1. 2015 NHSN Training Teresa Fox, CIC Quality Improvement Advisor
Central Line-Associated Bloodstream Infections -CLABSI
Surgical Site Infections-SSI
Ventilator-Associated Events- VAE

2. Objectives
Define key terms and concepts for primary and secondary bloodstream infections (BSI), surgical site infections (SSI) and ventilator-associated infections (VAE)
Identify 2015 surveillance definition and protocol changes
Identify 2015 CLABSI and SSI CMS-required reporting for IQR program

3. New CLABSI Reporting Requirements
In addition to ICUs, report CLABSI from all patient care locations which are mapped as adult and pediatric wards:
Medical
Surgical
Medical/surgical
2015

4. BSI Key Terms
Date of Event- the date when the first element used to meet the NHSN site-specific infection criterion occurs for the first time in the Infection Window Period
Infection Window Period- 7-day period in which all infection criterion must be met. It includes the date of the first positive diagnostic test.
POA- date of event occurs on the day of admission or day after admission. POA period continues to include day of admission, 2 days before and the day after admission
HAI- date of event occurs on or after the 3rd of admission
RIT- 14-day timeframe during which no new infections of the same type are reported

5. BSI Key Terms cont’d
Central Lines- intravascular catheter that terminates at or close to the heart or in one of the GREAT VESSELS which is used for infusion, blood withdrawal or hemodynamic monitoring.
Great Vessels
Aorta
Pulmonary arteries
Superior vena cava
Inferior vena cava
Brachiocephalic veins
Internal jugular veins
Subclavian veins
External iliac veins
Common iliac veins
Femoral veins
Umbilical artery and veins in neonates
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6. Central Line Notes
Introducer is considered an intravascular catheter and depending on the location of the tip it may be a central line
Pacemaker wires and other non-lumened devices into great vessels or heart are not considered central lines
Extracoporeal membrane oxygenation, femoral arterial catheters and intraaortic balloon pumps are not considered central lines
Assistance with determining if a device is a central line, to

7. Infusions
Introduction of a solution through a catheter lumen into a blood vessel
Includes:
Continuous infusions such as nutritious fluids or medications
Intermittent infusions such as flushed or IV antimicrobial administration
Administration of blood or blood products in the case of transfusion or hemodialysis

8. Types of Central Lines Temporary Central Lines
A non-tunneled, non-implanted catheter
Permanent Central Lines
Tunneled catheters, including certain dialysis catheters
Implanted catheters (including ports)

9. Central Line-associated Bloodstream Infection (CLABSI)
CLABSI surveillance utilizes the Major Event Type: BSI
Specific Event Type: Laboratory Confirmed Bloodstream Infection (LCBI)

10. Central Line-Associated Bloodstream Infection (CLABSI)
Central line-associated BSI (CLABSI): A laboratory- confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1,
AND
a CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the date of event of the LCBI must be the day of discontinuation or the next day.

11. Central Line-Associated Bloodstream Infection (CLABSI) cont’d
If patient is admitted or transferred into a facility with an implanted central line (port) in place, and that is the patient’s only central line, the day of first access in an inpatient location is considered Day 1.
Access is defined as line placement, infusion or withdrawal through the line. Such lines continue to eligible for CLABSI once they are accessed until patient is discharged or line is discontinued.

12. Associating Central Line (CL) Use to BSI
Patient A is eligible for a CLABSI beginning on March 31, through April 6, since a CL was in place for some portion of each calendar day until April 6. A BSI with date of event on April 6 would be a CLABSI since the CL had been in place greater than 2 days and was removed the day before the date of event.

13. Positive Blood Cultures
One or more blood cultures means that at least one bottle from a blood draw is reported as having at least one organism
Recognized pathogen does not include organisms considered as common commensals by NHSN
Bacillus, Corynebacterium, Staph epi or hominis, etc

14. Blood Culture Specimens
All blood culture specimens must be included in surveillance if participating in NHSN CLABSI surveillance
Venipuncture
Vascular catheter
Cannot be considered a contaminant unless a single unmatched common commensal is reported.

