© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
NHSN VAE Surveillance Definition Review
Presented by:Kathleen Speck, MPHJanuary 24, 2013Armstrong Institute for Patient Safety and Quality
Learning Objectives
• While we are not using VAE surveillance - To become more comfortable with the new VAE surveillance definitions
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History of NHSN VAE Surveillance Definition
• Current NHSN VAP surveillance definition– Subjective
• Not sensitive or specific1-3
• Requires radiographic findings – often unclear• Requires clinical signs and symptoms• Doesn’t allow accurate validation of success of
prevention strategies4-7
• Doesn’t allow establishment of valid benchmarks
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1. Klompas M, JAMA 20022. Klompas M, Am J Infect Control 20103. Klompas M, et al, Clin Infect Dis 20084. Zilberberg MD, et al, Clin Infect Dis 2010
5. Girard T, et al, Lancet 20086. Strom T, et al, Lancet 20107. The Acute Respiratory Distress Syndrome Network , N
Engl J Med 2000
Development of new VAE Surveillance Definition
• Working group – 2011– Critical Care Societies Collaborative– American Association for Respiratory Care– Association of Professionals in Infection Control
and Epidemiology– Council of State and Territorial Epidemiologists– Healthcare Infection Control Practices Advisory
Committee’s Surveillance Working Group– Infectious Diseases Society of America– Society for Healthcare Epidemiology of America
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NHSN VAE Definition
• Objective • Streamlined• Potentially automatable• Will define a broad range of conditions and
complications occurring in mechanically ventilated patients8
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Which locations should use VAE surveillance?8
• Inpatient – Acute care hospitals– Long term care hospitals– Rehabilitation facilities
• Unit type (examples)– Critical/intensive care units– Specialty care units– Step-down units– Long term care units
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Inclusions and Exclusions for VAE Surveillance in 2012 -2013
• Excluded patients:– < 18 years of age– on high frequency ventilation or extracorporeal
life support• Included patients:
– ≥ 18 years of age– Receiving conventional mode of mechanical
ventilation while prone or while receiving nitric oxide or epoprontenal therapy
– On APRV or related therapy• Use changes in PEEP only
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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
Other VAE Associated Definitions
VAE Definition Tiers8
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Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Ventilator-Associated Condition (VAC)
General evidence of infection/inflammation
Infection-Related Ventilator-Associated Complication (IVAC)
Positive results of microbiological testing
Possible or Probable VAP
• Respiratory status component
• Infection / inflammation component
• Additional evidence
Possible Future Public
Reporting Definitions
Internal Quality
Improvement
8. Draft – CDC Device-associated Events – VAE
NHSN Surveillance 2012-2013
• Assessment must take place for all VAE tiers– VAC - Ventilator-associated Condition– IVAC - Infectious Ventilator-associated
Condition– Possible VAP – Possible Ventilator-
associated Pneumonia– Probable VAP – Probable Ventilator-
associated Pneumonia
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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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Episode of Mechanical Ventilation
• A period of days during which the patient is mechanically ventilated for at least a portion of each day.
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VAC Definition Criteria8
• Patient on mechanical ventilation for > 2 calendar days
• Baseline stability – Baseline time period:
• The 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2
– Stability:• The same 2 calendar days with stable or
decreasing daily minimum PEEP or FiO2
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Definition – Worsening oxygenation
• Worsening oxygenation – Changes sustained for ≥ calendar days:– Increase in daily min PEEP of ≥ 3 cm H2O
over PEEP baseline period– Increase in daily min FiO2 of ≥ 0.20 (20%)
over the daily minimum FiO2.
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Example - VAC: Basic Case 1
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MV Day Min PEEP Min FiO21 5 1002 5 803 5 604 5 505 5 506 5 707 5 708 5 80
This is a VAC. In this case, the Day of Event = MV day 6 (red). The Baseline Period of Stability = MV day 4-5 (yellow)Change in FiO2 >=20 points
Standard 5 day VAE window period
MV Day Min PEEP Min FiO21 5 1002 5 803 5 604 5 505 5 606 8 707 8 708 5 80
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This is a VAC. In this case, the Day of Event = MV day 6 (red). The Baseline Period of Stability = MV day 4-5 (yellow)Change in PEEP of >= 3
4 and 3 day VAE window period (Both of these are VACs)
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MV Day Min PEEP Min FiO21 8 1002 5 603 5 604 8 605 8 506 5 707 5 708 5 80
MV Day Min PEEP Min FiO21 5 602 5 603 5 804 5 805 5 506 5 707 5 708 5 80
4 day VAE window
3 day VAE window
Change in PEEP and/or FiO2
MV Day Min PEEP Min FiO21 5 1002 5 803 5 604 5 605 5 506 5 707 5 708 5 80
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This is not a VAC.Days 4 and 5 qualify as baseline (2 days of stable or decreasing FiO2).However, the >= 20 point change requirement must be met for both days.
Subsequent VAEs
• The time period for a VAE is 14 days– Starts on day 1 of worsening oxygenation– New VAE cannot be reported until 14 day
period has elapsed
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MV Day Min PEEP Min FiO2
1 5 100
2 5 80
3 5 60
4 5 50
5 5 50
6 6 70 14 day
7 7 70 event
8 9 80 period
9 5 65
10 5 50
11 5 50
12 5 55
13 5 60
14 5 60
15 5 60
16 8 80 Not
17 8 80 VAC
18 8 80
19 8 75
20 7 70
21 7 65
22 7 60
23 6 55
14 day Event period
Is this event an IVAC? Criteria
Criteria must be met within the VAE event window (3, 4 or 5 day)
1. Criteria 1: • Temp (max) >38C (100F) or <36C (97F)
OR• WBC >=12,000 cells/mm3 or <=4,000
cells/mm32. Criteria 2:
• New antimicrobial agent(s) is started and is continued for >=4 days
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New Antimicrobial Agent
• A new antimicrobial agent– Started within the VAE window period– Was not given to the patient on either of the 2
days immediately preceding the window period
– Is continued for 4 consecutive days (QADs)• Requirement can be met with different agents
– Administered IV, IM, via digestive tract or via respiratory tract
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Included Antimicrobials
– Includes broad range of antimicrobials• Also includes agents not used to treat
respiratory infections– Oral vancomycin– Fidaxomicin– Remember IVAC does not necessarily mean a
respiratory infection. It is an infectious ventilator-associated condition
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Excluded Antimicrobials
• Drugs that aren’t used include– Anti-HIV drugs– Anti-TB drugs– Agents used to treat viral hepatitis– Agents used to treat herpes infections– Anti-parasitics
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IVAC: Basic Case
MV Day Min PEEP
Min FiO2 Tmin Tmax WBCmax
WBCmin
QAD
1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 3 5 60 37.5 38.1 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD6 5 70 37.5 37.9 12500 9000 QAD
7 5 70 37.1 37.4 8000 7000 QAD8 5 80 37.5 37.9 QAD
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VAC IVAC
IVAC with 3 or 4 day VAE event window
MV Day
Min PEEP
Min FiO2
Tmin Tmax WBCmax
WBCmin
QAD
1 8 100 38.0 39.1 5000 4500
2 5 60 37.8 38.2
3 5 60 37.5 37.6 6000 5500 QAD
4 8 60 37.6 37.9 7500 7000 QAD
5 8 50 37.5 37.9 9000 8000 QAD
6 5 70 37.5 37.9 10000 9000 QAD
7 5 70 37.1 37.4 8000 7000
8 5 80 37.5 37.9
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VAC NotIVAC
Determination of QADs
For this section, we will assume that requirements for the following have already been met:• VAC• Temperature and WBC (IVAC)
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IVAC Abx: Basic Case
VAE day
Abx -4 -3 -2 -1 1 2 3 4 5 6
Levofloxacin
Yes Yes Yes Yes
QAD QAD QAD QAD QAD
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3 day VAE Event Window and QADs
VAE dayAbx No
MVNo MV
-2 -1 1 2 3 4 5 6
Pip/Tazo Yes Yes Yes Yes Yes
QAD X X X X X
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Doesn’t meet Abx criteria
IVAC Abx – Multiple Abx, Example 1
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VAE dayAbx -4 -3 -2 -1 1 2 3 4 5 6Levofloxacin
Yes Yes Yes Yes Yes
Pip/Tazo Yes Yes Yes
Tobramycin Yes Yes Yes
QAD QAD QAD QAD QAD QAD QAD
Meets Abx criteria
IVAC Abx – Multiple Abx, Example 2
VAE dayAbx -4 -3 -2 -1 1 2 3 4 5 6Levofloxacin
Yes Yes Yes Yes Yes
Pip/Tazo Yes Yes Yes
Tobramycin
Yes Yes Yes
QAD QAD QAD QAD X X X
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Doesn’t meet Abx criteria
IVAC Abx – Consecutive days definition
VAE dayAbx -4 -3 -2 -1 1 2 3 4 5 6Vancomycin
Yes Yes Yes
QAD QAD QAD QAD QAD QAD
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When the same Abx is given every other day, the day in between is considered a QAD. Meets Abx criteria.
If VAC and IVAC, does patient have Possible or Probable VAP?
• Patient must meet ONE of the criteria in the next 2 slides. Only ONE of the two criteria need to be met
• The criteria can be met at any time within the appropriate length of VAE Event Window
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Possible VAP – Criteria 1
• Criteria 1: Purulent respiratory secretions (from one or more specimen collections)– Defined as secretions from the lungs,
bronchi or trachea that contain ≥25 neutrophils and ≤10 squamous epithelial cells per low power field[lpf, x100]• If the lab reports semi-quantitative results,
those results must be the equivalent to the above quantitative results.
• ORArmstrong Institute for Patient Safety and Quality
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Possible VAP – Criteria 2
• Criteria 2: Positive culture (qualitative, semi-qualitative or quantitative) of sputum, endotracheal aspirate, bronchoalveolar lavage, lung tissue or protected specimen brushing.– Excludes the following
• Normal respiratory flora, mixed respiratory/oral flora or equivalent
• Candida species of yeast, not otherwise specified• Coagulase-negative Staphylococcus species• Enterococcus species
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Possible VAP Case 1
MV Day
Min PEEP
Min FiO2
Tmin
Tmax
WBCmax
WBCmin
QAD Specimen Polys Epis Organism
1 5 100 38.0 39.1 2 5 80 37.8 38.2 5500 5500 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 Sputum ≥25/≤10 Normal
Respiratory Flora
5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 12500 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD
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Possible VAP criteria fulfilled. Purulent sputum was collected within window. Organism is not used here.
Possible VAP Case 2
MV Day
Min PEEP
Min FiO2
Tmin
Tmax
WBCmax
WBCmin
QAD Specimen
Polys Epis
Organism
1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 12500 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD BAL Heavy S.
aureus
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Possible VAP criteria fulfilled. BAL collected within 5 day VAE event window. Grew heavy S. aureus, known pathogen.
Possible VAP Case 3
MV Day Min PEEP
Min FiO2
Tmin
Tmax
WBCmax
WBCmin
QAD Specimen
Polys Epis
Organism
1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 5 5 50 37.5 37.9 6 5 60 37.5 37.9 10000 9000 7 5 70 37.1 37.4 8000 7000 8 7 80 37.5 37.9 6000 5000 BAL Heavy S.
aureus9 7 90 38.1 38.5
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Possible VAP criteria not fulfilled. Criteria for VAC are not fulfilled.
If IVAC, does patient meet criteria for Probable VAP?
• Patient must meet either Criteria 1 (two parts) or Criteria 2. The criteria can be met at any time within the appropriate length of VAE Event Window
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Probable VAP Criteria 1, part 1
• Part 1 - Essentially the first part of this criteria is the same as the first criteria from Possible VAP.– Purulent respiratory secretions (from one or
more specimen collections)• Defined as secretions from the lungs, bronchi or
trachea that contain ≥25 neutrophils and ≤10 squamous epithelial cells per low power field [lpf, x100]
– If the lab reports semi-quantitative results, those results must be the equivalent to the above quantitative results.
ANDArmstrong Institute for Patient Safety and Quality
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Probable VAP Criteria 1, part 2
– One of the following • Positive culture of endotracheal aspirate, ≥ 105 CFU/ml or
equivalent semi-quantitative result• Positive culture of a bronchoalveolar lavage, ≥ 104 CFU/ml or
equivalent semi-quantitative result• Positive culture of lung tissue, ≥ 104 CFU/ml or equivalent semi-
quantitative result• Positive culture of protected specimen brush, ≥ 103 CFU/ml or
equivalent semi-quantitative result• Excludes the following
– Normal respiratory flora, mixed respiratory/oral flora or equivalent– Candida species of yeast, not otherwise specified– Coagulase-negative Staphylococcus species– Enterococcus species
• ORArmstrong Institute for Patient Safety and Quality
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Probable VAP Criteria 2
• Criteria 2: One of the following – without the requirement for purulent respiratory secretions:– Positive pleural fluid culture (where specimen was obtained during
thoracentesis or initial placement of chest tube and not from an indwelling chest tube)• Includes these otherwise excluded organisms
– Candida species or yeast not otherwise specified– Coagulase-negative Staphylococcus species– Enterrococcus species (including VRE)
– Positive lung histopathology• Includes these otherwise excluded organisms
– Candida species or yeast not otherwise specified– Coagulase-negative Staphylococcus species– Enterrococcus species (including VRE)
– Positive diagnostic test for Legionella spp.– Positive diagnostic test on respiratory secretions for influenza virus,
respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus and coronavirus.
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Probable VAP- Case 1MV Day
Min PEEP
Min FiO2
Tmin
Tmax
WBCmax
WBCmin
QAD Specimen
Polys Epis
Organism
1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 12500 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD BAL ≥25/
≤10S. aureus≥ 104 CFU/ml
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Possible VAP criteria are fulfilled, purulent sputum and positive culture with pathogen.
Probable VAP- Case 2
MV Day
Min PEEP
Min FiO2
Tmin
Tmax
WBCmax
WBCmin
QAD Specimen
Polys Epis
Organism
1 5 100 38.0 39.1 5000 4500 2 5 80 37.8 38.2 5500 5000 3 5 60 37.5 38.1 6000 5500 4 5 50 38.6 39.0 7500 7000 5 5 50 37.5 37.9 9000 8000 QAD 6 5 70 37.5 37.9 10000 9000 QAD 7 5 70 37.1 37.4 8000 7000 QAD 8 5 80 37.5 37.9 6000 5000 QAD Lung
tissue Yeast
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Possible VAP criteria are fulfilled, while yeast is not a pathogen, the specimen is lung tissue, therefore criteria are met.
Steps to generate linelist for VAE
• Begin with “Daily Linelist”• Enter patient identifier, date, daily minimum
PEEP and FiO2 for every ventilated patient for every calendar day the patient spends any time on a ventilator
• If a patient is not identified as having VAC, don’t collect any further information for that patient.
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Determination of IVAC
• Only look at patients where VAC has 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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Determination of Possible VAP or Probable VAP
• Only look at 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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Semiquantitative Scale for Polys and Epis
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None Enter 0Few, rare, ≤10 cells/lpf Enter 1Moderate, ≥25 cells/lpf Enter 2Many Enter 3Abundant Enter 4
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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• Questions?
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