Prevention does not always improve patient outcomes—use of a ventilator associated events prevention bundle as a quality metric

Over the last decade, and particularly since the public reporting of the Center for Medicare and Medicaid Service’s (CMS) quality based performance evaluation of potentially preventable conditions in hospitalized patients, the incidence of ventilator associated pneumonia (VAP) has taken a sharp drop with several institutions in United States reporting a “zero incidence” (1). Lately this discrepancy between VAP rates among quality monitoring reports and the actual care given to patients has widened, and the accuracy of reporting zero VAP has been questioned. While the application of several infection prevention measures, implemented as a “bundled approach” ,with effective implementation, has been viewed to be an effective measure for decreasing the incidence of VAP, the credibility of these reports has been questioned (2-5). Recognizing the formidable challenge of accurately diagnosing VAP and the existing gaps between surveillance and clinical definitions, the Centers for Disease Control and Prevention (CDC) in 2013 shifted its focus to complications related to ventilation, rather than to identifying infection, through the new surveillance definition—ventilator associated events (VAE) (6). VAE includes ventilator-associated complications (VAC), infection-related ventilator-associated complications (IVAC), as well as possible and probable VAP (PVAP).