case study unit 2

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What is a case study?

A case study is a type of research method. In case studies, the unit of analysis is a case . The case typically provides a detailed account of a situation that usually focuses on a conflict or complexity that one might encounter in the workplace.

• Case studies help explain the process by which a unit (a person, department, business, organization, industry, country, etc.) deals with the issue or problem confronting it, and offers possible solutions that can be applied to other units facing similar situations.
• The information presented in case studies is usually qualitative in nature - gathered through methods such as interview, observation, and document collection.
• There are different types of case study, including  intrinsic, instrumental, naturalistic,  and  pragmatic.

This research guide will assist you in finding individual case studies, as well as providing information on designing case studies. If you need assistance locating information, please Ask a Librarian .

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• Unit 2: Application of Concepts to Case Studies

Created and compiled by:

Lisa Doner (Plymouth State University), Lorraine Motola (Metropolitan College of New York), and Patricia Stapleton (Worcester Polytechnic Institute).

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Science and Engineering Practices

Analyzing and Interpreting Data: Use graphical displays (e.g., maps, charts, graphs, and/or tables) of large data sets to identify temporal and spatial relationships. MS-P4.2:

Using Mathematics and Computational Thinking: Use mathematical, computational, and/or algorithmic representations of phenomena or design solutions to describe and/or support claims and/or explanations. HS-P5.2:

Obtaining, Evaluating, and Communicating Information: Communicate scientific and/or technical information or ideas (e.g. about phenomena and/or the process of development and the design and performance of a proposed process or system) in multiple formats (i.e., orally, graphically, textually, mathematically). HS-P8.5:

Engaging in Argument from Evidence: Evaluate the claims, evidence, and/or reasoning behind currently accepted explanations or solutions to determine the merits of arguments. HS-P7.2:

Engaging in Argument from Evidence: Construct, use, and/or present an oral and written argument or counter-arguments based on data and evidence. HS-P7.4:

Analyzing and Interpreting Data: Analyze data using tools, technologies, and/or models (e.g., computational, mathematical) in order to make valid and reliable scientific claims or determine an optimal design solution. HS-P4.1:

Cross Cutting Concepts

Stability and Change: Change and rates of change can be quantified and modeled over very short or very long periods of time. Some system changes are irreversible. HS-C7.2:

Energy and Matter: Energy drives the cycling of matter within and between systems. HS-C5.4:

Disciplinary Core Ideas

The Roles of Water in Earth's Surface Processes: Water’s movements—both on the land and underground—cause weathering and erosion, which change the land’s surface features and create underground formations. MS-ESS2.C5:

Natural Hazards: Mapping the history of natural hazards in a region, combined with an understanding of related geologic forces can help forecast the locations and likelihoods of future events. MS-ESS3.B1:

Defining and Delimiting Engineering Problems: Criteria and constraints also include satisfying any requirements set by society, such as taking issues of risk mitigation into account, and they should be quantified to the extent possible and stated in such a way that one can tell if a given design meets them. HS-ETS1.A1:

Performance Expectations

Earth and Human Activity: Analyze and interpret data on natural hazards to forecast future catastrophic events and inform the development of technologies to mitigate their effects. MS-ESS3-2:

Engineering Design: Evaluate a solution to a complex real-world problem based on prioritized criteria and trade-offs that account for a range of constraints, including cost, safety, reliability, and aesthetics as well as possible social, cultural, and environmental impacts. HS-ETS1-3:

This activity was selected for the On the Cutting Edge Reviewed Teaching Collection

This activity has received positive reviews in a peer review process involving five review categories. The five categories included in the process are

For more information about the peer review process itself, please see https://serc.carleton.edu/teachearth/activity_review.html .

In Unit 2, students apply and evaluate foundational concepts about storm hazards and risk in the context of two cases studies: Superstorm Sandy (2012) and the Storm of the Century (1993). Through different activities and assignments, students develop skills for finding, evaluating, and relating data to case studies and build an understanding of preparedness, response, and resilience. The activities include: an analysis of hazard mitigation plans for their local community, examination of storm-related geophysical processes in the context of societal risks, preparation of a press release for community preparedness, and a peer review and revision opportunity for the press releases. Instructors may also end this unit by having students revise their concept maps from Unit 1, applying lessons learned in Units 1 and 2.

Expand for more detail and links to related resources

Activity Classification and Connections to Related Resources Collapse

Grade level, diversity, equity, inclusion and justice.

Learning Goals

After completing Unit 2, students will be able to:

• Find and analyze long-term sea-level and storm surge data;
• Evaluate the Hazard Mitigation Plan (HMP) for their local community in the context of major storms;
• Assess risk communication plans;
• Identify stakeholder positions for risk communication plans; and
• Develop their own risk communication plans and effectively communicate them in writing.

Context for Use

This Unit is designed to be implemented over two consecutive 90-minute class sessions, with homework after each session.

Students should complete Unit 1 of this module before Unit 2 begins. Unit 2 can be covered in ~ 3 course hours. Instructors should assign Unit 2 readings prior to starting Unit 2. Additionally, between class sessions, the following should be assigned as homework for Unit 2:

• HMP Review of Hurricane Sandy and the Storm of the Century
• Press Release Activity (complete before or during Class 4)
• Coastal Erosion Activity (optional)
• TEDxBarcelona talk "Sand Wars"

Unit 2 requires basic mathematics, locational geography, deductive reasoning, critical thinking, writing and editing skills appropriate for science and non-science majors at the university or advanced high-school level. It can be used in a lecture, lab, or online setting. Internet access, however, is essential for the research activities and to access data. Students also need a PDF-reader. Students should have successfully completed Unit 1 and demonstrated a solid understanding of risk assessment and risk management in order to reach the expected outcomes. For online courses, students should be able to make and upload drawings, such as their initial and revised concept maps.

