Ventilator-Associated Pneumonia
As a cardiologist who infrequently manages patients on ventilators, I was surprised to see the kinds of visceral responses that these three words can evoke in conversation among my critical care specialist colleagues. Simply arriving at a consensus about what ventilator-associated pneumonia (VAP) means is a challenging, if not impossible, task if there are more than two or three experts in the room. Therein lies the dilemma. There is no debate that new opacities, with or without fever and leukocytosis, develop in patients supported by artificial ventilation. Whether this represents infection, inflammation, or localized atelectasis is not easily determined; thus, the approach to management can vary from watchful waiting to see if the opacity disappears (many of them do) to aggressive diagnostic evaluation and treatment to stave off a presumed underlying infection in an already severely ill patient. Layered on top of this clinical conundrum is the simplistic approach considered by many third-party payers, including the Centers for Medicare and Medicaid Services (CMS), that VAP should be a “nonevent” and that its presentation, however defined, reflects a preventable complication and should not be reimbursed. Unfortunately, even with perfect attention to well-validated prophylactic measures, the syndrome of VAP still emerges.
Here is where I would appreciate some dialog and discussion. Payers are grappling with how to set reimbursement rates for VAP, or the lack thereof, and they are looking for help from professional societies to arrive at definitions. The medical profession cannot agree upon a consistent definition of VAP, so many have advocated for silence on this issue rather than choose a definition that will satisfy some people and alienate others. Representing the ACCP, I feel uncomfortable with the “head in the sand” approach and wish to suggest another tactic. I would suggest that we avoid the trap of a definition and propose to CMS that, if clinicians can document they followed standard measures to prevent VAP, if VAP occurs, regardless of the definition used, there should be no physician reimbursement penalty. The ACCP Quality Improvement Committee came to a similar conclusion more than 1 year ago, and I have asked them to work with the Critical Care NetWork and Chest Infections NetWork to revisit the issue and recommend a plan of action for the ACCP. However, given the controversy over this issue, I am also seeking advice from our membership on how to proceed. Do you have an opinion or approach we should consider when dealing with this issue? Your help would be much appreciated.
About the Author
David Gutterman
About From the Presidents
To enhance coordination and collaboration among ACCP members and leaders like you, the College launched the From the Presidents blog. From the Presidentswill feature blogs about the College, medical and health-care issues, the medical profession, and other member-related topics of interest. The posts will be written by David D. Gutterman, MD, FCCP, ACCP Immediate Past President; Suhail Raoof, MBBS, FCCP, ACCP President; Darcy D. Marciniuk, MD, FCCP, ACCP President-Elect; and Michael Baumann, MD, FCCP, President-Designate. Learn more about the presidents.
The goals of From the Presidents,as described by ACCP President David Gutterman, are twofold. First, the presidents want to directly inform members about issues important to the ACCP. Second, the presidents want to encourage two-way conversations by soliciting feedback from members on these issues and encourage member input on other items of relevance to the College.
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VAP
Dr. Gutterman; I am responsible for reporting VAP's to our hospital Board of Trustees. They don't seem to be interested in the extraneous issues surrounding VAP. They want to see results. The endeavors of the ACCP regarding this topic are being anxiously awaited. Thanks for the insight and education on this subject.
Defining VAP
David I think you're right on. So long as their is so much subjectivity in the overall definition of VAP, I think it's going to be near impossible. What do you think an appropriate medically sound definition ought to be?
VAP - is this it ?
Sometimes I wonder, how much one can do to prevent. So much focus on cost saving but the means are focused on physician care rather than a partnership with cutting malpractice cost, patient responsibilty if they smoke or drink, compliance issues, education, etc. I like your post :)
Appropriate Preventative Process Measures?
Here is an excerpt from UpToDate:
As you can read, to avoid creating a single definition of VAP, the guidelines skirt the issue by merely say fulfilling those criteria potentially warrant empiric antibiotics. Elsewhere in UpToDate, they summarize the literature using various techniques to diagnose (thereby defining) VAP, with a calculable specificity and sensitivity in comparison to various gold standards such as lung biopsies or autopsy specimens. There are hundreds of research articles on VAP, and they probably utilize minor variations upon a small number of mildly different definitions, which is why I agree that we shouldn't be putting our heads in the sand. I think we can come up with a definition, but prefer the solution of proposing appropriate preventative process measures. I would consider whether the rhetoric in your blog post should reflect a facility payment consequence rather than a physician payment consequence (and I suspect it would mean no incremental reimbursement to the hospital, not a complete zero reimbursement).
VAP definition
It's interesting how different definitions of VAP lead to different definitions of reimbursement to the hospital!