15. “Sameness” of Common Commensals
Assume that the organisms are the same if the organism from one culture is identified to both genus and species and the companion culture is identified to only the genus
Antibiograms are not used to determine “sameness”
Always report the most resistant organism

16. CLABSI Examples
Patient has a central line inserted on June 1. On June 3, the central line is removed and on June 4 the patient has a positive blood culture with S. aureus.
This is a CLABSI because the central line was in place for >2 calendar days (June 1, 2, and 3), and was in place the day before the date of event (June 4).
A central line is placed in the facility on May 30th. On June 3, the central line is removed and on June 5 patient spikes a fever of 38.3°C. Two blood culture sets collected on June 6 are positive for S. epidermidis.
May be a healthcare-associated bloodstream infection but it is not a CLABSI because the Date of Event (June 5) did not occur on the day the central line was discontinued (June 3) or the next day (June 4).

17. Inpatient Dialysis
Inpatients receiving dialysis are included in any CLABSI surveillance in the location in which they are housed, regardless of whether or not the central line is the only central line and only accessed for dialysis. This also applies to patients in Long-Term Acute Care (LTAC) facilities within Acute Care Facilities when dialysis is received from the Acute Care Facility staff.
Example:
Patient on Unit A receives onsite dialysis by contracted dialysis staff
Dialysis staff travels to Unit A to provide dialysis to Unit A patient
Patient resides on Unit A for inpatient care, but is transported to dialysis unit within the facility for dialysis.
Since CLABSIs cannot be attributed to non-bedded locations, such an event must be attributed to the inpatient location housing the patient

18. Laboratory Confirmed BSI Criterion
LCBI
LCBI 1
LCBI 2
LCBI 3
MBI-LCBI 1
MBI-LCBI 2
MBI-LCBI 3

19. LCBI Infection Window Period

20. Common Commensal
Patient has a central line inserted on 9/3. On 9/6 she was hypotensive and an elevated WBC. 9/7, 2 BC are drawn. One set grew coag-neg Staph and the other S. epi. No other source of infection was identified. Is this an CLABSI? If so, what is the date of event?
Yes, meets criteria for LCBI 2
(common commensal)

21. MBI-LCBI
Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infections
Subset of LCBI criteria
Must meet LCBI 1, 2 or 3 prior to applying the MBI-LCBI criteria
If an MBI-LCBI is reported, and a subsequent BC occurs during the RIT of the MBI-LCBI with an organism that is excluded from the MBI criteria, the primary MBI-LCBI event is edited to become an LCBI and the organism is added to the event
A single common commensal does not exclude from meeting MBI- LCBI criteria
List of Eligible Enterobacteriaceae is available on the NHSN website
MCI-LCBI will be removed from the 2016 CLABSI metrics shared with CMS

22. Determining BSI What is the date of event?
What is the Infection Window Period?
What is the RIT?
What type of event?
LCBI 1
Infection Window
RIT
Remember!!
There is not Secondary BSI Attribution
Period for LCBI 1

23. CLABSI Summary
Clinical and surveillance definitions will sometimes differ
Accurate data collection is necessary for successful prevention efforts and is dependent on a variety of factors
No substantive changes of 2015 CLABSI definitions and protocols
New Terms

24. Secondary Bloodstream Infection
Secondary BSI Guidance updates
Chapter 17- NHSN Surveillance Definitions for Specific Types of Infections updated
Chapter 4 Appendix 1; Secondary Bloodstream Infection Guide is not applicable to Ventilator-Associated Events (VAE). Guidance is central for determining surveillance of primary vs. secondary BSIs.

25. “…and organism cultured from blood is not related to an infection at another site…”
BSI that is associated with an infection at another site is referred to as a Secondary BSI and is never reported into NHSN
CLABSI may not be secondary to an infection at another site, it is always primary BSI
Primary BSI is identified by ruling out all non-blood sites as the source of the BSI

26. LCBI associated with an NHSN defined primary site of infection
Secondary BSI
LCBI associated with an NHSN defined primary site of infection
Primary infection meeting one of the NHSN infection definitions in Chapter 17 identified
BSI and primary infection site are related according to guidelines as described in NHSN Appendix 1 of Chapter 4
AND

