Elliott Doug, Elliott Rosalind, Burrell Anthony, Harrigan Peter, Murgo Margherita, Rolls Kaye, Sibbritt David
Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia.
NSW Clinical Excellence Commission, Sydney, New South Wales, Australia.
BMJ Open. 2015 Oct 29;5(10):e008924. doi: 10.1136/bmjopen-2015-008924.
With disagreements on diagnostic criteria for ventilator-associated pneumonia (VAP) hampering efforts to monitor incidence and implement preventative strategies, the study objectives were to develop a checklist for clinical surveillance of VAP, and conduct an audit in Australian/New Zealand intensive care units (ICUs) using the checklist.
Online survey software was used for checklist development. The prospective audit using the checklist was conducted in 10 ICUs in Australia and New Zealand.
Checklist development was conducted with members of a bi-national professional society for critical care physicians using a modified Delphi technique and survey. A 30-day audit of adult patients mechanically ventilated for >72 h.
Presence of items on the screening checklist; physician diagnosis of VAP, clinical characteristics, investigations, treatments and patient outcome.
A VAP checklist was developed with five items: decreasing gas exchange, sputum changes, chest X-ray infiltrates, inflammatory response, microbial growth. Of the 169 participants, 17% (n=29) demonstrated characteristics of VAP using the checklist. A similar proportion had an independent physician diagnosis (n=30), but in a different patient subset (only 17% of cases were identified by both methods). The VAP rate per 1000 mechanical ventilator days for the checklist and clinician diagnosis was 25.9 and 26.7, respectively. The item 'inflammatory response' was most associated with the first episode of physician-diagnosed VAP.
VAP rates using the checklist and physician diagnosis were similar to ranges reported internationally and in Australia. Of note, different patients were identified with VAP by the checklist and physicians. While the checklist items may assist in identifying patients at risk of developing VAP, and demonstrates synergy with the recently developed Centers for Disease Control (CDC) guidelines, decision-making processes by physicians when diagnosing VAP requires further exploration.
由于呼吸机相关性肺炎（VAP）诊断标准存在分歧，影响了对其发病率的监测及预防策略的实施，本研究旨在制定一份VAP临床监测清单，并使用该清单对澳大利亚/新西兰重症监护病房（ICU）进行审核。
使用在线调查软件制定清单。使用该清单进行的前瞻性审核在澳大利亚和新西兰的10个ICU中进行。
通过改良的德尔菲技术和调查，与一个跨两国的重症医学专业医师协会成员共同制定清单。对机械通气超过72小时的成年患者进行为期30天的审核。
筛查清单上各项内容的存在情况；医生对VAP的诊断、临床特征、检查、治疗及患者结局。
制定了一份包含五项内容的VAP清单：气体交换恶化、痰液变化、胸部X线浸润、炎症反应、微生物生长。169名参与者中，17%（n = 29）根据清单显示出VAP特征。有独立医生诊断的比例相似（n = 30），但患者子集不同（两种方法仅识别出17%的病例）。清单和临床医生诊断的每1000个机械通气日的VAP发生率分别为25.9和26.7。“炎症反应”这一项与医生诊断的VAP首发事件关联最为密切。
使用清单和医生诊断得出的VAP发生率与国际及澳大利亚报道的范围相似。值得注意的是，清单和医生识别出的VAP患者不同。虽然清单项目可能有助于识别有发生VAP风险的患者，并与最近制定的疾病控制中心（CDC）指南显示出协同作用，但医生在诊断VAP时的决策过程仍需进一步探索。
