Vol. 21 •Issue 22 • Page 8
Guest Editorial
Some Contributors to VAP Can Go by Unnoticed
Each incident of ventilator-associated pneumonia (VAP) adds tens of thousands of dollars to the cost of health care and causes significantly higher mortality rates.
There’s an endless list of potential protective strategies against VAP, including head-of-bed elevation, hand-washing, suction techniques and closed suction, ventilator bundles, oral care, subglottic suction endotracheal tubes and silver-coated endotracheal tubes.
All these approaches have their own degree of effectiveness, but I’m not certain that any one is a panacea. Even in concert, I have doubts of the potential total eradication of VAP.
A number of my peers brag they have no VAP, while others cannot eliminate that dreaded diagnosis-related group no matter what they do.
I will use my hospital as an example of a frustrated facility in the face of those with a zero rate of VAP. We sit below the national average, but we feel the pressure to adhere to the new perception that VAP is 100 percent avoidable.
We currently implement all the aforementioned protective strategies with the exception of the silver-coated endotracheal tubes. In addition, we have three groups of team members who track all VAP-related issues and review every case.
The multidisciplinary group (nursing, respiratory and infection control) meets weekly to ensure every protective measure is in place on patients suspected of VAP and that our diagnosis is in compliance with Centers for Medicare and Medicaid guidelines.
Interestingly enough, prior to the implementation of most of our protective strategies, we did have zero cases of VAP. This led me to investigate what had changed.
I found we had made adjustments in the infection control department, bringing in staff with a much higher degree of VAP experience. This division allowed us to devote more resources to this issue and offered the autonomy to function independently of any pressures within the organization.
I also asked other hospitals with zero VAP about their monitoring. One hospital stated that when staff members suspect a VAP case, they call the attending and ask him if he wants this coded as VAP. If the attending said he doesn’t, then it’s not VAP.
Another organization said it doesn’t review all charts, and it tends to not review the thickest charts because it is too time-consuming.
At my facility, we follow the guidelines to the letter and will err on the side of calling it VAP rather than possibly erroneously dismiss a case. While the guidelines seem clear, there appears to be a moderate amount of discretion in their application.
While this in no way directly contributes to VAP, it is an indicator of reported rates. In addition, organizations that under-report VAP would be less likely to implement protective measures. The oversight may indirectly result in higher, unreported VAP rates.
With the possible consequences of lost revenue and now with the open reporting of patient outcomes and complications, some organizations will be punished for following the exact guidelines, while others with lower standards may have the appearance of providing the best care.
The regulatory agencies need to look at how data are monitored and acquired as well as the protective measures involved. With everyone’s information just an Internet search away, we should keep the playing field level, for our patients’ sake.
Adam K. North is the manager of respiratory therapy at Our Lady of the Lake Regional Medical Center in Baton Rouge, La.
