Ventilator-Associated Pneumonia Rises in Long-term Hospitals

Nancy A. Melville

November 12, 2012

SAN FRANCISCO — The rate of ventilator-associated pneumonia (VAP) in long-term-care hospitals has increased over the last 5 years, leading to increased costs and patients' length of stay, researchers reported here at the American Public Health Association (APHA) 140th Annual Meeting.

VAP, the leading cause of nosocomial mortality among patients with respiratory failure, is an ongoing challenge for hospitals. It often extends a patient's length of stay and increases costs, as well as the risk for death.

Although the complication has been extensively evaluated in acute and trauma care settings, researchers have not focused previously on its prevalence and characteristics among the elderly in long-term-care hospitals.

Therefore, researchers with the Center for Medicare and Medicaid Innovation (CMMI), part of the Centers for Medicare and Medicaid Services (CMS) in Baltimore, Maryland, evaluated MEDPAR discharge data from 13,759 patients at long-term-care hospitals who had procedure codes for continuous mechanical ventilation for 96 consecutive hours or longer between 2005 and 2010. The researchers identified VAP patients as those with ICD-9-CM codes 481.xx – 486.xx.

During the study period, the percentage of patients on mechanical ventilation who developed VAP at the long-term-care hospitals increased from 25.9% to 30%.

The investigators found no significant difference between those patients on mechanical ventilation who did or did not develop VAP in level of frailty, age (71 to 72 years), or even the percentage of patients dying in hospital.

They also analyzed ICD codes for other comorbidities, including those for renal failure, diabetes, hypertension, stroke, chronic obstructive pulmonary disease (COPD), and congestive heart failure. Contrary to the researchers' assumptions, however, patients who developed VAP had less comorbidity than those who did not develop VAP.

"We were surprised to see fewer numbers of comorbidities among those with VAP," said lead author William Buczko, PhD, a research analyst with the CMS/CMMI. "We know the long-term-care hospital population is one that is severely ill and likely has comorbidities, but we find that the patients who didn't pick up VAP in fact had more comorbidity.

"The same can be said for in-hospital deaths — it was a surprise that there was no significant difference between the 2 groups," he said.

There were, however, significant increases in length of stay, averaging about 4 to 5 days longer for patients with VAP, and total Medicare-covered charges, ranging from about $10,000 to nearly $50,000 more for VAP patients. Those findings were less surprising.

"Our findings mirror what other studies have found regarding in-patient hospital settings, which is if a patient has VAP, they will have longer lengths of stay," Dr. Buczko said.

"These are important factors because they show that VAP does create a cost impact, and one hopes that this would help to make a business case for long-term-care hospitals to take measures to better control VAP."

Coordinated care bundles have shown some success in helping prevent VAP, and even the implementation of key measures can help reduce rates, Dr. Buczko noted.

"The use of specific precautions such as adjusting the patient's head or even, surprisingly, focusing on dental care to prevent bacteria from aiding and abetting VAP, can help," he said. "With these types of coordinated packages of interventions, it is possible that VAP incidence could be avoided and better outcomes can be achieved."

The findings run counter to improved efforts to control other types of hospital-acquired infections, according to Nancy Foster, vice president of quality and patient safety for the American Hospital Association.

"It used to be that a decade ago, we expected a certain level of infection with hospital stays, and it was thought that it was likely not possible to reduce the number of patients below about 2% to 4%, but our whole perspective on that changed when researchers showed that central line bloodstream infections could be driven down to zero or near zero for an extended period of time," she said.

Although the new findings are a concern, Foster speculated that some factors in the data analysis could explain some of the increase.

"The findings are a bit surprising, in part because not only have general acute-care hospitals but long-term acute-care hospitals as well have been working to use the techniques that have been shown to be effective in reducing VAP.

"It made me wonder if there is something else going on with the billing data from which the data were drawn that suggests there is a reason to believe VAP is going up," she continued.

"In addition, the experts at the Centers for Disease Control and Prevention have had differing opinions on what constituted VAP vs just a growth of bacteria that could become a pneumonia if not watched, so there have been different definitions of VAP in some data collections," she said.

Dr. Buczko and Foster have disclosed no relevant financial relationships.

American Public Health Association (APHA) 2012 Annual Meeting. Abstract 262818. Presented October 30, 2012.