Evaluation of the effect of diagnostic methodology on the reported incidence of ventilator-associated pneumonia.

BACKGROUND: The optimal method for diagnosing ventilator-associated pneumonia (VAP) is controversial and its effect on reported incidence uncertain. This study aimed to model the impact of using either endotracheal aspirate or bronchoalveolar lavage on the reported incidence of pneumonia and then to test effects suggested from theoretical modelling in clinical practice. METHODS: A three-part single-centre study was undertaken. First, diagnostic performance of aspirate and lavage were compared using paired samples from 53 patients with suspected VAP. Secondly, infection surveillance data were used to model the potential effect on pneumonia incidence and antibiotic use of using exclusively aspirate or lavage to investigate suspected pneumonia (643 patients; 110 clinically suspected pneumonia episodes). Thirdly, a practice change initiative was undertaken to increase lavage use; pneumonia incidence and antibiotic use were compared for the 12 months before and after the change. RESULTS: Aspirate overdiagnosed VAP compared with lavage (89% vs 21% of clinically suspected cases, p<0.0001). Modelling suggested that changing from exclusive aspirate to lavage diagnosis would decrease reported pneumonia incidence by 76% (95% CI 67% to 87%) and antibiotic use by 30% (95% CI 20% to 42%). After the practice change initiative, lavage use increased from 37% to 58%. Although clinically suspected pneumonia incidence was unchanged, microbiologically confirmed VAP decreased from 18 to 9 cases per 1000 ventilator days (p = 0.001; relative risk reduction 0.61 (95% CI 0.46 to 0.82)), and mean antibiotic use fell from 9.1 to 7.2 antibiotic days (21% decrease, p = 0.08). CONCLUSIONS: Diagnostic technique impacts significantly on reported VAP incidence and potentially on antibiotic use.

Where to from here: patients of a day hospital rehabilitation programme perceived needs following stroke.

The loss of ability to perform routine activities can result in difficulties for the stroke patient to resume their normal lifestyle. A desire to assist stroke patients after discharge prompted this pilot study into the needs of these patients during and after a program of rehabilitation at a day hospital. A longitudinal approach was used for this pilot study. The aim of the study was to identify patients' needs pertaining to the resumption of their lifestyle, and social and emotional well-being, that emerged during the rehabilitation programme at the day hospital, on its completion and within six months of discharge from the day hospital. The study consisted of three semi-structured interviews with ten stroke patients over a period of nine to twelve months. The semi-structured interview employed open-ended questions to collect information from the participants. The interview process sought to elicit the needs of the participants during their time at the day hospital and then after discharge. It was evident from the interviews that the needs of the participants were primarily the opportunity to practice activities which could improve physical capabilities as the physical limitations placed on the participants by the stroke affected their motivation, morale and general sense of self. The day hospital was instrumental in providing participants with opportunities to learn to 'use' what was functioning, and therefore help the participants improve their physical capabilities. This assisted them to regain their independence. During the interviews participants also spoke about social and emotional needs. While they received some support from interactions with the staff and other patients at the day hospital, participants stated that mostly social and emotional support came from their families. After discharge from the day hospital participants were unable to identify specific needs which they believed the day hospital could provide.