Description and Teaching Materials

Jump to: Preparation for Unit 2 | Unit 2, Day 1 | Homework Between Classes | Unit 2, Day 2 | Formative Assessment: Concept Map | Optional Activity: Coastal Erosion

Overview of Unit 2

While Unit 1 focuses on developing conceptual literacy, Unit 2 emphasizes relevant skill development. The activities encourage and promote data access, use, visualization, and analysis, as well as data-based writing. The lessons integrate the geophysical processes that create natural hazards with the social environment that creates risk. Through Unit 2, students learn how to employ the literacy in climate hazards, risks, and social response through emergency management and strategic planning to perform research tasks. In addition to building on their growing knowledge of the foundational concepts, students will find, evaluate, and relate geophysical data to case studies and their communities in the context of preparedness, response, and resilience. The unit helps students understand that for each storm, impacts and risk are part of a coupled natural and human system. Instructors may choose to end the Unit with students revisiting the concept map they created for Unit 1, by making changes that incorporate lessons learned in Units 1 and 2. The peer review process provides a low-stakes activity that reinforces systems thinking and the collaborative nature of risk assessment, management, and communication between experts and public officials. The opportunity to revise press releases at the end of Unit 2 reinforces the iterative nature of risk assessment, management, and communication. In addition, the process of identifying stakeholders and their roles helps prepare the students for the town-hall style debate at the end of the module.

Through a series of five assignments, students learn how to find, evaluate, and relate data to selected case studies: Hurricane Sandy and the 1993 Storm of the Century. Students apply these skills in a systems thinking approach to their own community and assess preparedness, response and resilience. Instructors may wish to supplement the provided materials with videos related to the case studies (information below in Teaching Notes and Tips).

As noted above, this unit is designed to be implemented after Unit 1, over two consecutive 90-minute class sessions. At the end of this unit, students should revise their Unit 1 concept maps, either in class or as homework, before starting Unit 3. Students should be encouraged to expand the map to include new system components and linkages in the system. The original and revised maps are a useful assessment for gauging how far the students have advanced their systems thinking skills within this module.

General Purpose:

This unit's purpose is to provide students with details about these two case studies (Superstorm Sandy and the Storm of the Century), so students can use the concepts and vocabulary introduced in Unit 1 to examine and understand real-world events. In addition, the unit introduces habits of mind regarding the interactions of short-term events like storms and long-term processes like sea-level rise. Students encounter real-world management decisions which were based on cost control and short-term risk mitigation, but which failed to consider how geologic services can also benefit societal needs.

The Sea-Level Rise Activity exposes students to map data and to model estimates of long-term and future sea level change. It reminds them about the relationships between hazard magnitude, frequency, recurrence interval and probability. Students use this information to answer questions related to storm surge and coastal flooding. Students examine the potential impact of these phenomena to critical infrastructure. For example, students compare current sea level and storm surge heights in recent storm disasters to predicted sea levels for 2050. They apply this new information to hazard assessment plans.

In the Press Release activity, students learn to critically assess their local hazard mitigation plans for a specific event---hurricanes and winter storms---and learn how risk is communicated to the general public at a time of crisis. The students use examples of weather-related press releases from government entities to develop new press releases that communicate risk related to a particular storm and storm stage. Students then evaluate the effectiveness of their communication in the Press Release Revision activity.

Specific Aims:

The initial activities and assignments in Unit 2 provide students with a common understanding of two major storms, and a deeper understanding of the complex impacts on, and interactions with, natural and human systems. The homework prepares students for class discussion and facilitates completion of Unit 2's activities and assignments. In addition to developing skills in utilizing and analyzing real science data, students work with complex geophysical systems and develop perspectives about long- and short-term geologic processes.

The Sea-Level Rise Activity encourages and promotes skills in data management, data visualization, data analysis, and writing for students in a real-world context. Student apply those skills and systems thinking to assess vulnerabilities, preparedness, response, and resilience. The activity requires that students consider storm hazards in terms of long-term processes of the Earth, like sea-level rise.

In the Peer Review activity, students have the opportunity to consider different elements of assessing and communicating risk for different storm types. They also develop awareness about risk communication---specifically the importance of clear, concise, and high-quality writing---and have the opportunity to receive feedback and incorporate that feedback in a revised draft.

Preparation for Unit 2

Students should successfully complete Unit 1 of the Major Storms Module before beginning Unit 2. Students must also complete readings on the two selected case studies before the first class in Unit 2.

Unit 2 Homework (to be completed before starting Part I)

Superstorm Sandy:

• Superstorm Sandy: Hurricane Sandy Retrospective Analysis : found in "2014 New York City Hazard Mitigation Plan," Chapter 3, pages 201-212;
• The Science Behind Superstorm Sandy's Crippling Storm Surge , an article from Scientific American;
• Superstorm Sandy Anniversary , an article from the Weather Channel.

