Barriers to the adoption of ventilator-associated events surveillance and prevention

The CDC expanded the purview of safety surveillance for ventilated patients from ventilator-associated pneumonia (VAP) to ventilator-associated events (VAE) in 2013. CDC created VAE definitions to simplify surveillance, increase objectivity, and broaden prevention efforts. Many U.S. hospitals are conducting VAE surveillance but uptake beyond the U.S. has been limited. Review of recent publications suggest three major barriers to the adoption of VAE surveillance and prevention: 1) ongoing uncertainty about VAE and concern about its limited overlap with clinically-defined VAP, 2) a paucity of studies defining risk factors for VAEs and how best to prevent VAEs, and 3) lack of emphasis on VAE surveillance and prevention by regulatory agencies. Emerging data partially address the first two points. Possible VAPs missed by VAE surveillance are associated with lower mortality rates than VAEs and have similar outcomes whether treated with ≤3 days of antibiotics or more conventional courses, suggesting VAE focuses surveillance on severe events. Potentially-modifiable VAE risk factors include deep sedation, positive fluid balance, blood transfusions, and mandatory modes of mechanical ventilation with high inspiratory pressures. Potential interventions to prevent VAEs include avoiding intubation, minimizing sedation, paired daily spontaneous awakening and breathing trials, conservative fluid management, conservative transfusion thresholds, low tidal volume ventilation, and early mobility. There are important limitations to all existing prevention studies, however, and no study has thus far has tested a VAE prevention bundle that includes all these interventions. Further work is needed to better define the clinical significance of VAPs missed by VAE surveillance, to rigorously evaluate the impact of an optimized VAE prevention bundle on VAEs and other outcomes, and to weigh whether these additional data provide adequate evidence to support mandating VAE surveillance and prevention.