1

Telligen Quality Innovation Network-Quality Improvement OrganizationVentilator Associated Events –VAEJune 26, 2015

This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-OL-C1-6/2015-11086

Ventilator Associated Events (VAE)

Boulos (Paul) Nassar, MD MPHAssistant Professor

University of Iowa Hospitals and Clinics

Objectives

• Departure from the 2002 CDC definition of Ventilator Associated Pneumonia (VAP)

• Definition and algorithms of VAE• Limitations of VAE• VAE diagnosis with case studies• Proven strategies to prevent VAE

Ventilator associated pneumonia (VAP)

• >300,000 patients receive mechanical ventilation each year in the US

• VAP is an important cause of morbidity, mortality, and increased health-care costs in patients who are mechanically ventilated

• VAP is a nosocomially acquired infection• VAP is a complication of mechanical ventilation

patient safety measure

• Incidence rates: 0-6 per 1000 ventilator-daysMuscedere-Chest 13

Ventilator associated pneumonia (VAP)

• VAP is a hospital acquired infection (HAI)• Public reporting is mandated for HAI

• Surveillance programs attempt to identify events and analyze the circumstances surrounding their occurrence

• Surveillance programs are fundamental for effective prevention of future cases

CDC VAP definition (2002)

1. New or progressive and persistent radiographic abnormality developing in a patient on mechanical ventilation

2. >=1 systemic sign (fever, leukopenia or leukocytosis, or altered mental status)

3. Selected pulmonary criteria (change in respiratory secretions, worsening oxygenation, new onset of cough, dyspnea or rales)

Illustrative case #1

• 57 year old male patient is admitted with acute pancreatitis

• He is orally intubated and started on mechanical ventilation

• He is receiving aggressive fluid resuscitation• 72 hours into his illness, he becomes febrile and

his FiO2 requirements increase from 50% to 70%• A chest radiograph is obtained

Did he develop VAP?

Polling Question

Did this patient develop VAP?1) Yes2) No3) I don’t know

Limitations of chest radiograph

Pneumonia on autopsy No pneumonia on autopsy 24 45

Air bronchograms New 0 2

Worsened 4 3

Alveolar infiltrates New 0 6

Worsened 7 15

Wunderink et.al.Chest 92

Limitations of chest radiograph

• A chest radiograph may demonstrate a haziness that could be pneumonia, atelectasis, or pleural effusion

• Chest radiograph could represent pulmonary edema or ARDS

• Findings are more challenging to characterize on a portable film

• Inter-observer variability in interpretation

Other limitations in the definition

• Clinical signs and symptoms are unreliable for surveillance purposes

• Microbiological evidence is problematic because it is difficult to distinguish between colonization and infection– 22% of 95 intensive care unit patients became

colonized within 24 hours

• The 2002 CDC definition was found to be neither sensitive nor specific for VAP and cannot be accurately used for surveillance

• Definition met through different pathways• Burdensome to capture data

New definition

• Centers for Disease Control and Prevention’s new surveillance paradigms for patients who are mechanically ventilated

• This new VAE definition promotes surveillance in a uniform and consistent manner at all hospitals

New definition

• Uses objective data1. deterioration in respiratory status after a period

of stability or improvement on the ventilator2. evidence of infection or inflammation3. laboratory evidence of respiratory infection

• Chest radiograph is no longer part of the definition

New definition

• Reliable and standardize reporting

1. Public reporting2. Comparison among institutions 3. Pay-for-performance calculations

New VAE approach

• VAE groups all the conditions that result in a significant and sustained deterioration in oxygenation– > than 20% increase in the daily minimum FiO2

or – > 3 cm H2O in the daily minimum positive end-

expiratory pressure (PEEP)

What fulfills this new VAE definition?

What fulfills this new VAE definition?

1. Infectious conditions (tracheitis, tracheobronchitis, and pneumonia)

2. Noninfectious conditions (atelectasis, pulmonary embolism, pulmonary edema, ventilator-induced lung injury)

Timeline for VAE

• The day of intubation and initiation of mechanical ventilation is day 1

• Patients must be mechanically ventilated for more than 2 calendar days

• The earliest date of event for VAE (the date of onset of worsening oxygenation) is day 3

• The earliest day on which VAE criteria can be fulfilled is day 4

Timeline for VAE

D2D1 D3 D4

VAE

Ventilator associated

condition (VAC) Patient develops hypoxemia for a

sustained period of >2 days

The etiology of the hypoxemia is not

considered

Infection-related ventilator-associated

complication (IVAC)

