Welcome !!!

1. Welcome !!! Please join us via phone for the audio portion of the webinar, you will be connected by the operator when the meeting begins. Conference Line : • Line: 888-847-9717 • Code: 2402919 Please complete the EMR Surveillance Assessment at your convenience : https://www.research.net/s/HospitalEMR

2. VAE Surveillance Definition & Electronic Capture Webinar Hosted by Armstrong Institute of Patient Safety and Quality July 31st & August 2nd Sean Berenholtz , MD, MPH, FCCM Kathleen Speck , MPH

3. Sponsors and Affiliate Partners

4. Agenda • 1:00 pm – 1:10pm - Welcome and Introduction • Sean Berenholtz MD, MHS • 1:10 pm - 1:30pm - Surveillance for Ventilator- Associated Events in Adults: A new Approach for the National Healthcare Safety Network (NHSN) • Shelley Magill MD, PhD, • 1:30 pm – 1:50pm – Improving Surveillance Definitions for Ventilator- Associated Events: Better Surveillance, Better Care • Michael Klompas, MD, MPH • 1:50pm- 2:00pm- Question and Answer Session

5. Learning Objectives • To introduce the new surveillance definition of Ventilator Associated Event (VAE) • To gain insights into your perceptions about the new VAE definition and existing infrastructure to capture VAE data using Electronic Medical Records (EMR) Armstrong Institute for Patient Safety and Quality

6. Expert Panel & Presenters • Dr. Magill will be discussing the new NHSN surveillance definitions. • Dr. Klompas will be discussing techniques for implementing electronic surveillance focusing on experience with the CDC’s Epicenters for Excellence group. Armstrong Institute for Patient Safety and Quality

7. Surveillance for Ventilator-Associated Events in Adults: A New Approach for the National Healthcare Safety Network (NHSN) Shelley S. Magill, MD, PhD Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Atlanta, GA National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

8. The Problem • Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation • But other bad things also happen to patients on ventilators • No valid, reliable definition for VAP • Need more accurate diagnostics … • Until those are available, how do we conduct surveillance and track prevention progress? • Commonly used definitions include subjective elements and are neither sensitive nor specific for VAP • Not ideal in an era of public reporting of healthcare-associated infection (HAI) rates, comparisons among facilities, pay-for-performance programs • Need a new approach

9. Current PNEU Definitions Three sets of criteria Chest x-ray evidence required Signs/symptoms required Lab evidence used if available from acceptable specimen type VAP is a PNEU event that meets the “ventilator-associated” criterion— Endotracheal tube (ETT)/ventilator must have been in place at some time during the 48 hours preceding the onset of PNEU No required amount of time that the ETT/ventilator must have been in place for a PNEU to count as a VAP

10. Limitations of Current VAP Definitions References include but are not limited to the following: 1Wunderink R, et al., Chest 1992;101;458-63; 2Young M, et al., Arch Intern Med 1994;154:2729-32; 3Fabregas N, et al., Thorax 1999;54:867-73; 4Kirtland SH, et al., Chest 1997;112:445-57; 5Berton DC, et al., Cochrane Database Syst Rev 2008; 6Ruiz M, et al., Am J RespirCrit Care Med 2000;162:119-25.

11. Goals for Modifying Current NHSN Definitions • Achieve face validity/clinical credibility • Improve reliability • Reduce burden

12. From VAP to VAE Ventilator-Associated LOwerRespiratory Infection (VALORI) Ventilator-Associated Events (VAE) Streamlined VAP (“sVAP”) 2009-2010 2011 2011-2012 • Evaluated draft definition in collaboration with the CDC Prevention Epicenters • Definition based on work done by Klompas and others1,2 • Received expert feedback during HHS-sponsored meetings • Convened VAP Surveillance Definition Working Group, with Critical Care Societies Collaborative and other society/organization representatives (2011-2012) • Funded Epicenters proposal to evaluate feasibility and preventability of “sVAP” 1Klompas et al., Infect Control HospEpidemiol 2008;29:31-7; 2Klompas et al., 5th Decennial International Conference on Healthcare-Associated Infections, Atlanta, GA, March 18-22, 2010, abstract #741.

