robert garcia, bs, mmt(ascp), cic infection control
TRANSCRIPT
Slide 1Infection Control Preventionist
NHSN, Clinical Pulmonary Infection Score, European surveillance definitions, etc.) all use combinations of criteria:
Chest x-ray Clinical signs/symptoms
Microbiological evidence
References include but are not limited to the following: ¹Wunderink R, et al., Chest 1992;101;458-63; ²Young M, et al., Arch Intern Med 1994;154:2729-32; ³Fabregas N, et al., Thorax 1999;54:867-73; Kirtland SH, et al., Chest 1997;112:445-57; Berton DC, et al., Cochrane Database Syst Rev 2008; Ruiz , et al., Am J Respir Crit Care Med 2000;162:119-25.
• Lack specificity for VAP¹ • Interobserver variability² • Not within purview of IP
expertise
• Lack sensitivity and specificity³ • Some are highly subjective • Documentation varies
• Lack sensitivity and specificity • Practices vary among providers • Controversy about best
practices
New Definition Detects complications and
conditions including, but not limited to VAP
Requires a minimum period of time on ventilator
Focuses on readily available, objective, clinical date
Does not include chest radiograph findings
The goal for implementation in NHSN (National Healthcare Safety Network) is January 2013.
3
The New VAE Algorithm It is a surveillance algorithm and is not intended for use in
the clinical management of patients There are 3 Tiers of the new VAE definition
Tier 1: Ventilator-Associated Conditions
Tier 2: Infection-Related Ventilator-Associated Complications These tiers were developed to be appropriate for the potential future uses of public reporting and pay-for –performance programs.
Tier 3: Possible and Probable VAP This tier was developed for healthcare facilities to use in internal quality improvement efforts.
4
THE “WHO” AND “WHEN” OF VAE SURVEILLANCE
Who is eligible for VAE surveillance? Patients on mechanical ventilation who are…
….≥ 18 years of age, and are….
…. Inpatients of acute care hospitals, long term acute
care hospitals, inpatient rehabilitation facilities
(some forms of ventilation are excluded, see NHSN documents)
When will VAE surveillance be available in NHSN, and what is happening to PNEU/VAP? VAE available January 2013. In 2013, current VAP protocol will still be used for
neonatal and pediatric patients ONLY. Pediatric and Neonatal VAE Surveillance Definition Working Group
kick-off meeting held on September 6, 2012.
In 2013, the current PNEU definitions will still be available for off-plan surveillance of VAP in adults or non-ventilated PNEU in adults or children.
“WHAT” IS VAE? REVIEW OF DEFINITIONS
***Note that these are NOT clinical definitions and are not intended for use in the management of patients. ***
VAE Definition Algorithm Summary
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Fever or WBC and
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Purulent secretions and/or other
positive laboratory evidence
Tier 1: VAC Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO.
After a period of stability or improvement on the ventilator, the patient has at least ONE of the following indicators of worsening oxygenation:
1. Increase in daily minimum FiO of ≥ 0.20 (20 points) over the daily minimum FiO in the baseline period, sustained for ≥ 2 calendar days
OR 2. Increase in daily minimum PEEP values of ≥ 3 cmHO over the daily minimum PEEP in the baseline period, sustained for ≥ 2 calendar days.
AND
VAC
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets BOTH of the following criteria: *See Appendix for eligible agents.
1) Temperature > 38 °C or < 36 °C , OR white blood cell count ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³. AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days.
AND
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met:
*Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeasts not otherwise specified • Coagulase-Negative Staphylococcus species • Enterococcus species
Tier 3: Possible VAP Patient meets criteria for VAC and IVAC
1) Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi, or trachea that contain ≥ 25
neutrophils and ≤ 10 squamous epithelial cells per low power field (lpf, x100) • If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds. OR
2) Positive culture (qualitative, semi-quantitative) or sputum* endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing*
AND
VAC, IVAC plus the following …
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 1) Purulent respiratory secretions (from one or more specimen collections—and
defined as for possible VAP)
AND one of the following (see Table 2): • Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or equivalent semi-
quantitative result • Positive culture of bronchoalveolar lavage*, 10 CFU/ml or equivalent semi-
quantitative result • Positive culture of lung tissue, 10 CFU/g or equivalent semi-quantitative
result • Positive culture of protected specimen brush*, 10³ CFU/ml or equivalent
semi-quantitative result
2) One of the following (without requirement for purulent respiratory secretions):
• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)
• Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus,
repiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
Do I have to use the entire algorithm? Can I decide to conduct surveillance only for IVAC, for example? Conducting in-plan VAE surveillance in 2013 requires
assessing patients for ALL events: VAC IVAC Possible or Probable VAP
Hierarchy of definitions: If a patient meets criteria for VAC and IVAC, report as IVAC. If a patient meets criteria for VAC, IVAC and Possible VAP, report
Possible VAP. If a patient meets criteria for VAC, IVAC and Probably VAP, report
Probable VAP. If a patient meets criteria for VAC, IVAC, Possible VAP and Probable
VAP, report Probable VAP.
