Shilla Patel OD, CIC [email protected] UC San Diego...
Transcript of Shilla Patel OD, CIC [email protected] UC San Diego...
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Shilla Patel OD, CIC [email protected]
UC San Diego Health System Infection Prevention/Clinical Epidemiology
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Name 3 adverse outcomes of VAE events
Identify 4 most common causes of VAE
Review latest research on VAE preventability
Review updated 2014 VAE Prevention guidelines
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VAP VAE ≠
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3 Large Academic Medical Centers
600 pts ◦ 300 on vent 2-6 days
◦ 300 on vent >7days
VAC ◦ PEEP increase by 2.5 > or Equal to 2 days
◦ FiO2 increase by 15 > or equal to 2 days
VAP – IPs assessed for CDC definition
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Table 2. Comparison of outcomes for ventilator-associated complication positive and negative patients and ventilator-associated pneumonia positive and negative patients.
Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, et al. (2011) Multicenter Evaluation of a Novel Surveillance Paradigm for Complications of Mechanical Ventilation. PLoS ONE 6(3): e18062. doi:10.1371/journal.pone.0018062 http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062
http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062
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Table 5. Qualitative analysis of 52 patients flagged with ventilator-associated complications or ventilator-associated pneumonia.
Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, et al. (2011) Multicenter Evaluation of a Novel Surveillance Paradigm for Complications of Mechanical Ventilation. PLoS ONE 6(3): e18062. doi:10.1371/journal.pone.0018062 http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062
http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062
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Hayashi et al. (2012)Towards improved surv: the impact of VAC on length of stay and antibiotic use in pts in ICUs. Clin Inf Dis. 56(4):471-7 ◦ Royal Brisbane and Women’s Hospital (Australia)
◦ VAC signif assoc w/ increase ICU LOS, Duration of MV, antibiotic use
Prospero et al. (2012) Learning from Galileo: VAP Surveillance. Am J Respir Crit Care Med. 186(12):1308-9 ◦ Teaching hospital in Central Italy
◦ VAC signif assoc w/ duration of MV, hospital LOS and mortality
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Prospective cohort study in two Dutch academic medical centers (2011–2012).
VAE surveillance was electronically implemented as well as ongoing VAP surveillance.
The VAE algorithm detected at most 32% of the patients with VAP identified by prospective surveillance.
VAC IVAC VAE VAP VAP
10.0 4.2 3.2 8.0
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VAC signals were most often caused by volume overload and infections, but not necessarily VAP.
The large number of VACs occurring on the third or fourth day of ventilation could be representative of ongoing clinical deterioration as opposed to insufficient quality of care
IVACs appeared to detect respiratory infections not related to MV.
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Retrospective Cohort Study
Academic tertiary care center
2006-2011
Rates
Rate per 1000 vent days
VAC plus (VAE) 12.4
IVAC plus 4.7
Poss VAP 1.5
Prob VAP 1.4
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% PVAP CDC VAP 2009-10
%
29% S. aureus S. aureus 24%
14% P. aeruginosa P. aeruginosa 17%
7.9% Klebsiella spp Klebsiella spp 10%
7.9% Enterobacter spp
Enterobacter spp
8.6%
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110 pts with VAC matched to controls
Risk factors for VAC ◦ Positive fluid balance
CHF was protective – 1/3 less fluids given
◦ % of days on mandatory modes of vent
Risk factors for IVAC (n=38) ◦ Benzodiazepines
◦ Total opioid administered
◦ Paralytic meds
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CDC Prevention Epicenters Wake Up and Breathe Collaborative
20 ICUs from 13 academic and community hospital
12 ICUs included SAT/SBT and VAE surv
8 ICUs only did VAE surv
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12 ICUs included SAT/SBT and VAE surv ◦ SAT 14% - 77% (when indicated) ◦ SBT 49% - 75% (when indicated) ◦ Coordinated SAT/SBT 6% - 87% ◦ Decreased MV days and hospital LOS ◦ Decreased VAE rate per 100 episodes
VAE 9.7 to 5.2
IVAC 3.5 to 0.52
PVAP 0.88 to 0.52
No change in VAE risk when using vent days
8 ICUs only VAE surv ◦ No Change
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Prospective time series study
11 North American ICUs
VAP clinical practice guidelines implemented ◦ Prevention, Diagnosis and Treatment
Each ICU enrolled 30 pts on vent >48 hrs
Applied old VAP def
Retrospectively applied VAC, IVAC def
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Date of download: 4/14/2015
Copyright © American College of Chest Physicians. All rights reserved.
From: The Clinical Impact and Preventability of Ventilator-Associated Conditions in Critically Ill Patients Who
Are Mechanically VentilatedImpact of Ventilator-Associated Conditions
Chest. 2013;144(5):1453-1460. doi:10.1378/chest.13-0853
The relationship between VAP, VAC, and iVAC. iVAC = infection-related ventilator-
associated complication; VAC = ventilator-associated condition; VAP = ventilator-
associated pneumonia.
Figure Legend:
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VAC IVAC OLD VAP
ICU LOS Significant Significant Significant
Hopital LOS Significant
Significant
Significant
Duration of MV Significant Significant
Significant
# Antibiotic Days
Significant
Significant
Significant
Hospital Mortality
Significant
P= 0.07 P= 0.67
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Date of download: 4/14/2015
Copyright © American College of Chest Physicians. All rights reserved.
From: The Clinical Impact and Preventability of Ventilator-Associated Conditions in Critically Ill Patients Who
Are Mechanically VentilatedImpact of Ventilator-Associated Conditions
Chest. 2013;144(5):1453-1460. doi:10.1378/chest.13-0853
Rates of VAP, VAC, and iVAC and concordance across the four data enrollment periods. See Figure 2 legend for expansion of
abbreviations.
Figure Legend:
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Oral Route of intubation (100%)
Vent Circuit changes only if soiled or damaged (83%)
Changing heat & moisture exchangers every 5-7 days (2%)
Use closed endotracheal suctioning system and change only when indicated (100%)
Subglottic Secretion Drainage (36% - 58%)
HOB 45 deg (29% - 41%)
CHG Oral Antiseptic (16% - 50%)
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Objectives: To investigate whether fluid management guided by daily BNP plasma concentrations improves weaning outcomes compared with empirical therapy dictated by clinical acumen. Methods: In a randomized controlled multicenter study, we allocated 304 patients to either a BNP-driven or physician-driven strategy of fluid management during ventilator weaning. The primary end point was time to successful extubation. Measurements and Main Results: In the BNP-driven group, More negative median fluid balance during weaning. Time to successful extubation was significantly shorter with the BNP-
driven strategy (58.6 vs. 42.4 P 0.034). The BNP-driven strategy increased the number of ventilator-free days
but did not change length of stay or mortality. The two strategies did not differ significantly regarding electrolyte
imbalance, renal failure, or shock. Conclusions: Our results suggest that a BNP-driven fluid management strategy decreases the duration of weaning without increasing adverse events, especially in patients with left ventricular systolic dysfunction.
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Assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation
We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America.
We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization
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We found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP (VAC) risk in patients who are mechanically ventilated.
RESULTS Control N=152
Intervention N=152
Total N-304
P value
VAC 27 (17.8%) 13 (8.6%) 40 (13.2%)
0.02
VAP 27 (17.8%) 14 (9.2%) 41 (13.5%) 0.03
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Why is VAE BAD? ◦ Increased LOS, vent days, mortality
What events is VAE detecting? ◦ Pneumonia, pulmonary edema, ARDS, atelectasis,
Is VAE preventable? ◦ Some are, not sure all of them.......
How can we prevent them? ◦ HOB, Oral Care, Subglotic suctioning
◦ SBT, SAT, doing them together
◦ Fluid management?
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Michael Klompas, MD, MPH; Richard Branson, MSc, RRT; Eric C. Eichenwald, MD; Linda R. Greene, RN, MPS, CIC; Michael D. Howell, MD, MPH; Grace Lee, MD; Shelley S. Magill, MD, PhD; Lisa L. Maragakis, MD, MPH; Gregory P. Priebe, MD; Kathleen Speck, MPH; Deborah S. Yokoe, MD, MPH; Sean M. Berenholtz, MD, MHS
Infection Control and Hospital Epidemiology, Vol. 35, No. 8 (August 2014), pp. 915-936
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Almost all of the existing literature on VAP prevention is based on traditional VAP definitions rather than VAE definitions.
Little or no data at present on the impact of traditional VAP prevention strategies on VAE
Of note, VAC and IVAC intentionally flag more than just pneumonia; hence, interventions directed solely against pneumonia may not be sufficient to reduce VAE rates.
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We prioritize VAP interventions that have been shown to improve objective outcomes, ◦ duration of MV,
◦ intensive care or hospital LOS,
◦ Mortality
◦ costs in RCTs
In addition, the potential benefits of different interventions are balanced against their feasibility, costs, and potential harm.
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Rationale
Intervention Quality of Evidence
Good evidence the intervention decreases the ave duration of mechanical ventiliation, LOS, mortalily a/o costs; benefits likely outweigh risks
Use NIPPV in select populations High
Manage pts w/o sedation whenever possible Mod
Interrupt sedation daily High
Assess readiness to extubate daily High
Perform SBT with sedatives turned off Mod
Facilitate early mobility Mod
Use endotracheal tubes w/subglotic secretion drainage ports for pts expected to be on vent > 48-72hrs
High
Change vent circuit only if visibly soiled or malfunctioning
Low
HOB 30-45 degrees Low
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Rationale Intervention Quality of Evidence
Good evidence that it improves outcomes but insufficient data available on poss risks
Selective Oral or digestive decontamination
High
May lower VAP rates but insuff data to determine impact on Duration of vent, LOS, mortality
Regular Oral care with CHG Mod
Prophylactic probiotics Mod
Ultrathin polyurethane endotrach tube cuffs
Low
Automated control of endotrach tube cuff pressure
Low
Saline instillation before trach suctioning
Low
Mechanical tooth brushing Low
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Rationale Intervention Quality of Evidence
Lowers VAP rates but ample data suggest no impact on duration of MV, LOS or mortality
Silver coated endo tubes Mod
Kinetic beds Mod
Prone positioning Mod
No impact on VAP rates, Duration of MV, LOS or mortality
Stress ulcer prophylaxis Mod
Early tracheotomy High
Monitoring residual gastric volumes Mod
Early parenteral nutrition Mod
No recommendation
Closed/in line endo suctioning Mod
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HRET (Health Research & Educational Trust)
HHS (US dept of Health and Human Services)
American Hospital Association
http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286
http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286
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HOB 30-45deg
Peptic Ulcer Disease Prophylaxis (PUD)
Venous Thromboembolism Prophylaxis (VTE)
Oral Care
ABCDE Bundle
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• Use visual cues so that it is easy to identify when the bed is in the proper position. • Designate one person to check for visual cues every 1-2 hours in the entire unit. • Establish procedures for head-of-bed elevation as tolerated in non-ICU areas, such as the Emergency Department (ED), during transport within the hospital, and during transport via ambulance between hospitals. • Patient and family engagement in head of bed elevation.
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Educate the RN staff about the rationale
Create visual cues to demonstrate compliance with oral care. ◦ Examples include keeping empty holders of oral care
products by the bedside or dating and timing oral care products used.
Engage Respiratory Therapy in the performance of oral care; make it a joint RN and RT function.
Use a whiteboard to document the delivery of oral care; omissions will make missed interventions more obvious.
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A – Awakening trials for ventilated patients
B – Spontaneous Breathing trials
C – RN and respiratory therapist Coordination to perform spontaneous breathing trials by reducing or stopping sedation so as to awaken the patient
D – Standard Delirium assessment program, including treatment and prevention options
E – Early mobilization and ambulation of critically ill
patients.
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Passive ROM TID
Turn Q 2 hrs.
Active resistance PT
Sitting position 20 mins. TID
Passive ROM TID
Turn Q 2 hrs.
Active resistance PT
Sitting position 20 mins. TID
Sitting on edge of bed
Passive ROM TID
Turn Q 2 hrs.
Active resistance PT
Sitting position 20 mins. TID
Sitting on edge of bed
Active transfer to chair 20 mins./day
Passive ROM TID
Turn Q 2 hrs.
Active resistance PT
Sitting position 20 mins. TID
Sitting on edge of bed
Active transfer to chair 20 mins./day
Ambulation (marching in place, walking in halls)
Able to
move arm
against
gravity
Able to
move leg
against
gravity
Safety Screening (Patient must meet all criteria)
M – Myocardial stability • No evidence of active
myocardial ischemia x 24
hrs.
• No dysrhythmia requiring
new antidysrhythmic
agent x 24 hrs.
O – Oxygenation adequate on:
• FiO2 < 0.6
• PEEP < 10 cm H2O
V - Vasopressor(s) minimal
• No increase of any
vasopressor x 2 hrs.
E – Engages to voice
• Patient responds to verbal
stimulation
Level 1
Level 2
Level 3
Level 4
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Summary of the Infection-Related Provisions in CMS FY 2015 Prospective Payment System
Long-Term Care Hospital Quality Reporting (LTCHQR) Program Final Rules for Inpatient Settings ◦ CMS finalized the addition of the NHSN VAE
Outcome Measure to the LTCHQR Program for FY2018 payment determination and future years as proposed.
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VAEs are mostly caused by pneumonia, ARDS, pulmonary edema, atelectasis
Traditional VAP prevention methods still likely to lower the VAE rate
May consider adding SAT, SBT, early mobility and fluid management to future VAE bundle
VAE will be publicly reported in the future
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http://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdf
http://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdfhttp://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdfhttp://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdfhttp://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdf