Mandated self-reporting of ventilator-associated pneumonia bundle and catheter-related bloodstream infection bundle compliance and infection rates.

IMPORTANCE: As quality measures increasingly become tied to payment, evaluating the most effective ways to provide high-quality care becomes more important. OBJECTIVES: To determine whether mandated reporting for ventilator and catheter bundle compliance is correlated with decreased infection rates, and to determine whether labor-intensive audits are correlated with compliance. DESIGN, SETTING, AND PARTICIPANTS: Multiyear retrospective review of aggregated data from all patients admitted to 15 intensive care units in a Veterans Affairs hospital setting (the Veterans Integrated Service Network 16) from 2009 to 2011. EXPOSURES: Ventilator-associated pneumonia and catheter-related bloodstream infections. MAIN OUTCOMES AND MEASURES: Mean rates of ventilator-associated pneumonia and catheter-related bloodstream infection were analyzed by year. Relationships between infection rates, self-reported compliance, and audits were analyzed by Pearson correlation. RESULTS: During the study period, ventilator-associated pneumonia decreased from 2.50 to 1.60 infections per 1000 ventilator days (P = .07). The rate of pneumonia was not correlated with self-reported compliance overall (R = 0.19) or by individual year (2009, R = 0.30; 2010, R = 0.24; 2011, R = 0.46); there was a correlation in cardiac intensive care units (R = -0.70) but not other types of intensive care units (mixed, R = -0.18; medical, R = 0.42; surgical, R = 0.34). Catheter-related bloodstream infections decreased from 2.38 to 0.73 infections per 1000 catheter days (P = .04). The rate of catheter infection was not correlated with self-reported compliance overall (R = -0.18), by individual year (2009, R = -0.39; 2010, R = -0.42; 2011, R = 0.37), or by intensive care unit type (mixed, R = -0.19; cardiac, R = 0.55; medical, R = 0.17; surgical, R = -0.44). CONCLUSIONS AND RELEVANCE: Current mandated self-reported compliance and audit measures are poorly correlated with decreased ventilator-associated pneumonia or catheter-related bloodstream infection.

Endobronchial ultrasonography-guided transbronchial needle aspiration biopsy for preoperative nodal staging of lung cancer in a veteran population.

IMPORTANCE: Recently, preoperative lung cancer staging has evolved to include endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) biopsies of the hilar and mediastinal lymph nodes, but the feasibility and usefulness of the procedure have not been well studied in the veteran population. OBJECTIVE: To determine the safety and effectiveness of EBUS-TBNA as a key component of a preoperative staging algorithm for lung cancer in veterans. DESIGN, SETTING, AND PARTICIPANTS: Review of a prospectively maintained thoracic surgery database that includes patients who underwent lung resection for lung cancer between January 1, 2009, and December 31, 2012, at a single Veterans Affairs medical center among a consecutive cohort of 166 patients with clinically early-stage (I or II) lung cancer who underwent lobectomy with nodal dissection. INTERVENTIONS: Endobronchial ultrasonography-guided transbronchial needle aspiration mediastinal staging (EBUS group) in 62 patients (37.3%) was compared with noninvasive nodal staging plus integrated positron emission tomography-computed tomography only (PET/CT-only group) in 104 patients (62.7%). The accuracy of nodal staging was assessed by comparison with the final pathological staging after complete nodal dissection (the gold standard). MAIN OUTCOMES AND MEASURES: Primary outcomes were feasibility, safety, accuracy, and negative predictive value of EBUS-TBNA for preoperative nodal staging. A secondary outcome was the rate of nontherapeutic lung resection for occult N2 disease, with comparison between the EBUS group and the PET/CT-only group. RESULTS: No significant complications were attributable to the EBUS-TBNA procedure. In the EBUS group, 258 lymph node stations were sampled. N1 hilar metastases were diagnosed in 8 patients (12.9%) before surgery, and the remainder were staged N0. Accuracy and negative predictive value of EBUS-TBNA were 93.5% (58 of 62) and 92.6% (50 of 54), respectively. The overall rate of nontherapeutic lung resection performed in patients with occult N2 disease was 10.8% (18 of 166) (8.1% in the EBUS group and 12.5% in the PET/CT-only group) (P = .37). CONCLUSION AND RELEVANCE: A preoperative lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective in a veteran population, resulting in a low rate of nontherapeutic operations because of occult N2 nodal disease.