Jo Henman MPH,CIC

After attending presentation and completing case studies, attendees will be able to:

Apply new NHSN definitions to identify Ventilator Associated Events (VAE)

Create effective surveillance methods to detect VAE

Ventilator-associated penumonia Sepsis Acute Respiratory Distress Syndrome

(ARDS) Barotrauma Pulmonary edema

Longer time on the ventilator Longer hospitalization Increased healthcare costs Disability Mortality

24% in patient 15-1960% for patients >85

More than 300,000 patients are placed on ventilator assistance every year

NHSN data from 20101,700 facilities reported data (Compared to

over 3,000 for CLABSI)3,525 VAP cases reported Rates ranged from 0.0 – 5.8/1,000 patient

days

Research has shown that its not sensitive or specific

Major drawback is reliance on chest x-ray which is highly variable and subjective.

Also heavily relies on subjective clinical data which lowers validity

Standardized, objective definition for public reporting

Increased opportunities for prevention and improvement in care

Many proven efforts to improve outcomes aren’t specifically targeted to prevent infections

Only one outcome—either patient had VAP or didn’t

Several choices along pathway Ventilator Associated

Condition (VAC) Infection-Related

Ventilator Complication (IVAC)

Possible VAP Probable VAP

Designed for

public reporting and P4P

Designed for

internal QI

Started with chest x-ray

Unclear definitions on when something is hospital acquired

Subjective clinical symptoms (increased sputum production)

Starts with changes in ventilator requirements

Explicit timing definitions for inclusion in surveillance

Objective clinical criteria that is clearly defined

Eligible patients/wardsOnly for patients 18 and olderAcute care, long term acute care and

inpatient rehab facilities Excluded types of ventilation

High frequency ventilation (>60 breaths per minute with small tidal volumes)

Extracorporeal life supportNOTE: patients on airway pressure release

ventilation (APRV) those in the prone position and those receiving nitric oxide therapy should be included in surveillance

Date of Event: FIRST day that the worsening oxygenation threshold is met

VAE Window Period: The time period when all elements of a definition must be met. It usually includes the 2 days before and the 2 days after the date of event.

Episode of ventilation: Days when a patient is on a vent for some portion of each consecutive day. Patient must be off ventilator for one full calendar for new episode to begin.

Location of attribution- Where patient was at date of eventException – If date of event occurs on the

day of or day after transfer then the event is attributed to transferring location

Reporting – In 2013 MUST report all events in the VAE algorithm

Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2.

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 FiO2 of ≥ 0.20 (20 points) over the daily minimum FiO2 in the baseline period, sustained for ≥ 2 calendar days.

2) Increase in daily minimum PEEP values of ≥ 3 cmH2O over the daily minimum PEEP in the baseline period, sustained for ≥ 2 calendar days.

and

Ventilator Day FI02 PEEP

1 100% 8

2 50% 6

3 40% 5

4 40% 5

5 70% 6

6 70% 6

Ventilator Day FI02 PEEP

1 100% 8

2 50% 6

3 35% 5

4 40% 5

5 70% 6

6 70% 6

Is this case a VAC?

Why? PEEP was stable or declining on days 2 and 3, then increased by at least 3 on days 4 and 5.

Bonus: What was the Date of the Event?

Is this case a VAC?

Why? PEEP increased between day 2 and 3 so there wasn’t a 2 day period of stable or increasing ventilator requirements prior to them going up to 10.

And

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:

Ventilator Day FI02 PEEP

1 100% 8

2 50% 6

3 75% 5

4 75% 5

5 70% 6

6 70% 6

This is the VAE Window Period and all elements of definition must be met during this time period.

Ventilator Day FI02 PEEP

1 100% 8

2 50% 6

3 40% 5

4 35% 5

5 70% 6

6 70% 6

7 40% 5

And

A NEW antimicrobial that is contained in the NHSN Appendix that is given by IV, IM, Respiratory or Digestive tract route during the VAE Window Period.

NEW means an antimicrobial that wasn’t received in the previous 2 days and continues for 4 “qualifying antimicrobial days” (QAD’s)

A day when the patient received a new antimicrobial agent.

QAD’s must start within the VAE Window Period and continue for four consecutive days…..KIND OF! In NHSN world if the SAME antimicrobial is

given on days 1 and 3 that is considered consecutive and would count as THREE QAD’s. There can be no more than one calendar day between doses to count as consecutive.

Does this case meet the definition for IVAC?

Did your group come to the same conclusion? Lets review the details

Ventilator Day

4 5 6 7 8 9

VAC Criteria

Stable Stable Increased vent requirements

Increased vent requirements

Increased vent requirements

Stable

Temp 37.5 38.9 38.0 37.5 37.0 39.0

WBC 15.0 17.5 18.5 12.0 11.5 14.0

Antimicrobial Agent

Doxy Doxy Vancomycin None Vancomycin Doxy

Assume that “increased vent requirements” meet the VAC definition for worsening oxygenation

Does this case meet the definition for IVAC?

Did your team come up with the answer?

Ventilator Day

1 2 3 4 5 6

VAC Criteria Stable Stable Increased vent requirements

Increased vent requirements

Increased vent requirements

Stable

Temp 37.5 38.9 38.0 37.5 37.0 39.0

WBC 15.0 17.5 18.5 12.0 11.5 14.0

Antimicrobial Agent

Doxy Vancomycin

None Vancomycin None Vancomycin

Assume that “increased vent requirements” meet the VAC definition for worsening oxygenation

We have now traveled half way down the VAE Pathway!

Patient meets criteria for VAC and IVAC

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: 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 quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing*Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species

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)

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.>25 neutrophils = 4+ OR Heavy<10 epis = 1+ or 2+ OR Rare, Occasional or Few

Patient meets criteria for VAC and IVAC

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: 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 quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing*Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species

2) Positive culture (qualitative, semi-quantitative or quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing*Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species

NOTE:• Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species That is isolated from lung tissue or pleural fluid cultures may be reported and will count as meeting criteria for a possible VAP

Secondary BSIs may be reported for possible VAP given the following:At least one organism isolated from blood

cultures matches an isolate from the respiratory culture that was used to meet the possible VAP criteria

The blood culture was drawn during a 14 day event period, with the event date for VAC counting as day 1.

If no positive culture or only organisms that can’t be used to meet possible VAP criteria are isolated then a secondary BSI may not be reported.

Ventilator Day

4 5 6 7 8 9

VAC Criteria Stable Stable Increased vent requirements

Increased vent requirements

Increased vent requirements

Stable

Temp 37.5 38.9 38.0 37.5 37.0 39.0 WBC 15.0 17.5 18.5 12.0 11.5 14.0Antimicrobial Agent

Doxy Doxy Vancomycin None Vancomycin Doxy

Gram Stain Few EpiMany WbcMod GPCFew GNB

Sputum Culture

Heavy Coagulase Negative Staphylococcus

Does this meet criteria for possible VAPIf yes, which of the criteria does it meetIf the patient had a blood culture with coagulase negative Staphylococcus on Day 9 would this count as a secondary BSI?

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*, ≥ 105 CFU/ml or equivalent semi-

quantitative result • Positive culture of bronchoalveolar lavage*, ≥ 104 CFU/ml or equivalent semi-

quantitative result • Positive culture of lung tissue, ≥ 104 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. OR 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

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*, ≥ 105

CFU/ml or equivalent semi-quantitative result • Positive culture of bronchoalveolar lavage*, ≥ 104

CFU/ml or equivalent semi-quantitative result • Positive culture of lung tissue, ≥ 104 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. equivalent semi-quantitative result = 2+, 3+ or 4+ OR

Moderate or Heavy Growth

Ventilator Day

4 5 6 7 8 9

VAC Criteria Stable Stable Increased vent requirements

Increased vent requirements

Increased vent requirements

Stable

Temp 37.5 38.9 38.0 37.5 37.0 39.0 WBC 15.0 17.5 18.5 12.0 11.5 14.0Antimicrobial Agent

Doxy Doxy Vancomycin None Vancomycin Doxy

Gram Stain Many EpiMany WbcMod GPCFew GNB

Sputum Culture

Moderate growth of MRSA

Would this case meet the criteria for probable VAP?

OR 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

This section of the definition does NOT require that a gram stain meet the purulent criteria.Acceptable tests for Legionella include:Urinary antigenRespiratory culture4 fold rise in titer between acute and convalescent antibody tests

PCR done on respiratory specimensSpecial fluorescent and immunohistochemical stains

Acceptable tests for respiratory virus:PCRAntigen detectionViral cell culture4 fold rise in titer between acute and convalescent antibody testsNOTE: HSV and CMV infections are considered “re-activation” of a latent infection and would NOT be considered health-care acquired.

Now that you’ve learned the theory behind the new VAE surveillance definitions….here is the calculator instead of pencil and paper determination

Manual vs. Electronic Only need to look at patients who are on

the vent for at least 4 days Probably need to partner with RT and IS Can capture from electronic charting if

used Can be set up in IC software programs

to run initial algorithm if used

Patient A 9999999999 22222222 1/4/2013 1001/5/2013 50 -501/6/2013 50 01/7/2013 70 20 11/8/2013 60 -101/9/2013 50 -10

1/10/2013 40 -101/11/2013 50 101/12/2013 50 01/13/2013 40 -101/14/2013 40 01/15/2013 30 -101/16/2013 30 01/17/2013 30 01/18/2013 30 01/19/2013 30 01/20/2013 30 01/21/2013 30 01/22/2013 30 01/23/2013 30 01/24/2013 30 0

My Contact Information:

Jo Henman MPH,CIClhenman2@ohiohealth.com614-566-5793

1) Behrendt CE. Acute respiratory failure in the United States: incidence and 31-day survival. Chest 2000;118:1100-5.

2) Kahn JM, Goss CH, Heagerty PJ, et al. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 2006;355:41-50.

3) Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Crit Care Med 2010;38:1947-53.

4) Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med 2005;353:1685-93.

5) Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002;287:345-55.

6) Dudeck MA, Horan TC, et. al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2010, Device-associated Module. Available at http://www.cdc.gov/nhsn/PDFs/dataStat/NHSNReport_DataSummaryfor2010.pdf.

7) Klompas M. Does this patient have ventilator-associated pneumonia? JAMA 2007;297:1583-93.

8) Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control 2010;38:237-9.

9) Klompas M, Kulldorff M, Platt R. Risk of misleading ventilator-associated pneumonia rates with use of standard clinical and microbiological criteria. Clin Infect Dis 2008;46:1443-6.

NHSN VAE Definition Jan 2013. http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf.