Zero: the enemy of objectivity
I had a busy travel week, first at the Remington course and then a HICPAC meeting. It was interesting to begin the week giving a lecture on VAP prevention, and then to end the week discussing changes to the VAP definition that increase objectivity, and even make it amenable to a purely electronic reporting algorithm. Since this proposed new measure is already being reviewed by the National Quality Forum, I thought I would share the general outline with the course attendees. A couple of them came up to me afterwards, nervous about a more objective definition. You see, by virtue of the fact that the new definition is based mostly on objective measures of sustained respiratory decline in a stable/improving ventilated patient, it isn’t meant to define VAP, but rather “ventilator associated complication”, or “VAC”. There are subcategories of VAC for events associated with an inflammatory response and/or signs of infection (call them “iVAC”), but the main measure destined for public reporting is meant to be VAC.
The problem? For those centers that have successfully pushed their VAP rate to “zero”, by whatever means necessary, the new VAC definition is threatening. Not only will a new definition unmask the gaming that occurs with subjective definitions, but the number of VACs will greatly exceed the VAPs at most centers. Take a look at the table below (double-click it to expand it), from a recent PLoS One paper that compared VAC and VAP at three hospitals in the Prevention Epicenters program. There were more than twice as many VACs as VAPs. Also of interest, VAC was associated with in-hospital mortality. VAP, not so much….not at all, in fact.
Although VAC may be the first in line, the concept is the same for other definitional changes—achieving greater objectivity in surveillance definitions requires that our unhealthy focus on zero (or “elimination”) must itself be eliminated.
For more VAP-happy goodness, check out this thought piece by Mike Klompas, the master of all things VAP.
The problem? For those centers that have successfully pushed their VAP rate to “zero”, by whatever means necessary, the new VAC definition is threatening. Not only will a new definition unmask the gaming that occurs with subjective definitions, but the number of VACs will greatly exceed the VAPs at most centers. Take a look at the table below (double-click it to expand it), from a recent PLoS One paper that compared VAC and VAP at three hospitals in the Prevention Epicenters program. There were more than twice as many VACs as VAPs. Also of interest, VAC was associated with in-hospital mortality. VAP, not so much….not at all, in fact.
Although VAC may be the first in line, the concept is the same for other definitional changes—achieving greater objectivity in surveillance definitions requires that our unhealthy focus on zero (or “elimination”) must itself be eliminated.
For more VAP-happy goodness, check out this thought piece by Mike Klompas, the master of all things VAP.
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