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Original Research: Critical Care |

The Clinical Impact and Preventability of Ventilator-Associated Conditions in Critically Ill Patients Who Are Mechanically VentilatedImpact of Ventilator-Associated Conditions FREE TO VIEW

John Muscedere, MD; Tasnim Sinuff, MD, PhD; Daren K. Heyland, MD; Peter M. Dodek, MD, MHSc; Sean P. Keenan, MD; Gordon Wood, MD; Xuran Jiang, MSc; Andrew G. Day, MSc; Denny Laporta, MD; Michael Klompas, MD, MPH; for the Canadian Critical Care Trials Group
Author and Funding Information

From the Department of Medicine (Drs Muscedere and Heyland, Ms Jiang, and Mr Day), Kingston General Hospital, Queen’s University, Kingston, ON; the Sunnybrook Research Institute (Dr Sinuff), Sunnybrook Health Sciences Center and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON; the Center for Health Evaluation and Outcome Sciences and Department of Medicine (Dr Dodek), Providence Health Care and University of British Columbia, Vancouver, BC; the Department of Critical Care Medicine (Dr Keenan), Fraser Health Authority, BC, and the Department of Medicine (Dr Keenan), University of British Columbia, Vancouver, BC; the Vancouver Island Health Authority (Dr Wood), Victoria, BC; and the Jewish General Hospital (Dr Laporta), McGill University, Montreal, QC, Canada; the Department of Population Medicine (Dr Klompas), Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; and Brigham and Women’s Hospital (Dr Klompas), Boston, MA.

Correspondence to: John Muscedere, MD, Room 5-411, Angada 4, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada; e-mail: muscedej@kgh.kari.net


For editorial comment see page 1429

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1453-1460. doi:10.1378/chest.13-0853
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Background:  Ventilator-associated conditions (VACs) and infection-related ventilator-associated complications (iVACs) are the Centers for Disease Control and Prevention’s new surveillance paradigms for patients who are mechanically ventilated. Little is known regarding the clinical impact and preventability of VACs and iVACs and their relationship to ventilator-associated pneumonia (VAP). We evaluated these using data from a large, multicenter, quality-improvement initiative.

Methods:  We retrospectively applied definitions for VAC and iVAC to data from a prospective time series study in which VAP clinical practice guidelines were implemented in 11 North American ICUs. Each ICU enrolled 30 consecutive patients mechanically ventilated > 48 h during each of four study periods. Data on clinical outcomes and concordance with prevention recommendations were collected. VAC, iVAC, and VAP rates over time, the agreement (κ statistic) between definitions, associated morbidity/mortality, and independent risk factors for each were determined.

Results:  Of 1,320 patients, 139 (10.5%) developed a VAC, 65 (4.9%) developed an iVAC, and 148 (11.2%) developed VAP. The agreement between VAP and VAC was 0.18, and between VAP and iVAC it was 0.19. Patients who developed a VAC or iVAC had significantly more ventilator days, hospital days, and antibiotic days and higher hospital mortality than patients who had neither of these conditions. Increased concordance with VAP prevention guidelines during the study was associated with decreased VAP and VAC rates but no change in iVAC rates.

Conclusions:  VACs and iVACs are associated with significant morbidity and mortality. Although the agreement between VAC, iVAC, and VAP is poor, a higher adoption of measures to prevent VAP was associated with lower VAP and VAC rates.

Figures in this Article

Ventilator associated pneumonia (VAP) remains an important cause of morbidity, mortality, and increased health-care costs in patients who are mechanically ventilated.1,2 Because VAP is a nosocomially acquired infection, it is regarded as an important patient safety measure, and there have been numerous efforts to promote its prevention.3,4 Reported VAP rates have been falling, and surveillance data in the United States up to 2010 reported incidences ranging from zero to six cases per 1,000 ventilator-days.5 However, there is concern that reported rates are variable depending on the personnel who collect the data, the intensity of surveillance, and interpretation of clinical or laboratory data.6,7 Further, it is recognized that surveillance of VAP may systematically underestimate its occurrence and that true rates may be much higher.8,9 Particularly problematic is that VAP rates as reported from surveillance initiatives, where there may be variability and difficulty applying current definitions, may not correlate with patient-centered outcomes.10