27. Secondary BSI Attribution Period
Period when a positive blood culture must be collected to be considered a secondary BSI to a primary site infection
Period includes the Infection Window Period plus the Repeat Infection Timeframe (RIT)
Period is days in length depending on the date of event
NOTE: A primary BSI will NOT have a Secondary BSI Attribution Period

28. Secondary BSI Attribution Period
Infection Window Period
Secondary BSI
Attribution Period
Infection Window +
Repeat Infection
Timeframe
15 days

29. Secondary BSI Attribution
Secondary BSI may be attributed to a primary site infection
If,
BC pathogen matches at least one organism found in a site- specific infection culture used to meet the primary site infection criterion OR
Positive BC is an element used to meet the primary site infection criterion

30. Secondary BSI Case Scenario 1
Blood and site-specific cultures match:
At least one organism match
That organism cannot be an excluded organism for that site- specific infection
Site-specific criteria must be met using the site-specific culture
Example
Patient meets criterion 1 for a symptomatic UTI (suprapubic tenderness and > 100,000 CFU/ml of E.coli) and BC collected 5 days later grows E. coli.

31. Secondary BSI Attribution
Attribution Period
Secondary BSI
17 days
SUTI with a Secondary
BSI Pathogen of E. coli
Date of event: Day 13

32. Secondary BSI Scenario 1 Ex. 2
Patient meets criterion 1 for SUTI (suprapubic tenderness and >100,000 CFU/ml of E. coli and > 100,000 of Candida glabrata) and BC is collected 5 days later which is within the BSI Attribution period grows Candida glabrata and S. aureus.
This is a SUTI with E. coli and a primary BSI with Candida glabrata and S. aureus if no other primary infection site is identified
Candida is an excluded organism for UTIs
S. aureus does not match at least one organism found in the site specific culture (urine)

33. Secondary BSI Scenario 2
Blood and site-specific cultures do NOT match
If blood isolate is an element used to meet the site-specific criterion, then the BSI is reported as a Secondary to that site
Example
Patient is afebrile, has a new onset of cough and has positive chest X-ray showing the presence of infiltrate. P. aeruginosa is isolated from the blood. Because the patient meet the PNU 2 definition the blood is considered a secondary BSI to the PNEU. No primary BSI would be reported

34. Secondary BSI Attribution Scenario 2√

35. Secondary BSI Attribution Scenario 2
Secondary BSI Attribution Period
15 days
PNU 2 with Secondary BSI Pathogen
P. Aeruginosa
Date of event is Day 11

36. Secondary BSI Guide

37. Pathogen Assignment for Secondary BSI
Additional eligible pathogens identified within a RIT are added to the index event
Pathogen exclusions for specific definitions also apply to secondary BSI pathogen attribution
Excluded pathogens must be attributed to another primary site specific infection as either a secondary BSI or as a primary BSI

38. Secondary BSI Summary Understand new terminology Date of event
Infection Window Period
Repeat Infection Timeframe (RIT)
Consider another primary source for infections
Consistently apply Secondary BSI Guidance
Assign pathogens appropriately

39. Surgical Site Infections: SSI

40. CMS Reporting Requirements
Updated December, 2014

41. Supporting Resources

42. Monthly Reporting Plan
Plans are very important to your surveillance and CMS Reporting
ONLY data included in the Monthly Reporting Plans will be used to aggregate data analysis and submit to CMS appropriately
Plans drive much of the business logic of NHSN
Must have a plan for every month
Must apply all definitions and protocols, reporting all superficial, deep and organ space SSIs

43. Surveillance Methods Active SSI Surveillance Methods
Post-discharge SSI Surveillance Method

44. How do the new terms and definitions apply to SSI?
Infection Window Period, POA, HAI and RIT and secondary bloodstream infection attribution period definitions DO NOT apply to SSI, VAE or LabID Events.
Secondary BSIs may be attributed to SSI events
Guidance specific to SSIs see Secondary BSI Attribution Period and the SSI and BSI protocols

45. NHSN Operative Procedure
An NHSN operative procedure is a procedure
• that is included in Table 1
and
• takes place during an operation where at least one incision (including laparoscopic approach) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure
• takes place in an operating room [OR], defined as a patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated [9]. This may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab.

46. Date of Event
Date of event (DOE): For an SSI the date of event is the date when the first element used to meet the SSI infection criterion occurs for the first time during the surveillance period. Synonym: infection

47. SSI Reporting
SSIs are always reported at the deepest level that they occur within the surveillance period.
If during the surveillance period a patient’s initial SSI meets criteria for a deeper level, then the date of event should be the date for the deepest level.
For example:
Day 1 –COLO procedure
Day 6 –DOE for meeting a superficial incisional SSI
Day 25 –DOE for the meeting an organ space IAB SSI
Only report one SSI with the DOE for the organ space IAB.

48. Pathogen Assignment
The Pathogen Assignment Guidance found in Chapter 2 “Identifying HAIs” is based on Repeat Infection Timeframes (RIT) which is NOT used with SSIs
SSI are procedure based and have long surveillance periods (30 to 90 days)
SSIs can progress to a deeper level during a surveillance period and a new pathogen can be found
Pathogen Assignment for SSI has not changed

49. Primary Closure
Primary Closure is defined as closure of the skin level during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision. This category includes surgeries where the skin is closed by some means. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.
NOTE: If a procedure has multiple incision/laparoscopic trocar sites and any of the incisions are closed primarily, then the procedure is entered as having been closed primarily.
This change removed the phrase “all tissue levels” from the definition. This definition will be easier to apply and is closer to definitions used by other surgical professional groups.

50. Non-Primary Closure
Non-primary Closure is defined as closure that is other than primary and includes surgeries in which the skin level is left completely open during the original surgery and therefore cannot be classified as having primary closure. For surgeries with non-primary closure, the deep tissue layers may be closed by some means (with the skin level left open), or the deep and superficial layers may both be left completely open. An example of a surgery with non-primary closure would be a laparotomy in which the incision was closed to the level of the deep tissue layers, sometimes called “fascial layers” or “deep fascia,” but the skin level was left open. Another example would be an “open abdomen” case in which the abdomen is left completely open after the surgery. Wounds with non- primary closure may or may not be described as "packed” with gauze or other material, and may or may not be covered with plastic, “wound vacs,” or other synthetic devices or materials.
One sentence was removed since this scenario would actually meet criteria for a primary closure since the skin was closed.

51. Wound Closure Primary Closure Closure other than primary

52. Primary vs Non-primary Closures
A patient is admitted with a ruptured diverticulum and a COLO procedure is performed in the inpatient OR. Case is entered as a wound class 3. Specimen is obtained in the OR which later returns (+) for E. coli. Surgeon staples closed the skin at 4 locations with packing placed between the staples.
Is this procedure primarily closed in 2015?
If you are following COLO, should you include this case in your denominator data?
YES
The skin is closed at some points along the skin incision.
Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.
YES

53. Diabetes
NHSN has added another option for users to answer the question of diabetes on the denominator for procedure form.
NHSN users can chose to use, assignment of the discharge ICD-9-CM codes in the 250 to range to answer YES to this diabetes field question.
The 2014 definition is also still in place as a choice to answer this field.

54. BSI Secondary to an SSI
Secondary BSI Attribution Period: The secondary BSI attribution period for SSI is a 17-day period that includes the date of event, 3 days prior and 13 days after.
Why does SSI have its own secondary BSI attribution period?
For other HAIs the Secondary BSI attribution period is determined by using the Infection Window Period and the Repeat Infection Timeframe. These two definitions do not apply to SSIs.

55. NEW BSI Secondary to an SSI
Any blood culture that occurs during the SSI Secondary BSI attribution period will be assessed using Appendix 1 in the BSI protocol to determine if the blood meets Secondary BSI criteria.
If a (+) blood culture occurs after the SSI secondary BSI attribution period it should be fully evaluated to see if at that time it is meeting criteria to be secondary to an ongoing SSI.

