NHSN VAE Surveillance Definition Review

transcript

Presented by:Kathleen Speck, MPHJanuary 24, 2013Armstrong 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

Armstrong Institute for Patient Safety and Quality2

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

1. Klompas M, JAMA 20022. Klompas M, Am J Infect Control 20103. Klompas M, et al, Clin Infect Dis 20084. Zilberberg MD, et al, Clin Infect Dis 2010

5. Girard T, et al, Lancet 20086. Strom T, et al, Lancet 20107. The Acute Respiratory Distress Syndrome Network , N

Engl J Med 2000

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

NHSN VAE Definition

• Objective • Streamlined• Potentially automatable• Will define a broad range of conditions and

complications occurring in mechanically ventilated patients8

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

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

Other VAE Associated Definitions

VAE Definition Tiers8

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 (IVAC)

Positive results of microbiological testing

Possible or Probable VAP

• Respiratory status component

• Infection / inflammation component

• Additional evidence

Possible Future Public

Reporting Definitions

Internal Quality

Improvement

8. Draft – CDC Device-associated Events – VAE

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

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

Episode of Mechanical Ventilation

• A period of days during which the patient is mechanically ventilated for at least a portion of each day.

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

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.

Example - VAC: Basic Case 1

MV Day Min PEEP Min FiO21 5 1002 5 803 5 604 5 505 5 506 5 707 5 708 5 80

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

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

4 and 3 day VAE window period (Both of these are VACs)

4 day VAE window

3 day VAE window

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.

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

MV Day Min PEEP Min FiO2

1 5 100

2 5 80

3 5 60

4 5 50

5 5 50

6 6 70 14 day

7 7 70 event

8 9 80 period

9 5 65

10 5 50

11 5 50

12 5 55

13 5 60

14 5 60

15 5 60

16 8 80 Not

17 8 80 VAC

18 8 80

19 8 75

20 7 70

21 7 65

22 7 60

23 6 55

14 day Event period

Is this event an IVAC? Criteria

Criteria must be met within the VAE event window (3, 4 or 5 day)

1. Criteria 1: • Temp (max) >38C (100F) or <36C (97F)

OR• WBC >=12,000 cells/mm3 or <=4,000

cells/mm32. Criteria 2:

• New antimicrobial agent(s) is started and is continued for >=4 days

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

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

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

IVAC: Basic Case

MV Day Min PEEP

Min FiO2 Tmin Tmax WBCmax

WBCmin

1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 3 5 60 37.5 38.1 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD6 5 70 37.5 37.9 12500 9000 QAD

7 5 70 37.1 37.4 8000 7000 QAD8 5 80 37.5 37.9 QAD

VAC IVAC

IVAC with 3 or 4 day VAE event window

MV Day

Min PEEP

Min FiO2

Tmin Tmax WBCmax

WBCmin

1 8 100 38.0 39.1 5000 4500

2 5 60 37.8 38.2

3 5 60 37.5 37.6 6000 5500 QAD

4 8 60 37.6 37.9 7500 7000 QAD

5 8 50 37.5 37.9 9000 8000 QAD

6 5 70 37.5 37.9 10000 9000 QAD

7 5 70 37.1 37.4 8000 7000

8 5 80 37.5 37.9

VAC NotIVAC

Determination of QADs

For this section, we will assume that requirements for the following have already been met:• VAC• Temperature and WBC (IVAC)

IVAC Abx: Basic Case

VAE day

Abx -4 -3 -2 -1 1 2 3 4 5 6

Levofloxacin

Yes Yes Yes Yes

QAD QAD QAD QAD QAD

3 day VAE Event Window and QADs

VAE dayAbx No

MVNo MV

-2 -1 1 2 3 4 5 6

Pip/Tazo Yes Yes Yes Yes Yes

QAD X X X X X

Doesn’t meet Abx criteria

IVAC Abx – Multiple Abx, Example 1

VAE dayAbx -4 -3 -2 -1 1 2 3 4 5 6Levofloxacin

Yes Yes Yes Yes Yes

Pip/Tazo Yes Yes Yes

Tobramycin Yes Yes Yes

QAD QAD QAD QAD QAD QAD QAD

Meets Abx criteria

IVAC Abx – Multiple Abx, Example 2

VAE dayAbx -4 -3 -2 -1 1 2 3 4 5 6Levofloxacin

Yes Yes Yes Yes Yes

Pip/Tazo Yes Yes Yes

Tobramycin

Yes Yes Yes

QAD QAD QAD QAD X X X

Doesn’t meet Abx criteria

IVAC Abx – Consecutive days definition

VAE dayAbx -4 -3 -2 -1 1 2 3 4 5 6Vancomycin

Yes Yes Yes

QAD QAD QAD QAD QAD QAD

When the same Abx is given every other day, the day in between is considered a QAD. Meets Abx criteria.

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

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.

• ORArmstrong Institute for Patient Safety and Quality

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

Possible VAP Case 1

MV Day

Min PEEP

Min FiO2

WBCmax

WBCmin

QAD Specimen Polys Epis Organism

1 5 100 38.0 39.1 2 5 80 37.8 38.2 5500 5500 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 Sputum ≥25/≤10 Normal

Respiratory Flora

5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 12500 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD

Possible VAP criteria fulfilled. Purulent sputum was collected within window. Organism is not used here.

Possible VAP Case 2

MV Day

Min PEEP

Min FiO2

WBCmax

WBCmin

QAD Specimen

Polys Epis

Organism

1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 12500 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD BAL Heavy S.

aureus

Possible VAP criteria fulfilled. BAL collected within 5 day VAE event window. Grew heavy S. aureus, known pathogen.

Possible VAP Case 3

MV Day Min PEEP

Min FiO2

WBCmax

WBCmin

QAD Specimen

Polys Epis

Organism

1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 5 5 50 37.5 37.9 6 5 60 37.5 37.9 10000 9000 7 5 70 37.1 37.4 8000 7000 8 7 80 37.5 37.9 6000 5000 BAL Heavy S.

aureus9 7 90 38.1 38.5

Possible VAP criteria not fulfilled. Criteria for VAC are not fulfilled.

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

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.

ANDArmstrong Institute for Patient Safety and Quality

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

• ORArmstrong Institute for Patient Safety and Quality

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.

Probable VAP- Case 1MV Day

Min PEEP

Min FiO2

WBCmax

WBCmin

QAD Specimen

Polys Epis

Organism

1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 12500 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD BAL ≥25/

≤10S. aureus≥ 104 CFU/ml

Possible VAP criteria are fulfilled, purulent sputum and positive culture with pathogen.

Probable VAP- Case 2

MV Day

Min PEEP

Min FiO2

WBCmax

WBCmin

QAD Specimen

Polys Epis

Organism

1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 10000 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD Lung

tissue Yeast

Possible VAP criteria are fulfilled, while yeast is not a pathogen, the specimen is lung tissue, therefore criteria are met.

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.

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

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.

Semiquantitative Scale for Polys and Epis

None Enter 0Few, rare, ≤10 cells/lpf Enter 1Moderate, ≥25 cells/lpf Enter 2Many Enter 3Abundant Enter 4

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

• Questions?

NHSN VAE Surveillance Definition Review

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