Moreover, because the definition of VAP is nonspecific and does not correlate with histopathologic findings of pneumonia, irrespective of the method of microbiologic confirmation chosen,11,12 it has been argued that VAP is not an acceptable quality measure in the ICU.13 The Centers for Disease Control and Prevention have consequently implemented an alternate surveillance paradigm for patients who are mechanically ventilated, moving from pneumonia to broader complications in general. These new surveillance definitions were designed to be more objective and more efficient to collect and are termed ventilator-associated conditions (VACs) and infection-related ventilator-associated complications (iVACs), where iVAC is a subset of VAC.14

Evaluative data regarding these new concepts are limited. In initial studies, VAC was found to correlate with clinical outcomes and require less time than VAP for its determination.15 Further, the objective measures of respiratory deterioration as measured by sustained increases in ventilator settings, such as those quantified in VAC, correlate with increased length of stay (LOS) and hospital mortality.16

Because VAP may be a cause of VAC, and given the current focus on VAP rates and implementation of measures to prevent VAP, there is a need for further data regarding the association between VAC, iVAC, and VAP, their clinical outcomes, and their responsiveness to measures that are designed to prevent VAP. We sought to determine these relationships in a large dataset of patients in whom the Canadian VAP guidelines17,18 were implemented and herein report the results.

This was a retrospective analysis of a prospective, multicenter study that measured the implementation of VAP clinical practice guidelines over 24 months. The study was conducted in six academic and five community, medical/surgical/trauma ICUs (10 Canada, one United States); the average number of beds was 18.5 (SD, 3.7), and 10 had a “closed” administrative structure. The complete description of the ICUs and full study details have been published elsewhere.19,20 Briefly, in an interrupted time-series design, evidence-based recommendations for the prevention, diagnosis, and treatment of VAP were introduced using a multifaceted intervention. The effect of these interventions on concordance with guideline recommendations and clinical outcomes was then assessed.

Study Enrollment

In each ICU, 30 consecutive adult patients who met the inclusion criteria of age > 16 years and who were mechanically ventilated for > 48 h were enrolled during the baseline and three follow-up data collection periods at 6, 15, and 24 months after the baseline period between June 1, 2007 and December 1, 2009. For patients who met the inclusion criteria, there were no exclusion criteria. A total of 330 patients were enrolled during each data collection period for a total of 1,320 patients. The median number of days required for patient enrollment per site over the four study periods was 55 days (range, 23-140 days).

Data Collection/Outcomes

Patient characteristics collected included age, sex, comorbidities, APACHE (Acute Physiologic and Chronic Health Evaluation) II21 score at the time of ICU admission, and Sequential Organ Failure Assessment (SOFA)22 scores at the time of study enrollment (48 h after admission). Clinical outcomes collected included duration of mechanical ventilation, ICU LOS, hospital LOS, antibiotic use, and ICU and hospital mortality.

Research coordinators collected data by direct observation or chart review for concordance with each of the 14 guideline recommendations, including 10 prevention recommendations. Concordance was determined as previously described.20,23 The percent concordance with each prevention recommendation and in aggregate was calculated for each of the four data collection periods. Although not formally part of the VAP guideline, best practices for discontinuation of mechanical ventilation were encouraged throughout the study, and data regarding spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) were collected prospectively.24

Clinically suspected VAP was defined as new or progressive and persistent infiltrates on a chest radiograph plus two of the following: abnormal WBC count, presence of fever or hypothermia, purulent sputum, and deterioration in gas exchange (Table 1).25 Study patients were screened daily for these criteria based on data that were collected for clinical purposes only; the diagnosis was then confirmed by the attending physician and the site principal investigator. In the absence of a reference standard for VAP, all suspected cases were adjudicated centrally by the study coprincipal investigators (J. M., T. S.) to confirm that the clinical course was compatible with VAP, based on culture results, antibiotic response, and lack of other causes to explain the signs and symptoms. Discrepancies were resolved by consensus.

Table Graphic Jump Location
Table 1 —Definitions of VACs, iVACs, and VAP

iVAC = infection-related ventilator-associated complication; PEEP = positive end expiratory pressure; VAC = ventilator-associated condition; VAP = ventilator-associated pneumonia.

