1. VAP as a quality indicator in Europe? Jean-François Timsit Medical ICU INSERM U823 Grenoble, France

2. VAP in ICU: a quality indicator? Frequent event High morbidity and mortality Event easy to measure with reproducible definitions Easy to survey Avoidable Quality indicator study group; ICHE 1995;16:308

3. VAP in ICU: a quality indicator? Frequent event High morbidity and mortality Event easy to measure with reproducible definitions Easy to survey Avoidable Quality indicator study group; ICHE 1995;16:308

4. Incidence of VAP (cohorts) is variable Safdar et al - Crit Care Med 2005; 33:2184 –2193 38 prospective studies 48,112 patients Pooled cumulative incidence 9.7% (95% CI, 7.0 –12.5). 3% 44%

5. Incidence of VAP (RCTs) is variable Safdar et al - Crit Care Med 2005; 33:2184 –2193 51 control group of randomized studies 4,802 patients Pooled cumulative incidence 22.8% (95% CI, 18.8 –26.9%)

6. Incidence per 100 ventilated patients (REA-RAISIN network) Year 20042005 2006 Number of ICUs116141158 N Patients14 75219 69322 090 Exposed Patients intubationn87331207113541 Incidence / 100 ventilated patients VAP14.2714.4913.49

7. Incidence of VAP (histology) is variable Klompas M- JAMA 2007; 297:1583 Summary prevalence, 47%; 95% CI, 35%-59%)

8. VAP in ICU: a quality indicator? Frequent event  Yes but variable High morbidity and mortality Event easy to measure with reproducible definitions Easy to survey Avoidable Quality indicator study group; ICHE 1995;16:308

9. « attributable » mortality adjusted exposed-unexposed study only Adapted from Safdar et al – Crit Care Med 2005; 33:2184 Test for heterogeneity Q = 61,1018, DF = 8, P < 0,0001

10. Adjusted exposed-unexposed study (*) Matched exposed unexposed studies (admission severity) (†) Matched exposed unexposed studies (admisison severity and duration of exposure) † † † †

11. VAP are associated with an increase risk of death mainly when they are not appropriately treated Moine P et al OUTCOME-REA database

12. Why so important discordances? The definition used Cook 1998 The adequation of ABx Iregui 2002 Intensity of the inflammatory response Bonten 1997 The micro-organism Kollef 1993 Fagon 1996

13. VAP in ICU: a quality indicator? Frequent event  Yes but variable High morbidity and mortality  controversies, variable Event easy to measure with reproducible definitions Easy to survey Avoidable Quality indicator study group; ICHE 1995;16:308

14. Clinical radiological and biological signs are of limited values Klompas M – JAMA2007; 297:1583 FindingSe %Sp% Fever45-6733-76 Abnormal WBC50-867-76 Sputum purulence50-7933-67 Crepitation on auscultation7340 Hypoxemia6440 New infiltrate78-10033-75

15. Empiric Abx without previous bacterial sampling largely decreases the number of depicted VAP Prats et al - Eur Respir J 2002; 19: 944–951

16. Proximal or distal Bronchoscopically guided or not?

17. NOSOREF What bacteriological sampling are performed (often or always) when VAP is suspected? (more than one anwer by ICU, n=251) L’Hériteau et al - Infect Control Hosp Epidemiol 2005;26:13-20).

18. NOSOREF- Per-fibroscopic exams by regions P=0.01 L’Hériteau et al - Infect Control Hosp Epidemiol 2005;26:13-20).

19. Definitions 1- Chest X ray or CT abnormalities 2- Fever (>38°C) with no other cause and/or leukopenia ( 12000) 3- Purulent aspirates or worsening gas exchange + PN1: Positive quantitative culture from minimally contaminated LRT specimen (PSB, BAL) PN2: Positive quantitative culture from possibly contaminated LRT specimen (TA) PN3: alternative (pleural fluid, histology, Legionella, Aspergillus, viruses, intra cellular organisms)

20. Numerator Could we take into account the first episode only? What are the criteria for relapses vs reinfections?

21. Easy and precise enough? There is a role for automatic data capture using electronic surveillance… Klompas M et al - Infect Control Hosp Epidemiol 2008; 29:31-37 If all the informations are computed… Very good positive predictive value of an algorithm in diagnosing CDC defined VAP… But Qualitative sampling only Short ICU stay No new empirical antimicrobials…  need to be validated in other countries (case- mix)

22. Denominator Stratification? "Case-mix " issues Patients’ severity? Incidence or incidence density? Specific incidence density?: VM (NIV?)

