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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 NHSN VAE Surveillance Definition Review Presented by: Kathleen Speck,

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Presentation on theme: "© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 NHSN VAE Surveillance Definition Review Presented by: Kathleen Speck,"— Presentation transcript:

1 © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 NHSN VAE Surveillance Definition Review Presented by: Kathleen Speck, MPH January 24, 2013 Armstrong Institute for Patient Safety and Quality

2 Learning Objectives While we are not using VAE surveillance - To become more comfortable with the new VAE surveillance definitions Armstrong Institute for Patient Safety and Quality 2

3 History of NHSN VAE Surveillance Definition Current NHSN VAP surveillance definition –Subjective Not sensitive or specific 1-3 Requires radiographic findings – often unclear Requires clinical signs and symptoms Doesn’t allow accurate validation of success of prevention strategies 4-7 Doesn’t allow establishment of valid benchmarks Armstrong Institute for Patient Safety and Quality 3 1.Klompas M, JAMA 2002 2.Klompas M, Am J Infect Control 2010 3.Klompas M, et al, Clin Infect Dis 2008 4.Zilberberg MD, et al, Clin Infect Dis 2010 5.Girard T, et al, Lancet 2008 6.Strom T, et al, Lancet 2010 7.The Acute Respiratory Distress Syndrome Network, N Engl J Med 2000

4 Development of new VAE Surveillance Definition Working group – 2011 –Critical Care Societies Collaborative –American Association for Respiratory Care –Association of Professionals in Infection Control and Epidemiology –Council of State and Territorial Epidemiologists –Healthcare Infection Control Practices Advisory Committee’s Surveillance Working Group –Infectious Diseases Society of America –Society for Healthcare Epidemiology of America Armstrong Institute for Patient Safety and Quality 4

5 NHSN VAE Definition Objective Streamlined Potentially automatable Will define a broad range of conditions and complications occurring in mechanically ventilated patients 8 Armstrong Institute for Patient Safety and Quality 5

6 Which locations should use VAE surveillance? 8 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 Armstrong Institute for Patient Safety and Quality 6

7 Inclusions and Exclusions for VAE Surveillance in 2012 -2013 Excluded patients: –< 18 years of age –on high frequency ventilation or extracorporeal life support Included patients: –≥ 18 years of age –Receiving conventional mode of mechanical ventilation while prone or while receiving nitric oxide or epoprontenal therapy –On APRV or related therapy Use changes in PEEP only Armstrong Institute for Patient Safety and Quality 7

8 © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Other VAE Associated Definitions

9 VAE Definition Tiers 8 Armstrong Institute for Patient Safety and Quality 9 Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC)General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testingPossible or Probable VAP Respiratory status component Infection / inflammation component Additional evidence Possible Future Public Reporting Definitions Internal Quality Improvement 8.Draft – CDC Device-associated Events – VAE

10 NHSN Surveillance 2012-2013 Assessment must take place for all VAE tiers –VAC - Ventilator-associated Condition –IVAC - Infectious Ventilator-associated Condition –Possible VAP – Possible Ventilator- associated Pneumonia –Probable VAP – Probable Ventilator- associated Pneumonia Armstrong Institute for Patient Safety and Quality 10

11 VAE Outcomes VAE = VAC, IVAC, Possible VAP and Probable VAP VAC = Significant respiratory deterioration after 2 or more days of stability IVAC = VAC + abnormal temp or WBC + ≥ 4 days of new antibiotics Possible VAP = IVAC + purulent sputum or positive sputum/BAL culture Probable VAP = IVAC + purulent sputum AND positive sputum/BAL culture Armstrong Institute for Patient Safety and Quality 11

12 Episode of Mechanical Ventilation A period of days during which the patient is mechanically ventilated for at least a portion of each day. Armstrong Institute for Patient Safety and Quality 12

13 VAC Definition Criteria 8 Patient on mechanical ventilation for > 2 calendar days Baseline stability –Baseline time period: The 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2 –Stability: The same 2 calendar days with stable or decreasing daily minimum PEEP or FiO2 Armstrong Institute for Patient Safety and Quality 13

14 Definition – Worsening oxygenation Worsening oxygenation – Changes sustained for ≥ calendar days: –Increase in daily min PEEP of ≥ 3 cm H 2 O over PEEP baseline period –Increase in daily min FiO2 of ≥ 0.20 (20%) over the daily minimum FiO2. Armstrong Institute for Patient Safety and Quality 14

15 Example - VAC: Basic Case 1 Armstrong Institute for Patient Safety and Quality 15 MV DayMin PEEPMin FiO2 15100 2580 3560 4550 55 6570 75 8580 This is a VAC. In this case, the Day of Event = MV day 6 (red). The Baseline Period of Stability = MV day 4-5 (yellow) Change in FiO2 >=20 points

16 Standard 5 day VAE window period MV DayMin PEEPMin FiO2 15100 2580 3560 4550 5560 6870 78 8580 Armstrong Institute for Patient Safety and Quality 16 This is a VAC. In this case, the Day of Event = MV day 6 (red). The Baseline Period of Stability = MV day 4-5 (yellow) Change in PEEP of >= 3

17 4 and 3 day VAE window period (Both of these are VACs) Armstrong Institute for Patient Safety and Quality 17 MV DayMin PEEPMin FiO2 18100 2560 35 48 5850 6570 75 8580 MV DayMin PEEPMin FiO2 1560 25 3580 45 5550 6570 75 8580 4 day VAE window 3 day VAE window

18 Change in PEEP and/or FiO2 MV DayMin PEEPMin FiO2 15100 2580 3560 45 5550 6570 75 8580 Armstrong Institute for Patient Safety and Quality 18 This is not a VAC. Days 4 and 5 qualify as baseline (2 days of stable or decreasing FiO2). However, the >= 20 point change requirement must be met for both days.

19 Subsequent VAEs The time period for a VAE is 14 days –Starts on day 1 of worsening oxygenation –New VAE cannot be reported until 14 day period has elapsed Armstrong Institute for Patient Safety and Quality 19

20 Armstrong Institute for Patient Safety and Quality 20 MV DayMin PEEPMin FiO2 15100 2580 3560 4550 55 667014 day 7770event 8980period 9565 10550 11550 12555 13560 14560 15560 16880Not 17880VAC 18880 19875 20770 21765 22760 23655 14 day Event period

21 Is this event an IVAC? Criteria Criteria must be met within the VAE event window (3, 4 or 5 day) 1.Criteria 1: Temp (max) >38C (100F) or <36C (97F) OR WBC >=12,000 cells/mm3 or <=4,000 cells/mm3 2.Criteria 2: New antimicrobial agent(s) is started and is continued for >=4 days Armstrong Institute for Patient Safety and Quality 21

22 New Antimicrobial Agent A new antimicrobial agent –Started within the VAE window period –Was not given to the patient on either of the 2 days immediately preceding the window period –Is continued for 4 consecutive days (QADs) Requirement can be met with different agents –Administered IV, IM, via digestive tract or via respiratory tract Armstrong Institute for Patient Safety and Quality 22

23 Included Antimicrobials –Includes broad range of antimicrobials Also includes agents not used to treat respiratory infections –Oral vancomycin –Fidaxomicin –Remember IVAC does not necessarily mean a respiratory infection. It is an infectious ventilator- associated condition Armstrong Institute for Patient Safety and Quality 23

24 Excluded Antimicrobials Drugs that aren’t used include –Anti-HIV drugs –Anti-TB drugs –Agents used to treat viral hepatitis –Agents used to treat herpes infections –Anti-parasitics Armstrong Institute for Patient Safety and Quality 24

25 IVAC: Basic Case MV Day Min PEEP Min FiO2TminTmax WBC max WBC min QAD 1510038.039.150004500 258037.838.2 356037.538.1 455038.639.075007000 555037.537.990008000QAD 657037.537.9125009000QAD 757037.137.480007000QAD 858037.537.9 QAD Armstrong Institute for Patient Safety and Quality 25 VAC IVAC

26 IVAC with 3 or 4 day VAE event window MV Day Min PEEP Min FiO2 TminTmax WBC max WBC min QAD 1810038.039.150004500 256037.838.2 356037.537.660005500QAD 486037.637.975007000QAD 585037.537.990008000QAD 657037.537.9100009000QAD 757037.137.480007000 858037.537.9 Armstrong Institute for Patient Safety and Quality 26 VAC Not IVAC

27 Determination of QADs For this section, we will assume that requirements for the following have already been met: VAC Temperature and WBC (IVAC) Armstrong Institute for Patient Safety and Quality 27

28 IVAC Abx: Basic Case VAE day Abx-4-3-2123456 Levoflox acin Yes QAD Armstrong Institute for Patient Safety and Quality 28

29 3 day VAE Event Window and QADs VAE day Abx No MV -2123456 Pip/Tazo Yes QAD XXXXX Armstrong Institute for Patient Safety and Quality 29 Doesn’t meet Abx criteria

30 IVAC Abx – Multiple Abx, Example 1 Armstrong Institute for Patient Safety and Quality 30 VAE day Abx-4-3-2123456 Levofloxaci n Yes Pip/Tazo Yes Tobramycin Yes QAD Meets Abx criteria

31 IVAC Abx – Multiple Abx, Example 2 VAE day Abx-4-3-2123456 Levoflox acin Yes Pip/Tazo Yes Tobramy cin Yes QAD XXX Armstrong Institute for Patient Safety and Quality 31 Doesn’t meet Abx criteria

32 IVAC Abx – Consecutive days definition VAE day Abx-4-3-2123456 Vancom ycin Yes Yes Yes QAD Armstrong Institute for Patient Safety and Quality 32 When the same Abx is given every other day, the day in between is considered a QAD. Meets Abx criteria.

33 If VAC and IVAC, does patient have Possible or Probable VAP? Patient must meet ONE of the criteria in the next 2 slides. Only ONE of the two criteria need to be met The criteria can be met at any time within the appropriate length of VAE Event Window Armstrong Institute for Patient Safety and Quality 33

34 Possible VAP – Criteria 1 Criteria 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 lab reports semi-quantitative results, those results must be the equivalent to the above quantitative results. OR Armstrong Institute for Patient Safety and Quality 34

35 Possible VAP – Criteria 2 Criteria 2: Positive culture (qualitative, semi- qualitative or quantitative) of sputum, endotracheal aspirate, bronchoalveolar lavage, lung tissue or protected specimen brushing. –Excludes the following Normal respiratory flora, mixed respiratory/oral flora or equivalent Candida species of yeast, not otherwise specified Coagulase-negative Staphylococcus species Enterococcus species Armstrong Institute for Patient Safety and Quality 35

36 Possible VAP Case 1 MV Day Min PEEP Min FiO2 T min T max WBC max WBC min QADSpecimenPolys EpisOrganism 1510038.039.1 258037.838.25500 356037.538.160005500 455038.639.075007000 Sputum≥25/≤10 Normal Respiratory Flora 555037.537.990008000QAD 657037.537.9125009000QAD 757037.137.480007000QAD 858037.537.960005000QAD Armstrong Institute for Patient Safety and Quality 36 Possible VAP criteria fulfilled. Purulent sputum was collected within window. Organism is not used here.

37 Possible VAP Case 2 MV Day Min PEEP Min FiO2 T min T max WBC max WBC min QAD Speci men Polys Epis Organis m 1510038.039.150004500 258037.838.255005000 356037.538.160005500 455038.639.075007000 555037.537.990008000QAD 657037.537.9125009000QAD 757037.137.480007000QAD 858037.537.960005000QADBAL Heavy S. aureus Armstrong Institute for Patient Safety and Quality 37 Possible VAP criteria fulfilled. BAL collected within 5 day VAE event window. Grew heavy S. aureus, known pathogen.

38 Possible VAP Case 3 MV Day Min PEEP Min FiO2 T min T max WBC max WBC min QAD Specim en Poly s Epis Organis m 1510038.039.150004500 258037.838.255005000 356037.538.160005500 455038.639.0 555037.537.9 656037.537.9100009000 757037.137.480007000 878037.537.960005000 BAL Heavy S. aureus 979038.138.5 Armstrong Institute for Patient Safety and Quality 38 Possible VAP criteria not fulfilled. Criteria for VAC are not fulfilled.

39 If IVAC, does patient meet criteria for Probable VAP? Patient must meet either Criteria 1 (two parts) or Criteria 2. The criteria can be met at any time within the appropriate length of VAE Event Window Armstrong Institute for Patient Safety and Quality 39

40 Probable VAP Criteria 1, part 1 Part 1 - Essentially the first part of this criteria is the same as the first criteria from Possible VAP. –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 lab reports semi-quantitative results, those results must be the equivalent to the above quantitative results. AND Armstrong Institute for Patient Safety and Quality 40

41 Probable VAP Criteria 1, part 2 –One of the following Positive culture of endotracheal aspirate, ≥ 10 5 CFU/ml or equivalent semi-quantitative result Positive culture of a bronchoalveolar lavage, ≥ 10 4 CFU/ml or equivalent semi-quantitative result Positive culture of lung tissue, ≥ 10 4 CFU/ml or equivalent semi- quantitative result Positive culture of protected specimen brush, ≥ 10 3 CFU/ml or equivalent semi-quantitative result Excludes the following –Normal respiratory flora, mixed respiratory/oral flora or equivalent –Candida species of yeast, not otherwise specified –Coagulase-negative Staphylococcus species –Enterococcus species OR Armstrong Institute for Patient Safety and Quality 41

42 Probable VAP Criteria 2 Criteria 2: One of the following – without the 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) Includes these otherwise excluded organisms –Candida species or yeast not otherwise specified –Coagulase-negative Staphylococcus species –Enterrococcus species (including VRE) –Positive lung histopathology Includes these otherwise excluded organisms –Candida species or yeast not otherwise specified –Coagulase-negative Staphylococcus species –Enterrococcus species (including VRE) –Positive diagnostic test for Legionella spp. –Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus and coronavirus. Armstrong Institute for Patient Safety and Quality 42

43 Probable VAP- Case 1 MV Day Min PEEP Min FiO2 T min T max WBC max WBC min QAD Specim en Polys Epis Organis m 1510038.039.150004500 258037.838.255005000 356037.538.160005500 455038.639.075007000 555037.537.990008000QAD 657037.537.9125009000QAD 757037.137.480007000QAD 858037.537.960005000QADBAL≥25/≤ 10 S. aureus ≥ 10 4 CFU/ml Armstrong Institute for Patient Safety and Quality 43 Possible VAP criteria are fulfilled, purulent sputum and positive culture with pathogen.

44 Probable VAP- Case 2 MV Day Min PEEP Min FiO2 T min T max WBC max WBC min QAD Specim en Polys Epis Organis m 1510038.039.150004500 258037.838.255005000 356037.538.160005500 455038.639.075007000 555037.537.990008000QAD 657037.537.9100009000QAD 757037.137.480007000QAD 858037.537.960005000QADLung tissue Yeast Armstrong Institute for Patient Safety and Quality 44 Possible VAP criteria are fulfilled, while yeast is not a pathogen, the specimen is lung tissue, therefore criteria are met.

45 Steps to generate linelist for VAE Begin with “Daily Linelist” Enter patient identifier, date, daily minimum PEEP and FiO2 for every ventilated patient for every calendar day the patient spends any time on a ventilator If a patient is not identified as having VAC, don’t collect any further information for that patient. Armstrong Institute for Patient Safety and Quality 45

46 Determination of IVAC Only look at patients where VAC has been determined Enter: –Tmin and Tmax –WBCmin and WBCmax –QAD – Qualifying antibiotic day IVAC requires 4 contiguous days of a new antibiotic starting within the 5 days starting 2 days before the onset Armstrong Institute for Patient Safety and Quality 46

47 Determination of Possible VAP or Probable VAP Only look at patients where IVAC has been determined From Sputum of BAL gram stain –Enter Polys – polys, neutrophils or WBC (semiquantitative scale) Epis – epithelial cells or squamous cells (semiquantitative scale) Culture – result Quantity - threshold (10^5 for endotracheal aspirate, 10^4 for BAL, 10^3 for protected specimen brush). Semi-quantitative equivalent also acceptable. Answer Yes or No. Armstrong Institute for Patient Safety and Quality 47

48 Semiquantitative Scale for Polys and Epis Armstrong Institute for Patient Safety and Quality 48 NoneEnter 0 Few, rare, ≤10 cells/lpfEnter 1 Moderate, ≥25 cells/lpfEnter 2 ManyEnter 3 AbundantEnter 4

49 VAE Outcomes VAE = VAC, IVAC, Possible VAP and Probable VAP VAC = Significant respiratory deterioration after 2 or more days of stability IVAC = VAC + abnormal temp or WBC + ≥ 4 days of new antibiotics Possible VAP = IVAC + purulent sputum or positive sputum/BAL culture Probable VAP = IVAC + purulent sputum AND positive sputum/BAL culture Armstrong Institute for Patient Safety and Quality 49

50 Questions? Armstrong Institute for Patient Safety and Quality 50


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