VAC was defined as an increase in daily minimum positive end expiratory pressure (PEEP) ≥ 3 cm H2O or an increase of the daily minimum Fio2 ≥ 0.20 sustained for ≥ 2 calendar days in a patient who had a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum Fio2 or PEEP. iVAC was defined as an episode of VAC associated with alterations in WBC count (≥ 12,000 cells/μL or ≤ 4,000 cells/μL) or temperature (> 38°C or < 36°C) within 2 calendar days of the start of the VAC and ≥ 4 days of new antibiotics.15 Although VAP outcomes were collected prospectively, VAC and iVAC definitions were applied as per guidance from the CDC’s National Healthcare Safety Network to all the patients in the dataset retrospectively by querying the electronic study database, which contained all the necessary variables to determine if VAC or iVAC were present.

Data Analysis

Baseline characteristics and clinical outcomes were compared between patients who had and those who did not have VAP, VAC, or iVAC. Categorical variables are described as counts and percentages and compared using the Mantel-Haenszel test stratified by ICU. Continuous variables are described as means and SDs or medians and quartiles for skewed data, and differences were assessed by linear mixed effects models with ICU as a random effect. Comparisons between groups were by independent t tests and between periods by one-way analysis of variance. Patients who died in ICU, hospital, or while ventilated were considered discharged at time of death. Since there is no reference standard for VAP, VAC and iVAC are proposed as alternative outcome measures rather than as proxies for VAP. Thus, the ability of VAC to predict VAP is not assessed by measures of diagnostic accuracy. Rather, the association between VAP, VAC, and iVAC is cross-tabulated, and the chance-corrected agreement is summarized by the κ statistic.26 Two conditional time-dependent Cox proportional hazards models were constructed to separately estimate the time-dependent effect of VAC and VAP on hospital mortality while adjusting for the following prespecified covariates: age, APACHE II score, baseline SOFA score, admission diagnosis, and number of comorbidities. Patients discharged from the hospital were assumed to have survived longer than any patients who died in hospital. Two separate multiple conditional logistic regression models were constructed to identify the effect of concordance with VAP-preventive recommendations on VAC and iVAC. The original multivariate model included baseline characteristics, percentage of mechanical ventilation days with SATs, percentage of mechanical ventilation with SBTs, and concordance for individual preventive measures with the exception of closed suctioning system, oral route of intubation, and povidone-iodine mouth wash (since these were all close to 100% or 0%). Backward selection was then used to arrive at the final result. The Cox and logistic models were conditional on (ie, stratified by) ICU.

All P values are two-sided without adjustment for multiple comparisons, and a P value of ≤ .05 was considered statistically significant. A trend toward statistical significance was considered to be present when the P value was ≤ .10 but > .05. Analyses were performed using SAS V9.2 (SAS Institute Inc). The original study was approved by the research ethics board of the coordinating center (DMED-983-06, Queen’s University, Kingston, Ontario) and the local research ethics board of each participating hospital.

A total of 1,320 patients were enrolled over the four study periods. There were no significant differences in baseline patient characteristics across the four study periods, with the exception that SOFA at the time of enrollment (48 h) was slightly lower during the third and fourth data collection periods, respectively (mean ± SD, 4.9 ± 3.3, 4.6 ± 3.2, 4.2 ± 3.1, 4.3 ± 3.2 for each time period; P = .04) (Table 2). Overall, enrolled patients had a high severity of illness, multiple comorbidities, prolonged hospitalization, and high mortality rates (Table 2).

Table Graphic Jump Location
Table 2 —Baseline Characteristics, Outcomes of All Patients Enrolled in the Study

APACHE = Acute Physiologic and Chronic Health Evaluation; LOS = length of stay; MV = mechanical ventilation; q = quartile; SOFA = Sequential Organ Failure Assessment.

Of the 1,320 patients, VAC developed in 139 (10.5%), iVAC in 65 (4.9%), and VAP in 148 (11.2%) (e-Table 1). The relationships between VAP, VAC, and iVAC are shown in Table 3 and Figure 1. The agreement (κ statistic) between VAP and VAC was 0.18 (95% CI, 0.11-0.26), and the agreement between VAP and iVAC was 0.19 (95% CI, 0.11-0.27). Patients who had VAC were more likely to also be diagnosed with VAP (39 of 139 [28.1%]) than patients who did not have VAC (109 of 1,181 [9.2%], P < .001). Patients who had iVAC were more likely to have VAP (26 of 65 [40.0%]) than patients who did not (122 of 1,255 [9.7%], P < .0001). There was a trend toward the diagnosis of less VAP in patients who had VAC as compared with those with iVAC (39 of 139 [28.1%] vs 26 of 65 [40.0%], P = .1). Of the patients who had VAP, 39 (26.4%) also had VAC, and 26 (17.6%) also had iVAC. Overall, 1,072 (81.2%) patients did not develop any of VAP, VAC, or iVAC. When participating centers were ranked on the basis of the incidence of VAC, iVAC, or VAP, some ICUs had similar rankings on all three measures, whereas some were significantly different between the three (e-Table 2).