HOW TO PREPARE FOR AND CONDUCT VAE SURVEILLANCE, AND KEY TERMS
Example: Operationalizing VAE
Org
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Ventilator Definition Ventilator is defined as a device to assist or control
respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation Intermittent positive-pressure breathing (IPPB); nasal positive end-
expiratory pressure (nasal PEEP); and continuous nasal positive airway pressure (CPAP, hypoCPAP) are not considered ventilators unless delivered via tracheostomy or endotracheal intubation (e.g., ET-CPAP)
No change from current NHSN ventilator definition
Episode of Mechanical Ventilation A period of days during which the patient was
mechanically ventilated for some portion of each consecutive day.
A break in mechanical ventilation of at least one full calendar day followed by reintubation and reinitiation of mechanical ventilation during the same hospitalization is a new episode.
What the PEEP!? =Positive End-Expiratory Pressure Most ventilators used today are positive-pressure, which
means there is a pressure gradient created in order for gas to flow into the lungs; this occurs naturally when you breathe
The vent can apply pressure during exhalation phase, which limits the lung’s ability to empty completely
This process increases FRC or functional residual pressure, which increases the mean airway pressure in you lungs….this process is called PEEP!
PEEP keeps alveoli open longer thus allowing for better oxygenation
22
What is FiO2 (Fraction of Inspired Oxygen)? The fraction of oxygen in inspired gas
For example, the FiO of ambient air is 0.21; the oxygen concentration of ambient air is 21%.
Inpatients on mechanical ventilation, the FiO is one of the key parameters that can be adjusted depending on the patient’s oxygenation needs
$#@^&% PEEP vs. FiO2 Oxygen can be toxic at certain levels and thus FiO2 is
rarely above 60% Raising PEEP allows better oxygenation and may then
allow FiO2 to be reduced PEEP is generally applied in increments of 2.5 cm up to
about 15.
24
After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation:
Tier 1: VAC Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO.
1) Increase in daily minimum FiO of ≥ 0.20 (20 points) over the daily minimum FiO in the baseline period, sustained for ≥ 2 calendar days.
2) Increase in daily minimum PEEP values of ≥ 3 cmHO over the daily minimum PEEP in the baseline period, sustained for ≥ 2 calendar days.
AND
Vent Day
PEEP min
1 10 60
2 5 40
3 5 40
4 8 60
5 8 50
6 7 40
7 5 40
8 5 40
2-day period of worsening, based on PEEP (≥3 cmH2O) or FiO (≥20 points)
Vent Day
PEEP min
= VAC
Not a VAC because a rise in PEEP is relative to BOTH baseline days. In this example, 8 is only 2 points above 6 even though its three points above five
Anticipated Problem Weaning!....or better yet, weaning failure When weaning a patient on vent, FiO2 may start at
80% then be lowered to 40%..... ….if patient does not tolerate this setting, then FiO2
returned to 80%....same for day #2 ….therefore for 2 days minimum is 40% and if next day
Fio2 returned to 80%..... ….then it would be VAC
32
Date of Event / Event Date The date of onset of worsening oxygenation (day 1 of the
required ≥ 2 day period or worsening oxygenation).
It is not the date in which all VAE criteria are met.
Vent Day
PEEP min
1 10 60
2 5 40
3 5 40
4 8 60
5 8 50
6 7 40
7 5 40
8 5 40
Event Date = Vent Day 4 (first day of worsening oxygenation 4
Why is the Event Date important? Defining the “VAE Window Period”
Period during which criteria for other events—IVAC, Possible, Probably VAP—must be met
Detecting multiple VAEs in the same patient Each VAE is 14 days in duration (arbitrary—to standardize). Day 1 is the Event Date—so if April 1 is date of onset of worsening
oxygenation and a VAC is reported, a second VAE cannot be detected and reported until April 15.
May not “upgrade” a VAE based on data collected outside the VAE Window Period but within the 14-day event period.
May not report a new VAE until that 14 day period has elapsed (keep in mind that 14 day period is event date to event date—so baseline period can occur during previous event period).
VAE Window Period This is the period of days around the event date (i.e.,
the day of onset of worsening oxygenation) within which other VAE criteria must be met.
It is usually a 5-day period …….and includes the 2 days before, …….the day of the VAE event (i.e., the first day of
worsening oxygenation, the day of VAE onset), and …….the 2 days after the VAE event date
VAE Window Period
MV Day No. 10 11 12 13 14 15 16 VAE Day -3 -2 -1 1 2 3 4
Worsening Oxygenation
Day 1 of worsening oxygena- tion
Day 2 of worsening oxygena- tion
Temperature or WBC abnormality
Antimicrobial agent
←Started on within this shaded period, and then continued for at least 4 days→
Purulent respiratory secretions, positive culture, positive histopathology
←Collected within this shaded period→
2 days before Event Date
2 days after Event Date Event Date
Infection-related Ventilator-Associated Complication (IVAC)
Patient meets criteria for VAC
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: *See Appendix for eligible agents.
1) Temperature > 38 °C or < 36 °C , OR white blood cell count ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³ AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days
AND
7 5 40
8 5 40
Look for abnormal temp or white count during VAE Window Period
NOTE: Look for MULTIPLE Temp/WBC readings per day and
record the MIN / MAX!!
Infection-related Ventilator-Associated Complication (IVAC)
Patient meets criteria for VAC
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: *See Appendix for eligible agents.
