1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Infection Prevention 2 VAE Surveillance Training: Infectious Ventilator-Associated Complication (IVAC) ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University February 25, 2015

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

3. VAE Surveillance Training: Infectious Ventilator-Associated Complication (IVAC) 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 – IVAC 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 – IVAC Objectives Review history of VAE surveillance Review the definitions of VAE tiers Discuss case finding and determination of the second tier in VAE–IVAC

6. 6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Polling Question Did you attend the CDC’s “Applying the 2015 Changes to Accurately Report HAIs” on Feb 17-19, 2015? 1.Yes – in Atlanta 2.Yes – online 3.No 

7. 7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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 – IVAC NHSN VAE Definition Objective Streamlined Potentially automatable Defines a broad range of conditions and complications occurring in mechanically ventilated patients

9. 9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Which Locations Should Use VAE Surveillance? 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

10. 10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC VAE Definition Tiers 8 Possible Ventilator-Associated Pneumonia (PVAP)

11. 11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC CUSP 4 MVP–VAP VAE Surveillance Assessment must take place for all VAE tiers VAC Ventilator-associated Condition IVAC Infectious Ventilator-associated Complication Possible VAP Possible Ventilator-associated Pneumonia

12. 12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC VAE Attributable Hospital Mortality 10 10 Klompas, Infect Control Hosp Epidemiol, 2014

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

14. 14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Relationship VAC – IVAC VAC must be determined before IVAC can be considered

15. 15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC VAC Definition Criteria Patient intubated for >2 calendar day –Earliest day of event is calendar day 3 Baseline stability –Stable baseline period –Two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO 2

16. 16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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 covered in VAC call)

17. 17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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

18. 18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC PEEP: Change ^ ≥ 3 MV DayMin PEEPMin FiO 2 18100 2770 3650 4670 5560 6550 7870 8980 9650 10750

19. 19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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

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

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC FiO 2 : Change ^ ≥ 20 – not a VAC MV DayMin PEEPMin FiO 2 18100 2770 3655 4650 5570 65 76 8680 9650 10750

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC FiO 2 : Change ^ ≥ 20 – not a VAC MV DayMin PEEPMin FiO 2 18100 2770 3645 4650 5570 65 76 8680 9650 10750

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC FiO 2 : Change ^ ≥ 20 – not a VAC MV DayMin PEEPMin FiO 2 18100 2770 3650 4645 5570 65 76 8680 9650 10750

25. 25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Tier 2: IVAC – 1 st Part 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 > 38 o C (100.4 o F) or < 36 o C (96.8 o F), OR WBC ≥ 12,000 cells/mm 3 or ≤ 4,000 cell/mm 3 AND –A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days

26. 26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 5-Day VAE Event Window - IVAC MV Day Min PEEP Min FiO 2 Temp min Temp max WBC min WBC max Abx 15100 2570 365012.1 475036.937.612.116.8 557038.139.214.515.9 657038.438.912.613.6 767036.537.811.1 8680 9650 10750

27. 27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Tier 2: IVAC – 1 st Part 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 > 38 o C (100.4 o F) or < 36 o C (96.8 o F), OR WBC ≥ 12,000 cells/mm 3 or ≤ 4,000 cell/mm 3 AND –A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days

28. 28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC IVAC Antimicrobial Criterion Can be complicated Standardizes assessment method of antimicrobial therapy without some information: –Dosing –Renal function –Indication for therapy

29. 29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC What Antimicrobial Drugs Are Included? NOW: Mostly antibacterials, antifungals, limited antivirals ORIGINALLY: Broad range of agents for HAIs, not just respiratory infections NOT INCLUDED –Anti-HIV agents –Anti-tuberculosis agents –Agents used to treat viral hepatitis –Agents used to treat herpes virus infection –Anti-parasitics Listed in the Appendix, 10-VAE_FINAL Listed in the Appendix, 10-VAE_FINAL

30. 30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

31. 31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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

32. 32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD

33. 33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 Consider Levo VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD ???????

34. 34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

35. 35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 Consider Mero VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD ????

36. 36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

37. 37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 Consider Mero VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD

38. 38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 Consider Vanc VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD ???

39. 39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

40. 40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 Consider Vanc VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD

41. 41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

42. 42 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

43. 43 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 1 Consider Vanc VAE Day -3-212345 AbxLevo AbxMero AbxVanc QAD √√√√√√

44. 44 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 2 Consider Vanc VAE Day -3-212345 AbxVanc--Vanc--Vanc--Vanc Abx QAD ????

45. 45 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

46. 46 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 2 Consider Vanc VAE Day -3-212345 AbxVanc--Vanc--Vanc--Vanc Abx QAD √√√√√√√

47. 47 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 3 VAE Day -3-212345 AbxLevo AbxVanc Abx QAD ???????

