Surveillance of ventilator-associated pneumonia (VAP) has been the common outcome measurement used for internal and external benchmarking for mechanically ventilated patients; and although not a clinical definition, it is commonly used as an outcome measurement for research studies. Criteria in the VAP definition include both subjective and objective components, leading to questions of validity. In addition, recent legislation has mandated the public reporting of healthcare-associated infections, including VAP, in many states. Infectious disease experts have recently recommended monitoring a new outcome, ventilator-associated events (VAE), that contain specific objective criteria. The Centers for Disease Prevention and Control (CDC) have refined this definition and released a new VAE protocol and algorithm, replacing the VAP surveillance definition, as a result. The VAE protocol assesses for ventilatorassociated conditions (VAC). The primary aims of this study were to determine the incidence of VAC; and to assess four predictors for VAC, including two VAP prevention strategies (use of the subglottic secretion drainage endotracheal-tube [SSD-ETT]), and daily sedation vacation); and two patient-related factors (alcohol withdrawal during mechanical ventilation, and history of COPD). In addition, the incidence for VAE, using a new national algorithm was determined. Using a retrospective study design, electronic medical records of 280 veterans were reviewed to identify cases of VAC using the VAE algorithm. The setting was two intensive care units (ICU) at a large Veterans Administration Healthcare System (VAHCS) from October 2009 to September 2011. In addition to demographic information, variables were collected to determine if cases met event criteria (VAC, infection-related ventilator-associated complication iii [IVAC], and possible or probable VAP). Incidence rates were calculated for VAC and IVAC. Comparative data between those with and without VAC were assessed with independent sample T-test or non-parametric equivalents. The study sample was predominantly male (97.1%), Caucasian (92.1%), non-Hispanic (90.7%); with a mean (SD) age of 67.2 (10.4) years. Twenty patients met the VAC definition resulting in a VAC incidence of 7.38 per 1000 ventilator days. There were no statistically significant differences in demographics or disease characteristics found between the two groups (patients with VAC and patients without VAC). Using logistic regression, the impact of the four predictors for VAC was assessed. None of the four explanatory variables were predictive of the occurrence of VAC. Secondary outcomes (e.g. mechanical ventilation days, ICU days, hospital days, and mortality) of veterans with VAC were compared to veterans without VAC. Results indicated that the VAC group was associated with a significantly longer duration of ICU stay, longer mechanical ventilation period, more likely to have a tracheostomy, and had a higher mortality during hospitalization. Expanding mechanical ventilation quality performance measures to include VAE/VAC provides a better representation of infectious and non-infectious ventilator-associated problems, and provides more accurate morbidity and mortality in this high-risk ICU population. Further research is necessary to explore patient characteristics and prevention strategies that impact the development of all VAC.

The purpose of the study was to investigate the assumptions that underpin contemporary hospital infection control programs from the perspective of the influence of clinical culture on the integration and ownership of the infection control program. The results of numerous studies have linked low levels of adherence with infection control principles amongst health care providers as the most significant factor contributing to nosocomial infection. Despite early successes in reducing nosocomial infection rates, results derived from current research demonstrate that nosocomial infection has remained a challenge to healthcare providers and patients alike and outbreaks are regularly reported in the infection control literature. Serious economic and social impact has resulted from the increasing levels of antibiotic resistance that have been reported amongst pathogens associated with nosocomial infection. This interpretive study takes an ethnographic approach, using multiple data sources to provide insight into the culture and context of infection control practice drawing upon clinicians' work and the clinician's perspective. There were three approaches to data collection. A postal survey of surgeons was conducted, a group of nurses participated in a quality activity, and a clinical ethnography was conducted in an intensive care unit and an operating theatre complex. Data were analysed in accordance with the qualitative and quantitative approaches to data management. Findings indicate that the clinical culture exerts significant influence over the degree to which the infection control program activities change practice and that rather than imposing the infection control program on the clinical practice setting from outside, sustained practice change is more likely to be achieved if the motivation and impetus for change is culturally based. Moreover surveillance, if it is to influence clinicians and their practice, must provide confidence in its accuracy. It must be meaningful to them and linked to patient care outcomes. Contemporary hospital infection control programs, based on assumptions about a combination of surveillance and control activities have resulted in decreased nosocomial infection rates. However, sustained infection control practice change has not been achieved despite the application of a range of surveillance and control strategies. This research project has utilized an ethnographic approach to provide an emic perspective of infection control practice within a range of practice contexts. The findings from this study are significant within the context of spiraling health costs and increasing antibiotic resistance associated with nosocomial infection.