23. 1234567891011121314151617181920 0.5 1 1.5 2 2.5 3 3.5 Duration of Mechanical Ventilation (days) Daily Hazard Rate of VAP (% patients at risk) The Daily Risk of VAP (Cook & the CCCTG, Ann Intern Med, 1998)

24. VAP in ICU: a quality indicator? Frequent event  yes but variable High morbidity and mortality  controversies, variable Event easy to measure with reproducible definition  not for the moment: internal comparisons only Easy to survey  no Avoidable Quality indicator study group; ICHE 1995;16:308

25. Prevention of VAP: Duration of mechanical ventilation Non invasive ventilation sedation modulation of gastric colonization Disinfection or sterilization of medical devices Oral decontamination semi-recumbent position subglottic aspiration Formation Surveillance SDD

26. Formation of HCW: effectiveness Ventilator associated pneumonia: Zack Critical Care Med 2002

27. Impact of educational program on nosocomial infections0 2 4 6 8 10 12 14 LRTIBSISepsis Cath site UTI Incidence density (p.1000 cvc-days) Interv. Control Eggimann et al, Lancet, 2000; 355: 1864-68. Eggimann et al, Lancet, 2000; 355: 1864-68.

28. Multi-modules intervention programs Gastemeier P – JHI 2007; 67:1

29. Classical biases Publication bias Regression to the mean effect Difference between case-mix before and after improvement programs Absence of relationship with « valid » outcome indicators –Decrease in VAP rate but no impact on duration of stay or mortality

30. VAP in ICU: a quality indicator? Frequent event  yes but variable High morbidity and mortality  controversies, variable Event easy to measure with reproducible definitions  not for the moment, only for internal comparisons Easy to survey  no Avoidable  yes (less than BSI?) Quality indicator study group; ICHE 1995;16:308

31. VAP as a candidate for european benchmarking? Case definitions –« Clinical » diagnosis of limited value –Various bacteriological samplings –Various published recommendations Disease severity –No standardized well-accepted scale for assessing disease severity of pneumonia Statistics –Incidence only –Denominator Case-mix –Under adjustement will punish excellent centers Surveillance –Precise, with integration of data from clinical reports, lab, pharmacy  dedicated staff Important risk of public reporting –Many biases in interpreting « high » or « low » levels –Erroneous comparisons will focus patients and public attention even in the absence of real clinical problems –Data are vulnerable to profund misuse by the media Uçkay I – Clin Infect Dis 2008; 46:557

32. Risk factors and preventive measures as a quality indicator? 3 levels: Stuctural: the stucture of a particular health care delivery system Process: on the process of health care delivery Outcome: on defined outcomes of health care delivery Donabedian A– ICHE 1990:11:117 That is not because VAP is very difficult to diagnose that we must ignore it…

33. VAP as a quality indicator? Structural indicators Uçkay I – Clin Infect Dis 2008; 46:557 Existence of a surveillance system Feedback Infection control policy Education of the staff Nurse to patient ratio Hydoalcoholic solution use Availability of bronchoscopy Sedation policy Weaning protocol…

34. VAP as a quality indicator? Process indicators Uçkay I – Clin Infect Dis 2008; 46:557 MV patients > 2 days Reintubation rate Orotracheal intubation Supine head position Transport out of the ICU Physiotherapy after surgery Oropharyngeal cleaning Removal of secretions Stress ulcer prophylaxis…

35. Structural and process indicators Easy to measure Good stimulation for improvement of care Public reporting more easy and precise  need to be measured and used…. But –Should be related with no doubt to precise outcome indicators…..

36. VAP as a quality indicator Outcome: –Careful definition –Dedicated staff –Case-mix adjustment  difficult in routine  only for internal comparisons Use risk factors and way of preventing VAP as process and stuctural indicators –But need carefull validation