Originally published by our sister publication Anesthesiology News
By Monica J. Smith
Despite limited data on ventilator-acquired pneumonia (VAP) in trauma patients, rates are reported to the trauma quality improvement program (TQIP) by all American College of Surgeons–verified trauma centers. New research, however, found VAP to be underreported in the trauma registry, calling into question its use as a quality metric.
“Recent studies have noted that trauma patients are often already colonized or infected with respiratory bacteria on presentation, which may potentiate later VAP or be used to exclude a respiratory infection as being ventilator-associated,” said Alison Mortemore, a medical student at Tulane University School of Medicine, in New Orleans, at the 2025 Southeastern Surgical Congress (abstract 13).
Hypothesizing that reported VAP rates would be lower than the number of clinically significant infections, Ms. Mortemore and her colleagues retrospectively analyzed trauma patients intubated at a Level I trauma center between 2019 and 2023, collecting demographics and infectious, injury, patient trauma registry and outcome data.
They defined trauma registry VAP using the National Trauma Data Standard (NTDS): pneumonia in which the patient is on mechanical ventilation for at least two days, as well as a positive quantitative respiratory culture with positive laboratory and imaging findings.
“Clinical VAP was defined as a moderate growth of at least 10,000 colony-forming units of a speciated organism on respiratory culture at least two days after intubation,” Ms. Mortemore said.
Of the 980 patients who met inclusion criteria, the majority were male with blunt injuries and an average age of 42 years. Chest trauma was common, with 32% having rib fractures and 17% having pulmonary contusions; aspiration was documented in 18% of patients. Of the total cohort, 32% underwent respiratory culture by hospital day 9 on average, at an average of seven days after intubation.
“Of the patients who had a respiratory culture, 75% had clinical VAP. This is 24% of the total patient cohort,” Ms. Mortemore said. VAP was noted in the trauma registry for about 8% of the total patient cohort. Of the registry VAP patients, nearly 84% met criteria for clinical VAP.
“For the clinical VAP patients, only 29% were reported in the trauma registry. Receiver operating characteristics show an area under the curve of 0.64, indicating poor correlation for trauma registry VAP as a predictor of clinical VAP.”
The researchers also noted that compared with trauma registry VAP patients, clinical VAP patients had a longer hospital length of stay, a longer ICU stay and more ventilator days.
In summary, only 30% of clinically significant respiratory infections were captured as a VAP in the trauma registry. “VAP is underreported in our trauma registry using the subjective NTDS definition, which may point to the limits of research utility of TQIP,” Mortemore said.
“Our registry was a poor predictor overall of clinical respiratory infection. Improved definitions, reporting standards and diagnostic use of respiratory cultures are essential for trauma patients, specifically to enhance the reliability and utility of VAP as a quality metric,” she noted.
William Hope, MD, a general surgeon with Novant Health and an adjunct professor of clinical medicine at the University of North Carolina at Chapel Hill, asked whether this discrepancy might be caused by hospitals’ reluctance to report VAP for the harm it might do to their scorecard.
“Yes, I do,” Ms. Mortemore replied. “Sometimes there can be unintended consequences of scorecards and quality measures that do not actually improve quality, as there are ways to manipulate data.”
Hope and Mortemore reported no relevant financial disclosures.
