1. CUSP 4 MVP-VAP IP VAE Surveillance, Call – 3
April 15, 2014
Kathleen Speck, MPH
Program support provided by MHA Keystone Center.
Scientific expertise and educational presentations provided by Harvard Medical School.
February 28, 2019

2. Objectives Restate definitions of VAE Tiers
Review the definitions of VAE Tiers
Discuss case finding and determination of Possible and Probable VAP (PoVAP and PrVAP.

3. Poll 1 – Who is on the call? IP - infection preventionist
RN – registered nurse
RT – respiratory therapist
PT – physical therapist
OT – occupational therapist
Unit project champion
Nurse manager
Physician champion
Executive partner
CE – coordinating entity
Other
February 28, 2019

4. 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
Probable VAP – Probable Ventilator-associated Pneumonia
February 28, 2019

5. VAE Definition Tiers

6. CUSP 4 MVP-VAP Quick Review VAC and IVAC
Program support provided by MHA Keystone Center.
Scientific expertise and educational presentations provided by Harvard Medical School.
February 28, 2019

7. 5-Day VAE Window Period MV Day Min PEEP Min FiO2 1 8 100 2 7 70 3 6 504 5 60 9 80 10
February 28, 2019

8. Why is the Event Date important?
Defines the “VAE Window Period”
Period during which criteria for other events must be met
Defines beginning of 14-day Event Period
Another VAE may not happen during the 14-day Event Period following the VAE in question
February 28, 2019

9. VAE Window Period
The period of days around the event within which other VAE criteria must be met.
It is usually a 5-day period and includes the 2 days before, the day of, and the 2 days after the VAE event day.
February 28, 2019

10. Tier 2: IVAC Patient meets criteria for VAC
On or after calendar day 3 of mechanical ventilation or after the onset of worsening oxygenation, the patient meets both of the following criteria:
Temp > 38oC (100.4oF) or < 36oC (96.8oF), OR WBC ≥ 12,000 cells/mm3 or ≤ 4,000 cell/mm3
AND
A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days
February 28, 2019

11. 3-day VAE Event Window – Not IVAC
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx 1 5 50
36.9
37.6 2
36.5
39.2
12.1
13.6 3 8
37.5
37.9
11.5
11.9 4
37.8
11.6
11.8 7 60
11.1 6 70
11.2 80 9 10
February 28, 2019

12. Tier 2: IVAC Patient meets criteria for VAC
On or after calendar day 3 of mechanical ventilation or after the onset of worsening oxygenation, the patient meets both of the following criteria:
Temp > 38oC (100.4oF) or < 36oC (96.8oF), OR WBC ≥ 12,000 cells/mm3 or ≤ 4,000 cell/mm3
AND
A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days
February 28, 2019

13. Qualifying Antimicrobials Day (QAD)
A day on which a patient was administered a “new” antimicrobial agent within the VAE Window Period
4 consecutive QADs are needed to meet the IVAC antimicrobial criterion, starting within the VAE Window Period
February 28, 2019

14. 3-day VAE Event Window - IVAC
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx 1 5 50
36.9
37.6 2
38.1
39.2
12.1
13.6 3 8
38.4
38.9
11.5 No 4
36.5
37.8
12.6
16.8 7 60
11.1
15.9
Yes 6 70
11.2 80 9 10
February 28, 2019

15. QAD – Example 1, Answer VAE Day -3 -2 -1 1 2 3 4 5 Abx Levo Mero Vanc
February 28, 2019

16. QAD – Example 2 VAE Day -3 -2 -1 1 2 3 4 5 Abx Levo Vanc QAD X
February 28, 2019

17. CUSP 4 MVP-VAP PoVAP and PrVAP
Possible and Probable VAP
February 28, 2019

18. PoVAP and PrVAP Patient must meet criteria for VAC and IVAC AND
February 28, 2019

19. PoVAP
On or after calendar day 3 of MV and within 2 days before or after the onset of worsening oxygenation, ONE of the following 2 criteria must be met.
February 28, 2019

