cusp 4 mvp – vap improving care for mechanically ventilated patients infection prevention 2 vae...

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

Infection Prevention 2VAE Surveillance Training: Infectious Ventilator-Associated Complication (IVAC)

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITYJohns Hopkins University

February 25, 2015

2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

CUSP 4 MVP – VAP

Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

VAE Surveillance Training: Infectious Ventilator-Associated Complication (IVAC)Kathleen Speck, MPH

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Polling Question

Who is on the call? • IP – infection preventionist• RN – registered nurse• RT – respiratory therapist• PT – physical therapist• OT – occupational therapist• MD – medical doctor• Healthcare executive• Educator• National project team• Other  

5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Objectives

• Review history of VAE surveillance

• Review the definitions of VAE tiers

• Discuss case finding and determination of the second tier in VAE–IVAC

6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Polling Question

Did you attend the CDC’s “Applying the 2015 Changes to Accurately Report HAIs” on Feb 17-19, 2015?

1. Yes – in Atlanta

2. Yes – online

3. No

7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Former NHSN VAE Surveillance Definition

• Subjective• Not sensitive or specific1-3

• Required radiographic findings – often unclear• Required clinical signs and symptoms• Did not allow accurate validation of success of

prevention strategies4-7

• Did not allow establishment of valid benchmarks for quality improvement projects

1. Klompas M, JAMA 20022. Klompas M, Am J Infect Control 20103. Klompas M, et al, Clin Infect Dis 20084. Zilberberg MD, et al, Clin Infect Dis 20105. Girard T, et al, Lancet 20086. Strom T, et al, Lancet 20107. The Acute Respiratory Distress Syndrome

Network , N Engl J Med 2000

8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

NHSN VAE Definition

• Objective

• Streamlined

• Potentially automatable

• Defines a broad range of conditions and complications occurring in mechanically ventilated patients

9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Which Locations Should Use VAE Surveillance?

• Inpatient – Acute care hospitals– Long-term care hospitals– Rehabilitation facilities

• Unit type (examples)– Critical/intensive care units– Specialty care units– Step-down units– Long-term care units 8CDC NHSN Device-associated Module Ventilator-

associated Event (VAE); http://www.cdc.gov/nhsn/pdfs/pscManual/10-VAE_FINAL.pdf

10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

VAE Definition Tiers8

Possible Ventilator-Associated Pneumonia (PVAP)

11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

CUSP 4 MVP–VAP VAE Surveillance

Assessment must take place for all VAE tiers• VAC

Ventilator-associated Condition

• IVACInfectious Ventilator-associated Complication

• Possible VAPPossible Ventilator-associated Pneumonia

12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

VAE Attributable Hospital Mortality10

10Klompas, Infect Control Hosp Epidemiol, 2014

Case Finding

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Relationship VAC – IVAC

• VAC must be determined before IVAC can be considered

15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

VAC Definition Criteria

• Patient intubated for >2 calendar day – Earliest day of event is calendar day 3

• Baseline stability – Stable baseline period– Two calendar days immediately preceding the

first day of increased daily minimum PEEP or FiO2

16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Determination of VAC

After period of stability or improvement on the ventilator, the patient exhibits at least one of these indicators of worsening oxygenation

• Daily minimum FiO2 values increase ≥ 0.20 over daily minimum for preceding 2 calendar days

• Daily minimum PEEP values increase ≥ 3 cm H2O over daily minimum for the preceding 2 calendar days

• PEEP or FiO2 must be maintained for ≥ 1 hour (two consecutive hour readings) (exceptions covered in VAC call)

17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Positive End-Expiratory Pressure (PEEP)

• Any value of PEEP ≥ 5 cm H2O

• PEEP < 5 cm H2O will be entered as 5 cm H2O

• Actual PEEP of < 5 cm H2O will be considered = to 5 cm H2O for determination of event

18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

PEEP: Change ^ ≥ 3

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 504 6 705 5 606 5 507 8 708 9 809 6 50

10 7 50

19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

VAC – Possible on MV Day 7

Two days of stable PEEP, followed by a change in PEEP

of ≥ 3 cm H2O. The change is

maintained or worsens for

≥ 2 days.