Table Graphic Jump Location
Table 3 —Relationship Between VAP, VAC, and iVAC

See Table 1 legend for expansion of abbreviations.

Figure Jump LinkFigure 1. The relationship between VAP, VAC, and iVAC. iVAC = infection-related ventilator-associated complication; VAC = ventilator-associated condition; VAP = ventilator-associated pneumonia.Grahic Jump Location

When patients who developed VAC were compared with those who did not, patients who had VAC had higher SOFA scores at the time of enrollment and had worse clinical outcomes, including increased duration of ICU stay, hospital stay, and mechanical ventilation, and higher hospital mortality (Table 4). Similarly, compared with patients who did not have iVAC, patients with iVAC had higher SOFA scores at the time of enrollment and had worse clinical outcomes, including longer duration of ICU stay, hospital stay, and mechanical ventilation, and a trend toward increased hospital mortality (Table 5). In contrast, compared with patients who did not have VAP, patients who developed VAP were younger and had fewer comorbidities but had longer ICU LOS, hospital LOS, and duration of mechanical ventilation (Table 6). There was no difference in mortality between patients who developed VAP and those who did not. In multivariate analysis, both VAC and VAP were associated with increased mortality (e-Table 3); the hazard ratio (95% CI) for VAC was 2.09 (1.59-2.75), P < .0001, and for VAP it was 1.50 (1.09-2.06), P = .01.

Table Graphic Jump Location
Table 4 —Comparison Between the Patients Who Developed VAC and Those Who Did Not

See Table 1 and 2 legends for expansion of abbreviations.

Table Graphic Jump Location
Table 5 —Comparison Between Patients Who Developed iVAC and Those Who Did Not

See Table 1 and 2 legends for expansion of abbreviations.

Table Graphic Jump Location
Table 6 —Comparison Between the Patients Who Developed VAP and Those Who Did Not

See Table 1 and 2 legends for expansion of abbreviations.

Although the rates of VAP and VAC decreased across the four time periods, iVAC rates remained steady (Fig 2, e-Table 4). Compared with patients who did not develop VAC, those who did develop VAC were less likely to be concordant with the oral route of intubation but were more likely to be concordant with the recommendations for the frequency of changes to heat moisture exchangers (every 7 days or if soiled), frequency of change with heated humidifier (per patient or if soiled or damaged), and frequency of change of suctioning system (per patient or if soiled or damaged) (e-Table 5). Compared with patients who did not have iVAC, patients who had iVAC were less likely to be concordant with the oral route of intubation and frequency of ventilator circuit changes (per patient or when soiled or damaged) but were more likely to be concordant with frequency of change of heated humidifier, heat moisture exchanger, and suctioning system. In multivariate analysis for the impact of VAP preventive measures on the development of VAC and iVAC, none reached statistical significance. However, for VAC, there was a trend for increased percentage of days with SAT and days with SBT to be protective (OR [95% CI], 0.93 [0.87-1.00], P = .05; 0.97 [0.94-1.01], P = .10, respectively). For iVAC, there was a trend toward increased percentage of days with SAT and increased frequency of concordance with changes in the suctioning system to be protective (OR [95% CI]: 0.89 [0.79-1.00], P = .05; 0.98 [0.97-1.00], P = .08, respectively).

Figure Jump LinkFigure 2. Rates of VAP, VAC, and iVAC and concordance across the four data enrollment periods. See Figure 2 legend for expansion of abbreviations.Grahic Jump Location

In a large dataset of patients who are mechanically ventilated, in which evidence-based VAP guidelines were systematically implemented, VAP, VAC, and iVAC were relatively common and associated with worse outcomes, including mortality. Of these, VAC had the strongest association with increased mortality. Patients who had VAC and iVAC were much more likely to be diagnosed with VAP. However, a significant number of patients who had VAC and iVAC were not diagnosed with VAP in spite of rigorous and systematic efforts to detect VAP. Conversely, only a minority of patients who were diagnosed as having VAP also met the definition for VAC or iVAC, and the agreement between VAC, iVAC, and VAP was low.