20. PoVAP – 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 laboratory reports semi-quantitative results, those results must be equivalent to the above quantitative thresholds.
See additional instructions for using the purulent respiratory secretions criterion in the VAE Protocol. (10-VAE_Final.pdf, page 14, Table 2) (Discusses interpretation of lab reports) OR
February 28, 2019

21. PoVAP – Criteria 2
Positive culture (qualitative, semi-quantitative or quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing*
*On next slide
February 28, 2019

22. *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
February 28, 2019

23. PrVAP – Criteria 1 (part A)
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.
See additional instructions for using the purulent respiratory secretions criterion in the VAE Protocol. (10-VAE_Final.pdf, page 14) (Discusses interpretation of lab reports)
AND
February 28, 2019

24. PrVAP – Criteria 1 (part B)
One of the following (for help with qualitative lab reports10-VAE_Final.pdf, page 14, Table 2)
Positive culture of endotracheal aspirate*, ≥ 105 CFU/ml or equivalent semi-quantitative result
Positive culture of BAL*, ≥ 104 CFU/ml or equivalent semi-quantitative result
Positive culture of lung tissue, ≥ 104 CFU/ml or equivalent semi-quantitative result
Positive culture of protected specimen brush*, ≥ 103 CFU/ml or equivalent semi-quantitative result
(Criteria 1, parts A AND B) OR
*Same organism exclusions as noted for PoVAP
February 28, 2019

25. PrVAP – Criteria 2
One of the following (no purulent secretions required)
Positive pleural fluid culture (specimen obtained during thoracentesis or initial placement of a chest tube and NOT from indwelling chest tube
Positive lung histopathology
Positive diagnostic test for Legionella spp.
Positive diagnostic test on respiratory secretions for influenza virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus
February 28, 2019

26. IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100 No 2 70 3 6 50
12.1
Trachea
>25/≤10
Rare C. albicans 4 7
36.9
37.6
16.8
38.1
39.2
14.5
15.9
38.4
38.9
12.6
13.6
Yes
36.5
37.8
11.1 8 80 9 10
February 28, 2019

27. PoVAP! Purulent secretions
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100 No 2 70 3 6 50
12.1
Trachea
>25/≤10
Heavy C. albicans 4 7
36.9
37.6
16.8
38.1
39.2
14.5
15.9
38.4
38.9
12.6
13.6
Yes
36.5
37.8
11.1 8 80 9 10
Purulent secretions
Specimen from trachea grew an excluded organism
February 28, 2019

28. IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
38.0
39.1
4.5
5.0 No 2 70
37.8
38.2
5.5 3 6 50
37.5
6.0 4 7
38.6
39.0
7.0
7.5
37.9
8.0
9.0
10.0
Yes
37.1
37.4 8 80
8.5
BAL
> 104 S. aureus 9
6.5 10
37.6
February 28, 2019

29. PoVAP! No purulent secretions
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
38.0
39.1
4.5
5.0 No 2 70
37.8
38.2
5.5 3 6 50
37.5
6.0 4 7
38.6
39.0
7.0
7.5
37.9
8.0
9.0
10.0
Yes
37.1
37.4 8 80
8.5
BAL
>104 S. aureus 9
6.5 10
37.6
No purulent secretions
Specimen from BAL met organism and growth criteria
February 28, 2019

30. IVAC, PoVAP, or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
39.5
40.0
10.0
10.5
BAL
Moderate
S. aureus 2 70
38.0
39.7
11.5
12.5 3 7 50
37.5
11.0
QAD 4
37.0 10
13.0 6
13.5
Sputum
>25/≤10 8
Patient expired
February 28, 2019

31. Poll 2 – IVAC, PoVAP, or PrVAP?
No event - S. aureus was present in BAL on MV day – pre-existing pneumonia
IVAC - purulent secretions and positive culture are required for PoVAP and PrVAP
PoVAP - sputum from MV day 7 qualifies, for purulent secretions – no positive culture is needed
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
39.5
40.0
10.0
10.5
BAL
Few S. aureus 2 70
38.0
39.7
11.5
12.5 3 7 50
37.5
11.0
QAD 4
37.0 10
13.0 6
13.5
Sputum
>25/≤10 8
Patient expired
February 28, 2019

32. Poll 2 – Is this a PoVAP?
No event - S. aureus was present in BAL on MV day – pre-existing pneumonia
IVAC - purulent secretions and positive culture are required for PoVAP and PrVAP
PoVAP - sputum from MV day 7 qualifies, for purulent secretions – no positive culture is needed
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
39.5
40.0
10.0
10.5
BAL
Few S. aureus 2 70
38.0
39.7
11.5
12.5 3 7 50
37.5
11.0
QAD 4
37.0 10
13.0 6
13.5
Sputum
>25/≤10 8
Patient expired
February 28, 2019

33. IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
38.0
39.1
10.0
10.5 2 80
37.8
38.2
11.5
12.5 3 60
37.5
38.1
11.0 4 50
38.6
39.0
37.9
13.0
QAD
Lung tissue
>25/≤10
Enterococcus spp. 6 70 7
37.1
37.4
13.5 8
February 28, 2019

34. Poll 3 - IVAC, PoVAP or PrVAP??
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
38.0
39.1
10.0
10.5 2 80
37.8
38.2
11.5
12.5 3 60
37.5
38.1
11.0 4 50
38.6
39.0
37.9
13.0
QAD
Lung tissue
>25/≤10
Enterococcus spp. ≥104 CFU/g 6 70 7
37.1
37.4
13.5 8
No VAE – the patient had a fever on MV day 1
PoVAP – purulent secretions, but organism is excluded
PrVAP – purulent secretions, Enterococcus spp. growth is sufficient, organism exclusions don’t apply to lung tissue samples
February 28, 2019

35. Poll 3 – IVAC, PoVAP or PrVAP?
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys Epis
Organism 1 5
100
38.0
39.1
10.0
10.5 2 80
37.8
38.2
11.5
12.5 3 60
37.5
38.1
11.0 4 50
38.6
39.0
37.9
13.0
QAD
Lung tissue
>25/≤10
Enterococcus spp. ≥104 CFU/g 6 70 7
37.1
37.4
13.5 8
No VAE – the patient had a fever on MV day 1
PoVAP – purulent secretions, but organism is excluded
PrVAP – purulent secretions, Enterococcus spp. growth is sufficient, organism exclusions don’t apply to lung tissue samples
February 28, 2019

36. CUSP 4 MVP-VAP Case 1 – Cheryl Morrin BS, MT(ASCP), CIC
Understanding PEEP and FiO2 with APRV, BiLevel, A/C and PCV
February 28, 2019

37. Case 1 - History 59 yo female w/ COPD on home cannula
From PCP wt/ S/S of fever, muscle pain and cxr w/ PNA “correlate clinically”
Admitted w/CPAP, +Legionella (POA)
MV started on HD1
February 28, 2019

38. Review Review of rules for PEEP and FiO2
Minimum PEEP = Minimum PEEP value that is maintained for ≥ 1 hour
PEEP from 0-5 = 5
APRV (and related modes) and PEEP
Partial day – use PEEP from non-APRV mode
Full day – skip PEEP, baseline starts with non-APRV mode PEEP readings on next day
February 28, 2019

39. Example patient = Non-APRV Readings
February 28, 2019

40. Case - APRV/BiLevel/PCV Readings
February 28, 2019

41. February 28, 2019

42. MV Day 1, 11/12 Patient on APRV/Bivent
11/12
21:53
23:14
MV mode
APRV/Bivent
FIO2
100
PEEP
Patient on APRV/Bivent
FiO2 for MV day 1 = 100, from 21:53 – 23:14
No PEEP
February 28, 2019

43. MV Day 2, 11/13 Patient on APRV/Bivent and BiLevel
02:00
2:25
3:17
4:01
5:00
7:55
8:25
MV Mode
APRV/Bivent
BiLevel
FiO2
100 90 80 70
PEEP
11/13
9:12
10:07
10:53
11:01
12:55
14:57
18:13
MV mode
BiLevel
FIO2 70
100 80
PEEP 7
11/13 
19:30
20:08
21:40
22:16
22:41
23:27
23:42
MV mode
BiLevel
FIO2 90
100 80 75
PEEP
Patient on APRV/Bivent and BiLevel
Use FiO2 for MV day 2 = 70, from 4:01-7:55
No PEEP
February 28, 2019

44. MV Day 3, 11/14 Patient on BiLevel and A/C modes
2:20
2:34
4:53
7:56
12:40
MV Mode
BiLevel
FiO2
100 90
PEEP
11/14
15:50
17:23
18:53
19:59
23:43
MV mode
BiLevel
A/C
FIO2 90 60 50
PEEP 14
Patient on BiLevel and A/C modes
FiO2 for MV day 3 = 50, from 18:53-19:59
PEEP for MV day 3 = 14, from 17:23-23:43
February 28, 2019

45. MV Day 4, 11/15 Patient on AC and PCV modes FiO2 for MV day 4 = 50
00:25
00:35
00:51
2:56
4:01
4:35
4:49
MV Mode
A/C
FiO2
100 90 60 50
PEEP 12
11/15
5:06
8:51
10:00
10:10
14:18
15:26
15:27
MV Mode
A/C
PCV
FiO2 50
100 75
PEEP 12
 11/15
15:53
17:06
18:52
19:38
20:12
22:41
MV Mode
PCV
FiO2 50
100 60
PEEP 14 12 10
Patient on AC and PCV modes
FiO2 for MV day 4 = 50
PEEP for MV day 4 = 12
February 28, 2019

46. MV Day 5, 11/16 MV Day 6, 11/17 Patient on AC and PCV modes
FiO2 for MV day 5 = 40, from 12:40-20:17
No PEEP
11/16
05:44
8:01
11:43
12:40
15:53
20:17
MV Mode
PCV
A/C
FiO2 50 40
PEEP 10 14
MV Day 6, 11/17
Patient on AC and PCV modes
FiO2 for MV day 6 = 40, from 00:00-06:47
PEEP for MV day 6 = 14
11/17
4:36
6:47
8:44
9:12
9:48
13:25
20:34
MV Mode
PCV AC
FiO2 40 45 50
PEEP 14 16
February 28, 2019

47. MV Day 7, 11/18 MV Day 8, 11/19 Patient on AC and PCV modes
FiO2 for MV day 7 = 50, from 00:00-2:00
PEEP for MV day 7 = 14
11/18
00:24
2:00
5:52
7:37
10:40
15:35
21:46
MV Mode
PCV
A/C
FiO2 50 60
PEEP 14 16
Patient on AC mode
FiO2 for MV day 8 = 40
PEEP for MV day 7 = 12
MV Day 8, 11/19
11/19
00:32
3:09
7:34
13:20
17:40
21:36
MV Mode
A/C
FiO2 55 50 40
PEEP 12
February 28, 2019

48. MV Day 9, 11/20 MV Day 10, 11/21 Patient on AC mode
FiO2 for MV day 9 = 40
PEEP for MV day 9 = 7
11/20
4:19
8:10
10:27
11:01
14:37
14:39
20:16
MV Mode
A/C
FiO2 40
PEEP 12 10 7
Patient on AC mode
FiO2 for MV day 10 = 40
PEEP for MV day 10 = 7
MV Day 10, 11/21
11/21
5:58
9:15
9:59
16:49
18:38
20:00
MV Mode
A/C
PCV
FiO2 40 70 60 50
PEEP 7 5 10
February 28, 2019

49. MV Day 11, 11/22 Patient on PCV mode FiO2 for MV day 11 = 40 No PEEP
00:20
5:00
7:32
8:30
10:11
17:47
20:22
MV Mode
PCV
FiO2 50 40
PEEP 10 5
Patient on PCV mode
FiO2 for MV day 11 = 40
No PEEP
February 28, 2019

50. MV Day 12, 11/23 Patient on PCV, SBT/PAV, A/C modes
00:11
4:42
5:30
5:32
5:34
5:48
7:44
MV Mode
PCV
SBT/PAV
FiO2 40 30
PEEP 5
15:51
20:10
21:49
23:36
MV Mode
A/C
FiO2 30
PEEP 5 7
Patient on PCV, SBT/PAV, A/C modes
FiO2 for MV day 12 = 30
PEEP for MV day 12 = 5
February 28, 2019

51. MV Day 13, 11/24 MV Day 14, 11/25 Patient on PCV, SBT/PAV, A/C modes
FiO2 for MV day 13 = 30
PEEP for MV day 13 = 5
MV Day 13, 11/24
11/24
04:38
4:47
4:48
8:20
16:34
22:35
MV Mode
A/C
SBT
PCV
FiO2 30
PEEP 5
MV Day 14, 11/25
Patient on A/C, SBT, and CPAP/pr sup modes
FiO2 for MV day 14 = 30
PEEP for MV day 14 = 5
11/25
4:18
4:32
4:37
7:23
17:14
20:44
MV Mode
A/C
SBT
CPAP/pr sup
FiO2 30
PEEP 5
February 28, 2019

52. Patient on SBT/PAV, A/C
FiO2 for MV day 17 = 30
PEEP for MV day 17 = 5
MV Day 15, 11/26
11/26
5:33
5:38
7:35
11:25
17:22
17:30
18:00
20:54
MV Mode
SBT
A/C
FiO2 30
100
PEEP 5
MV Day 16 and 17, 11/27 and 11/28
11/27
5:10
9:19
14:26
21:00
MV Mode
A/C
PAV
FiO2 30
PEEP 5
11/28
5:59
8:03
MV Mode
PAV
FiO2 30
PEEP 5
Patient on PAV, A/C
FiO2 for MV day 16 = 30
PEEP for MV day 16 = 5
Patient on PAV
FiO2 for MV day 17 = 30
PEEP for MV day 17 = 5
February 28, 2019

53. Longitudinal PEEP and FiO2
MV Day
FiO2
PEEP 1
100 - 2 70 3 50 14 4 12 5 40 6 7 8 9
MV Day
FiO2
PEEP 10 40 7 11 - 12 30 5 13 14 15 16 17
After digging and combing through all those data - There is no VAE!
February 28, 2019

54. Surveillance data can be complicated
Determining which values to use for your PEEP and FiO2 minimums can be time consuming
Before you use the calculator or make your final determination
Set up your own tables
Check the vent modes
Check the duration of the settings (≥ 1 hour)
February 28, 2019

55. CDC VAE Calculator http://www.cdc.gov/nhsn/VAE-calculator/
February 28, 2019

56. VAE Rates Registry Allison Ord - CECity
Entering Data and Accessing Reports
February 28, 2019

57. Going forward
Collect PEEP and FiO2 for your patients on mechanical ventilation
Determine whether they qualify as a VAC, IVAC, PoVAP or PrVAP
Use the IP site
Send in questions
February 28, 2019

58. Next Step – If you have been using NHSN defined VAE surveillance
We are asking for 6 months baseline data
If you ARE using the NHSN system, please confer rights to your CE if you haven’t already done so
CEs can download your data from NHSN and upload to the CECity platform
February 28, 2019

59. Next Step – If you have been using NHSN defined VAE surveillance
If you AREN’T using the NHSN surveillance system, or you choose not to confer rights, this data can be entered into the CECity system manually
February 28, 2019

60. Would you like to continue these calls?
Establish a community to discuss
Interesting cases
Confusing cases
Invite guest speakers
Changes in VAE surveillance as they arise
February 28, 2019

61. Poll 4 – Do you want to continue to have IP calls?
No more IP calls
Monthly calls
Every other month calls
Only when there are changes in VAE surveillance definitions
February 28, 2019

62. Next Steps
Complete the registration form so you can enter data into the data platform and view data reports.
Enter baseline VAE rates and Feb ‘14 rates.
February 28, 2019

63. Additional Resources CUSP 4 MVP-VAP website
NHSN VAE Surveillance Resources
February 28, 2019

64. address:
February 28, 2019