Wednesday, February 15, 2012

Big changes in the world of VAP?

As you may or may not be aware, the four main professional societies in the US that include large critical care constituencies, AACN, Chest, SCCM and ATS, have created something called a Critical Care Societies Collaborative (CCSC). Its purpose is essentially to give the critical care community a voice in shaping public policy. And, as you can imagine, one of the current-day issues they are tackling is performance measures.

Now, on this web site we have spent a lot of virtual ink talking about quality metrics, particularly where ventilator-associated pneumonia, or VAP, is concerned. Well, I am happy to report that finally, a strong voice in Critical Care medicine is in agreement with what we have been saying: the VAP bundle needs to go! In fact, here is the sum of the recommendations made to the National Quality Forum in a letter dated February 9, 2012, from the CCSC leaders about VAP (emphasis mine):
The Task Force felt that the VAP “care bundle” minimizes the importance of each individual component measure and neglects the fact that many elements of the existing VAP bundle are known to have important effects outside of VAP reduction, including improved patient survival. The task force also notes that one of the components of the VAP care bundle, stress ulcer prophylaxis, may actually increase the risk of VAP.51Therefore, the Task Force would like to make the following recommendations regarding measure gaps related to VAP:(1) Dissolve the VAP care bundle and instead develop a new group of quality measures related to general evidencebased practices for patients requiring mechanical ventilation (described above.) These potential measure gaps would include care processes known to reduce morbidity and mortality in patients who are ventilated.
(2) Develop measures using the VAPspecific measure gaps supported by recent guidelines.52,53 These may include measures for the following evidencedbased practices:
• Orotracheal rather than nasotracheal intubation to prevent VAP54;
• Subglottic secretion drainage to prevent VAP55;
• Elevating the head of bed to 45 degrees to prevent VAP56;
• Oral antiseptic administration to prevent VAP57;
• When empiric antibiotics are used to treat VAP, initial treatment based on qualitative endotracheal aspirates rather than quantitative bronchoscopic aspirates58; and
• No more than an 8day course of antibiotics as treatment for uncomplicated VAP.59
All of these VAP prevention strategies are supported by randomizedcontrolled trials. However, not all have favorable costbenefit profiles, and all have significant barriers, which may make widespread adoption unfeasible. Although we list them all here, we note that all may not be good quality measures.
So, here it is -- the recommendation. But will it be followed? When I was at SCCM, I heard a presentation that talked about some new metrics being developed by the CCSC in collaboration with the CDC, which will likely replace VAP as the focus of mechanical ventilation complications. I am in the process of learning more about these developments even as we speak, and will update my readers on what I learn. Suffice it to say, change is coming to the world of VAP. And it's about time. 

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