1993 Storm of the Century:

• The Blizzard of '93: The Overview , an article from the New York Times;
• Blizzard of '93: Why Was It the Storm of the Century? , an article from AccuWeather;
• Superstorm: Eastern and Central U.S., March 1993 , an article from Popular Mechanics.

Part I - Unit 2, Class 1: Sea Level

Instructors should present an overview of the data-related activities for the session (~ 15-20 minutes) to prepare students for in-class work. Allow time for questions and briefly review student outcomes from Unit 1. Students work in class on the Sea-Level Rise Activity (~ 1-1.5 hours); the activity can be completed as homework if students need extra time. Because students often need initial guidance in navigating the maps and software for this activity, we recommend beginning this activity in class. Reserve 10--15 minutes at the end of Class 1 to review student responses and answer questions.

Lesson Materials:

This file is only accessible to verified educators. If you are a teacher or faculty member and would like access to this file please enter your email address to be verified as belonging to an educator. Email Adress Submit

• Sea level Activity (Microsoft Word 76kB Jul15 17) ; Sea Level Activity pdf version (Acrobat (PDF) 129kB Jul15 17)
• Coastal Resilience Tool Step-by-Step Guide (Acrobat (PDF) 642kB Aug8 16)

Unit 2 Homework (assigned between classes)

Homework Material(s):

• Student handout: Press Release Assignment Student (Microsoft Word 2007 (.docx) 26kB Nov4 16) ; Press Release Assignment Student PDF Version (Acrobat (PDF) 107kB Nov4 16)

Part II – Unit 2, Class 2: Press Release and Peer Review Guidelines

Spend a few minutes discussing the results of the Sea Level Activity and homework assignments. Discuss mitigation efforts and recommendations for preparedness and resilience (~10 minutes). In this class session, instructors should form student pairs for the Peer Review Activity (students must have completed their Press Release Activity prior to the Peer Review). See Teaching Notes and Tips below regarding pair formation. Allow about ~20 minutes for students to complete the review and discuss feedback with their partner. Instructors should follow the Peer Review with ~10 minutes of class discussion, to review strengths and weaknesses of the press releases. Finally, if time remains, instructors should have students revise their concept maps from Unit 1 (time TBD by instructor).

• Press Release Peer Review Guidelines (Microsoft Word 18kB Nov4 16) ; Press Release Peer Review Guidelines PDF Version (Acrobat (PDF) 57kB Jul21 17)
• Press Release 1st Draft Rubric (Microsoft Word 2007 (.docx) 22kB Nov4 16)
• Press Release Revision Guidelines and the Press Release Rubric for the 2nd draft are found in Unit 3.

Unit 2 - Formative Activity: Revision of Major Storms, Storm Impacts, and Risk Concept Maps

This activity is intended to serve as a mid-module check point to assess student gains in systems awareness and understanding. It allows the students to revisit their initial perceptions about storms, storm impacts, and risks and either add onto their original concept maps or else start over with a new map that better represents their current breadth of knowledge. Before beginning this activity, instructors may find it helpful to review the activities of Units 1 and 2, and have students list some of the key concepts from those activities. Materials: Students revise their concept maps developed during Unit 1 in this formative assessment activity (intended for the end of Unit 2). If they wish to start a new ma, they should hand in both the new and old versions so the instructor can compare them. General Purpose: To serve as a formative assessment for learning targets in Units 1 and 2. Specific Aims: To reinforce ideas of systems thinking. It is recommended that instructors implement this activity during Class 2, if there is time. If the peer review process fills the full class, instructors can assign the revision of the concept map for homework, to be collected before the start of Unit 3.

Optional Add-on Activity for Unit 2: Coastal Erosion

This activity uses Hurricane Sandy as a case study to examine the intersection between geologic processes and societal risks and costs associated with storms. It places these in the context of long-term processes like glaciations, sediment budgets, beach formation and erosion, plus societal factors like development, post-storm beach reconstructions and sand debris removal. This activity engages the students in complex natural and societal systems thinking using a common, everyday material: sand. A more detailed introduction and instructor information is in this file: Coastal Erosion Activity Instructor Information -- private instructor-only file Hide Coastal Erosion Activity Instructor Information This file is only accessible to verified educators. If you are a teacher or faculty member and would like access to this file please enter your email address to be verified as belonging to an educator. Email Adress Submit General Purpose: The purpose of the coastal erosion activity is to familiarize students with geoscience data as it relates to major storms and storm impacts, especially with regard to long-term geologic processes that provide beneficial societal services, such as the creation and maintenance of coastal dunes and barrier beaches. While highly recommended for students in geoscience, physical geography, and environmental science, the activity is designed and written so that non-science students can also understand and complete it. Specific Aims: Through this activity, students use real geoscience data to develop perspectives unique to the geosciences, such as timescales of process. For example, the activity includes assessment of how short-duration events, like storms, affect longer-term natural processes like beach-building. Like the Sea-Level Rise Activity, the Coastal Erosion Activity helps students learn to apply those skills and a systems thinking approach to assess vulnerability, preparedness, response, and resilience of a community. The activity requires that students consider long-term natural processes, like sea-level rise, and how those processes may affect the impact of major storms. Students will also consider the role of stakeholders in the context of storm impacts. Thus, this activity will also work as a lead-in for the next homework assignments and Town Hall Meeting assignments of Unit 3.

