Post on 25-Aug-2020
transcript
Partnership For Patient Safety Ventilator Associated Pneumonias
Brian Koll, MD, FACP, FIDSAMedical Director and Chief, Infection Prevention BIMC
Professor of Clinical Medicine AECOM
The Problem with Ventilator Associated Pneumonias (VAPs)
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(VAP) is an important complication of mechanical ventilation
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Prior NHSN definitions•
Designed to be used for surveillance of all healthcare-associated PNEU
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Including, but not limited to VAP
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However, other bad things can also occur to patients on ventilators
The Problem with Ventilator Associated Pneumonias (VAPs)
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Chest Film•
Signs and Symptoms
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Microbiology
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Complex•
Subjective
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Lack of sensitivity•
Lack of specificity
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Variability•
Documentation
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Best Practices3
The Problem with Ventilator Associated Pneumonias (VAPs)
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Not ideal in an era of public reporting of healthcare-
associated infection (HAI) rates, comparisons among facilities, pay-for-
performance programs
The Problem of Reporting Ventilator Associated Pneumonias (VAPs)
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Exhausting
Defensive
Adversarial
The Problem with Ventilator Associated Pneumonias (VAPs)
Need definitions that are reliable, objective and valid
Ventilator Associated Events
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VAP Surveillance Definition Working Group•
September 2011
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Algorithm for detection of ventilator associated events (VAEs)
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Objective criteria•
Clinical data•
Improve sensitivity and specificity•
Potentially amenable to electronic data capture
New VAE Definition Algorithm
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Designed to detect•
Ventilator-associated conditions and complications
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including (but not necessarily limited to) VAP•
Requires a minimum period of time on the ventilator
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Focuses on readily-available, objective clinical data
AND•
Does not include chest radiograph findings
New VAE Definition Algorithm
New VAE Definition Algorithm
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January 2013•
Rate per 1,000 ventilator days
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Stratification•
ICU type
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Unit type•
Bed size
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Academic affiliation
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≥18 years of age•
Inpatients•
acute care hospitals
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long term acute care hospitals
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inpatient rehabilitation facilities
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Excluded•
high frequency ventilation
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extracorporeal life support
New VAE Definition Algorithm
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Included•
Patients who are receiving a conventional mode of mechanical ventilation while in the prone position
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Patients who are receiving a conventional mode of mechanical ventilation while receiving nitric oxide therapy or epoprostenol therapy
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Patients on Airway Pressure Release Ventilation (APRV) or related modes are INCLUDED
BUT•
VAC determined by changes in FiO2
only, since changes in PEEP as indicated in this surveillance algorithm may not be applicable to APRV
New VAE Definition Algorithm
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New VAE Definition Algorithm -
VAC
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New VAE Definition Algorithm -
VAC
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New VAE Definition Algorithm -
IVAC
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New VAE Definition Algorithm -
IVAC
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New VAE Definition Algorithm -
VAP
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New VAE Definition Algorithm Possible VAP
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New VAE Definition Algorithm Probable VAP
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New VAE Definition Algorithm
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VAEs defined by a 14 day period
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Event date = day 1•
A new VAE cannot be identified or reported until this 14 day period has elapsed
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Identifying VAEs
RoundsRespiratory TherapyPharmacyMicrobiologyCoding DepartmentIT DepartmentProcess Improvement
Chart ReviewRadiology Reports
Check List
Data Collection
Data Collection
What is Purulent Sputum?
Bacteria/100X Field or
WBC/10X FieldReport
0Bacteria:
“No Organisms Observed”WBC:
“No WBC Observed.”
1-5 Rare (1+)
6-10 Few (2+)
11-24 Moderate (3+)
≥
25 Many (4+)
Versalovic, J., K.C. Carol, G. Funke, J.H. Jorgensen, M. L. Landry, and D.W. Warnock.
2011.
Manual of Clinical Microbiology.10th ed., American Society for Microbiology, Washington, DC.
Following the Bundle
Following the Bundle
Following the Bundle
VAE Definitions
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Always follow the CDC NHSN surveillance criteria
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Biggest error……….not using the objective criteria but rather using subjective physician assessments
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Not all VAPs are diagnosed correctly by a physician
Reporting Data
•Don’t be bullied –
you are the experts•Concurrent review with your team•Don’t surprise anyone at the end of the month
VAP to VAE
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•New definitions•Improved quality•May not be comparable with past data•Lessons of the past still applicable
VAP BIB
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0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2005 2006 2007 2008 2009 2010 2011 2012
Rate per 1,000 Vent Days ICU
non‐ICU
New VAE Algorithm
location SummaryYr months vaecount numventdays vaeRate numpatdays VentDU VAPRate VAP_Mean
CSICU 2013 1 1 45 22.2 83 0.5 22.2 1.7
CCU 2013 1 0 89 0 229 0.4 0 1.1
MICU 2013 2 4 482 8.3 904 0.5 0 1.1
SICU 2013 1 0 99 0 297 0.3 0 2.4
ICU 2013 1 1 248 4.0 368 0.7 0 1.1
BIMC ICUs 6 963 6.2 1881 1.0 1.5
4VAC1 IVAC1 Possible PNEU
VAP Bundle Compliance
Unit VAP SIR VAP Rate VAP BundleMICU 0 0 100%5 Linsky Step-down 0 0 100%ICU 0 0 80%2 East 0 0 100%
Timely presentation of outcome and process dataRoot Cause AnalysesFailure Modes and Effects AnalysisSustainability
Team Building and Empowerment
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Board of TrusteesCaught Being Great
Administration
This Continues To Be A Team Effort