56. Infection Present at Time of Surgery
Infection present at time of surgery (PATOS) denotes that there is evidence of an infection present at the time of the start of or during the index surgical procedure (in other words, it is present pre-operatively).
This field is a required field and it is found on the SSI event form not on the denominator for procedure form.
PATOS does not apply if there is a period of wellness between the time of a pre-operative condition and the surgery.
The evidence of infection must be noted/documented preoperatively or found intraoperatively in a pre-operative or intra-operative note.

57. PATOS cont’d
Only select PATOS = YES, if it applies to the depth of SSI that is being attributed to the procedure
The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be evidence of infection or abscess present at the time of surgery.
(e.g., if a patient had evidence of an intraabdominal infection at the time of surgery and then later returns with an organ space SSI the PATOS field would be selected as a YES. If the patient returned with a superficial or deep incisional SSI the PATOS field would be selected as a NO).

58. Re-baselining of SSIs for 2016
NSHN is going to re-baseline all HAIs based on 2015 data. The 2015 data reported to NHSN will provide the baseline for calculating the Standardized Infection Ratio (SIR) for 2016 and subsequent years. SIRs calculated for the 2015 data will use the current baselines.
SSIs reported with PATOS = YES will be excluded from the SSI SIR beginning with 2016 data and the new baseline. These excluded SSIs will be analyzed separately.

59. PATOS
Patient was admitted with an acute abdomen, to OR for XLAP with findings of an abscess due to ruptured appendix and an APPY is performed. Patient returns 2 weeks later and meets criteria for an organ space IAB SSI.
Does this patient meet the criteria for PATOS?
YES
Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN ?

60. NHSN Inpatient/Outpatient Operative Procedure
Based on feedback provided by NHSN users regarding the 2015 changes to the Inpatient and Outpatient OR Procedure definition, NHSN has made a decision to rescind these changes. The SSI protocol and the Table of Instructions in the NHSN manual will be updated to reflect this change.
NHSN users were notified of this update via February NHSN release notes.
Therefore, for 2015, the NHSN SSI protocol will refer to inpatient and outpatient operative procedures, rather than operative procedures that are performed on inpatients or outpatients.
Please disregard earlier guidance to identify OR areas/suites as inpatient or outpatient.

61. Procedures Through Same Incision
If procedures in more than one NHSN operative procedure category are done through the same incision during the same trip to the OR, create a record for each procedure that you are monitoring in the Monthly Reporting Plan, and use the total time for the duration for each record.
Example: Patient had a coronary artery bypass graft with a chest incision only (CBGC) and also a mitral valve replacement (CARD). The time from PST to PF was 5 hours. A Denominator for Procedure form is completed for the CBGC and another for the CARD, indicating the duration as 5 hours and 0 minutes on each form.
EXCEPTION: If a patient has both a CBGC and a CBGB during the same trip to the OR, report only as a CBGB.

62. Incisions with 24- Hours
If the patient goes to the OR more than once during the same admission and another procedure of the same or different NHSN operative procedure category is performed through the same incision within 24 hours of the end of the original procedure, report only one Denominator for Procedure form for the original procedure combining the durations for both procedures.
Assign the surgical wound closure that applies when the patient leaves the OR from the principal operative procedure. This instruction should be followed in scenarios where a patient leaves the OR with non-primary closure, but returns to the OR for a subsequent procedure that results in primary closure of the procedure.
Patient had colon surgery (COLO) performed on Tuesday morning which had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to the OR where the COLO incision was opened to repair a bleeding vessel (OTH). The duration of the second procedure was 1 hour and 10 minutes.
Report only one COLO with a combined duration of 4 hours and 20 minutes. Do not report an OTH record.

63. Additional Fields for Specific Procedures
There are 5 procedures for which additional risk factors are collected:
Cesarean Section –CSEC
Spinal Fusion and Refusion –FUSN; RFUSN
Hip Arthroplasty –HPRO
Knee Arthroplasty –KPRO

64. SSI

65. SSI Superficial
Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet criterion “d” for superficial incisional SSI. An incision that is draining or culture (+) is not considered a cellulitis.
A stitch abscess alone (minimal inflammation and discharge confined to the points of suture penetration) is not considered an SSI.
A localized stab wound or pin site infection. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under this module.
Note: a laparoscopic trocar site for an NHSN operative procedure is not considered a stab wound.
Superficial incisional primary (SIP)
A superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB
Superficial incisional secondary (SIS)
A superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CBGB)

66. If more than one operation is done through a single incision…
First, attempt to determine the procedure that is thought to be associated with the infection.
Example: If the patient had a CBGC and CARD done at the same time and develops an infected valve, then the SSI will be linked to the CARD.
If it’s not clear (as in the case of a superficial incisional SSI), use the NHSN Principal Operative Procedure Selection Lists to select which operative procedure to report.

67. SSI following invasive manipulation or accession of the operative site
If during the post-operative period the surgical site has an invasive manipulation/accession for diagnostic or therapeutic purposes (e.g., needle aspiration), and following this manipulation/accession an SSI develops, the infection is not attributed to the operation.
This reporting instruction does NOT apply to closed manipulation (e.g., closed reduction of a dislocated hip after an orthopedic procedure).
Invasive manipulation does not include wound packing, or changing of wound packing materials as part of postoperative care.

68. When a patient with an SSI has had more than one operation…
If a patient has several NHSN operations prior to an SSI, report the operation that was performed most closely in time prior to the infection date. This does not apply when 2 operative procedures are done within the same 24 hour period via the same incision.
Example: Patient underwent a COLO on 1/12/15. One week later on 1/19/15, he returns to OR for an CHOL via the same incision. He developed an incisional SSI on 1/28/15. This SSI is attributed to the second procedure (CHOL), not the COLO.

69. Reporting SSI for Patients who are Readmitted
Use the admission date of the surgical admission as the date admitted to facility, not the readmission date
Then the date of procedure and date of event will be in the correct sequence
Date Admitted to Facility ≤ Date of Procedure < Date of Event

70. Transition to ICD-10-CM/PCS and CPT Codes
Updated ICD-10-CM/PCS and CPT mappings to all NHSN operative procedure categories for SSI surveillance. These mappings are anticipated to be available Spring of 2015.
ICD-10-CM/PCS codes will replace ICD-9-CM codes on October 1, 2015 however NHSN will not have the ability to receive these codes until the January 2016 release.
The NHSN guidance for entry of surgical denominator data for the last quarter of 2015 data is to enter the NHSN Procedure Code (e.g. COLO or HYST) but do not enter any ICD-10- CM/PCS

71. Ventilator-Associated Events (VAE)

72. VAE Surveillance Changes for 2015
Modification 1: Consolidation of Third Tier of VAE algorithm
PVAP (possible VAP) replaced the original possible and probable VAP
Uses the same parameters
Culture and non-culture based identification of pathogens, purulent respiratory secretions
Provides simplification and consistent with plan for analysis

73. VAE Surveillance Changes for 2015
Modification 2: Exception to the requirement that a daily minimum PEEP and FiO2 values be maintained for at least 1 hour in select circumstances
When no value documented to have been maintained for at least 1 hour, the minimum value is the lowest value set on the vent during the calendar day
Modification 3: Additional pathogen exclusions
Community associated fungal pathogens that are either not know to cause or rarely cause HAIs
Modification 4: Introduction of a new denominator: Episodes of Mechanical Ventilation (EMV)

74. NHSN Lower Respiratory Event
VAE is the only in-plan option available for ventilated patients in adult locations
VAP (Ventilator-associated Pneumonia) is the only in-plan option for ventilated patients in pediatric locations (pedVAC)

75. VAE Surveillance Changes for 2015
Modification 4: Introduction of a new denominator: Episodes of Mechanical Ventilation (EMV)
Total number of episodes occurring during month
Evidence based practices that improve outcomes in vent patient focusing on getting patient off
Need to explore use of other denominator with this new surveillance method
Vent days (required) and APRV (required)
EMV (optional)

76. NHSN Surveillance NHSN Lower Respiratory Event Surveillance
PNEU definitions are still available
Off-plan of VAP in adults, children, neonates and non-ventilated PNEU in adults, children and neonates
PNEU definitions are in Chapter 6, titled Pneumonia (Ventilator-Associated (VAP) and Non-ventilator-Associated Pneumonia (PNEU) Event
Purulent sputum is determined by direct exam/ Gram stain results
PNEU Pathogen exclusions are the same as for VAE protocol
Candida species or yeast not otherwise specified, Coag-neg Staph species, and Enterococcus species are excluded unless from lung tissue or pleural fluid
Cryptococcus, Histoplasma, Coccidioides, Paraoccidioides, Blastomyces, Pneumocystis are excluded for use in PNEU definition (PNEU 2, PNEU 3)

77. PNEU/VAP Modification 3
Pathogen reporting and secondary BSI attribution for the PNEU 1 is not permitted
NHSN application will default to NO for secondary BSI and NO for pathogens when PNEU1 is selected
Modification of the specific event to PNU1 to PNU2 or PNU3 is permitted if PNU 2 or 3 definitions are met within the RIT
Matching pathogens recovered from a respiratory culture and blood culture alone do not allow for assignment of a BSI as secondary to PNEU

78. PNEU/VAP
Endotracheal aspirate and sputum specimens are not minimally contaminated LRT specimens
Quantitative and semi-quantitative equivalent reporting of pathogens recovered from minimally contaminated LRT specimens (BAL, protected specimen brush) are now acceptable

79. Identifying HAIs for NHSN Surveillance
SSI
LabID
VAE
Infection Window Period
N/A
Date of Event
YES
POA
HAI
Repeat Infection Timeframe (RIT)
Secondary BSI Attribution Period *
Not Applicable

80. Who is eligible for VAE?
Inpatients of acute care hospitals, long term acute care hospitals, inpatient rehabilitation facilities
Patients in adult locations are eligible for VAE surveillance
Pediatric patients in adult locations are included in surveillance
Adult patients in pediatric locations are included in pedVAP surveillance
Patients ventilated for ≥ 3 days
Patients not on high frequency ventilation (HFV) or extracorporeal life support (ECLS)

81. What about other alternative modes of mechanical ventilation?
Include patients who are receiving a conventional mode of ventilation and:
Prone positioning
Nitric oxide therapy
Helium-oxygen mixture
Epoprostenol therapy
Include patients on Airway Pressure Release Ventilation (APRV) or related modes

82. APRV and VAC Determinations
Evaluation for VAC will be limited to the FiO2 parameter when the patient is on APRV for the entire calendar day, since changes in PEEP as indicated in this surveillance algorithm may not apply to APRV
Do not use Hi/Lo values
Do not designate PEEP as “0” on data collection tool or VAE calculator
PEEP is N/A
When patient is on APRV for parts of calendar day PEEP values recorded during periods of time when the patient in on conventional mode of ventilation is used to determine daily minimum PEEP

83. PEEP and FIO2
A sustained increase in the daily minimum PEEP of ≥ 3 cmH20 following a period of stability or improvement on the ventilator is one of two criteria that can be used to meet the VAC definition
A sustained increase in the daily minimum FIO2 of ≥0.20 (20%) following a period of stability or improvement on the ventilator is the second of the two criteria that can be used to meet the VAC definition

84. Daily Minimum PEEP and FIO2
PEEP and FIO2 settings are documented across the calendar day are used to identify daily minimum PEEP and FIO2
Typically both are recorded in the paper or electronic medical record on respiratory therapy and/or nursing flowsheets
Always use a calendar day
Choose the lowest PEEP and FIO2 setting during the calendar day that was maintained for at least 1 hour, if no value was maintained for 1 hour, select the lowest value regardless of timeframe
Exception to 1 hour maintenance
Ventilation began late in calendar day
Ventilation stopped early in calendar day
Ventilation setting unstable throughout calendar day

85. VAE Definition Algorithm Summary
FIO2 or Peep
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
Positive results of microbiological testing
Possible Ventilator Associated Pneumonia (PVAP)
Respiratory
Status
Component
Infection
Inflammation
Component
Additional
evidence

86. VAE Baseline Period .

87. VAE Baseline Period
In the example below, there is no VAC, because the FiO2 on MV day 4 is higher than the FiO2 on MV day 3 (and therefore not stable or decreasing) – even though the FiO2 on MV days 3 and 4 meets the 20-point threshold when compared with the daily minimum FiO2 on MV days 5 and 6.

