Effect of ICU quality control indicators on VAP incidence rate and mortality: a retrospective study of 1267 hospitals in China
Authors: Ding Xin , Ma Xudong , Gao Sifa , Su Longxiang , Shan Guangliang , Hu Yaoda , Chen Jieqing , Ma Dandan , Zhang Feng , Zhu Wen , Sun Guoqiang , Meng Xiaoyang , Ma Lian , Zhou Xiang , Liu Dawei , Du Bin ,   China National Critical Care Quality Control Center Group, Wang Xue , Guan Xiangdong , Kang Yan , Xiong Bin , Qin Bingyu , Qian Kejian , Wang Chunting , Zhao Mingyan , Ma Xiaochun , Yu Xiangyou , Lin Jiandong , Pan Aijun , Qiu Haibo , Shen Feng , Li Shusheng , Ai Yuhang , Xie Xiaohong , Yan Jing , Wu Weidong , Duan Meili , Wan Linjun , Yang Xiaojun , Liu Jian , Xu Hang , Jiang Dongpo , Xu Lei , Chen Zhuang , Lin Guoying , Yang Zhengping , Hu Zhenjie 
Published: December 2022

Abstract
Purpose
To investigate the effects of ICU quality control indicators on the VAP incidence rate and mortality in China throughout 2019.

Methods
This was a retrospective study. A total of 1267 ICUs from 30 provinces in mainland China were included. Data were collected using the National Clinical Improvement System Data that report ICU information. Ten related quality control indicators were analyzed, including 5 structural factors (patient-to-bed ratio, physician-to-bed ratio, nurse-to-bed ratio, patient-to-physician ratio, and patient-to-nurse ratio), 3 process factors (unplanned endotracheal extubation rate, reintubation rate within 48 h, and microbiology detection rate before antibiotic use), and 2 outcome factors (VAP incidence rate and mortality). The information on the most common infectious pathogens and the most commonly used antibiotics in ICU was also collected. The Poisson regression model was used to identify the impact of factors on the incidence rate and mortality of VAP.

Results
The incidence rate of VAP in these hospitals in 2019 was 5.03 (2.38, 10.25) per 1000 ventilator days, and the mortality of VAP was 11.11 (0.32, 26.00) %. The most common causative pathogen was Acinetobacter baumannii (in 39.98% of hospitals), followed by Klebsiella pneumoniae (38.26%), Pseudomonas aeruginosa, and Escherichia coli. In 26.90% of hospitals, third-generation cephalosporin was the most used antibiotic, followed by carbapenem (24.22%), penicillin and beta-lactamase inhibitor combination (20.09%), cephalosporin with beta-lactamase inhibitor (17.93%). All the structural factors were significantly associated with VAP incidence rate, but not with the mortality, although the trend was inconsistent. Process factors including unplanned endotracheal extubation rate, reintubation rate in 48 h, and microbiology detection rate before antibiotic use were associated with higher VAP mortality, while unplanned endotracheal extubation rate and reintubation rate in 48 h were associated with higher VAP mortality. Furthermore, K. pneumoniae as the most common pathogen was associated with higher VAP mortality, and carbapenems as the most used antibiotics were associated with lower VAP mortality.

Conclusion
This study highlights the association between the ICU quality control (QC) factors and VAP incidence rate and mortality. The process factors rather than the structural factors need to be further improved for the QC of VAP in the ICU.