© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CUSP for VAP: EVAPNHSN VAE Surveillance Definition Review

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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CUSP for VAP: EVAPNHSN VAE Surveillance Definition ReviewPresented by:Kathleen Speck, MPHSeptember 13, 2012 Armstrong Institute for Patient Safety and Quality

Our Collaborators

– Karol G. Wicker, MHSSenior Director, Quality Policy & AdvocacyMaryland Hospital Associationkwicker@mhaonline.org

– Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvaniamcatanzaro@haponline.org

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Learning Objectives

• To discuss the NHSN VAE definition.• To discuss the linelist generator developed by

Dr. Michael Klompas

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NHSN Surveillance 2012-2013

• Assessment must take place for all VAE tiers– VAC - Ventilator-associated Condition– IVAC - Infectious Ventilator-associated

Condition– Possible Ventilator-associated Pneumonia– Probable Ventilator-associated Pneumonia

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VAC Definition Criteria8

• Patient intubated for > 2 calendar days• Baseline stability

– Baseline:• 2 calendar days immediately preceding the first

day of increased daily minimum PEEP or FiO2 requirements

– Stability:• ≥ 2 calendar days of stable or decreasing daily

minimum FiO2 or PEEP requirements

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Threshold change for VAC

• Threshold rise in daily minimum:– PEEP by ≥3 cm H2O or– FiO2 by ≥20 points – sustained ≥2 days

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Example - VAC

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Stable

Example – no VAC

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Unstable

Example – no VAC

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Subsequent VAEs

• VAEs are defined as 14 days– Starts on day 1 of worsening oxygenation– New VAE cannot be reported until 14 day

period has elapsed

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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

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Setting Up a Linelist

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Linelist Definitions

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Steps to generate linelist for VAE

• Begin with “Daily Linelist”• Enter daily minimum PEEP and FiO2 for

every ventilated patient for every calendar day the patient spends any time on a ventilator

• Worksheet will automatically flag events that fulfill criteria for VAC

• If a patient is not identified as having VAC, don’t collect any further information for that patient.

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Step 1 – VAC

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Determination of IVAC

• Patients where VAC has already 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

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Step 2 - IVAC

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New Antimicrobial AgentQualifying Antimicrobial Day (QAD)

• Any agent listed in the Appendix of the Device Associated Events: VAE (pages 10-19 through 10-21) that:– Is initiated on or after the third day of mechanical

ventilation AND – is started in the 5 day period defined by

• 2 days before • the day of the event• the 2 days after

AND– Was not given to the patient on either of the two days

preceding the current event

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Qualifying Antibiotic Days - Timing(VAC has already been established)

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Example Antibiotic Worksheet

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Determination of Possible VAP or Probable VAP

• 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.

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Step 3 – Possible VAP or Probable VAP

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• Questions?

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