88. Guidance for determining daily minimum PEEP and FIO2
Must be sufficient documentation of consecutive recordings to meet the minimum required duration of 1 hour
Must be consistent and standardized
Monday
12 am
3 am
4 am
5 am
6 am
9 am
12 pm
3 pm
MV mode
ACV
FIO2
0.80
0.70
0.75
PEEP 8

89. Daily Minimum PEEP and FIO2
Use both the daily minimum PEEP and FIO2 to assess for period of stability and improvement
Do not compare values from one calendar day to another calendar day to determine stability, improvement or worsening
Remember daily minimum PEEP values of 0-5 cmH2O are considered the same (equal 5) for VAE determinations
Daily Min PEEP
Daily Min FIO2
Monday 10
0.75
Tuesday 8
0.50
Wednesday 5
0.45
Thursday
0.40
Friday
Saturday
Sunday

90. Evidence of Worsening Oxygenation
After period of stability or improvement the patient has at least one of the following indicators:
Increase in minimum FIO2 of ≥ 0.20 over the daily minimum FIO2 in the baseline period which was sustained ≥ 2 calendar days OR
Increase in daily minimum PEEP values ≥ 3 cmH20 over the daily minimum PEEP the baseline period which was sustained ≥ 2 calendar days

91. Date of Event
Date of event of worsening oxygenation (day 1 of the required ≥ 2 day period)
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

92. 14-Day VAE Event Period Date of event sets VAE Event Period
VAE Event Period is the timeframe during which criteria for other events--- IVAC, PVAP----must be met
Each VAE Event Period is a 14-day in duration
Day 1 is the date of event
Cannot upgrade VAE on data collected outside of VAE Event Period
Blood cultures must be collected during the 14-day event period for a BSI to be secondary to VAE

93. VAE Surveillance Algorithm: VAE

94. VAE Surveillance Algorithm: IVAC

95. VAE Surveillance Algorithm: PVAP

96. VAE Surveillance Algorithm: PVAP

97. Temperature and WBC
If an abnormal temperature (> 38˚ C or < 36˚ C) or WBC ( > 12,000/ mm3 or ≤ 4,000) documented during the VAE Window Period, it should be used to determine to whether patient meets IVAC definition, regardless whether they occur on admission or outside VAE Window Period

98. IVAC New Antimicrobials
New antimicrobial is 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
Considered new if it was not given to patient on either days preceding the current start date
Must be continued for ≥ 4 consecutive days
No requirement that the same antimicrobial be given on all 4 consecutive days
Administered IV, IM digestive tract or respiratory tract

99. PVAP VAC and IVAC must be met
Laboratory test collection dates must occur
On or after calendar day 3 of ventilation and within 2 calendar days before or after onset of worsening oxygenation (VAE Window Period)
Organism exclusions must be considered
Normal respiratory/oral flora, mixed respiratory/oral flora
Candid species or yeast not otherwise specified, coag-neg Staph species, Enterococcus species, unless isolated from lung tissue or pleural fluid
Community-associated pathogens

100. Pathogen Reporting Pathogens are not reported for VAC or for IVAC
Pathogens may be reported for PVAP, according to usual pathogen and antimicrobial susceptibility reporting methods

101. Secondary BSI to PVAP Secondary BSI may only be reported for PVAP
When at least one eligible organism from the blood culture specimen matches an eligible organism from an appropriate respiratory tract specimen collected during the VAE Window Period
And when the blood culture was collected during the 14-day event period

102. VAE Reporting Post-Discharge
It is not required to monitor for VAEs after discharge if a patient is transferred to another facility while still on mechanical ventilation.
VAEs discovered within 2 calendar days of discharge (where the day of discharge is day 1) should be reported to NHSN.
No additional ventilator days are reported.

103. Using VAE Calculator

104. VAE Summary Patient must be ventilated for more than 2 calendar days
Patient must have ≥ 2 calendar days of stability or improvement of oxygenation immediately followed by ≥ 2 calendar days of worsening oxygenation
Earliest date of event for VAE is mechanical ventilation day 3

105. Easy Approach

106. Thank you
Slides and information prepared using CDC/NHSN Training February 2015 slides
and materials