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NHSN VAE Surveillance Definition Review

NHSN VAE Surveillance Definition Review. Presented by: Kathleen Speck, MPH January 24, 2013 Armstrong Institute for Patient Safety and Quality. Learning Objectives. While we are not using VAE surveillance - To become more comfortable with the new VAE surveillance definitions.

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NHSN VAE Surveillance Definition Review

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  1. NHSN VAE Surveillance Definition Review Presented by: Kathleen Speck, MPH January 24, 2013 Armstrong Institute for Patient Safety and Quality

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

  3. History of NHSN VAE Surveillance Definition • Current NHSN VAP surveillance definition • Subjective • Not sensitive or specific1-3 • Requires radiographic findings – often unclear • Requires clinical signs and symptoms • Doesn’t allow accurate validation of success of prevention strategies4-7 • Doesn’t allow establishment of valid benchmarks Girard T, et al, Lancet 2008 Strom T, et al, Lancet 2010 The Acute Respiratory Distress Syndrome Network , N Engl J Med 2000 Klompas M, JAMA 2002 Klompas M, Am J Infect Control 2010 Klompas M, et al, Clin Infect Dis 2008 Zilberberg MD, et al, Clin Infect Dis 2010 Armstrong Institute for Patient Safety and Quality

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

  5. NHSN VAE Definition • Objective • Streamlined • Potentially automatable • Will define a broad range of conditions and complications occurring in mechanically ventilated patients8 Armstrong Institute for Patient Safety and Quality

  6. Which locations should use VAE surveillance?8 • Inpatient • Acute care hospitals • Long term care hospitals • Rehabilitation facilities • Unit type (examples) • Critical/intensive care units • Specialty care units • Step-down units • Long term care units Armstrong Institute for Patient Safety and Quality

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

  8. Other VAE Associated Definitions

  9. VAE Definition Tiers8 • Respiratory status component Possible Future Public Reporting Definitions • Infection / inflammation component • Additional evidence Internal Quality Improvement Draft – CDC Device-associated Events – VAE Armstrong Institute for Patient Safety and Quality

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

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

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

  13. VAC Definition Criteria8 • Patient on mechanical ventilation for > 2 calendar days • Baseline stability • Baseline time period: • The 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2 • Stability: • The same 2 calendar days with stable or decreasing daily minimum PEEP or FiO2 Armstrong Institute for Patient Safety and Quality

  14. Definition – Worsening oxygenation • Worsening oxygenation – Changes sustained for ≥ calendar days: • Increase in daily min PEEP of ≥ 3 cm H2O over PEEP baseline period • Increase in daily min FiO2 of ≥ 0.20 (20%) over the daily minimum FiO2. Armstrong Institute for Patient Safety and Quality

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

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

  17. 4 and 3 day VAE window period(Both of these are VACs) 4 day VAE window 3 day VAE window Armstrong Institute for Patient Safety and Quality

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

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

  20. 14 day Event period Armstrong Institute for Patient Safety and Quality

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

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

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

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

  25. IVAC: Basic Case VAC IVAC Armstrong Institute for Patient Safety and Quality

  26. IVAC with 3 or 4 day VAE event window Not IVAC VAC Armstrong Institute for Patient Safety and Quality

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

  28. IVAC Abx: Basic Case Armstrong Institute for Patient Safety and Quality

  29. 3 day VAE Event Window and QADs Doesn’t meet Abx criteria Armstrong Institute for Patient Safety and Quality

  30. IVAC Abx– Multiple Abx, Example 1 Meets Abx criteria Armstrong Institute for Patient Safety and Quality

  31. IVAC Abx – Multiple Abx, Example 2 Doesn’t meet Abx criteria Armstrong Institute for Patient Safety and Quality

  32. IVAC Abx– Consecutive days definition When the same Abx is given every other day, the day in between is considered a QAD. Meets Abx criteria. Armstrong Institute for Patient Safety and Quality

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

  34. Possible VAP – Criteria 1 • Criteria 1: Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi or trachea that contain ≥25 neutrophils and ≤10 squamous epithelial cells per low power field[lpf, x100] • If the lab reports semi-quantitative results, those results must be the equivalent to the above quantitative results. • OR Armstrong Institute for Patient Safety and Quality

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

  36. Possible VAP Case 1 Possible VAP criteria fulfilled. Purulent sputum was collected within window. Organism is not used here. Armstrong Institute for Patient Safety and Quality

  37. Possible VAP Case 2 Possible VAP criteria fulfilled. BAL collected within 5 day VAE event window. Grew heavy S. aureus, known pathogen. Armstrong Institute for Patient Safety and Quality

  38. Possible VAP Case 3 Possible VAP criteria not fulfilled. Criteria for VAC are not fulfilled. Armstrong Institute for Patient Safety and Quality

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

  40. Probable VAP Criteria 1, part 1 • Part 1 - Essentially the first part of this criteria is the same as the first criteria from Possible VAP. • Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi or trachea that contain ≥25 neutrophils and ≤10 squamous epithelial cells per low power field [lpf, x100] • If the lab reports semi-quantitative results, those results must be the equivalent to the above quantitative results. AND Armstrong Institute for Patient Safety and Quality

  41. Probable VAP Criteria 1, part 2 • One of the following • Positive culture of endotracheal aspirate, ≥ 105 CFU/ml or equivalent semi-quantitative result • Positive culture of a bronchoalveolar lavage, ≥ 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 • Excludes the following • Normal respiratory flora, mixed respiratory/oral flora or equivalent • Candida species of yeast, not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species • OR Armstrong Institute for Patient Safety and Quality

  42. Probable VAP Criteria 2 • Criteria 2: One of the following – without the requirement for purulent respiratory secretions: • Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and not from an indwelling chest tube) • Includes these otherwise excluded organisms • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterrococcus species (including VRE) • Positive lung histopathology • Includes these otherwise excluded organisms • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterrococcus species (including VRE) • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus and coronavirus. Armstrong Institute for Patient Safety and Quality

  43. Probable VAP- Case 1 Possible VAP criteria are fulfilled, purulent sputum and positive culture with pathogen. Armstrong Institute for Patient Safety and Quality

  44. Probable VAP- Case 2 Possible VAP criteria are fulfilled, while yeast is not a pathogen, the specimen is lung tissue, therefore criteria are met. Armstrong Institute for Patient Safety and Quality

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

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

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

  48. Semiquantitative Scale for Polys and Epis Armstrong Institute for Patient Safety and Quality

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

  50. Questions? Armstrong Institute for Patient Safety and Quality

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