Materials for Coastal Erosion Activity:

• NYC Hurricane Sandy After Action Report & Recommendations (May 2013) Please note: Students should focus on the "Debris Removal" section of the report (pp.22-23), although the entire document may be useful as reference material in their preparation for the Town Hall in Unit 3.
• USGS, Assess Community Vulnerability to Coastal Change Hazards for Hurricanes and Other Storm Scenarios

Recommendations for inclusion of optional activity: The Coastal Erosion Activity may be of particular interest to geoscience instructors who wish to more heavily emphasize the use of geoscience data and its application in their classrooms. It can build on the foundation established in the Sea-Level Rise Activity. Instructors in other disciplines (particularly non-science courses) may choose to opt out of the activity, depending on the skill level of the class. Assessment of the Sea-Level Activity should give instructors feedback on the appropriateness of employing the Coastal Erosion Activity. Instructors may want to consider the following in the context of the Sea-Level Rise Activity before including the Coastal Erosion Activity: 1) the length of time needed to complete the activity; 2) the level of student frustration and/or confidence in using data and map applications; 3) the level of student understanding in reviewing (potentially) unfamiliar geoscience processes. Instructors who choose not to include the Coastal Erosion Activity should consider where in the module they can introduce the role of stakeholders in decision-making, in preparation for the Town Hall Meeting. Instructors can highlight the role of stakeholders that should be included in risk communications (Press Release Assignment), for example, or as part of their HMP Analysis in Unit 1.

Teaching Notes and Tips

Additional Background Info Sources (videos and informational sites)

• To familiarize students with data available on storms, instructors may wish to demonstrate a couple of examples in class, using maps of sea level risk for NYC published in 2008 and maps of storm surge risk for the same areas created and published by Public Radio of New York's WNYC Data News.
• Instructors may wish to supplement the basic information included with videos of the two case studies. For Hurricane Sandy: National Geographic's Superstorm New York: What Really Happened PBS's Nova: Inside the Megastorm , or numerous short clips from news agencies. For the 1993 Super Storm (Storm of the Century), commentary is available online ( 20th Anniversary of the Blizzard of 1993 ). PBS Frontline has a follow-up story on problems with flood insurance coverage for Hurricane Sandy's called "Business of Disaster" that aired in May 2016.
• Activity materials include background information on particularly large storms using online data portals and reports such as NOAA's National Centers for Environmental Information (NCEI) Billion-Dollar Weather and Climate Disasters: Overview and their long-term impacts. Information on Superstorm Sandy (such as the Hurricane Sandy Retrospective Analysis can be found in the 2014 New York City Hazard Mitigation Plan /Chapter 3, pages 203-212 ) and the 1993 Storm of the Century are in numerous NOAA Reports. In addition, students will have to find Hazard Mitigation Plans for their local community, as well as geoscience data (flood stages, snowfall, windspeed, etc.) on a recent major storm that hit their community.
• Additional information is available from such non-profit agencies as Coastal Care , with special reports on risk mediation efforts in NYC after Hurricane Sandy, and storm surge discussions by weather agencies like the National Hurricane Center and the Weather Underground .

Press Release Assignment

• For the Press Release Assignment, students should be responsible for finding their local community's own hazard mitigation plan. However, instructors must identify in advance what HMP is available (at a city- or state-level) and give students guidance on where to look to find the appropriate materials. For example, elements of an HMP are included on the City of Worcester's website , but a more detailed Hazard Mitigation Planning is only available for the state of Massachusetts. Instructors should decide which materials they want students to use and guide them to the appropriate information. Instructors in small communities may wish to assign the HMP for a large city or their state.
• Instructors may use the provided examples related to the State of Massachusetts for the Press Release Assignment; however, we highly encourage instructors to use press release examples from their local community and, if winter storms and hurricanes are not a major threat to their area, to select storm types relevant to their local community.
• Students should be assigned one of two storm types (e.g., hurricanes or winter storms), in addition to a "phase" of the storm (e.g., pre-, during, or post-) as the focus of their press release. This is to illustrate that risk communication during different phases of a storm event will vary. For example, pre-storm communications may focus on preparedness, whereas post-storm are more likely to center on clean-up.
• Instructors should require that press releases be submitted in advance of the Unit 2, Day 2 class session (preferably by several hours, if not the day before). This will allow the instructor time to briefly review the assignment and determine if there are common mistakes or issues to be discussed during class.

Implementation of Peer Review

• Instructors may also review the earlier submissions to help determine how to pair students for the peer review. The authors recommend pairing students by contrasting storm types (e.g., a student who prepared a press release on winter storms with a student who prepared a press release on hurricanes) and with differing phases (e.g., a student who focused on pre-storm communication with a student who focused on communication during the event). Based on class size, this might not be possible for all pairs, but the priority should be on matching students with different storm types first.
• Students should receive feedback from their peers, as well as the instructor, with ample time before the next class meeting to allow them to incorporate feedback into their second drafts. Instructors may want to complete the rubrics before the Unit 2, Day 2 class session to return to students at the end of the session to help facilitate this. Another option would be to post completed rubrics online, or to email them to the students.
• Instructors should provide students with enough time during the peer review process to reflect on the feedback they have received. Students should be encouraged to use the back of their returned, completed rubric to note what revisions will be necessary and why.
• Instructors should follow the Peer Review with ~10 minutes of class discussion to review strengths and weaknesses of the press releases. During this time, instructors should highlight the importance of using data to support the points being communicated in the press release. Instructors should also use this time to discuss the role of stakeholders in risk communication and have students reflect on how stakeholders need to be addressed in their press releases.
• Instructors should use the second rubric provided to evaluate the revised press release (see Revision Guidelines and Rubric for 2nd Draft in Unit 3). Instructors may choose to distribute the 2nd rubric---in class or electronically---so that students have additional guidance in how they will be evaluated.
• The authors realize that instructors in some geographic regions (i.e., Southern California) may have difficulty selecting major storms relevant to their area. As such, we recommend using other major weather patterns (i.e., El Niño) or minor weather patterns (i.e., rain) coupled with other conditions that can cause hazards (i.e., mudslides).

The Sea Level Activity can be assessed using the embedded questions to evaluate how well the students were able to follow directions, read and assess visual information, and understand the implications of millions of residents losing infrastructure (roads, public transportation, medical, fire and police services) and access to critical resources (clean water, electricity, food) for some days after the storm.

The three parts of the Press Release Assignment can be assessed using the Press Release 1st Draft Rubric (Microsoft Word 2007 (.docx) 22kB Nov4 16) , which is filled out during peer review, and the Press Release Rubric - 2nd Draft (Microsoft Word 2007 (.docx) 23kB Nov4 16) or Press Release Rubric - 2nd Draft PDF Version (Acrobat (PDF) 84kB Nov4 16) .

The optional pre- and post-unit concept maps provide an additional formative assessment of student progress in applying higher-order systems thinking major storms, storm impacts, and storm risks. Instructors might refer to this completed activity to address gaps in understanding and to point out over-looked aspects before Unit 3.

Learning goals for Unit 2 are met when:

• Students correctly evaluate and relate geophysical data to their community in the context of preparedness, response, and resilience for a major storm;
• Students successfully translate data from their local HMP into a risk communication press release;
• Students demonstrate critical analysis of risk communications by evaluating a peer's press release;
• Students identify and accurately integrate knowledge about stakeholders' positions into their press releases; and
• Students demonstrate improvement in their writing skills by submitting a revised and improved second draft of their press release.

References and Resources

Additional resources and references for case studies.

Superstorm Sandy

• NPR's coverage of Sandy
• Flood, Rebuild, Repeat: Are We Ready for a Superstorm Sandy Every Other Year?

Storm of the Century

• Superstorm 1993: 20 Years Ago This Week
• Superstorm of 1993: Storm of the Century

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LIBF UNIT 4 APRIL 2024 CASE STUDY 2 QUIZ - 'Leslie' | FINANCIAL STUDIES DipFS U4 CS2 75x Q&A

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LIBF Diploma in Financial Studies Unit 4 (SFS) April 2024 Part B Exam - 75x ‘Leslie’ Case Study Questions

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• http://orcid.org/0000-0002-5764-1373 Bijesh Yadav 2 ,
• http://orcid.org/0000-0002-8615-5753 Karthik Gunasekaran 1 ,
• http://orcid.org/0000-0002-6977-1183 Kishore Pichamuthu 3 ,
• http://orcid.org/0000-0001-9117-1996 Vignesh Kumar Chandiraseharan 1 ,
• http://orcid.org/0000-0002-9443-0022 Sowmya Sathyendra 1 ,
• Samuel George Hansdak 1 ,
• http://orcid.org/0000-0001-8453-6205 Ramya Iyyadurai 1
• 1 Department of Medicine , Christian Medical College and Hospital Vellore , Vellore , Tamil Nadu , India
• 2 Department of Biostatistics , Christian Medical College and Hospital Vellore , Vellore , Tamil Nadu , India
• 3 Department of Critical Care Medicine , Christian Medical College and Hospital Vellore , Vellore , Tamil Nadu , India
• Correspondence to Dr Nivin Daniel Stanley; stanleynivin{at}gmail.com

Objectives To estimate all-cause mortality in ventilator-associated pneumonia (VAP) and determine whether antibiotic duration beyond 8 days is associated with reduction in all-cause mortality in patients admitted with VAP in the intensive care unit.

Design A prospective cohort study of patients diagnosed with VAP based on the National Healthcare Safety Network definition and clinical criteria.

Setting Single tertiary care hospital in Southern India.

Participants 100 consecutive adult patients diagnosed with VAP were followed up for 28 days postdiagnosis or until discharge.

Outcome measures The incidence of mortality at 28 days postdiagnosis was measured. Tests for association and predictors of mortality were determined using χ 2 test and multivariate Cox regression analysis. Secondary outcomes included baseline clinical parameters such as age, underlying comorbidities as well as measuring total length of stay, number of ventilator-free days and antibiotic-free days.

Results The overall case fatality rate due to VAP was 46%. There was no statistically significant difference in mortality rates between those receiving shorter antibiotic duration (5–8 days) and those on longer therapy. Among those who survived until day 9, the observed risk difference was 15.1% between both groups, with an HR of 1.057 (95% CI 0.26 to 4.28). In 70.4% of isolates, non-fermenting Gram-negative bacilli were identified, of which the most common pathogen isolated was Acinetobacter baumannii (62%).

Conclusion In this hospital-based cohort study, there is insufficient evidence to suggest that prolonging antibiotic duration beyond 8 days in patients with VAP improves survival.