It is a VAC.

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 504 6 705 5 606 5 507 8 708 9 809 6 50

10 7 50

20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

FiO2: Change ^ ≥ 20

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 504 6 505 5 706 5 707 6 708 6 809 6 50

10 7 50

21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

VAC – Possible on MV Day 5

Two days of stable FiO2,

followed by a change in FiO2

of ≥ 0.2. The change is

maintained or worsens for ≥ 2

days.

It is a VAC.

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 504 6 505 5 706 5 707 6 708 6 809 6 50

10 7 50

22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

FiO2: Change ^ ≥ 20 – not a VAC

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 554 6 505 5 706 5 707 6 708 6 809 6 50

10 7 50

23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

FiO2: Change ^ ≥ 20 – not a VAC

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 454 6 505 5 706 5 707 6 708 6 809 6 50

10 7 50

24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

FiO2: Change ^ ≥ 20 – not a VAC

MV Day Min PEEP Min FiO2

1 8 1002 7 703 6 504 6 455 5 706 5 707 6 708 6 809 6 50

10 7 50

25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Tier 2: IVAC – 1st Part

• Patient meets criteria for VAC• On or after calendar day 3 of mechanical

ventilation or after the onset of worsening oxygenation, the patient meets BOTH of the following criteria:– Temp > 38oC (100.4oF) or < 36oC (96.8oF), OR WBC ≥

12,000 cells/mm3 or ≤ 4,000 cell/mm3

AND– A new antimicrobial agent(s) is started, and is

continued for ≥ 4 calendar days

26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

5-Day VAE Event Window - IVAC

MV Day

Min PEEP

Min FiO2

Temp min

Temp max

WBC min

WBC max

Abx

1 5 1002 5 703 6 50 12.14 7 50 36.9 37.6 12.1 16.85 5 70 38.1 39.2 14.5 15.96 5 70 38.4 38.9 12.6 13.67 6 70 36.5 37.8 11.18 6 809 6 50

10 7 50

27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Tier 2: IVAC – 1st Part

• Patient meets criteria for VAC• On or after calendar day 3 of mechanical

ventilation or after the onset of worsening oxygenation, the patient meets BOTH of the following criteria:– Temp > 38oC (100.4oF) or < 36oC (96.8oF), OR WBC ≥

12,000 cells/mm3 or ≤ 4,000 cell/mm3

AND– A new antimicrobial agent(s) is started, and is

continued for ≥ 4 calendar days

28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

IVAC Antimicrobial Criterion

• Can be complicated

• Standardizes assessment method of antimicrobial therapy without some information:– Dosing

– Renal function

– Indication for therapy

29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

What Antimicrobial Drugs Are Included?

• NOW: Mostly antibacterials, antifungals, limited antivirals

• ORIGINALLY: Broad range of agents for HAIs, not just respiratory infections

• NOT INCLUDED– Anti-HIV agents– Anti-tuberculosis agents – Agents used to treat viral hepatitis – Agents used to treat herpes virus infection– Anti-parasitics

Listed in the Appendix,

10-VAE_FINAL

30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the on either of the 2

days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Qualifying Antimicrobials Day (QAD)

• A day on which a patient was administered a “new” antimicrobial agent within the VAE window period

• 4 consecutive QADs are needed to meet the IVAC antimicrobial criterion, starting within the VAE window period

32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD

33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1Consider Levo

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD ? ? ? ? ? ? ?

34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1Consider Mero

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD ? ? ? ?

36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1Consider Mero

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD

38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1Consider Vanc

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD ? ? ?

39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1Consider Vanc

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD

41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

42 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

43 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 1Consider Vanc

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo Levo Levo Levo Levo

Abx Mero Mero Mero Mero

Abx Vanc Vanc Vanc

QAD √ √ √ √ √ √

44 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 2Consider Vanc

VAE Day -3 -2 -1 1 2 3 4 5

Abx Vanc -- Vanc -- Vanc -- Vanc

Abx

Abx

QAD ? ? ? ?

