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



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


Objectives

• Review history of VAE surveillance

• Review the definitions of VAE tiers

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


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


NHSN VAE Definition

• Objective

• Streamlined

• Potentially automatable

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


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


VAE Definition Tiers8

Possible Ventilator-Associated Pneumonia (PVAP)


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


VAE Attributable Hospital Mortality10

10Klompas, Infect Control Hosp Epidemiol, 2014

Case Finding



Relationship VAC – IVAC

• VAC must be determined before IVAC can be considered


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


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)


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


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


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.


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

10 7 50


FiO2: Change ^ ≥ 20


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

10 7 50


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.


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

10 7 50


FiO2: Change ^ ≥ 20 – not a VAC


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

10 7 50




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

10 7 50




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

10 7 50


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


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


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


IVAC Antimicrobial Criterion

• Can be complicated

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

– Renal function

– Indication for therapy


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


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


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


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


QAD – Example 1Consider Levo

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



Abx Vanc Vanc Vanc

QAD ? ? ? ? ? ? ?



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





QAD – Example 1Consider Mero

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



Abx Vanc Vanc Vanc

QAD ? ? ? ?


QAD – Example 1Consider Mero

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



Abx Vanc Vanc Vanc

QAD


QAD – Example 1Consider Vanc

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



Abx Vanc Vanc Vanc

QAD ? ? ?



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



Abx Vanc Vanc Vanc

QAD



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



Abx Vanc Vanc Vanc

QAD √ √ √ √ √ √



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

Abx Vanc -- Vanc -- Vanc -- Vanc

Abx

Abx

QAD ? ? ? ?



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

Abx Vanc -- Vanc -- Vanc -- Vanc

Abx

Abx

QAD √ √ √ √ √ √ √


QAD – Example 3

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

Abx Levo Levo Levo

Abx Vanc Vanc Vanc

Abx

QAD ? ? ? ? ? ? ?


QAD – Example 3

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

Abx Levo Levo Levo

Abx Vanc Vanc Vanc

Abx

QAD


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


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


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


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


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.


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


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


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


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


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).


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


Case 2


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


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




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


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


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


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


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.


If You Already Perform VAE Surveillance

• Collect an interesting and/or complicated case for discussion

– 1 case

– Include case determination with APRV

• Email to [email protected] with the subject line VAE Surveillance Case

mailto:[email protected]


This Is Your Time!

• We have 1 more IP-dedicated session

• Share topics you would like to discuss


Cohort 2 VAE Data Submission July 2014 – Jan 2015

Next StepsKathleen Speck, MPH



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 [email protected]


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


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


1. CUSP

2. Daily Care Processes

3. Early Mobility

4. Low Tidal Volume Ventilation

CUSP 4 MVP–VAPCategories


CUSP 4 MVP – VAP Website

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

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





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

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

Documents

vae surveillance ivac1

mvp vapimproving care

prevention strategies4

patient safety

strom t

girard t

n engl j med

required radiographic