The low agreement between VAC, iVAC, and VAP may stem from the nonspecificity of each definition, because each may be caused by a variety of underlying pathophysiologic processes. The definition for VAC is intentionally broad and can include processes such as pulmonary edema, acute lung injury/ARDS, and atelectasis, in addition to pneumonia. Moreover, patients who meet the definition for iVAC may have VAC caused by an infectious nonpneumonic process or a noninfectious pulmonary process coincident with a nonpneumonic cause of fever, alteration in WBC count, or need for antibiotics. In theory, all VAP cases should be a subset of VAC cases, but we found that only a minority of patients who had VAP also met the definition for VAC or iVAC. A possible explanation is that some cases of VAP may not be severe enough to cause sufficient deterioration in parameters of mechanical ventilation to reach thresholds for the diagnosis of VAC. Alternatively, VAP that arises in patients without a 2-day period of stable or improving ventilatory settings would not meet criteria for VAC. In addition, some patients with early VAP may be mechanically ventilated for < 4 days and, hence, ineligible for VAC. These may, in turn, be influenced the patient’s physiologic reserve present and severity of illness; thus, differences between VAP and VAC rates may be dependent on the patient population in which they are measured. It is also possible that some patients adjudicated as having VAP had other conditions, such as ventilator-associated trachea-bronchitis, which would not be expected to cause significant physiologic deterioration.27 Moreover, discordance between rates of VAP, VAC, and iVAC may have resulted from difficulties and inaccuracies in data collection. This is likely minimal in the context of a research study in which the data are collected by trained research coordinators but would be more pronounced when these definitions are used broadly for surveillance. Electronic data collection and automated analysis, which is possible for VAC but not VAP, may mitigate this concern.

Although VAC and iVAC may not be specific, their higher correlation with worse outcomes, ease of data collection, and objective definitions make them promising options to replace VAP as quality indicators. However, with the minimal amount of overlap between VAP, VAC, and iVAC, the risk is that with the adoption of VAC and iVAC as quality measures, we will miss some clinically diagnosed cases of VAP, albeit by definition it will be cases of VAP without sustained increases in ventilator settings that meet the VAC thresholds. This is an important consideration as we move forward with implementation of quality improvement metrics for patients who are mechanically ventilated.

Moreover, there is a large body of knowledge demonstrating that preventive measures can reduce the incidence and associated costs of VAP.28,29 In this study, although VAP and VAC rates decreased significantly across the four time intervals, iVAC rates did not change despite increasing concordance with preventive measures, such as semirecumbency, subglottic secretion drainage, and chlorhexidine mouthwash. The increase in concordance and eventual degree of concordance for each of these interventions, however, was relatively modest (semirecumbency, 29%-41%; subglottic secretion drainage, 36%-58%; and chlorhexidine mouthwash, 16%-50%). This may have limited the capacity to realize an impact on IVAC rates. Moreover, it is possible that these interventions may have little effect on VAC and iVAC rates because they have been designed solely for the prevention of pulmonary infection. Although some VACs and iVACs may be caused by infection, many VACs have noninfectious (eg, cardiogenic, noncardiogenic pulmonary edema, atelectasis) causes.15 However, both VACs and iVACs should be responsive to measures that reduce the time at risk for complications incurred while invasively mechanically ventilated, and in multivariate analysis, there was a trend toward a reduced risk of VAC and iVAC with increased rates of SATs and SBTs.

Strengths of this study include the large database, the rigorous adjudication of VAP, the measurement of concordance, as well as the broad inclusion criteria with few exclusion criteria, which increases the generalizability of our findings. A limitation of this study is that we did not address the differential feasibility of implementing VAP, VAC, and iVAC definitions in our patient population, but this has been reported on in other studies.15 Further limitations include the lack of data on the total number of patients from which this cohort was selected, the observational nature of this study with the inability to make causal inferences instead of associations, and the relatively modest increase in concordance with guidelines across the time span of the study. However, to further investigate the impact of measures that have been shown to prevent VAP on rates of VAC and iVAC, a randomized control trial would be required. Future trials of VAP-prevention strategies should include VAC and iVAC as outcomes, or perhaps these interventions should be designed solely for VACs or iVAC prevention.

In summary, VAP, VAC, and iVAC continue to be relatively common in critically ill patients who are mechanically ventilated and are associated with adverse outcomes. There is some overlap between them, but the agreement between VAC, iVAC, and VAP is low. Given the association between VAC and iVAC and adverse outcomes, they may be useful quality indicators. However, further study is required to determine the preventability of VAC and iVAC and their relationship to other quality indicators in the ICU, such as adherence to best practices for ventilator management.

Author contributions: Dr Muscedere takes responsibility for the content of the manuscript, including data and data analysis.

Dr Muscedere: contributed to initial study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Sinuff: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Heyland: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Dodek: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Keenan: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Wood: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Ms Jiang: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Mr Day: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Laporta: contributed to study design and analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Dr Klompas: contributed to initial study design, analysis, interpretation of data, drafting of the submitted article, critical revisions for intellectual content, and providing final approval of the version to be published.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Klompas has received grant support for research on VAP surveillance from the Centers for Disease Control and Prevention. He has also received honoraria for lectures on VAP surveillance from professional societies and Premier Healthcare Alliance. Drs Muscedere, Sinuff, Heyland, Dodek, Keenan, Wood, and Laporta; Ms Jiang; and Mr Day have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Tables can be found in the “Supplemental Materials” area of the online article.

APACHE

Acute Physiologic and Chronic Health Evaluation

iVAC

infection-related ventilator-associated complication

LOS

length of stay

SAT

spontaneous awakening trial

SBT

spontaneous breathing trial

SOFA

Sequential Organ Failure Assessment

VAC

ventilator-associated condition

VAP

ventilator-associated pneumonia

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Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-134. [CrossRef] [PubMed]
 
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(5):309-332. [CrossRef] [PubMed]
 
Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37-46. [CrossRef]
 
Nseir S, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J. 2002;20(6):1483-1489. [CrossRef] [PubMed]
 
Lai KK, Baker SP, Fontecchio SA. Impact of a program of intensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia and its cost-effectiveness. Infect Control Hosp Epidemiol. 2003;24(11):859-863. [CrossRef] [PubMed]
 
Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30(11):2407-2412. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. The relationship between VAP, VAC, and iVAC. iVAC = infection-related ventilator-associated complication; VAC = ventilator-associated condition; VAP = ventilator-associated pneumonia.Grahic Jump Location
Figure Jump LinkFigure 2. Rates of VAP, VAC, and iVAC and concordance across the four data enrollment periods. See Figure 2 legend for expansion of abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Definitions of VACs, iVACs, and VAP

iVAC = infection-related ventilator-associated complication; PEEP = positive end expiratory pressure; VAC = ventilator-associated condition; VAP = ventilator-associated pneumonia.

Table Graphic Jump Location
Table 2 —Baseline Characteristics, Outcomes of All Patients Enrolled in the Study

APACHE = Acute Physiologic and Chronic Health Evaluation; LOS = length of stay; MV = mechanical ventilation; q = quartile; SOFA = Sequential Organ Failure Assessment.

Table Graphic Jump Location
Table 3 —Relationship Between VAP, VAC, and iVAC

See Table 1 legend for expansion of abbreviations.

Table Graphic Jump Location
Table 4 —Comparison Between the Patients Who Developed VAC and Those Who Did Not

See Table 1 and 2 legends for expansion of abbreviations.

Table Graphic Jump Location
Table 5 —Comparison Between Patients Who Developed iVAC and Those Who Did Not

See Table 1 and 2 legends for expansion of abbreviations.

Table Graphic Jump Location
Table 6 —Comparison Between the Patients Who Developed VAP and Those Who Did Not

See Table 1 and 2 legends for expansion of abbreviations.

References

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Scott IA, Harper CM. Guideline-discordant care in acute myocardial infarction: predictors and outcomes. Med J Aust. 2002;177(1):26-31. [PubMed]
 
Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-134. [CrossRef] [PubMed]
 
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(5):309-332. [CrossRef] [PubMed]
 
Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37-46. [CrossRef]
 
Nseir S, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J. 2002;20(6):1483-1489. [CrossRef] [PubMed]
 
Lai KK, Baker SP, Fontecchio SA. Impact of a program of intensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia and its cost-effectiveness. Infect Control Hosp Epidemiol. 2003;24(11):859-863. [CrossRef] [PubMed]
 
Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30(11):2407-2412. [CrossRef] [PubMed]
 
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