• Adult intensive & critical care
• INTERNAL MEDICINE
• GENERAL MEDICINE (see Internal Medicine)

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-077428

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Strengths and limitations of this study

This study collected consecutive patients with ventilator-associated pneumonia diagnosed primarily by objective methods such as the National Healthcare Safety Network criteria. It also included those patients who were diagnosed by the intensivist bedside (20%), thereby improving the external validity of the study.

A limitation is that patient recruitment relied on temporal sampling; resulting in the study not being sufficiently powered to precisely estimate differences in mortality among patients receiving short-duration and long-duration antibiotic therapy.

Lastly, study data are subject to the accuracy of electronic documentation of the treating team.

Introduction

Ventilator-associated pneumonia (VAP) is a growing challenge in critical care units owing to the widespread prevalence of multidrug-resistant (MDR) organisms resulting in increased mortality if inadequately treated. It is characterised by pneumonia occurring 2–3 days or thereafter postintubation characterised by appearance of new or progressive infiltrates on radiological imaging, signs of systemic infection (fever, altered white cell count), changes in sputum characteristics and detection of a causative pathogen. Previously patients with suspected VAP were often treated with course of antibiotics lasting for 14–21 days due to the high mortality rates and indeterminate clinico-radiological signs associated with the condition. 1

Majority of intensive care units in India often rely on endotracheal aspirates for diagnosis of VAP as opposed to specimens obtained from broncho-alveolar lavage or fibre-optic bronchoscopy. This non-invasive approach may lead to over-diagnosis of VAP resulting in unwarranted antibiotic use. 2 This contributes to emergence of MDR organisms along with increased risk of treatment-emergent adverse events and increased hospital costs. 3

Prior randomised control trials (RCTs) done in Europe revealed that shorter duration of antibiotic therapy is non-inferior in patients with microbiologically confirmed VAP as compared with conventional longer therapy. 4 5 Longer duration was associated with unnecessary antibiotic use and emergence of MDR pathogens. However, the majority of organisms implicated in these trials were Staphylococcus aureus, Streptococci spp and Pseudomonas aeruginosa .

Whether shorter antibiotic therapy would be effective against the growing threat of fermenting and non-fermenting Gram-negative bacilli (NF-GNB) responsible for VAP in Indian critical care units, such as Acinetobacter baumannii, Klebsiella pneumoniae and Stenotrophomonas maltophilia , remains doubtful. 6 Intensivists often individualise antibiotic therapy and extend the antibiotic duration considering the disease severity and causative organism. 7 This study aimed to determine whether antibiotic duration beyond 8 days is associated with a reduction in all-cause mortality among patients admitted with VAP in a tertiary care hospital in Southern India.

Our study was a prospective, observational study conducted in the medical intensive care and high-dependency units of a 2800-bed hospital in Southern India over a period of 11 months, from May 2019 to June 2020.

Inclusion criteria

All adult patients above 18 years of age receiving mechanical ventilation for greater than 48 hours were assessed for eligibility. Those fulfilling clinical criteria for VAP and based on the CDC National Healthcare Safety Network (NHSN) for VAP 8 who consented to enrol in the study were included.

All patients were diagnosed to have clinical VAP based on appearance of a new or progressive infiltrate on radiological imaging, signs of systemic infection (fever, altered white cell count), changes in sputum characteristics and detection of a causative pathogen from microbiological cultures and staining from endotracheal aspirates.

They were further classified according to the case definition as per NHSN, into infective ventilator-associated condition, probable and possible VAP based on increasing ventilatory support, presence of fever, leukocytosis or leucopenia with initiation and continuation of a new antimicrobial for >4 days along with purulent secretions and/or positive lower respiratory tract cultures.

Exclusion criteria

Patients who did not provide consent, along with those who were neutropenic at presentation or received long-term corticosteroids or immunosuppressive therapy were excluded due to higher risk of infections with atypical organisms.

Patient variables

Data were recorded by reviewing the patient’s electronic medical records and laboratory parameters. Details of demographic profile, primary admission diagnosis, baseline comorbidities, isolated pathogen and its antibiotic susceptibility profile were recorded. Duration of antibiotic therapy, number of ventilator-free days and antibiotic-free days were confirmed using patient’s medical chart and pharmacy records. The presence of renal dysfunction or need for organ support such as vasopressor use, or renal replacement therapy (RRT) was assessed.

Outcome assessment

The primary outcome was to measure all-cause mortality at 28 days and study association with antibiotic duration. If patients were discharged prior to 28 days from diagnosis, they were followed up telephonically. Secondary outcomes included assessing for predictors for mortality such as age, underlying comorbid conditions as well as measuring total length of stay, antibiotic-free days by 28 days and the number of ventilator-free days. Antibiotic-free days measured the number of days free of antibiotics at 28 days following VAP diagnosis and treatment.

The data collection was carried out by the primary investigator who was not involved in the decision-making regarding initiation or discontinuation of antibiotics, which was entirely determined by the primary treating unit. All consecutive eligible patients were recruited, to avoid selection bias. In order to limit potential confounding due to early mortality resulting in apparent shorter antibiotic duration, the number of antibiotic-free days at 28 days was recorded. The patients who had greater antibiotic-free days indicated shorter therapy whereas those who had lower antibiotic-free days had longer duration of therapy or early mortality. Furthermore, those patients who had unfavourable outcomes or early mortality less than day 9 were excluded from the secondary analysis to account for immortality time bias. This excluded those whose duration of treatment was dependent on the outcome of mortality rather than the clinical decision by the treating team to discontinue antibiotics at shorter intervals.