45 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

46 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 2Consider Vanc

VAE Day -3 -2 -1 1 2 3 4 5

Abx Vanc -- Vanc -- Vanc -- Vanc

Abx

Abx

QAD √ √ √ √ √ √ √

47 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 3

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo

Abx Vanc Vanc Vanc

Abx

QAD ? ? ? ? ? ? ?

48 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Definition:New Antimicrobial Agent

Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of

the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4

days• Must be administered IV, IM, via digestive tract or via

respiratory tract• Can be considered continuous if a single day is skipped

between two doses of the same agent

49 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

QAD – Example 3

VAE Day -3 -2 -1 1 2 3 4 5

Abx Levo Levo Levo

Abx Vanc Vanc Vanc

Abx

QAD

50 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

5-day VAE Event Window - IVAC

MV Day

Min PEEP

Min FiO2

Temp min

Temp max

WBC min

WBC max

Abx

1 5 100 No2 5 70 No3 6 50 12.1 No4 7 50 36.9 37.6 12.1 16.8 No5 5 70 38.1 39.2 14.5 15.9 No6 5 70 38.4 38.9 12.6 13.6 Yes7 6 70 36.5 37.8 11.1 Yes8 6 80 Yes9 6 50 Yes

10 7 50 No

51 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

3-day VAE Event Window - IVAC

MV Day

Min PEEP

Min FiO2

Temp min

Temp max

WBC min

WBC max

Abx

1 5 50 36.9 37.62 5 50 38.1 39.2 12.1 13.63 8 50 38.4 38.9 12.5 14.5 No4 8 50 36.5 37.8 12.6 16.8 No5 7 60 11.1 15.9 Yes6 5 70 11.2 Yes7 6 70 Yes8 6 80 Yes9 6 50 No

10 7 50 No

52 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

3-day VAE Event Window – Not IVAC

MV Day

Min PEEP

Min FiO2

Temp min

Temp max

WBC min

WBC max

Abx

1 5 50 36.9 37.62 5 50 36.5 39.2 12.1 13.63 8 50 37.5 37.9 14.0 14.94 8 50 37.9 37.8 11.6 12.85 7 60 11.1 11.96 5 70 11.27 6 708 6 809 6 50

10 7 50

53 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

5-day VAE Event Window – Not IVAC

MV Day

Min PEEP

Min FiO2

Temp min

Temp max

WBC min

WBC max

Abx

1 5 100 39.92 5 70 38.0 13.13 6 50 11.94 7 50 36.9 37.6 10.1 11.55 5 70 36.5 37.2 11.5 11.66 5 70 37.0 37.9 11.2 11.37 6 70 36.5 37.8 11.18 6 809 6 50

10 7 50

54 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 1

A 69-year old female is seen in the ER with an admitting diagnosis of community acquired pneumonia (CAP). She is admitted to the ICU the same day on a vent.

Review her ventilator settings and, if necessary, her temperature, white blood count (WBC) and antibiotic (ABX) information, and determine whether VAE criteria have been met and, if so, whether she meets VAC or IVAC criteria.

55 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 1:Is this a VAE? Find the Event DayMV Day Min

PEEPMin FiO2

Temp max

WBC max

Abx Abx

1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 809 6 50 Vanc IV

10 7 50

56 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 1:Event Day and WindowIs this really a VAE? VAC? IVAC?MV Day Min

PEEPMin FiO2

Temp max

WBC max

Abx Abx

1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 809 6 50 Vanc IV

10 7 50

57 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Polling Question

Is this a VAE?

If so, is it a VAC or IVAC?

1. No VAE, the patient had a CAP present on admission

2. VAC only

3. IVAC

MV Day

Min PEEP

Min FiO2

Temp max

WBC max

Abx Abx

1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 80

9 6 50 Vanc IV10 7 50

58 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Polling Question

Is this a VAE?

If so, is it a VAC or IVAC?

