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A qualitative assessment of the diagnosis and management of ventilator-associated pneumonia among critical care clinicians exploring opportunities for diagnostic stewardship

Published online by Cambridge University Press:  16 April 2021

Blaine Kenaa Open the ORCID record for Blaine Kenaa [Opens in a new window] ,
Lyndsay M. O’Hara ,
Mary Elizabeth Richert ,
Jessica P. Brown ,
Carl Shanholtz ,
Michael J. Armahizer  and
Surbhi Leekha
Blaine Kenaa*
Affiliation:
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Lyndsay M. O’Hara
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Mary Elizabeth Richert
Affiliation:
Department of Critical Care Medicine, National Institute of Health, Bethesda, Maryland
Jessica P. Brown
Affiliation:
Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Carl Shanholtz
Affiliation:
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Michael J. Armahizer
Affiliation:
Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
Surbhi Leekha
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
*
Author for correspondence: Blaine Kenaa, E-mail: [email protected]
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Abstract

Background:

Prompt diagnosis and intervention for ventilator-associated pneumonia (VAP) is critical but can lead to overdiagnosis and overtreatment.

Objectives:

We investigated healthcare provider (HCP) perceptions and challenges associated with VAP diagnosis, and we sought to identify opportunities for diagnostic stewardship.

Methods:

We conducted a qualitative study of 30 HCPs at a tertiary-care hospital. Participants included attending physicians, residents and fellows (trainees), advanced practice providers (APPs), and pharmacists. Interviews were composed of open-ended questions in 4 sections: (1) clinical suspicion and thresholds for respiratory culture ordering, (2) preferences for respiratory sample collection, (3) culture report interpretation, and (4) VAP diagnosis and treatment. Interviews transcripts were analyzed using Nvivo 12 software, and responses were organized into themes.

Results:

Overall, 10 attending physicians (75%) and 16 trainees (75%) trainees and APPs believed they were overdiagnosing VAP; this response was frequent among HCPs in practice 5–10 years (91%, n = 12). Increased identification of bacteria as a result of frequent respiratory culturing, misinterpretation of culture data, and fear of missing diagnosis were recognized as drivers of overdiagnosis and overtreatment. Although most HCPs rely on clinical and radiographic changes to initiate work-up, the fear of missing a diagnosis leads to sending cultures even in the absence of those changes.

Conclusions:

HCPs believe that VAP overdiagnosis and overtreatment are common due to fear of missing diagnosis, overculturing, and difficulty distinguishing colonization from infection. Although we identified opportunities for diagnostic stewardship, interventions influencing the ordering of cultures and starting antimicrobials will need to account for strongly held beliefs and ICU practices.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 3 , March 2022 , pp. 284 - 290
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Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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