48. 48 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Definition: New Antimicrobial Agent Any agent listed in the Appendix that is initiated in the VAE window period: New indicates it was not given to the patient on either of the 2 days preceding the current start date Must be continued for ≥ 4 consecutive days Does not need to be the same antimicrobial agent for the 4 days Must be administered IV, IM, via digestive tract or via respiratory tract Can be considered continuous if a single day is skipped between two doses of the same agent

49. 49 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC QAD – Example 3 VAE Day -3-212345 AbxLevo AbxVanc Abx QAD

50. 50 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 5-day VAE Event Window - IVAC MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx 15100No 2570No 365012.1No 475036.937.612.116.8No 557038.139.214.515.9No 657038.438.912.613.6Yes 767036.537.811.1Yes 8680Yes 9650Yes 10750No

51. 51 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 3-day VAE Event Window - IVAC MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx 155036.937.6 255038.139.212.113.6 385038.438.912.514.5No 485036.537.812.616.8No 576011.115.9Yes 657011.2Yes 7670Yes 8680Yes 9650No 10750No

52. 52 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 3-day VAE Event Window – Not IVAC MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx 155036.937.6 255036.539.212.113.6 385037.537.914.014.9 485037.937.811.612.8 576011.111.9 657011.2 7670 8680 9650 10750

53. 53 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 5-day VAE Event Window – Not IVAC MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx 1510039.9 257038.013.1 365011.9 475036.937.610.111.5 557036.537.211.511.6 657037.037.911.211.3 767036.537.811.1 8680 9650 10750

54. 54 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 1 A 69-year old female is seen in the ER with an admitting diagnosis of community acquired pneumonia (CAP). She is admitted to the ICU the same day on a vent. Review her ventilator settings and, if necessary, her temperature, white blood count (WBC) and antibiotic (ABX) information, and determine whether VAE criteria have been met and, if so, whether she meets VAC or IVAC criteria.

55. 55 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 1: Is this a VAE? Find the Event Day MV Day Min PEEP Min FiO2 Temp max WBC max Abx 18100 38.0Pip/Tazo 2650 39.0Pip/Tazo 3550 37.63.0Vanc IVPip/Tazo 4640 38.63.1 5670 39.03.0Vanc IV 6670 38.84.9 7670 38.05.0Vanc IV 8680 9650 Vanc IV 10750

56. 56 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 1:Event Day and Window Is this really a VAE? VAC? IVAC? MV Day Min PEEP Min FiO2 Temp max WBC max Abx 18100 38.0Pip/Tazo 2650 39.0Pip/Tazo 3550 37.63.0Vanc IVPip/Tazo 4640 38.63.1 5670 39.03.0Vanc IV 6670 38.84.9 7670 38.05.0Vanc IV 8680 9650 Vanc IV 10750

57. 57 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Polling Question Is this a VAE? If so, is it a VAC or IVAC? 1.No VAE, the patient had a CAP present on admission 2.VAC only 3.IVAC MV Day Min PEEP Min FiO2 Temp max WBC max Abx 18100 38.0Pip/Tazo 2650 39.0Pip/Tazo 3550 37.63.0Vanc IVPip/Tazo 4640 38.63.1 5670 39.03.0Vanc IV 6670 38.84.9 7670 38.05.0Vanc IV 8680 9650 Vanc IV 10750 

58. 58 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Polling Question Is this a VAE? If so, is it a VAC or IVAC? 1.No VAE, the patient had a CAP present on admission 2.VAC only 3.IVAC MV Day Min PEEP Min FiO2 Temp max WBC max Abx 18100 38.0Pip/Tazo 2650 39.0Pip/Tazo 3550 37.63.0Vanc IVPip/Tazo 4640 38.63.1 5670 39.03.0Vanc IV 6670 38.84.9 7670 38.05.0Vanc IV 8680 9650 Vanc IV 10750

59. 59 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 1: Discussion Patients are not excluded from VAE surveillance due to admitting diagnosis, symptoms existing before the VAE Window Period, presence of underlying conditions, or development of complications from admission criteria FiO 2 change is 20 points Temp >38C° WBC is ≤4,000 Days between administration of the same new Abx count as QADs as long as there is a gap of no more than 1 calendar day Vanc meets Abx criteria, Pip/Tazo does not

60. 60 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2 A 27-year old male is admitted to the neuro ICU following a motorcycle accident. He was intubated in the field and there was concern of aspiration upon intubation. Given the following information, identify event(s).

61. 61 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2 Polling Question Is this VAE? VAC only? IVAC? MV DayMin PEEPMin FiO2Temp minTemp maxWBC minWBC maxAbx 163037.137.64.3 None 263036.837.24.6 None 353037.037.95.4 None 463036.537.37.29.2None 563536.337.27.412.5None 665037.237.98.513.0Yes 765037.837.3Yes 864037.237.9Yes 965037.537.99.711.7Yes 1075037.437.19.610.9Yes 1174037.237.99.4 Yes 1283037.037.59.5 Yes 1383037.239.88.2 None 1473037.338.78.6 None 1576037.238.99.412.1Yes 1666037.139.813.013.5Yes 1768537.040.0Yes 18Patient Expires 

62. 62 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2 MV DayMin PEEPMin FiO2Temp minTemp maxWBC minWBC maxAbx 163037.137.64.3 None 263036.837.24.6 None 353037.037.95.4 None 463036.537.37.29.2None 563536.337.27.412.5None 665037.237.98.513.0Yes 765037.837.3Yes 864037.237.9Yes 965037.537.99.711.7Yes 1075037.437.19.610.9Yes 1174037.237.99.4 Yes 1283037.037.59.5 Yes 1383037.239.88.2 None 1473037.338.78.6 None 1576037.238.99.412.1Yes 1666037.139.813.013.5Yes 1768537.040.0Yes 18Patient Expires

63. 63 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2: Discussion Event is not on day 6, even though there is a 20 point increase in FiO2 from day 4 The FiO2 rates for days 4 and 5 aren’t stable: they are worsening

64. 64 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2 Polling Question Is this VAE? VAC only? IVAC? MV DayMin PEEPMin FiO2Temp minTemp maxWBC minWBC maxAbx 163037.137.64.3 None 263036.837.24.6 None 353037.037.95.4 None 463036.537.37.29.2None 563536.337.27.412.5None 665037.237.98.513.0Yes 765037.837.3Yes 864037.237.9Yes 965037.537.99.711.7Yes 1075037.437.19.610.9Yes 1174037.237.99.4 Yes 1283037.037.59.5 Yes 1383037.239.88.2 None 1473037.338.78.6 None 1576037.238.99.412.1Yes 1666037.139.813.013.5Yes 1768537.040.0Yes 18Patient Expires 

65. 65 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2 Polling Question Is this VAE? VAC only? IVAC? MV DayMin PEEPMin FiO2Temp minTemp maxWBC minWBC maxAbx 163037.137.64.3 None 263036.837.24.6 None 353037.037.95.4 None 463036.537.37.29.2None 563536.337.27.412.5None 665037.237.98.513.0Yes 765037.837.3Yes 864037.237.9Yes 965037.537.99.711.7Yes 1075037.437.19.610.9Yes 1174037.237.99.4 Yes 1283037.037.59.5 Yes 1383037.239.88.2 None 1473037.338.78.6 None 1576037.238.99.412.1Yes 1666037.139.813.013.5Yes 1768537.040.0Yes 18Patient Expires

66. 66 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Case 2 - Discussion Event is on day 15 (first day of worsening oxygenation) – FiO 2 ^ 30 points VAE Window Period is Day 13, 14 (2 days before), Day 15 (event day), and Days 16, 17 (2 days after) Abnormal WBC documented during VAE Window Period – 13,000 Abnormal Temp documented during VAE Window Period – Days 13-17 ≥ 38C However, only 3 QADs are documented prior to patient expiring

67. 67 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Remember! Gather FiO 2 and PEEP on all ventilated patients 1.Determine VAC first! 2.Then collect Temp and WBC 3.If Temp and WBC criteria for IVAC are met, then collect Abx information

68. 68 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Next Steps If you ARE using the NHSN system for VAE reporting: Upload six (6) months baseline data Confer rights to your CE, if you haven’t already done so CEs can then download your data from NHSN and upload to the CECity platform

69. 69 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Next Steps If you ARE NOT using the NHSN surveillance system, or you choose not to confer rights, this data can be entered into CECity system manually.

70. 70 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC If You Already Perform VAE Surveillance Collect an interesting and/or complicated case for discussion –1 case –Include case determination with APRV Email to cusp4mvp@jhmi.edu with the subject line VAE Surveillance Casecusp4mvp@jhmi.edu

71. 71 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC This Is Your Time! We have 1 more IP-dedicated session Share topics you would like to discuss

72. 72 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Cohort 2 VAE Data Submission July 2014 – Jan 2015

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

74. 74 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Final IP Session: March 25 VAE Surveillance: VAP (PVAP) Discuss solutions, barriers and ideas for data collection Discuss how to determine VAC if using APRV or other vent modes Cover determination of PVAC Discuss your cases Have questions or related topics of interest? Send requests to cusp4mvp@jhmi.edu Have questions or related topics of interest? Send requests to cusp4mvp@jhmi.edu

75. 75 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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

76. 76 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC Data Entry: Tablets Interface to data portal is the same as a computer Can enter manually as you walk unit Can use spreadsheet template to gather data and then upload to portal Can use our spreadsheet with dropdown menus and skip logic for both data collection and uploading

77. 77 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 1.CUSP 2.Daily Care Processes 3.Early Mobility 4.Low Tidal Volume Ventilation CUSP 4 MVP–VAP Categories

78. 78 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC CUSP 4 MVP – VAP Website Visit: https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx

79. 79 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC 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

80. 80 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsInfection Prevention: VAE Surveillance – IVAC