Ventilator-Associated Events A Patient Safety Opportunity Michael Klompas MD, MPH, FRCPC, FIDSA,...

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Ventilator-Associated EventsA Patient Safety Opportunity

Michael Klompas MD, MPH, FRCPC, FIDSA, FSHEA

Harvard Medical School,

Harvard Pilgrim Health Care Institute, and

Brigham and Women’s Hospital, Boston, USA

CUSP for Mechanically Ventilated Patients

November 19, 2014

Disclosures

Grant funding from the US Centers for Disease Control and Prevention

Honoraria from Premier Healthcare Alliance for lectures on VAP surveillance

Ventilator-associated pneumonia

Affects ~5-10% of ventilated patients

Increases ICU length of stay by ~4-7 days

Increases hospital length of stay by ~14 days

Crude mortality rate 30-50%

Attributable mortality 8-12%

Adds ~$10-50,000 to cost of hospital stay

CMS 1533-P, 2007Safdar et al, Crit Care Med 2005; 33:2184

Tejerina et al, J Crit Care 2006; 21:56 Muscedere et al, J Crit Care 2008;23:5-10

Eber et al, Arch Intern Med 2010;170:347-353Nguile-Makao et al, Intensive Care Med 2010;36:781-9

Beyersmann et al, Infect Control Hosp Epidemiol 2006;27:493

States with mandatory reporting legislation for healthcare-associated infections

Association for Professionals in Infection Control and Epidemiology 2012

Mandatory reporting enacted

Study bill

2016 National Patient Safety Goal(proposed)

Prevent ventilator-associated pneumonia

“Centers for Medicare and Medicaid Services (CMS)announced its decision to cease paying hospitals for some of the

care made necessary by ‘preventable complications’”

These initiatives all presume we can accurately identify and track who does and does not have VAP….

…but VAP is a difficult diagnosis.

Diagnostic Criteria for VAP

High Temp

Low Temp

High WBC

Low WBC

Low P:F Ratio

Increased vent settings

Purulent secretions

Gram stain neutrophils

New AntibioticStart

Infiltrate

CDC Old Definition ✓ ✓ ✓ ✓ ✓ ✓ ✓CDC New Definition ✓ ✓ ✓ ✓ ✓ ✓ ✓HELICS Criteria ✓ ✓ ✓ ✓ ✓ACCP Criteria ✓ ✓ ✓ ✓ ✓Clinical Pulmonary Infection Score ✓ ✓ ✓ ✓ ✓ ✓ ✓Johanson’s Criteria ✓ ✓ ✓ ✓

Ego et al. Chest 2014;ePub ahead of print

Impact of Diagnostic Criteria on VAP Prevalence

CDC Old

Criter

CDC New

HELICS

ACCPCPIS

sProspective surveillance, 1824 patients, Tertiary Med-Surg Unit, Belgium

Ego et al. Chest 2014;ePub ahead of print

CDC’s old surveillance definition for VAP

Patient must fulfill each of the three categories below:ChestRadiograph

Any one of the following:1. New, progressive, or persistent infiltrate2. Consolidation3. Cavitation

Systemic Signs

Any one of the following:1. Temperature >38°C2. WBC <4,000 or >12,000 WBC/mm3

3. For adults 70 years old, altered mental status with no other recognized cause

Pulmonary Signs

Any two of the following:1. New onset of purulent sputum, or change in character

of sputum, or increased respiratory secretions, or increased suctioning requirements

2. New onset or worsening cough, or dyspnea, or tachypnea

3. Rales or bronchial breath sounds4. Worsening gas exchange, increased oxygen

requirements, or increased ventilation demand

Complicated

Labor Intensive

Subjective

Non-Specific

“Diffuse patchy airspace disease right greater than left with obliteration of both hemi-diaphragms. Opacities possibly slightly increased since yesterday accounting for changes in patient position and inspiration. This could represent atelectasis, pneumonia, or effusion.”

Sources of fever and infiltrates

Diffuse alveolar damage

Thromboembolic disease

Hemorrhage

Infarction

Fibrosis

Carcinoma

Lymphoma

Contusion

Tracheobronchitis

CLABSI

Drug fever

Meduri, Chest 1994; 106:221-235Petersen, Scand J Infect Dis 1999; 31:299-303

Pulmonary edema

Atelectasis

Contusion

Fibrosis

Accuracy of clinical diagnosis of VAPRelative to 253 autopsies

0%PositivePredictiv

eValue

Tejerina et al., J Critical Care 2010;25:62

Sensitivity

Loose definition:Infiltrate and 2 of temp / wbc / purulence

Strict definition:Infiltrate and 3 of temp / wbc / purulence

Accuracy of quantitative BAL culturesRelative to histology

0%PositivePredictiv

eValue

Kirtland, Chest 1997;112:445Fabregas, Thorax 1999;54:867

Chastre, Am Rev Respir Dis 1984;130:924Torres, Am J Resp Crit Care Med 1994;149:324

Marquette, Am J Resp Crit Care Med 1995;151:1878Papazian, Am J Resp Crit Care Med 1995;152:1982

Sensitivity

Implications for surveillance

Interobserver agreement in VAP surveillance

IP 1 (11 VAPs)

IP 2(20 VAPs)3

IP 3 (15 VAPs)

Klompas, AJIC 2010:38:237Kappa = 0.40

50 ventilated patients with respiratory deterioration

6 Case Vignettes Presented to 43 Surveyors

Survey Respondents

Crit Care Med 2014;42:497

Ways to lower VAP ratesWithout meaningfully changing patient care

1. Narrowly interpret subjective clinical signs

2. Narrowly interpret radiographs

3. Seek consensus between multiple surveyors

4. Allow clinicians to veto surveillance determinations

5. Increase use of quantitative BAL for diagnosis

Klompas, Clin Infect Dis 2010:51:1123-26Klompas, Am J Infect Control 2012;40:408-10

U.S. National VAP ratesUnited States, 2004-2012

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

Source: CDC NNIS and NHSN

International VAP Rates

Austria

Scotla

France

Belgiu

USA Surg

USA Med

Source: CDC Europe and CDC USA

Increasing gap between clinical and surveillance VAP rates

Thomas et al. Am Surgeon 2011;77:998Skrupky et al. Crit Care Med 2012;40:281

Koulenti et al. Crit Care Med 2009;37:2360Vincent et al. JAMA 2009;302:2323

100Clinical Diagnosis Surveilance Diagnosis

15% of ICU pts on

VAP Rx on cross-sectional surveys

We need to publicly report VAP rates to catalyze

improved quality of care and save lives!

But the definition of VAP is ambiguous, hard to

implement, and open to be gamed!

Where does this leave hospitals?

Critical Care Medicine 2013;41:2467-2475

An alternative approach to surveillance

Broaden the focus from pneumonia alone to the syndrome of ventilator complications in general

• More accurate description of what can be reliably determined using surveillance definitions

• Emphasizes the importance of preventing all complications of mechanical ventilation, not just pneumonia

Streamline the definition using quantitative criteria

• Reduce ambiguity• Improve reproducibility• Enable electronic collection of all variables

Ventilator-associated conditions (VAC)

DatePEEP(min)

FiO2(min)

Jan 1 10 100

Jan 2 5 50

Jan 3 5 40

Jan 4 5 40

Jan 5 8 60

Jan 6 8 50

Jan 7 8 40

Jan 8 5 40

Jan 9 5 40

Sustained rise in daily minimum PEEP ≥3cm or FiO2 ≥20 points after a period of stable or improving daily minimum PEEP or FiO2

VACVentilator-Associated Condition

IVACInfection-related

Ventilator-Associated Complication

PossiblePneumonia

ProbablePneumonia

Infection-related ventilator-associated complications (IVAC)

DatePEEP(min)

FiO2(min)

WBCmin

WBCmax

Antibiotic Antibiotic

Jan 1 10 100

Jan 2 5 50

Jan 3 5 40 99.1 99.9 8.4 10.1

Jan 4 5 40 99.9 101.9 9.9 11.2 Linezolid Cefepime

Jan 5 8 60 98.6 102.2 12.1 15.3 Linezolid Cefepime

Jan 6 8 50 98.8 100.3 14.1 17.4 Cefepime

Jan 7 8 40 96.8 99.1 15.0 16.1 Cefepime

Jan 8 5 40 Cefepime

Jan 9 5 40 Cefepime

VAC with concurrent abnormal temp or WBC countAND ≥4 days of new antibiotics

Ventilator-associated pneumonia

DatePEEP(min)

FiO2(min)

Gram StainPolys

Gram Stain Epis

Culture

Jan 1 10 100

Jan 2 5 50

Jan 3 5 40

Jan 4 5 40 3+ 0 Klebsiella pneumoniae

Jan 5 8 60

Jan 6 8 50

Jan 7 8 40

Jan 8 5 40

Jan 9 5 40

PROBABLE VAP

IVAC with concurrent purulent sputum (Gram stain neutrophils)and / or positive pulmonary cultures

http://www.cdc.gov/nhsn/VAE-calculator

VAE9.9 events

per 1000 vent days

VAP10.6 events

per 1000 vent days

100 39 109

Muscedere et al. Chest 2013;144:1453

Canadian Critical Care Trials Group ABATE Study11 ICUs, 1330 patients, VAE vs VAP Surveillance

VAE ≠ VAP

Image from http://img.ehowcdn.com/article-new/ehow/images/a07/86/tp/increase-torque-cars-rear-end-800x800.jpg

Qualitative analysis of 153 VAEsRoyal Brisbane & Women’s Hospital, Queensland, Australia

Pneumonia38%

Edema26%

Atelectasis15%

ARDS 6%

Abx + Furosemide 6%

Other 8%Hayashi et al. Clin Infect Dis 2013;56:471-477

VAE = VAP + CHF + ARDS + Atelectasis +Others

Attributable Mortality of VAC versus VAP

Odds Ratio or Hazard Ratio1 10520.