1) Temperature > 38 °C or < 36 °C , OR white blood cell count ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³ AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days
AND
IVAC Antimicrobial Criterion Probably the most complicated portion of the VAE
surveillance definition algorithm Rules for meeting this criterion are not perfect—but
we need a standardized method for assessment of antimicrobial therapy, without needing knowledge of dosing, renal function, indication for therapy, etc.
Figuring out if a “new” antimicrobial agent(s) has been given New antimicrobial agent: Defined as any agent listed in the
protocol Appendix that is initiated on or after the third calendar day of mechanical ventilation AND in the VAE Window Period (i.e., the period typically defined by the 2 calendar days before, the day of, and the 2 calendar days after the onset date of the VAE). The agent is considered new for the purposes of this definition if it was
NOT given to the patient on either of the 2 days preceding the current start date.
A new agent must be continued for ≥ 4 consecutive days. There is no requirement that the same antimicrobial agent be given on
the 4 consecutive days. New agent must be administered IV, IM, via digestive tract or via
respiratory tract
What antimicrobial drugs are in the Appendix? Go to page 20 of the protocol. Broad range of agents that could be used to treat
healthcare-assiciated infections—mostly antibacterials, antifungals, limited antivirals Including agents that are not used to treat respiratory infections
(e.g., oral vancomycin, fidaxomicin) To emphasize that an “IVAC” does not mean that the “infection
related” event is respiratory in origin
Drugs that are not included = anti-HIV agents, anti-TB agents, agents used to treat viral hepatitis, agents used to treat herpes virus infections, anti-parasitics
Figuring out if ≥ 4 days of therapy have been given: Qualifiying Antimicrobial Days (QAD)
A day on which the patient was administered an antimicrobial agent that was determined to be “new” within the VAE Window Period.
Four consecutive QADs are needed to meet the IVAC antimicrobial criterion—starting within the VAE Window Period.
QADs: Same Agent Days between administrations of a new antimicrobial
agent also count as QADs as long as there is a gap of no more than 1 calendar day between administrations of the same drug. For example, if levofloxacin is given on VAE Day 1, has not been given in the 2 preceding calendar days, and is given again on VAE Days 3, 5, and 7, there are 7 QADs—because the days between levofloxacin does also count as QADs.
VAE Day
Abx #1 -- -- Levo -- Levo -- Levo -- Levo
QAD -- -- Yes Yes Yes Yes Yes Yes Yes
Same agent, given every other day = 7 consecutive QADs
QADs: Different Agents By contrast, days between administrations of different
antimicrobial agents do NOT count as QADs For example, if levofloxacin is given to the patient on VAE Days -2
and – 1 only, no antimicrobials are given on VAE Day 1, and meropenem is given only on VAE Day 2 (remember there is no VAE Day 0), then there are not 4 consecutive QADs. VAE Days -2 and -1 count as 2 consecutive QADs, but VAE Day 1 cannot be counted as a QAD because it is a day between different antimicrobial agents.
VAE Day
Abx #1 -- -- Levo Levo -- -- -- -- --
Different agents, with gap between agents: only 2 consecutive QADs
Vent Day
PEEP min
7 5 40 Yes
8 5 40 Yes
=IVAC
Possible VAP
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: *Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or years not otherwise specified • Coagulase-Negative Staphylococcus species • Enterococcus species
Patient meets criteria for VAC and IVAC
1) Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi, or trachea that contain ≥ 25
neutrophils and ≤ 10 squamous epithelial cells per low power field (lpf, x100) • If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds. 2) Positive culture (qualitative, semi-quantitative) or sputum* endotracheal aspirate*,
bronchoalveolar lavage*, lung tissue, or protected specimen brushing*
AND
Probable VAP VAC, IVAC plus the following…
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 1) Purulent respiratory secretions (from one or more specimen collections—and
defined as for possible VAP)
AND one of the following (see Table 2): • Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or equivalent
semi-quantitative result • Positive culture of bronchoalveolar lavage*, 10 CFU/ml or equivalent
semi-quantitative result • Positive culture of lung tissue, 10 CFU/g or equivalent semi-quantitative
result • Positive culture of protected specimen brush*, 10³ CFU/ml or equivalent
semi-quantitative result
*Same organism exclusions as noted for Possible VAP. 2) One of the following (without requirement for purulent respiratory secretions):
• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)
• Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus,
respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
Purulent Respiratory Secretions Look at Micro Gram Stain results: Gram stain polymorphonuclear leukocyte (“polys”,
“PMN”, neutrophil) counts and squamous epithelial cell counts
Prob VAP/Poss VAP are essentially defined by LOW tissue cells and HIGH neutrophils
How do I relate my lab’s semi-quantitative Gram stain reporting to the quantitative threshold is the algorithm? Ask your laboratory manager/director first—he/she may be able
to tell you If your laboratory does not have this information, use the
following guidance* … 1+ = occasional or rare = <1 cell per low power field (lpf) 2+ = few = 1-9 cells per lpf 3+ =moderate = 10-25 cells per lpf 4+ = heavy = >25 cells per lpf
This means that in the absence of information from your lab, “purulent respiratory secretions” are defined by “heavy” 4+ or ≥25 neutrophils per low power field AND “rare”, “occasional”, “few”, 1+ or 2+, or ≤ 10 squamous epithelial cells per lpf
This is preliminary! Please make sure to review the protocol in 2013 for updates
*Reference: Garcia, LS (Ed.). (2010). Clinical Microbiology Procedures Handbook. Herndon, VA: ASM Press, page 3.2.1.16.
Lower Respiratory Culture Results
Appropriate specimen types include: Sputum, endotracheal aspirate, bronchoalveolar lavage, protected
specimen brushings, lung tissue, pleural fluid Exclude the following as a pathogen unless isolated
from lung tissue or pleural fluid Candida species or yeast not otherwise specified Coagulase negative Staphylococcus species Enterococcus species
Exclude the following culture results (or similar) …
Normal respiratory flora / Normal oral flora Mixed respiratory flora / Mixed oral flora Altered oral / respiratory flora
Positive Culture Result Reporting
Histopathology (Lung) Results Identification of abscess formation or foci of
consolidation with intense neutrophil accumulation in bronchioles and alveoli
Evidence of lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms)
Evidence of infection with viral pathogens (immunohistochemical assays, cytology, microscopy)
Vent Day
PEEP min
1 10 60 None
2 5 40 None
3 5 40 36.9 37.6 12.1 12.1 None ETA >25/ <10
Staph aureus
7 5 40 Yes
Purulent respiratory secretions OR ETA culture positive for S. aureus
= Possible VAP
Probable VAP VAC, IVAC plus the following…
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 1) Purulent respiratory secretions (from one or more specimen collections—and
defined as for possible VAP) AND one of the following (see Table 2):
• Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or equivalent semi-quantitative result
• Positive culture of bronchoalveolar lavage*, 10 CFU/ml or equivalent semi-quantitative result
• Positive culture of lung tissue, 10 CFU/g or equivalent semi-quantitative result
• Positive culture of protected specimen brush*, 10³ CFU/ml or equivalent semi-quantitative result
*Same organism exclusions as noted for Possible VAP. 2) One of the following (without requirement for purulent respiratory secretions):
• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)
• Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus,
repiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
Vent Day
PEEP min
1 10 60 None
2 5 40 None
3 5 40 36.9 37.6 12.1 12.1 None ETA ≥25/ ≤10
10 cfu/ml S. aureus
4 8 60 38.1 39.2 14.5 16.8 Yes -- -- --
5 8 50 38.4 38.9 12.6 15.9 Yes -- -- --
6 7 40 36.5 37.8 11.1 13.6 Yes -- -- --
7 5 40 Yes
= Probable VAP
Vent Day
PEEP min
3 5 40 36.9 37.6 12.1 12.1 None Pleural Fluid
Staph aureus
7 5 40 Yes
Positive pleural fluid, lung histopathology, Legionella or viral test result
= Probable VAP
VAE Calculator
Summary VAE Patient must be ventilated more than 2 calendar days Patient must have ≥2 calendar days of stability or improvement of
oxygenation followed by ≥2 calendar days of worsening oxygenation Earliest date of event for VAE is mechanical ventilation day 3 (first
day of worsening oxygenation) First possible day that VAC criteria can be fulfilled is mechanical
ventilation day 4 VAC: stability + increase FiO2 OR PEEP (min/max) IVAC: VAC + fever/WBC (min/max) AND new antibiotic (4
consecutive QADs) Poss VAP: (VAC+IVAC) +purulent secretions (micro gram stains) OR
positive respiratory secretions Prob VAP: (VAC+IVAC) +purulent secretions (micro gram stains) AND
positive respiratory secretions OR pleural fluid culture, etc. w/o purulent secretions
Plan for Tackling VAE Read CDC/NHSN protocol Identify your population Create VAE Team
Information Technology Infection Prevention Pulmonary Medicine Critical Care Nursing Respiratory Therapy Pharmacy
Create VAE EMR Test Result Report via IT Educate care providers Understand microbiology and test interpretations Understand antibiotics and QADs Use VAE Team or key members for review of suspect cases
63
Improving Surveillance for Ventilator Associated Events in Adults
The New VAE Algorithm
Who is eligible for VAE surveillance?
When will VAE surveillance be available in NHSN, and what is happening to PNEU/VAP?
“WHAT” IS VAE? REVIEW OF DEFINITIONS
VAE Definition Algorithm Summary
VAE Definition Algorithm Summary
VAE Definition Algorithm Summary
VAE Definition Algorithm Summary
Tier 3: Possible VAP
Tier 3: Probable VAP
Do I have to use the entire algorithm? Can I decide to conduct surveillance only for IVAC, for example?
HOW TO PREPARE FOR AND CONDUCT VAE SURVEILLANCE, AND KEY TERMS
Example: Operationalizing VAE
$#@^&% PEEP vs. FiO2
Tier 1: VAC
Example: Operationalizing VAE
Slide Number 34
VAE Window Period
VAE Window Period
Figuring out if a “new” antimicrobial agent(s) has been given
What antimicrobial drugs are in the Appendix?
Figuring out if ≥ 4 days of therapy have been given: Qualifiying Antimicrobial Days (QAD)
QADs: Same Agent
QADs: Different Agents
Slide Number 47
Purulent Respiratory Secretions
How do I relate my lab’s semi-quantitative Gram stain reporting to the quantitative threshold is the algorithm?
Lower Respiratory Culture Results
Positive Culture Result Reporting
NHSN, Clinical Pulmonary Infection Score, European surveillance definitions, etc.) all use combinations of criteria:
Chest x-ray Clinical signs/symptoms
Microbiological evidence
References include but are not limited to the following: ¹Wunderink R, et al., Chest 1992;101;458-63; ²Young M, et al., Arch Intern Med 1994;154:2729-32; ³Fabregas N, et al., Thorax 1999;54:867-73; Kirtland SH, et al., Chest 1997;112:445-57; Berton DC, et al., Cochrane Database Syst Rev 2008; Ruiz , et al., Am J Respir Crit Care Med 2000;162:119-25.
• Lack specificity for VAP¹ • Interobserver variability² • Not within purview of IP
expertise
• Lack sensitivity and specificity³ • Some are highly subjective • Documentation varies
• Lack sensitivity and specificity • Practices vary among providers • Controversy about best
practices
New Definition Detects complications and
conditions including, but not limited to VAP
Requires a minimum period of time on ventilator
Focuses on readily available, objective, clinical date
Does not include chest radiograph findings
The goal for implementation in NHSN (National Healthcare Safety Network) is January 2013.
3
The New VAE Algorithm It is a surveillance algorithm and is not intended for use in
the clinical management of patients There are 3 Tiers of the new VAE definition
Tier 1: Ventilator-Associated Conditions
Tier 2: Infection-Related Ventilator-Associated Complications These tiers were developed to be appropriate for the potential future uses of public reporting and pay-for –performance programs.
Tier 3: Possible and Probable VAP This tier was developed for healthcare facilities to use in internal quality improvement efforts.
4
THE “WHO” AND “WHEN” OF VAE SURVEILLANCE
Who is eligible for VAE surveillance? Patients on mechanical ventilation who are…
….≥ 18 years of age, and are….
…. Inpatients of acute care hospitals, long term acute
care hospitals, inpatient rehabilitation facilities
(some forms of ventilation are excluded, see NHSN documents)
When will VAE surveillance be available in NHSN, and what is happening to PNEU/VAP? VAE available January 2013. In 2013, current VAP protocol will still be used for
neonatal and pediatric patients ONLY. Pediatric and Neonatal VAE Surveillance Definition Working Group
kick-off meeting held on September 6, 2012.
In 2013, the current PNEU definitions will still be available for off-plan surveillance of VAP in adults or non-ventilated PNEU in adults or children.
“WHAT” IS VAE? REVIEW OF DEFINITIONS
***Note that these are NOT clinical definitions and are not intended for use in the management of patients. ***
VAE Definition Algorithm Summary
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Fever or WBC and
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
Possible or Probable VAP
Purulent secretions and/or other
positive laboratory evidence
Tier 1: VAC Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO.
After a period of stability or improvement on the ventilator, the patient has at least ONE of the following indicators of worsening oxygenation:
1. Increase in daily minimum FiO of ≥ 0.20 (20 points) over the daily minimum FiO in the baseline period, sustained for ≥ 2 calendar days
OR 2. Increase in daily minimum PEEP values of ≥ 3 cmHO over the daily minimum PEEP in the baseline period, sustained for ≥ 2 calendar days.
AND
VAC
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets BOTH of the following criteria: *See Appendix for eligible agents.
1) Temperature > 38 °C or < 36 °C , OR white blood cell count ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³. AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days.
AND
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met:
*Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeasts not otherwise specified • Coagulase-Negative Staphylococcus species • Enterococcus species
Tier 3: Possible VAP Patient meets criteria for VAC and IVAC
1) Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi, or trachea that contain ≥ 25
neutrophils and ≤ 10 squamous epithelial cells per low power field (lpf, x100) • If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds. OR
2) Positive culture (qualitative, semi-quantitative) or sputum* endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing*
AND
VAC, IVAC plus the following …
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 1) Purulent respiratory secretions (from one or more specimen collections—and
defined as for possible VAP)
AND one of the following (see Table 2): • Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or equivalent semi-
quantitative result • Positive culture of bronchoalveolar lavage*, 10 CFU/ml or equivalent semi-
quantitative result • Positive culture of lung tissue, 10 CFU/g or equivalent semi-quantitative
result • Positive culture of protected specimen brush*, 10³ CFU/ml or equivalent
semi-quantitative result
2) One of the following (without requirement for purulent respiratory secretions):
• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)
• Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus,
repiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
Do I have to use the entire algorithm? Can I decide to conduct surveillance only for IVAC, for example? Conducting in-plan VAE surveillance in 2013 requires
assessing patients for ALL events: VAC IVAC Possible or Probable VAP
Hierarchy of definitions: If a patient meets criteria for VAC and IVAC, report as IVAC. If a patient meets criteria for VAC, IVAC and Possible VAP, report
Possible VAP. If a patient meets criteria for VAC, IVAC and Probably VAP, report
Probable VAP. If a patient meets criteria for VAC, IVAC, Possible VAP and Probable
VAP, report Probable VAP.
HOW TO PREPARE FOR AND CONDUCT VAE SURVEILLANCE, AND KEY TERMS
Example: Operationalizing VAE
Org
1
2
3
4
5
6
7
8
Ventilator Definition Ventilator is defined as a device to assist or control
respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation Intermittent positive-pressure breathing (IPPB); nasal positive end-
expiratory pressure (nasal PEEP); and continuous nasal positive airway pressure (CPAP, hypoCPAP) are not considered ventilators unless delivered via tracheostomy or endotracheal intubation (e.g., ET-CPAP)
No change from current NHSN ventilator definition
Episode of Mechanical Ventilation A period of days during which the patient was
mechanically ventilated for some portion of each consecutive day.
A break in mechanical ventilation of at least one full calendar day followed by reintubation and reinitiation of mechanical ventilation during the same hospitalization is a new episode.
What the PEEP!? =Positive End-Expiratory Pressure Most ventilators used today are positive-pressure, which
means there is a pressure gradient created in order for gas to flow into the lungs; this occurs naturally when you breathe
The vent can apply pressure during exhalation phase, which limits the lung’s ability to empty completely
This process increases FRC or functional residual pressure, which increases the mean airway pressure in you lungs….this process is called PEEP!
PEEP keeps alveoli open longer thus allowing for better oxygenation
22
What is FiO2 (Fraction of Inspired Oxygen)? The fraction of oxygen in inspired gas
For example, the FiO of ambient air is 0.21; the oxygen concentration of ambient air is 21%.
Inpatients on mechanical ventilation, the FiO is one of the key parameters that can be adjusted depending on the patient’s oxygenation needs
$#@^&% PEEP vs. FiO2 Oxygen can be toxic at certain levels and thus FiO2 is
rarely above 60% Raising PEEP allows better oxygenation and may then
allow FiO2 to be reduced PEEP is generally applied in increments of 2.5 cm up to
about 15.
24
After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation:
Tier 1: VAC Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO.
1) Increase in daily minimum FiO of ≥ 0.20 (20 points) over the daily minimum FiO in the baseline period, sustained for ≥ 2 calendar days.
2) Increase in daily minimum PEEP values of ≥ 3 cmHO over the daily minimum PEEP in the baseline period, sustained for ≥ 2 calendar days.
AND
Vent Day
PEEP min
1 10 60
2 5 40
3 5 40
4 8 60
5 8 50
6 7 40
7 5 40
8 5 40
2-day period of worsening, based on PEEP (≥3 cmH2O) or FiO (≥20 points)
Vent Day
PEEP min
= VAC
Not a VAC because a rise in PEEP is relative to BOTH baseline days. In this example, 8 is only 2 points above 6 even though its three points above five
Anticipated Problem Weaning!....or better yet, weaning failure When weaning a patient on vent, FiO2 may start at
80% then be lowered to 40%..... ….if patient does not tolerate this setting, then FiO2
returned to 80%....same for day #2 ….therefore for 2 days minimum is 40% and if next day
Fio2 returned to 80%..... ….then it would be VAC
32
Date of Event / Event Date The date of onset of worsening oxygenation (day 1 of the
required ≥ 2 day period or worsening oxygenation).
It is not the date in which all VAE criteria are met.
Vent Day
PEEP min
1 10 60
2 5 40
3 5 40
4 8 60
5 8 50
6 7 40
7 5 40
8 5 40
Event Date = Vent Day 4 (first day of worsening oxygenation 4
Why is the Event Date important? Defining the “VAE Window Period”
Period during which criteria for other events—IVAC, Possible, Probably VAP—must be met
Detecting multiple VAEs in the same patient Each VAE is 14 days in duration (arbitrary—to standardize). Day 1 is the Event Date—so if April 1 is date of onset of worsening
oxygenation and a VAC is reported, a second VAE cannot be detected and reported until April 15.
May not “upgrade” a VAE based on data collected outside the VAE Window Period but within the 14-day event period.
May not report a new VAE until that 14 day period has elapsed (keep in mind that 14 day period is event date to event date—so baseline period can occur during previous event period).
VAE Window Period This is the period of days around the event date (i.e.,
the day of onset of worsening oxygenation) within which other VAE criteria must be met.
It is usually a 5-day period …….and includes the 2 days before, …….the day of the VAE event (i.e., the first day of
worsening oxygenation, the day of VAE onset), and …….the 2 days after the VAE event date
VAE Window Period
MV Day No. 10 11 12 13 14 15 16 VAE Day -3 -2 -1 1 2 3 4
Worsening Oxygenation
Day 1 of worsening oxygena- tion
Day 2 of worsening oxygena- tion
Temperature or WBC abnormality
Antimicrobial agent
←Started on within this shaded period, and then continued for at least 4 days→
Purulent respiratory secretions, positive culture, positive histopathology
←Collected within this shaded period→
2 days before Event Date
2 days after Event Date Event Date
Infection-related Ventilator-Associated Complication (IVAC)
Patient meets criteria for VAC
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: *See Appendix for eligible agents.
1) Temperature > 38 °C or < 36 °C , OR white blood cell count ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³ AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days
AND
7 5 40
8 5 40
Look for abnormal temp or white count during VAE Window Period
NOTE: Look for MULTIPLE Temp/WBC readings per day and
record the MIN / MAX!!
Infection-related Ventilator-Associated Complication (IVAC)
Patient meets criteria for VAC
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: *See Appendix for eligible agents.
1) Temperature > 38 °C or < 36 °C , OR white blood cell count ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³ AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days
AND
IVAC Antimicrobial Criterion Probably the most complicated portion of the VAE
surveillance definition algorithm Rules for meeting this criterion are not perfect—but
we need a standardized method for assessment of antimicrobial therapy, without needing knowledge of dosing, renal function, indication for therapy, etc.
Figuring out if a “new” antimicrobial agent(s) has been given New antimicrobial agent: Defined as any agent listed in the
protocol Appendix that is initiated on or after the third calendar day of mechanical ventilation AND in the VAE Window Period (i.e., the period typically defined by the 2 calendar days before, the day of, and the 2 calendar days after the onset date of the VAE). The agent is considered new for the purposes of this definition if it was
NOT given to the patient on either of the 2 days preceding the current start date.
A new agent must be continued for ≥ 4 consecutive days. There is no requirement that the same antimicrobial agent be given on
the 4 consecutive days. New agent must be administered IV, IM, via digestive tract or via
respiratory tract
What antimicrobial drugs are in the Appendix? Go to page 20 of the protocol. Broad range of agents that could be used to treat
healthcare-assiciated infections—mostly antibacterials, antifungals, limited antivirals Including agents that are not used to treat respiratory infections
(e.g., oral vancomycin, fidaxomicin) To emphasize that an “IVAC” does not mean that the “infection
related” event is respiratory in origin
Drugs that are not included = anti-HIV agents, anti-TB agents, agents used to treat viral hepatitis, agents used to treat herpes virus infections, anti-parasitics
Figuring out if ≥ 4 days of therapy have been given: Qualifiying Antimicrobial Days (QAD)
A day on which the patient was administered an antimicrobial agent that was determined to be “new” within the VAE Window Period.
Four consecutive QADs are needed to meet the IVAC antimicrobial criterion—starting within the VAE Window Period.
QADs: Same Agent Days between administrations of a new antimicrobial
agent also count as QADs as long as there is a gap of no more than 1 calendar day between administrations of the same drug. For example, if levofloxacin is given on VAE Day 1, has not been given in the 2 preceding calendar days, and is given again on VAE Days 3, 5, and 7, there are 7 QADs—because the days between levofloxacin does also count as QADs.
VAE Day
Abx #1 -- -- Levo -- Levo -- Levo -- Levo
QAD -- -- Yes Yes Yes Yes Yes Yes Yes
Same agent, given every other day = 7 consecutive QADs
QADs: Different Agents By contrast, days between administrations of different
antimicrobial agents do NOT count as QADs For example, if levofloxacin is given to the patient on VAE Days -2
and – 1 only, no antimicrobials are given on VAE Day 1, and meropenem is given only on VAE Day 2 (remember there is no VAE Day 0), then there are not 4 consecutive QADs. VAE Days -2 and -1 count as 2 consecutive QADs, but VAE Day 1 cannot be counted as a QAD because it is a day between different antimicrobial agents.
VAE Day
Abx #1 -- -- Levo Levo -- -- -- -- --
Different agents, with gap between agents: only 2 consecutive QADs
Vent Day
PEEP min
7 5 40 Yes
8 5 40 Yes
=IVAC
Possible VAP
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: *Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or years not otherwise specified • Coagulase-Negative Staphylococcus species • Enterococcus species
Patient meets criteria for VAC and IVAC
1) Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi, or trachea that contain ≥ 25
neutrophils and ≤ 10 squamous epithelial cells per low power field (lpf, x100) • If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds. 2) Positive culture (qualitative, semi-quantitative) or sputum* endotracheal aspirate*,
bronchoalveolar lavage*, lung tissue, or protected specimen brushing*
AND
Probable VAP VAC, IVAC plus the following…
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 1) Purulent respiratory secretions (from one or more specimen collections—and
defined as for possible VAP)
AND one of the following (see Table 2): • Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or equivalent
semi-quantitative result • Positive culture of bronchoalveolar lavage*, 10 CFU/ml or equivalent
semi-quantitative result • Positive culture of lung tissue, 10 CFU/g or equivalent semi-quantitative
result • Positive culture of protected specimen brush*, 10³ CFU/ml or equivalent
semi-quantitative result
*Same organism exclusions as noted for Possible VAP. 2) One of the following (without requirement for purulent respiratory secretions):
• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)
• Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus,
respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
Purulent Respiratory Secretions Look at Micro Gram Stain results: Gram stain polymorphonuclear leukocyte (“polys”,
“PMN”, neutrophil) counts and squamous epithelial cell counts
Prob VAP/Poss VAP are essentially defined by LOW tissue cells and HIGH neutrophils
How do I relate my lab’s semi-quantitative Gram stain reporting to the quantitative threshold is the algorithm? Ask your laboratory manager/director first—he/she may be able
to tell you If your laboratory does not have this information, use the
following guidance* … 1+ = occasional or rare = <1 cell per low power field (lpf) 2+ = few = 1-9 cells per lpf 3+ =moderate = 10-25 cells per lpf 4+ = heavy = >25 cells per lpf
This means that in the absence of information from your lab, “purulent respiratory secretions” are defined by “heavy” 4+ or ≥25 neutrophils per low power field AND “rare”, “occasional”, “few”, 1+ or 2+, or ≤ 10 squamous epithelial cells per lpf
This is preliminary! Please make sure to review the protocol in 2013 for updates
*Reference: Garcia, LS (Ed.). (2010). Clinical Microbiology Procedures Handbook. Herndon, VA: ASM Press, page 3.2.1.16.
Lower Respiratory Culture Results
Appropriate specimen types include: Sputum, endotracheal aspirate, bronchoalveolar lavage, protected
specimen brushings, lung tissue, pleural fluid Exclude the following as a pathogen unless isolated
from lung tissue or pleural fluid Candida species or yeast not otherwise specified Coagulase negative Staphylococcus species Enterococcus species
Exclude the following culture results (or similar) …
Normal respiratory flora / Normal oral flora Mixed respiratory flora / Mixed oral flora Altered oral / respiratory flora
Positive Culture Result Reporting
Histopathology (Lung) Results Identification of abscess formation or foci of
consolidation with intense neutrophil accumulation in bronchioles and alveoli
Evidence of lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms)
Evidence of infection with viral pathogens (immunohistochemical assays, cytology, microscopy)
Vent Day
PEEP min
1 10 60 None
2 5 40 None
3 5 40 36.9 37.6 12.1 12.1 None ETA >25/ <10
Staph aureus
7 5 40 Yes
Purulent respiratory secretions OR ETA culture positive for S. aureus
= Possible VAP
Probable VAP VAC, IVAC plus the following…
On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 1) Purulent respiratory secretions (from one or more specimen collections—and
defined as for possible VAP) AND one of the following (see Table 2):
• Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or equivalent semi-quantitative result
• Positive culture of bronchoalveolar lavage*, 10 CFU/ml or equivalent semi-quantitative result
• Positive culture of lung tissue, 10 CFU/g or equivalent semi-quantitative result
• Positive culture of protected specimen brush*, 10³ CFU/ml or equivalent semi-quantitative result
*Same organism exclusions as noted for Possible VAP. 2) One of the following (without requirement for purulent respiratory secretions):
• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)
• Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus,
repiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
Vent Day
PEEP min
1 10 60 None
2 5 40 None
3 5 40 36.9 37.6 12.1 12.1 None ETA ≥25/ ≤10
10 cfu/ml S. aureus
4 8 60 38.1 39.2 14.5 16.8 Yes -- -- --
5 8 50 38.4 38.9 12.6 15.9 Yes -- -- --
6 7 40 36.5 37.8 11.1 13.6 Yes -- -- --
7 5 40 Yes
= Probable VAP
Vent Day
PEEP min
3 5 40 36.9 37.6 12.1 12.1 None Pleural Fluid
Staph aureus
7 5 40 Yes
Positive pleural fluid, lung histopathology, Legionella or viral test result
= Probable VAP
VAE Calculator
Summary VAE Patient must be ventilated more than 2 calendar days Patient must have ≥2 calendar days of stability or improvement of
oxygenation followed by ≥2 calendar days of worsening oxygenation Earliest date of event for VAE is mechanical ventilation day 3 (first
day of worsening oxygenation) First possible day that VAC criteria can be fulfilled is mechanical
ventilation day 4 VAC: stability + increase FiO2 OR PEEP (min/max) IVAC: VAC + fever/WBC (min/max) AND new antibiotic (4
consecutive QADs) Poss VAP: (VAC+IVAC) +purulent secretions (micro gram stains) OR
positive respiratory secretions Prob VAP: (VAC+IVAC) +purulent secretions (micro gram stains) AND
positive respiratory secretions OR pleural fluid culture, etc. w/o purulent secretions
Plan for Tackling VAE Read CDC/NHSN protocol Identify your population Create VAE Team
Information Technology Infection Prevention Pulmonary Medicine Critical Care Nursing Respiratory Therapy Pharmacy
Create VAE EMR Test Result Report via IT Educate care providers Understand microbiology and test interpretations Understand antibiotics and QADs Use VAE Team or key members for review of suspect cases
63
Improving Surveillance for Ventilator Associated Events in Adults
The New VAE Algorithm
Who is eligible for VAE surveillance?
When will VAE surveillance be available in NHSN, and what is happening to PNEU/VAP?
“WHAT” IS VAE? REVIEW OF DEFINITIONS
VAE Definition Algorithm Summary
VAE Definition Algorithm Summary
VAE Definition Algorithm Summary
VAE Definition Algorithm Summary
Tier 3: Possible VAP
Tier 3: Probable VAP
Do I have to use the entire algorithm? Can I decide to conduct surveillance only for IVAC, for example?
HOW TO PREPARE FOR AND CONDUCT VAE SURVEILLANCE, AND KEY TERMS
Example: Operationalizing VAE
$#@^&% PEEP vs. FiO2
Tier 1: VAC
Example: Operationalizing VAE
Slide Number 34
VAE Window Period
VAE Window Period
Figuring out if a “new” antimicrobial agent(s) has been given
What antimicrobial drugs are in the Appendix?
Figuring out if ≥ 4 days of therapy have been given: Qualifiying Antimicrobial Days (QAD)
QADs: Same Agent
QADs: Different Agents
Slide Number 47
Purulent Respiratory Secretions
How do I relate my lab’s semi-quantitative Gram stain reporting to the quantitative threshold is the algorithm?
Lower Respiratory Culture Results
Positive Culture Result Reporting