1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance Training: An Overview ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University

2. 2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview CUSP 4 MVP – VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

3. VAE Surveillance Training: An Overview Kathleen Speck, MPH CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

4. 4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Who is on the call? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist MD – medical doctor Healthcare executive Educator National project team Other 

5. 5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Objectives Review history of VAE surveillance Review the definitions of VAE tiers Discuss case finding and determination of the first tier in VAE–VAC

6. 6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question What technique have you or do you currently use for VAE surveillance?  1.Follow NHSN definitions and enter cases into NHSN system 2.Follow NHSN definitions, don’t use NHSN system 3.Only collect PVAP 4.Don’t currently perform VAE surveillance 5.I don’t know

7. 7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Former NHSN VAE Surveillance Definition Subjective Not sensitive or specific 1-3 Required radiographic findings – often unclear Required clinical signs and symptoms Did not allow accurate validation of success of prevention strategies 4-7 Did not allow establishment of valid benchmarks for quality improvement projects 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

8. 8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Development of New VAE Surveillance Definition 2011 Working Group 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

9. 9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview NHSN VAE Definition Objective Streamlined Potentially automatable Defines a broad range of conditions and complications occurring in mechanically ventilated patients

10. 10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview 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 8 CDC NHSN Device-associated Module Ventilator- associated Event (VAE); http://www.cdc.gov/nhsn/pdfs/pscManual/10- VAE_FINAL.pdf

11. 11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAE Definition Tiers 8 Possible Ventilator-Associated Pneumonia (PVAP)

12. 12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview CUSP 4 MVP–VAP VAE Surveillance Assessment must take place for all VAE tiers VAC Ventilator-associated Condition IVAC Infectious Ventilator-associated Condition Possible VAP Possible Ventilator-associated Pneumonia

13. 13 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Why Is VAC Important? Of all tiers, VAC has the strongest association with mortality. 9 9 Muscedere, Chest, 2013

14. 14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAE Attributable Hospital Mortality 10 10 Klompas, Infect Control Hosp Epidemiol, 2014

15. Case Finding CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

16. 16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAC Definition Criteria Patient intubated for >2 calendar day (earliest day of event is calendar day 3 Baseline stability –Stable baseline period –The 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO 2

17. 17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview 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 FiO 2 values increase ≥ 0.20 over daily minimum for preceding 2 calendar days Daily minimum PEEP values increase ≥ 3 cm H 2 O over daily minimum for the preceding 2 calendar days PEEP or FiO2 must be maintained for ≥ 1 hour (two consecutive hour readings) (exceptions)

18. 18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Positive End-Expiratory Pressure (PEEP) Any value of PEEP ≥ 5 cm H 2 O PEEP < 5 cm H 2 O will be entered as 5 cm H 2 O Actual PEEP of < 5 cm H 2 O will be considered = to 5 cm H 2 O for determination of event

19. 19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Exceptions To One-Hour Rule If PEEP or FiO 2 values aren’t recorded hourly, use lowest value If PEEP or FiO 2 values aren’t stable for at least one hour, use the lowest value –Patient extubated early in the day –Patient admitted late in the day

20. 20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 1: PEEP TIME6PM7PM8PM9PM10PM11PM PEEP (cm H 2 O) 1085586

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Which PEEP value is the Daily Minimum?  10  8  6  5  I don’t know 

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 1: PEEP TIME6PM7PM8PM9PM10PM11PM PEEP (cm H 2 O) 1085586 One hour rule: 2 consecutive hours with the lowest PEEP Daily minimum PEEP = 5

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 2: PEEP TIME6PM7PM8PM9PM10PM11PM PEEP (cm H 2 O) 885856

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Which PEEP value is the Daily Minimum?  8  6  5  I don’t know 

25. 25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 2: PEEP TIME6PM7PM8PM9PM10PM11PM PEEP (cm H 2 O) 885856 One hour rule: 2 consecutive hours with the lowest PEEP Daily minimum PEEP = 8

26. 26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 3: PEEP TIME12AM4AM8AM12PM4PM8PM PEEP (cm H 2 O) 5858510

27. 27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Which PEEP value is the Daily Minimum?  10  8  5  I don’t know 