1. No VAE, the patient had a CAP present on admission

2. VAC only

3. IVAC

MV Day

Min PEEP

Min FiO2

Temp max

WBC max

Abx Abx

1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 80

9 6 50 Vanc IV10 7 50

59 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 1: Discussion

• Patients are not excluded from VAE surveillance due to admitting diagnosis, symptoms existing before the VAE Window Period, presence of underlying conditions, or development of complications from admission criteria

• FiO2 change is 20 points

• Temp >38C°• WBC is ≤4,000• Days between administration of the same new Abx count

as QADs as long as there is a gap of no more than 1 calendar day

• Vanc meets Abx criteria, Pip/Tazo does not

60 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2

A 27-year old male is admitted to the neuro ICU following a motorcycle accident. He was intubated in the field and there was concern of aspiration upon intubation.

Given the following information, identify event(s).

61 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2 Polling QuestionIs this VAE? VAC only? IVAC?

MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None

2 6 30 36.8 37.2 4.6 4.6 None

3 5 30 37.0 37.9 5.4 5.4 None

4 6 30 36.5 37.3 7.2 9.2 None

5 6 35 36.3 37.2 7.4 12.5 None

6 6 50 37.2 37.9 8.5 13.0 Yes

7 6 50 37.8 37.3 Yes

8 6 40 37.2 37.9 Yes

9 6 50 37.5 37.9 9.7 11.7 Yes

10 7 50 37.4 37.1 9.6 10.9 Yes

11 7 40 37.2 37.9 9.4 9.4 Yes

12 8 30 37.0 37.5 9.5 9.5 Yes

13 8 30 37.2 39.8 8.2 8.2 None

14 7 30 37.3 38.7 8.6 8.6 None

15 7 60 37.2 38.9 9.4 12.1 Yes

16 6 60 37.1 39.8 13.0 13.5 Yes

17 6 85 37.0 40.0 Yes

18 Patient Expires

62 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2

MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None

2 6 30 36.8 37.2 4.6 4.6 None

3 5 30 37.0 37.9 5.4 5.4 None

4 6 30 36.5 37.3 7.2 9.2 None

5 6 35 36.3 37.2 7.4 12.5 None

6 6 50 37.2 37.9 8.5 13.0 Yes

7 6 50 37.8 37.3 Yes

8 6 40 37.2 37.9 Yes

9 6 50 37.5 37.9 9.7 11.7 Yes

10 7 50 37.4 37.1 9.6 10.9 Yes

11 7 40 37.2 37.9 9.4 9.4 Yes

12 8 30 37.0 37.5 9.5 9.5 Yes

13 8 30 37.2 39.8 8.2 8.2 None

14 7 30 37.3 38.7 8.6 8.6 None

15 7 60 37.2 38.9 9.4 12.1 Yes

16 6 60 37.1 39.8 13.0 13.5 Yes

17 6 85 37.0 40.0 Yes

18 Patient Expires

63 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2: Discussion

• Event is not on day 6, even though there is a 20 point increase in FiO2 from day 4

• The FiO2 rates for days 4 and 5 aren’t stable: they are worsening

64 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2 Polling QuestionIs this VAE? VAC only? IVAC?

MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None

2 6 30 36.8 37.2 4.6 4.6 None

3 5 30 37.0 37.9 5.4 5.4 None

4 6 30 36.5 37.3 7.2 9.2 None

5 6 35 36.3 37.2 7.4 12.5 None

6 6 50 37.2 37.9 8.5 13.0 Yes

7 6 50 37.8 37.3 Yes

8 6 40 37.2 37.9 Yes

9 6 50 37.5 37.9 9.7 11.7 Yes

10 7 50 37.4 37.1 9.6 10.9 Yes

11 7 40 37.2 37.9 9.4 9.4 Yes

12 8 30 37.0 37.5 9.5 9.5 Yes

13 8 30 37.2 39.8 8.2 8.2 None

14 7 30 37.3 38.7 8.6 8.6 None

15 7 60 37.2 38.9 9.4 12.1 Yes

16 6 60 37.1 39.8 13.0 13.5 Yes

17 6 85 37.0 40.0 Yes

18 Patient Expires

65 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2 Polling QuestionIs this VAE? VAC only? IVAC?

MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None

2 6 30 36.8 37.2 4.6 4.6 None

3 5 30 37.0 37.9 5.4 5.4 None

4 6 30 36.5 37.3 7.2 9.2 None

5 6 35 36.3 37.2 7.4 12.5 None

6 6 50 37.2 37.9 8.5 13.0 Yes

7 6 50 37.8 37.3 Yes

8 6 40 37.2 37.9 Yes

9 6 50 37.5 37.9 9.7 11.7 Yes

10 7 50 37.4 37.1 9.6 10.9 Yes

11 7 40 37.2 37.9 9.4 9.4 Yes

12 8 30 37.0 37.5 9.5 9.5 Yes

13 8 30 37.2 39.8 8.2 8.2 None

14 7 30 37.3 38.7 8.6 8.6 None

15 7 60 37.2 38.9 9.4 12.1 Yes

16 6 60 37.1 39.8 13.0 13.5 Yes

17 6 85 37.0 40.0 Yes

18 Patient Expires

66 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Case 2 - Discussion

• Event is on day 15 (first day of worsening oxygenation) – FiO2 ^ 30 points

• VAE Window Period is Day 13, 14 (2 days before), Day 15 (event day), and Days 16, 17 (2 days after)

• Abnormal WBC documented during VAE Window Period – 13,000

• Abnormal Temp documented during VAE Window Period – Days 13-17 ≥ 38C

• However, only 3 QADs are documented prior to patient expiring

67 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Remember!

Gather FiO2 and PEEP on all ventilated patients

1. Determine VAC first!

2. Then collect Temp and WBC

3. If Temp and WBC criteria for IVAC are met, then collect Abx information

68 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Next Steps

If you ARE using the NHSN system for VAE reporting: • Upload six (6) months baseline data• Confer rights to your CE, if you haven’t already

done so• CEs can then download your data from NHSN and

upload to the CECity platform

69 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Next Steps

If you ARE NOT using the NHSN surveillance system, or you choose not to confer rights, this data can be entered into CECity system manually.

70 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

If You Already Perform VAE Surveillance

• Collect an interesting and/or complicated case for discussion

– 1 case

– Include case determination with APRV

• Email to cusp4mvp@jhmi.edu with the subject line VAE Surveillance Case

71 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

This Is Your Time!

• We have 1 more IP-dedicated session

• Share topics you would like to discuss

72 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Cohort 2 VAE Data Submission July 2014 – Jan 2015

Next StepsKathleen Speck, MPH

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

74 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Final IP Session: March 25VAE Surveillance: VAP (PVAP)

• Discuss solutions, barriers and ideas for data collection

• Discuss how to determine VAC if using APRV or other vent modes

• Cover determination of PVAC• Discuss your cases

Have questions or related topics of interest?Send requests to cusp4mvp@jhmi.edu

75 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Login Information

Expect to receive information 10 days after you submit• Letter of Commitment (LOC)• Data Use Agreement (DUA)

– If the DUA is edited, this can be a longer process

76 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

Data Entry: Tablets

Interface to data portal is the same as a computer• Can enter manually as you walk unit• Can use spreadsheet template to gather data and

then upload to portal• Can use our spreadsheet with dropdown menus

and skip logic for both data collection and uploading

77 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

1. CUSP

2. Daily Care Processes

3. Early Mobility

4. Low Tidal Volume Ventilation

CUSP 4 MVP–VAPCategories

78 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

CUSP 4 MVP – VAP Website

Visit: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx

79 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC

What Can I Find on the CUSP 4 MVP – VAP Website?

• CUSP Tools and Guides

• HSOPS Resources

• Data Collection Tools

• Educational Materials

– Toolkits

– Literature Reviews

– Fast Fact Sheets

• Archive of webinars led by subject matter experts

80 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC