VAE Learning Your way through the new ventilator event pathway

1. VAELearning Your way through the new ventilator event pathway Jo Henman MPH,CIC

4. Objectives After attending presentation and completing case studies, attendees will be able to: • Apply new NHSN definitions to identify Ventilator Associated Events (VAE) • Create effective surveillance methods to detect VAE

5. Risks with Ventilator Use • Ventilator-associated penumonia • Sepsis • Acute Respiratory Distress Syndrome (ARDS) • Barotrauma • Pulmonary edema

6. Undesired Outcomes • Longer time on the ventilator • Longer hospitalization • Increased healthcare costs • Disability • Mortality • 24% in patient 15-19 • 60% for patients >85

7. Incidence • More than 300,000 patients are placed on ventilator assistance every year • NHSN data from 2010 • 1,700 facilities reported data (Compared to over 3,000 for CLABSI) • 3,525 VAP cases reported • Rates ranged from 0.0 – 5.8/1,000 patient days

8. So what’s wrong with how we always done it? • Research has shown that its not sensitive or specific • Major drawback is reliance on chest x-ray which is highly variable and subjective. • Also heavily relies on subjective clinical data which lowers validity

9. Why the change? • Standardized, objective definition for public reporting • Increased opportunities for prevention and improvement in care • Many proven efforts to improve outcomes aren’t specifically targeted to prevent infections

10. What are the big differences ? • Only one outcome—either patient had VAP or didn’t • Several choices along pathway • Ventilator Associated Condition (VAC) • Infection-Related Ventilator Complication (IVAC) • Possible VAP • Probable VAP Designed for public reporting and P4P Designed for internal QI VAP VAE

11. Old vs New • Started with chest x-ray • Unclear definitions on when something is hospital acquired • Subjective clinical symptoms (increased sputum production) • Starts with changes in ventilator requirements • Explicit timing definitions for inclusion in surveillance • Objective clinical criteria that is clearly defined VAP VAE

12. Criteria for surveillance • Eligible patients/wards • Only for patients 18 and older • Acute care, long term acute care and inpatient rehab facilities • Excluded types of ventilation • High frequency ventilation (>60 breaths per minute with small tidal volumes) • Extracorporeal life support • NOTE: patients on airway pressure release ventilation (APRV) those in the prone position and those receiving nitric oxide therapy should be included in surveillance

13. Noteworthy definitions • Date of Event: FIRST day that the worsening oxygenation threshold is met • VAE Window Period: The time period when all elements of a definition must be met. It usually includes the 2 days before and the 2 days after the date of event. • Episode of ventilation: Days when a patient is on a vent for some portion of each consecutive day. Patient must be off ventilator for one full calendar for new episode to begin.

14. Definitions • Location of attribution- Where patient was at date of event • Exception – If date of event occurs on the day of or day after transfer then the event is attributed to transferring location • Reporting – In 2013 MUST report all events in the VAE algorithm

16. Ventilator Associated Condition (VAC) Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2. After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: • 1) Increase in daily minimum FiO2 of ≥ 0.20 (20 points) over the daily minimum FiO2 in the baseline period, sustained for ≥ 2 calendar days. • 2) Increase in daily minimum PEEP values of ≥ 3 cmH2O over the daily minimum PEEP in the baseline period, sustained for ≥ 2 calendar days. and

17. Some Examples

18. Is this a VAC?

20. Exercise #1 • Is this case a VAC? YES! Why? PEEP was stable or declining on days 2 and 3, then increased by at least 3 on days 4 and 5. Bonus: What was the Date of the Event?

21. Exercise #2 • Is this case a VAC? No Why? PEEP increased between day 2 and 3 so there wasn’t a 2 day period of stable or increasing ventilator requirements prior to them going up to 10.

23. The next piece of the pathway…IVAC Patient meets criteria for VAC On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: • 1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000 cells/mm3 AND • 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days. And

24. On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: This is the VAE Window Period and all elements of definition must be met during this time period.

25. Another Example

27. The next piece of the pathway…IVAC Patient meets criteria for VAC On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: • 1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000 cells/mm3 AND • 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days. And

28. What is “New Antimicrobial Start” • A NEW antimicrobial that is contained in the NHSN Appendix that is given by IV, IM, Respiratory or Digestive tract route during the VAE Window Period. • NEW means an antimicrobial that wasn’t received in the previous 2 days and continues for 4 “qualifying antimicrobial days” (QAD’s)

29. OK….what is a QAD? • A day when the patient received a new antimicrobial agent. • QAD’s must start within the VAE Window Period and continue for four consecutive days…..KIND OF! • In NHSN world if the SAME antimicrobial is given on days 1 and 3 that is considered consecutive and would count as THREE QAD’s. There can be no more than one calendar day between doses to count as consecutive.

33. Exercise # 3 • Does this case meet the definition for IVAC? YES Did your group come to the same conclusion? Lets review the details

34. Assume that “increased vent requirements” meet the VAC definition for worsening oxygenation

35. Exercise #4 • Does this case meet the definition for IVAC? No Did your team come up with the answer?

36. Assume that “increased vent requirements” meet the VAC definition for worsening oxygenation

38. CONGRATULATIONS!!!!! • We have now traveled half way down the VAE Pathway!

39. Patient meets criteria for VAC and IVAC and On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 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 laboratory reports semi-quantitative results, those results must be equivalent to the above quantitative thresholds. OR 2) Positive culture (qualitative, semi-quantitative or quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing *Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species

40. Let’s break it down • On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: Vae Window Period

41. Next step on the pathway • 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 laboratory reports semi-quantitative results, those results must be equivalent to the above quantitative thresholds. • >25 neutrophils = 4+ OR Heavy • <10 epis = 1+ or 2+ OR Rare, Occasional or Few

42. Patient meets criteria for VAC and IVAC and On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: 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 laboratory reports semi-quantitative results, those results must be equivalent to the above quantitative thresholds. OR 2) Positive culture (qualitative, semi-quantitative or quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing *Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species

43. 2) Positive culture (qualitative, semi-quantitative or quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing *Excludes the following: • Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species NOTE: • Candida species or yeast not otherwise specified • Coagulase-negative Staphylococcus species • Enterococcus species That is isolated from lung tissue or pleural fluid cultures may be reported and will count as meeting criteria for a possible VAP

44. Possible VAP and CLABSI • Secondary BSIs may be reported for possible VAP given the following: • At least one organism isolated from blood cultures matches an isolate from the respiratory culture that was used to meet the possible VAP criteria • The blood culture was drawn during a 14 day event period, with the event date for VAC counting as day 1. • If no positive culture or only organisms that can’t be used to meet possible VAP criteria are isolated then a secondary BSI may not be reported.

45. Does this meet criteria for possible VAP If yes, which of the criteria does it meet If the patient had a blood culture with coagulase negative Staphylococcus on Day 9 would this count as a secondary BSI?

46. The end of the pathway……

47. Probable VAP • On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: • 1) Purulent respiratory secretions (from one or more specimen collections—and defined as for possible VAP) • AND one of the following (see Table 2): • • Positive culture of endotracheal aspirate*, ≥ 105 CFU/ml or equivalent semi-quantitative result • • Positive culture of bronchoalveolar lavage*, ≥ 104 CFU/ml or equivalent semi-quantitative result • • Positive culture of lung tissue, ≥ 104 CFU/g or equivalent semi-quantitative result • • Positive culture of protected specimen brush*, ≥ 103 CFU/ml or equivalent semi-quantitative result • *Same organism exclusions as noted for Possible VAP. • OR • 2) One of the following (without 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) • • Positive lung histopathology • • Positive diagnostic test for Legionella spp. • • Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus

48. So let’s look at each section • On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met: • 1) Purulent respiratory secretions (from one or more specimen collections—and defined as for possible VAP) • AND one of the following (see Table 2): • • Positive culture of endotracheal aspirate*, ≥ 105 CFU/ml or equivalent semi-quantitative result • • Positive culture of bronchoalveolarlavage*, ≥ 104 CFU/ml or equivalent semi-quantitative result • • Positive culture of lung tissue, ≥ 104 CFU/g or equivalent semi-quantitative result • • Positive culture of protected specimen brush*, ≥ 103 CFU/ml or equivalent semi-quantitative result • *Same organism exclusions as noted for Possible VAP. • equivalent semi-quantitative result = 2+, 3+ or 4+ OR Moderate or Heavy Growth

49. Would this case meet the criteria for probable VAP?

50. OR 2) One of the following (without 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) • Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus This section of the definition does NOT require that a gram stain meet the purulent criteria. Acceptable tests for Legionella include: Urinary antigen Respiratory culture 4 fold rise in titer between acute and convalescent antibody tests PCR done on respiratory specimens Special fluorescent and immunohistochemical stains Acceptable tests for respiratory virus: PCR Antigen detection Viral cell culture 4 fold rise in titer between acute and convalescent antibody tests NOTE: HSV and CMV infections are considered “re-activation” of a latent infection and would NOT be considered health-care acquired.