Hypoxemia develops in the

setting of generalized infection or

inflammation, and antibiotics are instituted for a

minimum of 4 days

Probable or possible ventilator-associated

pneumonia (VAP) Additional lab

evidence of WBC on Gram stain of

respiratory secretions of acceptable quality,

or presence of respiratory pathogens

on quantitative cultures, in patients

with IVAC

Possible or Probable VAP

Positive results of microbiological testing

IVAC

General evidence of infection/inflammation

VAC

Baseline period of stability or improvement, followed by sustained period (>2 days) of worsening oxygenation

Patient on mechanical ventilation > 2 days Respiratory status

Infection/Inflammation

Micro data

Tier 1: Ventilator associated condition (VAC)

• VAC is defined by a sustained period of worsening oxygenation that immediately follows a baseline period of stability or improvement

• Captures both infectious and non-infectious condition and complication occurring in mechanically ventilated patients

• Detects variety of conditions, not all of which are preventable; hence they are called conditions not complications

Tier 2:Infection-related ventilator-associated complication (IVAC)

• Identifies the subset of VACs that are potentially related to infection1. Abnormal WBC2. Abnormal Temperature3. Initiation of a new antimicrobial agent

• IVAC will likely capture patients with pulmonary infections and extrapulmonary infections of sufficient severity to trigger respiratory deterioration

Tier 3: Probable or possible ventilator associated pneumonia (VAP)

• Patient who met 1 and 2 with • respiratory infections as manifested by

objective evidence of purulent respiratory secretions and/or positive results of microbiological tests performed on respiratory specimens

Tier 3: Probable or possible ventilator associated pneumonia (VAP)

• Possible VAP– presence of purulent secretions or a positive lower

respiratory tract culture• Probable VAP

– purulent secretions in addition to a positive lower respiratory tract culture meeting certain quantitative or semiquantitative thresholds of pathogen growth

– presence of a positive pleural fluid culture, lung tissue with histopathological evidence of infection, or positive diagnostic tests for Legionella or respiratory tract viruses

Limitations• Limited science to truly define VAP• Surveillance definitions don’t always align with

clinical events• Only 21% of “traditional” VAP are detected by

VAC and 17% by IVAC – Definition criteria– VAC does not equal VAP

• Minimum of duration of mechanical ventilation could miss a fraction of patients

Lilly et.al.Chest 13

Limitations• Measure physician behavior rather than

physiologic parameters or pathologic patient conditions – The measure can improve with changes in

behavior to game the system that do not reflect improvement in the condition of the patient

Lilly et.al.Chest 13

Pointers

• Acknowledge the limitations of the current definition• Cost of this surveillance program might be less• Avoid “manipulating” data to avoid detection of

events and lower the rates without improving delivery of care

• Opportunity of partnership between infection preventionist and other stakeholders – Tumor board model?

• Use VAC flag to make sure all VAP preventive measures are in place

Example 1: VAC or no VAC?

MV day Daily minimum PEEP

Daily minimum FiO2

1 0 100%2 0 50%3 5 50%4 5 50%5 8 50%6 8 50%

Polling Question

Does this case represent VAC?

1) VAC

2) No VAC

Example 2: VAC or no VAC?

MV day Daily minimum PEEP

Daily minimum FiO2

1 8 100%2 6 50%3 5 35%4 5 40%5 6 70%6 6 70%

Polling Question

Does this case represent VAC?

1) VAC

2) NO VAC

How do we prevent VAP?High to moderate evidence

• Use non invasive positive pressure ventilation!• Early discontinuation of mechanical ventilation• Minimize sedation • Daily interruption of sedation• Assess readiness to extubate daily • Early mobilization• Change the ventilator circuit only if visibly soiled• Utilize endotracheal tubes with subglottic secretion

drainage port • Head-of-bed elevation (30º to 45º)

How do we prevent VAP?Less evidence

• Oral decontamination and care with chlorhexidine

• Mechanical tooth brush

How do we prevent VAP?Generally not recommended

• Early tracheostomy• Early parenteral nutrition• Monitoring residual gastric volumes• Stress ulcer prophylaxis• Silver coated endotracheal tubes

Take home points

• New definition is a surveillance algorithm and not a clinical definition

• There is an opportunity to involve multiple stakeholders in addressing VAP

• Surveillance program is an opportunity to signal to the clinician when a VAC has occurred

• Anticipate changes as more data is being collected on the performance of this new algorithm

Questions

40

Contacts

Karen BolandSr. Quality Improvement FacilitatorEmail: karen.boland@area-d.hcqis.orgPhone: 630-928-5828

Debbie CamachoSenior QI ManagerEmail: debbie.camacho@are-d.hcqis.orgPhone: 630-928-5815

Meghan FoleyProject Assistant II Email: meghan.foley@area-d.hcqis.orgPhone: 630-928-5828