13. Working Group Members and Participants

14. Working Group Objectives • Critically review CDC’s draft, streamlined VAP surveillance definition for use in adult patients; • Suggest modifications to enhance reliability and credibility within the critical care community; • Propose final adult definition algorithm that will be implemented for use in NHSN for the potential purposes of public reporting, inter-facility comparisons, and federal pay-for-reporting and -performance programs.

15. Working Group Progress • Kick-off meeting 9/2011, multiple follow up calls • Revised definition algorithm—tiered approach • Definitions suitable for potential use in public reporting: objective, general measures of ventilator-associated conditions and complications • Similar definitions evaluated by Klompas et al. identified events associated with longer duration of mechanical ventilation, longer ICU stay, and increased mortality—and were more efficient to apply than current VAP definitions(PLoS One 2011;6:e18062, Crit Care Med 2012; in press) • Internal use definitions: possible and probable VAP, incorporating laboratory evidence • Research agenda items • Mechanism for intensive care unit-level risk adjustment or stratification (to account for differences in severity of illness) • Denominator data collection

16. ***Note that this is NOT a clinical definition algorithm and is not intended for use in the management of patients.*** Ventilator-associated events (VAE) Surveillance Definition Algorithm

17. Patients Eligible for VAE Surveillance • ≥18 years of age • Inpatients of acute care hospitals, long term acute care hospitals, inpatient rehabilitation facilities • NOTE: Patients receiving high frequency ventilation or extracorporeal life support are excluded from surveillance.

18. VAE Definition Algorithm Summary

19. VAE Definition Algorithm Summary

20. Ventilator-Associated Condition (VAC)

21. VAE Definition Algorithm Summary

22. Infection-related Ventilator-Associated Complication (IVAC)

23. VAE Definition Algorithm Summary

24. Possible VAP

25. Probable VAP VAC, IVAC plus the following…

26. Key Operational Details* • In 2013, in-plan surveillance for ventilator-associated PNEU may still be conducted for neonatal and pediatric patients ONLY. • In 2012 and 2013, the PNEU definitions are still available for those units seeking to conduct off-plan PNEU surveillance for mechanically-ventilated adults or non-ventilated adults or children. • Conducting in-plan VAE surveillance means assessing patients for the presence of ALL events included in the algorithm—from VAC to IVAC to Possible and Probable VAP. A unit participating in in-plan VAE surveillance cannot decide, for example, that only surveillance for VAC (and not for IVAC or Possible or Probable VAP) will be performed. *Preliminary and subject to change.

27. More Key Operational Details* • “New” antimicrobial agent • How to determine whether a new antimicrobial agent has been given for at least 4 days (including in patients with renal insufficiency) • Single doses of vancomycin • Multiple VAEs during a single hospitalization • VAEs in patients who’ve been recently extubated • Pathogens and secondary BSIs • Lung histopathology • Diagnostic tests for viruses and Legionella spp. • Time frame within which VAE criteria must be fulfilled *Preliminary and subject to change.

28. Next Steps

29. Options for Tracking VAP/VAE Rates, 2012-2013 • Implement VAE early • Forms and protocol • Training • Data management • Continue VAP surveillance into 2013 • Will remain available off-plan in NHSN application—but probably only until end of CY 2013 • Do both

30. Acknowledgments • Patients and staff in NNIS and NHSN facilities • VAP Surveillance Definition Working Group • Other subject matter experts • HHS Office of Healthcare Quality • CDC Prevention Epicenters • CDC VALORI/draft sVAP project facilities, Premier, Inc., expert reviewers • CDC/DHQP colleagues The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

31. Thank you! smagill@cdc.gov National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

32. Expert Panel & Presenters • Dr. Magill will be discussing the new NHSN surveillance definitions. • Dr. Klompas will be discussing techniques for implementing electronic surveillance focusing on experience with the CDC’s Epicenters for Excellence group. Armstrong Institute for Patient Safety and Quality

33. Improving surveillance definitions for ventilator-associated eventsBetter SURVEILLANCE, better CAREJULY 31, 2012 Michael klompas md, mph, FRCPC Harvard medical school dept of population medicine BRIGHAM AND WOMEN’S HOSPITAL, boston, ma

34. outline • CDC Prevention Epicenters’ studies of objective surveillance • Operationalizing the new definitions

35. CDC Prevention EpiCenters For Kathy: text in this image be included in the alt text.

36. Multicenter Evaluation Of A Novel Surveillance Paradigm For Complications Of Mechanical Ventilation • Retrospective comparison of VAC surveillance versus conventional surveillance in medical and surgical patients ventilated ≥48 hours in 3 university hospitals • Brigham and Women’s Hospital (Boston, MA) • Ohio State University Medical Center (Columbus, OH) • LDS Hospital (Salt Lake City, UT) • 597 patients ventilated for 6,347 days

37. Length of stay: vap versus vac Model adjusted for vent days prior to event, age, sex, hospital, unit, and co-morbidities VAP or VAC negative VAP or VAC positive *** VAP Ventilator days *** VAC *** VAP ICU days VAC *** * VAP Hospital days * VAC 0 20 15 10 5 Days PLoS ONE 2011;6: e18062

38. Mortality: vap versus vac Model adjusted for vent days prior to event, age, sex, hospital, unit, and co-morbidities VAP VAC 3.0 0 2.5 2.0 1.0 0.5 1.5 Odds Ratio PLoS ONE 2011;6: e18062

39. Qualitative Analysisof CasesCritical care MD blinded to VAC or VAP status VAC VAP 30 25 20 Percent of Patients 15 10 5 0 Mucous Plug Sepsis LobarCollapse/Atelectasis PulmEdema ARDS Pneumonia XRTpneumonitis PE PLoS ONE 2011;6: e18062

40. Objective surveillance definitions for ventilator-associated pneumonia Retrospective analysis of all patients on mechanical ventilation in 8 different U.S. hospitals Community, academic, VA hospitals 8,123 patients 8,735 ventilation episodes 50,324 ventilator-days VAC patients matched to non-VAC patients. Regression analyses adjusting for age, sex, comorbidities, APACHE score, unit, hospital, pre-morbid time on ventilator Klompas et al. 2012; Critical Care Medicine; in press

41. results Klompas et al. 2012; Critical Care Medicine; in press

42. sensitivity & PPV of surveillance definitions for hospital death Klompas et al. 2012; Critical Care Medicine; in press

43. VAC summary • Simple and objective measure • Captures important complications, most cases due to: • Pneumonia • Pulmonary edema • ARDS • Atelectasis • Associated with prolonged mechanical ventilation, length of stay, and hospital mortality

44. VAE surveillancein Practice

45. VAC Sustained increase in ventilator support after≥2 days of stable or decreasing settings ventilator-associated condition iVAC VAC + (abnormal temp or WBC count) AND new antibiotic for 4 days or more infection-related ventilator-associated complication VAP iVAC + positive respiratory culture OR gram stain with ≥25 polys and ≤10 epis possible iVAC + positive respiratory culture AND gram stain with ≥25 polys and ≤10 epis probable

46. How on earth do we apply these definitions?

47. Begin with vac • Criteria • ≥2 days of stable or decreasing daily minimum PEEP or FiO2 followed by • Rise in daily minimum PEEP by ≥3 cm H2O or FiO2 by ≥20 points sustained ≥2 days

48. Operationalizing the definitioncreate a daily linelist

49. Operationalizing the definitioncreate a daily linelist

50. Operationalizing the definitioncreate a daily linelist