USA – 3 centersPLoS ONE 2011;6:e18062

USA – 8 centersCrit Care Med 2012;40:3154

Canada – 11 centersChest 2013;144:1453

Netherlands – 2 centersAm J Resp Crit Care Med 2014;189:947

USA – 2 centersCrit Care Med 2014;ePub

USA – 1 centerInfect Control Hosp Epidemiol 2014;5:502

VAC VAP

VAE Prevention

Strategies for preventing VAEs

Decrease duration of mechanical ventilation

Target the primary

conditions associated with VAEs

Strategies for preventing VAEs

Decrease duration of mechanical ventilation

Target the primary

conditions associated with VAEs

Minimize sedation

Paired SATs and SBTs

Early mobility

Low tidal volume ventilation

Conservative fluidmanagement

Minimize blood transfusions

Conservative fluid management

http://microgravity.grc.nasa.gov/SOPO/ICHO/HRP/ExMC/IVFluids/images/IVbag.jpg

About a third of VACs are due to pulmonary edema

Elevated central venous pressures associated with increased mortality rates

Randomized controlled trial showing conservative fluid management associated with more ventilator-free days compared to liberal fluid management

Boyd et al., Crit Care Med 2011;39:259ARDSnet, NEJM 2006;354:2564

BNP Driven Fluid Management

• Randomized controlled trial of ventilator weaning

• 304 patients randomized to daily BNP levels versus usual care

• Patients randomized to daily BNP levels• More diuretics• More negative fluid balance• Less time to extubation• 50% fewer VAEs 0%

20%VAEs

UsualCare

DailyBNP

Mekontso Dessap et al. Chest 2014; ePub ahead of print

Baseline 6 months 15 months 24 months0

Oral Intubation Closed Suctioning SystemETT with Subglottic Drainage Vent Circuit ChangesHeated Humidifier Changes Suction System ChangesHOB elevation CHG mouthwash

Canadian Critical Care Trials Group ABATE StudyEnhanced care for vented patients, 11 ICUs, 1330 patients

Sinuff et al. Crit Care Med 2013;41:15-23

Canadian Critical Care Trials Group ABATE StudyEnhanced care for vented patients, 11 ICUs, 1330 patients

Muscedere et al. Chest 2013;144:1453-1460

Baseline 6 months 15 months 24 months0

16VAC Rate (trend P=.05)

CDC Prevention Epicenters’Wake Up and Breathe Collaborative

Prospective quality improvement collaborative

Goal: prevent VAEs through less sedation and earlier liberation from mechanical ventilation

Mechanism: increase performance of paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)

12 ICUs affiliated with 7 hospitals

Klompas et al., IDWeek 2014, Abstract 1236

CDC Prevention Epicenters’Wake Up and Breathe Collaborative

63% in SATs

16% in SBTs

81% in SBTs done with

sedatives off

37% in VACs

65% in IVACs

SATs / SBTs VAEs

Klompas et al., IDWeek 2014, Abstract 1236

Ventilator-associated eventsA patient safety opportunity

Broaden Awareness

• VAE surveillance provides hospitals with a fuller picture of serious complications in mechanically ventilated patients

Catalyze Prevention

• A significant portion of VAEs are likely preventable

Reflect and Inform Progress

• VAE surveillance provides an efficient and objective yardstick to track one’s progress relative to oneself and to peers

NEJM 2013;368:1472

Thank You!

Michael Klompas (mklompas@partners.org)

Next Steps

CUSP for Mechanically Ventilated Patients

Next Steps: Homework

By January 28, 2015

Determine where data needed for VAE surveillance is stored.

Going forward, collect PEEP and FiO2 data for all mechanically ventilated patients in the unit.

Next Onboarding Call: Assessing Patient Safety Culture using the Hospital Survey on Patient Safety (HSOPS)

December 3, 2014 1:00 – 2:00 PM EST

Examine the purpose of collecting HSOPS data.

Review data to be collected for the duration of the project.

Implement a plan to collect data in your unit.

Mark Your Calendar:Upcoming Onboarding Sessions

ACTION DATEOrientation Webinars

4: Assessing Patient Safety Culture using the Hospital Survey on Patient Safety (HSOPS)

Dec 3, 1–2 pm EST

Project Kick-Off Dec 17, 1–3 pm EST

CUSP 4 MVP

Resources

Visit: https://armstrongresearch.hopkinsmedicine.org/

cusp4mvp.aspx

Email: cusp4mvp@jhmi.edu

Ventilator-Associated Events A Patient Safety Opportunity Michael Klompas MD, MPH, FRCPC, FIDSA,...

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