using NHSN methods as the most problematic aspect of
case-finding
because the interpretations of radiographs and the
language used in reporting radiographic findings vary within and among
institutions. Variability in interpretation and
reporting of radiographic findings, subjectivity of some clinical
criteria
included in the definitions, and variability of
specimen collection and culturing practices affect case-finding among
institutions.
This scenario makes interfacility comparisons using
the current NHSN VAP definitions problematic. In addition, the
complexity
and time burden involved for infection preventionists
applying the case definitions make the current definitions inadequate
for mandated use, given the limited resources
available in many US hospitals for surveillance activities.
Further complicating issues surrounding VAP
surveillance is the lack of a gold-standard definition to which a new
VAP surveillance
definition could be compared. Accurate diagnosis of
VAP, for patient care purposes and for enrollment in clinical research,
remains a significant challenge, and currently
available definitions, including the frequently cited Clinical Pulmonary
Infection
Score [4],
are arguably no more sensitive or specific than current NHSN
surveillance definitions. Given this, and to address head-on
the concerns of applying the current NHSN VAP
definitions to any public reporting metric, efforts by NHSN staff have
focused
on creating a new outcome measure for mechanically
ventilated patients that captures ventilator-associated, pneumonia-like
events in a way that is reliable, objective,
clinically meaningful, and straightforward. To this end, we have
convened a working
group to finalize such a definition for implementation
in NHSN. This working group was established in collaboration with the
Critical Care Societies Collaborative and includes
representatives from the American Association of Critical-Care Nurses,
the American College of Chest Physicians, the American
Thoracic Society, and the Society of Critical Care Medicine, as well
as representatives from the Association for
Professionals in Infection Control and Epidemiology, the Council of
State and
Territorial Epidemiologists, the Infectious Diseases
Society of America, and the Society for Healthcare Epidemiology of
America.
Research by Klompas and others has demonstrated that surveillance using streamlined measures of VAP [5] or more general measures of “ventilator-associated complications” (VAC) [6]
can be implemented successfully and requires less time than traditional
surveillance. In addition, and of particular significance,
events detected by these new measures are associated
with important outcomes such as increased duration of mechanical
ventilation,
length of ICU and hospital stays, and mortality.
Although the approach outlined by Klompas and colleagues does not
specifically
identify VAP, the spectrum of clinical events detected
by their definition likely encompasses VAP—and does so in a
reproducible
and simple way.
At an initial September 2011 meeting, members
of the working group described above agreed on some fundamental
approaches to
developing a surveillance definition to detect VACs.
The approach outlined by Klompas, which relies on objective measures
of respiratory deterioration after a period of
stability on a ventilator, is at the core of our working definition.
Adding
objective criteria to a VAC definition to capture
events likely to be infectious in nature would ensure reliable
case-finding
across ICUs and healthcare facilities and maintain
focus on infection prevention and improving antimicrobial use in ICUs.
In addition, by relying on data elements that should
be readily available in the clinical care records of all mechanically
ventilated patients and that can potentially be
captured electronically (eg, changes in the fraction of inspired oxygen
or
positive end expiratory pressure), tracking ventilated
patients with infectious complications has the potential to prevent
the gamesmanship that may occur in settings where
reporting is required or when measures are used for payment
determinations
and comparisons between facilities. Such gamesmanship
can occur when measures are dependent on definitions that are subjective
and easily manipulated to produce the appearance of
lower infection rates.
It is essential that events detected using a
new definition be responsive to interventions that improve the care and
outcomes
of mechanically ventilated patients. Demonstrating
that rates of infection-related VACs can be reduced through performance
of specific evidence-based strategies, such as daily
sedation interruption or assessment of eligibility for and performance
of spontaneous breathing trials, will require
additional work and resources. However, such demonstration efforts will
be essential
to building confidence that the new measure is
clinically meaningful and linked to performance. This focus on
infection-related
VACs may provide information that may be helpful in
identifying additional or novel interventions.
Finally, we anticipate that there will be
many challenges with implementation of a new NHSN VAC definition.
Clinicians, epidemiologists,
healthcare administrators, consumers, and payors are
familiar with the notion of VAP—it is studied by medical researchers,
written about in textbooks and in the medical
literature, blogged about on the Web, and has its own ICD-9-CM code.
However,
the same cannot currently be said of a more general
complications measure, with the exception of a limited number of recent
publications, and this presents a challenge. Another
significant challenge is the recognition that not all complications of
mechanical ventilation, as detected by a VAC
definition, are preventable—patients on mechanical ventilation are
critically
ill, frequently suffer from complex acute illness
complicated by multiple comorbidities, and may require extraordinary
life-saving
measures. A shift in the focus of HAI surveillance
from VAP to VAC will require a substantial amount of stakeholder
education
and potentially a concomitant shift in how prevention
strategies are conceived and implemented. Although the exact
specifications
of a new NHSN surveillance definition for VAC and/or
infection-related VAC are not completely developed at present, NHSN is
committed to completing this development with
continued input from critical care colleagues and other working group
partners
and stakeholders in the coming months. With input from
these key constituents, NHSN is prepared to make changes that will
maximize reliable case identification, be responsive
to new scientific findings, and simplify implementation through
utilization
of advances in health information technology, while
maintaining clinical and epidemiological credibility through
partnerships
with key providers and state health departments.
Notes
Disclaimer.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
Potential conflicts of interest.
All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider
relevant to the content of the manuscript have been disclosed.
- Received October 4, 2011.
- Accepted October 6, 2011.
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