Patient and public Involvement

Prior to study initiation, we had received input from multiple patients affected with conditions linked with antibiotic overuse, namely Clostridium difficile colitis and drug-resistant hospital-acquired infections. There seemed to be significant direct and indirect costs secondary to prolonged therapy and hospital stay among these patients. This influenced our research question to focus on antibiotic stewardship which would potentially limit these complications and their economic impact on families. Though patients were not directly involved in study design, their feedback was solicited during the follow-up period. We provided basic educational materials to family members of affected patients using simple language, to encourage familiarity with medical terminology and help understand possible side effects of antibiotic therapy. Once the study has been published, the survivors and immediate family of non-survivors will be informed of the results through a centralised messaging service.

Sample size

All consecutive patients diagnosed with VAP from May 2019 to June 2020 were included and a total of 100 subjects were enrolled in the study.

Statistical analysis

All continuous variables such as age, length of stay and antibiotic duration were reported as mean (SD) and median (IQR). Frequency and percentage were used for description of categorical variables. For each statistical analysis, a p value ≤0.05 was considered to be statistically significant. Predictors of mortality that were significant in a univariate Cox regression analysis were included in a multivariate Cox proportional hazard regression model. In multivariate analysis, apart from presence of shock and need for RRT; age, presence of underlying comorbidities, admission diagnosis with underlying pneumonia and antibiotic-free days at day 28 were introduced into the model to explore the confounding relationship of these covariates on mortality. Kaplan-Meier survival analysis was used to show the effect of antibiotic duration on mortality with respect to patients with VAP during their hospital stay. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), V.26.0 (IBM, Armonk, New York, USA).

Patient characteristics

A total of 100 eligible patients with VAP were enrolled in the study. The mean (SD) age of patients was 49.3 (18) years with a male preponderance of 70%. Baseline demographic and clinical characteristics including spectrum of VAP were similar in both antibiotic duration groups except for prevalence of pre-existing systemic hypertension, diabetes mellitus and chronic lung disease ( table 1 ). Systemic hypertension (32%), diabetes mellitus (31%) and ischaemic heart disease (11%) were among the commonly encountered comorbidities. The spectrum of VAP diagnosis included in this study group were probable VAP (61%), possible VAP (4%), infection-related ventilator-associated condition (IVAC; 15%) and clinical VAP (20%). Most cases were recruited from the medical critical care unit (80%), whereas the remainder of patients were recruited from the medical wards.

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Clinical profile of patients with VAP

Pathogen characteristics

Among all subjects, 85 patients had significant growth on endotracheal aspirate culture confirming VAP diagnosis whereas 15 cultures did not have significant growth, however fulfilled the clinical criteria for IVAC. Gram-negative organisms accounted for majority of culture isolates, with A. baumannii (62%) being the most common organism followed by K. pneumoniae (23%) and P. aeruginosa (15%) ( online supplemental figure 1 ). NF-GNB were identified in 70.4% of total isolates. 74% of all isolates were carbapenem-resistant. Polymyxin susceptibility among Acinetobacter spp isolates was sensitive in 58.1%, intermediate susceptibility in 16.1% and unavailable in 25.8% of isolates. 67% of the VAP cases were mono-microbial whereas 25% were poly-microbial.

Supplemental material

Duration of antibiotic therapy.

The median duration of appropriate antibiotic therapy used to treat VAP was 8 days (IQR 6–12 days) and was particularly variable (range 1–23 days). It was observed that mortality rate was markedly higher in patients receiving less than 5 days of antibiotics after VAP diagnosis as compared with those who received for greater and equal to 5 days (80% and 46%, respectively). This is possibly due to increased disease severity either secondary to the admission diagnosis or delay in VAP diagnosis and hence 15 cases were excluded (n=85). Similarly, an additional 17 individuals who expired before day 9 postdiagnosis of VAP were excluded to account for immortality time bias (n=68). The median duration of antibiotics among this subgroup was 10 days (IQR 7–14 days; range 6–23 days). The distribution of treatment duration based on the patient’s outcome status is illustrated in figure 1 .

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Duration of antibiotic therapy segregated based on patient outcome.

Association of antibiotic therapy with patient characteristics and outcomes

The overall case fatality rate for ventilator-associated events was 46% with lower mortality noted among those who received greater than 8 days of antibiotic therapy with a risk difference of 15.1% ( figure 2 ). 34 patients (34%) expired while on therapy including 25 before day 9, 4 between days 10 and 15 and 4 after day 15. A small proportion of deaths (11%) occurred after completion of antibiotic treatment. Among those who survived till day 9, there was no statistically significant difference in mortality between both antibiotic duration groups, with an HR of 1.05 (95% CI 0.26 to 4.28). There was no linear relationship between length of stay and antibiotic duration with a Pearson correlation coefficient of 0.371 (R 2 =0.138). Clinical outcomes of 68 cases included in the secondary analysis are represented in table 2 . Shock requiring vasopressors was associated with increased mortality with HR of 4.14 (95% CI 1.05 to 16.21) ( online supplemental figure 2 ).

Survival rate of the cohort stratified based on antibiotic duration.

Secondary outcomes and determinants of all-cause mortality

VAP continues to be a leading cause of mortality with a case fatality rate of 46% as noted in our study, which is comparable to prior studies done in Northern India. 9 This indicates a gap in understanding of the disease with regard to appropriate management and prevention. There is often ambiguity in managing such patients, especially regarding the optimal timing and duration of antimicrobial therapy. The lack of a standard diagnostic algorithm and substantial variation in the causative pathogens worldwide further adds to the problem.

The majority of organisms isolated in our study were Acinetobacter spp , Klebsiella sp and Pseudomonas sp. These findings are in line with existing Indian data. 6 Staphylococcus sp accounted for only 3% of culture isolates indicating a paradigm shift to NF-GNB as the leading agent responsible for VAP. 74% of the isolated pathogen were carbapenem-resistant, whereas among the Acinetobacter spp 19.4% had intermediate susceptibility to colistin. Despite emergence of colistin resistance with a global prevalence of 4.7% based on genotypic testing, 10 none of the endotracheal aspirates in this study showed colistin resistance. Majority of trials published so far argue against shorter antibiotic therapy for NF-GNB 3 11 In our study, the clinical spectrum of VAP was similar in both groups. Though shorter duration of antibiotic therapy (8 days and less) was associated with increased mortality, there was a lack of statistical evidence to support this claim. Thus, cautious attempts can be made to limit the duration of antibiotic therapy on a case-by-case basis, bearing in mind that this reduces selection pressure contributing to emergence of drug resistance. The higher case fatality rate noted with the shorter duration group could be due to confounding by multiple variables such as severity of illness and higher incidence of septic shock.

A recent meta-analysis by Daghmouri et al including five RCTs from the USA, France and Tunisia with a moderate certainty of evidence (GRADE, (Grading of Recommendations, Assessment, Development, and Evaluations)) and low heterogeneity, revealed that there was no significant difference for recurrence and relapse of VAP among those receiving short- and long-course antibiotic therapy (OR=1.48, 95% CI 0.96 to 2.28, p=0.08). 12 A similar meta-analysis with relatively higher proportion of NF-GNB isolates (45.4%) by Cheema et al revealed that while there was no difference in mortality or length of stay, the short course regimen was associated with slightly increased risk of recurrence in NF-GNB VAP. 13 Our study did not have any incidence of recurrence reported among both groups of patients. In this study, infection with resistant pathogens such as A. baumannii , Klebsiella and Pseudomonas species were associated with higher mortality rates (48%, 59% and 33%, respectively) which is similar to global data. 14

Our study coincided with the COVID-19 pandemic, and this was particularly challenging due to the overlapping clinical features of COVID-19 Acut respiratory distress syndrome (ARDS) and VAP. Observational studies show that more than 90% of COVID-19 patients with critical disease had a high score on frequently used bedside scoring systems such as the Clinical Pulmonary Infection Score (CPIS) without documented VAP or superadded bacterial infection, due to the presence of persistent fever, non-specific radiographic findings and high ventilatory requirements. 15 This leads to overuse of broad-spectrum antibiotics leading to emergence of highly resistant bacteria and fungi due to prolonged ventilatory support required in these patients. Though useful at the bedside, CPIS is often criticised for its poor specificity (17%) and low degree of interobserver agreement (kappa=0.16). 16 Our study did not include such scores and focused primarily on a composite of clinical parameters and microbiological evidence using the NHSN criteria. Prior studies revealed that these criteria had a specificity of 100%, with varying sensitivity (53%–93%) when compared with other validated scores such as HELICS. 17 There were several limitations which should be acknowledged. First, given the observational nature of this study, it is not possible to establish a causal inference. Second, patient recruitment was based on temporal sampling approach, therefore the study is underpowered in its ability to estimate a comparative difference in mortality between both groups of antibiotic therapy. Lastly, study data were subject to the accuracy of electronic documentation of the treating team. Our study did not exclude those patients who fulfilled clinical criteria for VAP diagnosis made bedside by the intensivist, despite not strictly fulfilling the NHSN criteria for infection-related VAC. Nevertheless, this mimics the clinical scenarios seen in practice and improves the external validity of the study. Despite these limitations, this study has significant clinical implications as it adds to the growing body of evidence in favour of limiting antibiotic therapy to the bare minimum while treating severe infections. This would in turn reduce antibiotic burden and hinder drug resistance. Further clinical trials incorporating improved diagnostic algorithms for VAP are recommended to determine tailored strategies to individualise antibiotic therapy and duration.

In this hospital-based cohort study, among patients admitted with VAP due to predominantly NF-GNB, evidence is lacking to support extending antibiotic duration for more than 8 days to improve survival. We conclude that it is reasonable to consider discontinuing antibiotics at a shorter duration as this strategy can potentially hinder emergence of drug resistance and reduce in-hospital costs.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study was approved by the Institutional Review Board and Ethics panel prior to commencement (IRB Min. No 11969 dated 2 April 2019). Patient data were kept confidential using a password-protected Google spreadsheet with access only to primary investigator. Informed consent to participate in the study was obtained from the accessible next of kin.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3

Contributors NDS was involved in the conception of study design, data collection, wrote the statistical analysis plan, cleaned and analysed the data, involved in drafting and revising the paper. RI was the guarantor and along with JAJ were involved in the conception of study design and statistical analysis, monitoring of data collection and revising and approving the draft paper. BY was involved in the conception of study design, statistical analysis plan and approved the draft paper. KG, KP, VKC, SS and SGH were involved in the conception of study design, reviewed and approved the draft paper.

Funding This research was supported by institutional postgraduate thesis fund (Grant number—not applicable).

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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