Ventilator-associated events prevention, learning lessons from the past: A systematic review Jad Chahoud, MD a , Adele Semaan, MPH b , Khalid F. Almoosa, MD, MS, FCCP a, c, * a Department of Internal Medicine, School of Medicine, University of Texas Health Science Center, Houston, TX, USA b Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA c Transplant Surgery ICU, Memorial Hermann Hospital TMC, Houston, TX, USA article info Article history: Received 28 August 2014 Received in revised form 16 January 2015 Accepted 20 January 2015 Available online xxx Keywords: Ventilator-associated pneumonia Ventilator-associated Events Prevention Bundles Surveillance Critical care abstract Background: Preventing Ventilator-associated events (VAE) is a major challenge. Strictly monitoring for ventilator-associated pneumonia (VAP) is not sufficient to ensure positive outcomes. Therefore, the surveillance definition was updated and a change to the broader VAE was advocated. Objective: This paper summarizes the scientific efforts assessing VAP preventive bundles and the recent transition in surveillance methods. Methods: We conducted a systematic review to identify lessons from past clinical studies assessing VAP prevention bundles. We then performed a thorough literature review on the recent VAE surveillance algorithm, highlighting its advantages and limitations. Conclusion: VAP prevention bundles have historically proven their efficacy and the introduction of the new VAE definition aimed at refining and objectivizing surveillance methods. Randomized controlled trials remain vital to determine the effect of VAE prevention on patient outcomes. We recommend expanding beyond limited VAP prevention strategies towards VAE prevention bundles. Ó 2015 Elsevier Inc. All rights reserved. Introduction Ventilator-associated pneumonia (VAP) is prominent in inten- sive care units worldwide. In the United States, VAP accounts for approximately 300,000 cases of ICU acquired infections per year. 1 VAP is not only the most common hospital-acquired infection in ICUs, it is also associated with increased mortality, morbidity, and economical burden on the health care system. 2e8 The impact of VAP on mortality has always been controversial due to limitations in most of the previous studies. Small sample sizes, inability to perform relevant subgroup analyses and the presence of several confounding factors, have hampered a reliable measurement of VAP-attributable mortality rates. In the literature, a wide range of estimates was reported for VAP-attributable mor- tality rates ranging between 20 and 55%. A recent meta-analysis, published by Melhsen et al (2013) used original individual patient data from published randomized trials on VAP prevention. With a total sample size of 6284 patients from 24 trials, the reported overall VAP-attributable mortality was 13%. 9 Acquiring VAP is also associated with increased ICU length of stay (LOS). In fact, studies have shown an increase in ICU LOS ranging from 4.3 to 13 days, with an average of a 6-day increase attributable to VAP. 10e13 This ultimately led to increasing the cost of each hospital admission associated with a diagnosis of VAP by more than $40,000. 14e16 VAP is the hospital acquired infection with the highest economic impact per episode. With an added cost per episode of more than twice that of a central line-associated bloodstream infection and ten times that of an episode of catheter-associated urinary tract or Clostridium Difficile infection. 17 During the first week of mechanical ventilation, patients are at highest risk of acquiring VAP with risk rates of approximately 3% per day. 18 A potentially growing burden of VAP is to be anticipated in the future, as a consequence of population aging. 19 Furthermore, an Abbreviations: VAE, ventilator-associated events; ICU, intensive care unit; VAP, ventilator-associated pneumonia; CDC, centers for disease control; LOS, length of stay; IHI, Institute of Healthcare Improvement; HOB, head of bed; PUD, peptic ulcer disease; DVT, deep vein thrombosis; CINAHL, Cumulative Index to Nursing and Allied Health; IVAC, infection-related ventilator-associated complications; NHSN, National Healthcare Safety Network; PEEP, positive end-expiratory pressure; FIO 2 , fraction of inspired oxygen; ATS, American Thoracic Society; IDSA, Infectious Dis- eases Society of America. * Corresponding author. Department of Internal Medicine, School of Medicine, University of Texas Health Science Center, 6431 Fannin Street, MSB 1.134, Houston, TX 77030, USA. Tel.: þ1 713 500 6839; fax: þ1 713 500 6829. E-mail address: Khalid.F.Almoosa@uth.tmc.edu (K.F. Almoosa). Contents lists available at ScienceDirect Heart & Lung journal homepage: www.heartandlung.org 0147-9563/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2015.01.010 Heart & Lung xxx (2015) 1e9