28. 28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 3: PEEP TIME12AM4AM8AM12PM4PM8PM PEEP (cm H 2 O) 5858510 PEEP collected every 4 hours, therefore use the minimum PEEP listed Daily minimum PEEP = 5

29. 29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 4: PEEP TIME10:45PM11:15PM11:45PM PEEP (cm H 2 O) 10 9

30. 30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Which PEEP value is the Daily Minimum?  10  9  I don’t know 

31. 31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Example 4: PEEP TIME10:45PM11:15PM11:45PM PEEP (cm H 2 O) 10 9 No PEEP value was maintained for at least one hour, therefore use the minimum PEEP listed Daily minimum PEEP = 9

32. 32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview PEEP and FiO 2 Daily Minimums, Review Daily minimum FiO 2 values increase ≥ 0.20 over daily minimum for preceding 2 calendar days Daily minimum PEEP values increase ≥ 3 cm H 2 O over daily minimum for the preceding 2 calendar days

33. 33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview PEEP: Change ^ ≥ 3 MV DayMin PEEPMin FiO 2 18100 2770 3650 4670 5560 6550 7870 8980 9650 10750

34. 34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Which mechanically ventilated day has a possible event?   1  2  3  4  5  6  7  8  9  10  I don’t know

35. 35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAC – Possible on MV Day 7 Two days of stable PEEP, followed by a change in PEEP of ≥ 3. MV DayMin PEEPMin FiO 2 18100 2770 3650 4670 5560 6550 7870 8980 9650 10750

36. 36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAC – Possible on MV Day 7 Two days of stable PEEP, followed by a change in PEEP of ≥ 3 cm H 2 O. The change is maintained or worsens for ≥ 2 days. It is a VAC. MV DayMin PEEPMin FiO 2 18100 2770 3650 4670 5560 6550 7870 8980 9650 10750

37. 37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview FiO 2 : Change ^ ≥ 20 MV DayMin PEEPMin FiO 2 18100 2770 3650 46 5570 65 76 8680 9650 10750

38. 38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Which mechanically ventilated day has a possible event?   1  2  3  4  5  6  7  8  9  10  I don’t know

39. 39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAC – Possible on MV Day 5 Two days of stable FiO 2, followed by a change in FiO 2 of ≥ 0.2. MV DayMin PEEPMin FiO 2 18100 2770 3650 46 5570 65 76 8680 9650 10750

40. 40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview VAC – Possible on MV Day 5 Two days of stable FiO 2, followed by a change in FiO 2 of ≥ 0.2. The change is maintained or worsens for ≥ 2 days. It is a VAC. MV DayMin PEEPMin FiO 2 18100 2770 3650 46 5570 65 76 8680 9650 10750

41. 41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Is This a VAC? MV DayMin PEEPMin FiO 2 18100 2770 3655 4650 5570 65 76 8680 9650 10750

42. 42 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Is this a ventilator-associated condition (VAC)?  Yes  No  I don’t know 

43. 43 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Change in FiO 2 ≥ 20 MV DayMin PEEPMin FiO 2 18100 2770 3655 4650 5570 65 76 8680 9650 10750

44. 44 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Change in FiO 2 ≥ 20 MV DayMin PEEPMin FiO 2 18100 2770 3655 4650 5570 65 76 8680 9650 10750 No. There is no two-day stability period before the.20 increase.

45. 45 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Is This a VAC? MV DayMin PEEPMin FiO 2 15100 2570 3855 4950 5570 65 76 8680 9650 10750

46. 46 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Polling Question Is this a ventilator-associated condition (VAC)?  Yes  No  I don’t know 

47. 47 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Is This a VAC? MV DayMin PEEPMin FiO 2 15100 2570 3850 49 5570 65 76 8680 9650 10750

48. 48 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Is This a VAC? MV DayMin PEEPMin FiO 2 15100 2570 3850 49 5570 65 76 8680 9650 10750 Yes. Even though the two-day stability starts on MV Day 1, there is a two- day stability period before the increase of 3.

49. 49 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Case 1 54 year old male admitted to the ICU transferred on ventilator from the ED. Review vent settings to determine if VAE criteria are met. If so, on what day? POLL:  No VAC  Day 4  Day 7  Day 8 MV Day Min PEEP Min FiO 2 18100 2770 3650 4670 5560 6650 7670 8580 9550 10550

50. 50 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Case 1 54 year old male admitted to the ICU transferred on ventilator from the ED. Review vent settings to determine if VAE criteria are met. If so, on what day? POLL:  No VAC  Day 4  Day 7  Day 8 MV Day Min PEEP Min FiO 2 18100 2770 3650 4670 5560 6650 7670 8580 9550 10550

51. 51 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Case 2 54 year old male admitted to the ICU transferred on ventilator from the ED. Would the criteria be met with these settings? If so, on what day? POLL:  No VAC  Day 4  Day 7  Day 8 MV Day Min PEEP Min FiO 2 18100 2770 3650 4670 5550 66 7670 8580 9550 10550

52. 52 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Case 2 54 year old male admitted to the ICU transferred on ventilator from the ED. Would the criteria be met with these settings? If so, on what day? POLL:  No VAC  Day 4  Day 7  Day 8 MV Day Min PEEP Min FiO 2 18100 2770 3650 4670 5550 66 7670 8580 9550 10550

53. 53 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Data Needed To Determine VAC FiO 2 PEEP

54. 54 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Data Collection Ideas Where can you find these data? Are they in the EMR as data points? Are they in the EMR as notes? Are they on paper at the bedside? Are they in the RT notes?

55. 55 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Next Steps Where will you find your data? Look for data sources Make plans for data collection processes Practice collecting data for next call

56. 56 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Going Forward Collect PEEP and FiO 2 for patients on mechanical ventilation Determine whether they qualify as a VAC Submit questions for discussion on the next call to CUSP4MVP@jhmi.eduCUSP4MVP@jhmi.edu

57. 57 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview If You Already Perform NHSN Surveillance Collect interesting and/or complicated cases for group discussion Send cases to cusp4mvp@jhmi.edu

58. 58 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Cohort 2 VAE Data Submission 7/14 – 1/15

59. Next Steps Kathleen Speck, MPH CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

60. 60 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview DATETOPIC Feb 25, 2015–VAE Surveillance Training: Infection-related Ventilator- associated Complication (IVAC) Mar 25, 2015–VAE Surveillance Training: VAP (PVAP) Upcoming IP Sessions Have questions or related topics of interest? Send requests to cusp4mvp@jhmi.edu Fourth Wednesday of Jan, Feb and March from 11:00 am – 12:00 pm EST

61. 61 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Next IP VAE Surveillance Call Discuss solutions, barriers and ideas for data collection Discuss how to determine VAC if using APRV or other vent modes Cover determination of IVAC Discuss your questions, cases, ideas, issues, etc.

62. 62 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview 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

63. 63 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview Data entry – Tablets Interface to data portal is the same as a computer –Data can be entered manually as you walk through the unit –Can use spreadsheet to gather data and then upload to portal

64. 64 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview 1.CUSP 2.Daily Care Processes 3.Early Mobility 4.Low Tidal Volume Ventilation CUSP 4 MVP–VAP Categories

65. 65 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview References 1.Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA. 2002; 287(17):2262-72. PMID: 11980527. 2.Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control. 2010; 38(3):237-9. PMID: 20171757. 3.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(9):1443-6. PMID: 18419450. 4.Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clin Infect Dis. 2010; 51 Suppl 1:S131-5. PMID: 20597663. 5.Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008; 371(9607):126-34. PMID: 18191684.

66. 66 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview References 6.Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010 Feb 6;375(9713):475-80. PMID: 20116842. 7.The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000; 342(18):1301-8. PMID: 10793162. 8.CDC NHSN Device-associated Module Ventilator-associated Event (VAE); http://www.cdc.gov/nhsn/pdfs/pscManual/10-VAE_FINAL.pdf. Accessed Jan 25, 2015. http://www.cdc.gov/nhsn/pdfs/pscManual/10-VAE_FINAL.pdf 9.Muscedere J, Sinuff T, Heyland DK, Dodek PM, Keenan SP, Wood G, Jiang X, Day AG, Laporta D, Klompas M; Canadian Critical Care Trials Group. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest. 2013; 144(5):1453-60. PMID: 24030318. 10.Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol. 2014; 35(5):502-510. PMID: 24709718.

67. 67 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview CUSP 4 MVP – VAP Website Visit: https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx

68. 68 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview 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

69. 69 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance Overview