CUSP 4 MVP-VAP IP VAE Surveillance, Call – 3 April 15, 2014 Kathleen Speck, MPH Program support provided by MHA Keystone Center. Scientific expertise and educational presentations provided by Harvard Medical School. February 28, 2019

Objectives Restate definitions of VAE Tiers Review the definitions of VAE Tiers Discuss case finding and determination of Possible and Probable VAP (PoVAP and PrVAP.

Poll 1 – Who is on the call? IP - infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist Unit project champion Nurse manager Physician champion Executive partner CE – coordinating entity Other February 28, 2019

CUSP 4 MVP-VAP VAE Surveillance 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 February 28, 2019

VAE Definition Tiers

CUSP 4 MVP-VAP Quick Review VAC and IVAC Program support provided by MHA Keystone Center. Scientific expertise and educational presentations provided by Harvard Medical School. February 28, 2019

5-Day VAE Window Period MV Day Min PEEP Min FiO2 1 8 100 2 7 70 3 6 50 4 5 60 9 80 10 February 28, 2019

Why is the Event Date important? Defines the “VAE Window Period” Period during which criteria for other events must be met Defines beginning of 14-day Event Period Another VAE may not happen during the 14-day Event Period following the VAE in question February 28, 2019

VAE Window Period The period of days around the event within which other VAE criteria must be met. It is usually a 5-day period and includes the 2 days before, the day of, and the 2 days after the VAE event day. February 28, 2019

Tier 2: IVAC Patient meets criteria for VAC On or after calendar day 3 of mechanical ventilation or after the onset of worsening oxygenation, the patient meets both of the following criteria: Temp > 38oC (100.4oF) or < 36oC (96.8oF), OR WBC ≥ 12,000 cells/mm3 or ≤ 4,000 cell/mm3 AND A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days February 28, 2019

3-day VAE Event Window – Not IVAC MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx 1 5 50 36.9 37.6 2 36.5 39.2 12.1 13.6 3 8 37.5 37.9 11.5 11.9 4 37.8 11.6 11.8 7 60 11.1 6 70 11.2 80 9 10 February 28, 2019

Tier 2: IVAC Patient meets criteria for VAC On or after calendar day 3 of mechanical ventilation or after the onset of worsening oxygenation, the patient meets both of the following criteria: Temp > 38oC (100.4oF) or < 36oC (96.8oF), OR WBC ≥ 12,000 cells/mm3 or ≤ 4,000 cell/mm3 AND A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days February 28, 2019

Qualifying Antimicrobials Day (QAD) A day on which a patient was administered a “new” antimicrobial agent within the VAE Window Period 4 consecutive QADs are needed to meet the IVAC antimicrobial criterion, starting within the VAE Window Period February 28, 2019

3-day VAE Event Window - IVAC MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx 1 5 50 36.9 37.6 2 38.1 39.2 12.1 13.6 3 8 38.4 38.9 11.5 No 4 36.5 37.8 12.6 16.8 7 60 11.1 15.9 Yes 6 70 11.2 80 9 10 February 28, 2019

QAD – Example 1, Answer VAE Day -3 -2 -1 1 2 3 4 5 Abx Levo Mero Vanc February 28, 2019

QAD – Example 2 VAE Day -3 -2 -1 1 2 3 4 5 Abx Levo Vanc QAD X February 28, 2019

CUSP 4 MVP-VAP PoVAP and PrVAP Possible and Probable VAP February 28, 2019

PoVAP and PrVAP Patient must meet criteria for VAC and IVAC AND February 28, 2019

PoVAP On or after calendar day 3 of MV and within 2 days before or after the onset of worsening oxygenation, ONE of the following 2 criteria must be met. February 28, 2019

PoVAP – 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 laboratory reports semi-quantitative results, those results must be equivalent to the above quantitative thresholds. See additional instructions for using the purulent respiratory secretions criterion in the VAE Protocol. (10-VAE_Final.pdf, page 14, Table 2) (Discusses interpretation of lab reports) OR February 28, 2019

PoVAP – Criteria 2 Positive culture (qualitative, semi-quantitative or quantitative) of sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen brushing* *On next slide February 28, 2019

*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 February 28, 2019

PrVAP – Criteria 1 (part A) 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. See additional instructions for using the purulent respiratory secretions criterion in the VAE Protocol. (10-VAE_Final.pdf, page 14) (Discusses interpretation of lab reports) AND February 28, 2019

PrVAP – Criteria 1 (part B) One of the following (for help with qualitative lab reports10-VAE_Final.pdf, page 14, Table 2) Positive culture of endotracheal aspirate*, ≥ 105 CFU/ml or equivalent semi-quantitative result Positive culture of BAL*, ≥ 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 (Criteria 1, parts A AND B) OR *Same organism exclusions as noted for PoVAP February 28, 2019

PrVAP – Criteria 2 One of the following (no purulent secretions required) Positive pleural fluid culture (specimen obtained during thoracentesis or initial placement of a chest tube and NOT from indwelling chest tube Positive lung histopathology Positive diagnostic test for Legionella spp. Positive diagnostic test on respiratory secretions for influenza virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus February 28, 2019

IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 No 2 70 3 6 50 12.1 Trachea >25/≤10 Rare C. albicans 4 7 36.9 37.6 16.8 38.1 39.2 14.5 15.9 38.4 38.9 12.6 13.6 Yes 36.5 37.8 11.1 8 80 9 10 February 28, 2019

PoVAP! Purulent secretions MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 No 2 70 3 6 50 12.1 Trachea >25/≤10 Heavy C. albicans 4 7 36.9 37.6 16.8 38.1 39.2 14.5 15.9 38.4 38.9 12.6 13.6 Yes 36.5 37.8 11.1 8 80 9 10 Purulent secretions Specimen from trachea grew an excluded organism February 28, 2019

IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 38.0 39.1 4.5 5.0 No 2 70 37.8 38.2 5.5 3 6 50 37.5 6.0 4 7 38.6 39.0 7.0 7.5 37.9 8.0 9.0 10.0 Yes 37.1 37.4 8 80 8.5 BAL > 104 S. aureus 9 6.5 10 37.6 February 28, 2019

PoVAP! No purulent secretions MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 38.0 39.1 4.5 5.0 No 2 70 37.8 38.2 5.5 3 6 50 37.5 6.0 4 7 38.6 39.0 7.0 7.5 37.9 8.0 9.0 10.0 Yes 37.1 37.4 8 80 8.5 BAL >104 S. aureus 9 6.5 10 37.6 No purulent secretions Specimen from BAL met organism and growth criteria February 28, 2019

IVAC, PoVAP, or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 39.5 40.0 10.0 10.5 BAL Moderate S. aureus 2 70 38.0 39.7 11.5 12.5 3 7 50 37.5 11.0 QAD 4 37.0 10 13.0 6 13.5 Sputum >25/≤10 8 Patient expired February 28, 2019

Poll 2 – IVAC, PoVAP, or PrVAP? No event - S. aureus was present in BAL on MV day – pre-existing pneumonia IVAC - purulent secretions and positive culture are required for PoVAP and PrVAP PoVAP - sputum from MV day 7 qualifies, for purulent secretions – no positive culture is needed MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 39.5 40.0 10.0 10.5 BAL Few S. aureus 2 70 38.0 39.7 11.5 12.5 3 7 50 37.5 11.0 QAD 4 37.0 10 13.0 6 13.5 Sputum >25/≤10 8 Patient expired February 28, 2019

Poll 2 – Is this a PoVAP? No event - S. aureus was present in BAL on MV day – pre-existing pneumonia IVAC - purulent secretions and positive culture are required for PoVAP and PrVAP PoVAP - sputum from MV day 7 qualifies, for purulent secretions – no positive culture is needed MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 39.5 40.0 10.0 10.5 BAL Few S. aureus 2 70 38.0 39.7 11.5 12.5 3 7 50 37.5 11.0 QAD 4 37.0 10 13.0 6 13.5 Sputum >25/≤10 8 Patient expired February 28, 2019

IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 38.0 39.1 10.0 10.5 2 80 37.8 38.2 11.5 12.5 3 60 37.5 38.1 11.0 4 50 38.6 39.0 37.9 13.0 QAD Lung tissue >25/≤10 Enterococcus spp. 6 70 7 37.1 37.4 13.5 8 February 28, 2019

Poll 3 - IVAC, PoVAP or PrVAP?? MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 38.0 39.1 10.0 10.5 2 80 37.8 38.2 11.5 12.5 3 60 37.5 38.1 11.0 4 50 38.6 39.0 37.9 13.0 QAD Lung tissue >25/≤10 Enterococcus spp. ≥104 CFU/g 6 70 7 37.1 37.4 13.5 8 No VAE – the patient had a fever on MV day 1 PoVAP – purulent secretions, but organism is excluded PrVAP – purulent secretions, Enterococcus spp. growth is sufficient, organism exclusions don’t apply to lung tissue samples February 28, 2019

Poll 3 – IVAC, PoVAP or PrVAP? MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx Speci-men Polys Epis Organism 1 5 100 38.0 39.1 10.0 10.5 2 80 37.8 38.2 11.5 12.5 3 60 37.5 38.1 11.0 4 50 38.6 39.0 37.9 13.0 QAD Lung tissue >25/≤10 Enterococcus spp. ≥104 CFU/g 6 70 7 37.1 37.4 13.5 8 No VAE – the patient had a fever on MV day 1 PoVAP – purulent secretions, but organism is excluded PrVAP – purulent secretions, Enterococcus spp. growth is sufficient, organism exclusions don’t apply to lung tissue samples February 28, 2019

CUSP 4 MVP-VAP Case 1 – Cheryl Morrin BS, MT(ASCP), CIC Understanding PEEP and FiO2 with APRV, BiLevel, A/C and PCV February 28, 2019

Case 1 - History 59 yo female w/ COPD on home cannula From PCP wt/ S/S of fever, muscle pain and cxr w/ PNA “correlate clinically” Admitted w/CPAP, +Legionella (POA) MV started on HD1 February 28, 2019

Review Review of rules for PEEP and FiO2 Minimum PEEP = Minimum PEEP value that is maintained for ≥ 1 hour PEEP from 0-5 = 5 APRV (and related modes) and PEEP Partial day – use PEEP from non-APRV mode Full day – skip PEEP, baseline starts with non-APRV mode PEEP readings on next day February 28, 2019

Example patient = Non-APRV Readings February 28, 2019

Case - APRV/BiLevel/PCV Readings February 28, 2019

February 28, 2019

MV Day 1, 11/12 Patient on APRV/Bivent   11/12 21:53 23:14 MV mode APRV/Bivent FIO2 100 PEEP Patient on APRV/Bivent FiO2 for MV day 1 = 100, from 21:53 – 23:14 No PEEP February 28, 2019

MV Day 2, 11/13 Patient on APRV/Bivent and BiLevel 02:00   2:25 3:17 4:01 5:00 7:55 8:25 MV Mode APRV/Bivent BiLevel FiO2 100 90 80 70 PEEP   11/13 9:12 10:07 10:53 11:01 12:55 14:57 18:13 MV mode BiLevel FIO2 70 100 80 PEEP 7   11/13  19:30 20:08 21:40 22:16 22:41 23:27 23:42 MV mode BiLevel FIO2 90 100 80 75 PEEP Patient on APRV/Bivent and BiLevel Use FiO2 for MV day 2 = 70, from 4:01-7:55 No PEEP February 28, 2019

MV Day 3, 11/14 Patient on BiLevel and A/C modes 2:20   2:34 4:53 7:56 12:40 MV Mode BiLevel FiO2 100 90 PEEP   11/14 15:50 17:23 18:53 19:59 23:43 MV mode BiLevel A/C FIO2 90 60 50 PEEP 14 Patient on BiLevel and A/C modes FiO2 for MV day 3 = 50, from 18:53-19:59 PEEP for MV day 3 = 14, from 17:23-23:43 February 28, 2019

MV Day 4, 11/15 Patient on AC and PCV modes FiO2 for MV day 4 = 50 00:25   00:35 00:51 2:56 4:01 4:35 4:49 MV Mode A/C FiO2 100 90 60 50 PEEP 12 11/15 5:06   8:51 10:00 10:10 14:18 15:26 15:27 MV Mode A/C PCV FiO2 50 100 75 PEEP 12  11/15 15:53   17:06 18:52 19:38 20:12 22:41 MV Mode PCV FiO2 50 100 60 PEEP 14 12 10 Patient on AC and PCV modes FiO2 for MV day 4 = 50 PEEP for MV day 4 = 12 February 28, 2019

MV Day 5, 11/16 MV Day 6, 11/17 Patient on AC and PCV modes FiO2 for MV day 5 = 40, from 12:40-20:17 No PEEP 11/16 05:44   8:01 11:43 12:40 15:53 20:17 MV Mode PCV A/C FiO2 50 40 PEEP 10 14 MV Day 6, 11/17 Patient on AC and PCV modes FiO2 for MV day 6 = 40, from 00:00-06:47 PEEP for MV day 6 = 14 11/17 4:36   6:47 8:44 9:12 9:48 13:25 20:34 MV Mode PCV AC FiO2 40 45 50 PEEP 14 16 February 28, 2019

MV Day 7, 11/18 MV Day 8, 11/19 Patient on AC and PCV modes FiO2 for MV day 7 = 50, from 00:00-2:00 PEEP for MV day 7 = 14 11/18 00:24   2:00 5:52 7:37 10:40 15:35 21:46 MV Mode PCV A/C FiO2 50 60 PEEP 14 16 Patient on AC mode FiO2 for MV day 8 = 40 PEEP for MV day 7 = 12 MV Day 8, 11/19 11/19 00:32   3:09 7:34 13:20 17:40 21:36 MV Mode A/C FiO2 55 50 40 PEEP 12 February 28, 2019

MV Day 9, 11/20 MV Day 10, 11/21 Patient on AC mode FiO2 for MV day 9 = 40 PEEP for MV day 9 = 7 11/20 4:19   8:10 10:27 11:01 14:37 14:39 20:16 MV Mode A/C FiO2 40 PEEP 12 10 7 Patient on AC mode FiO2 for MV day 10 = 40 PEEP for MV day 10 = 7 MV Day 10, 11/21 11/21 5:58   9:15 9:59 16:49 18:38 20:00 MV Mode A/C PCV FiO2 40 70 60 50 PEEP 7 5 10 February 28, 2019

MV Day 11, 11/22 Patient on PCV mode FiO2 for MV day 11 = 40 No PEEP 00:20   5:00 7:32 8:30 10:11 17:47 20:22 MV Mode PCV FiO2 50 40 PEEP 10 5 Patient on PCV mode FiO2 for MV day 11 = 40 No PEEP February 28, 2019

MV Day 12, 11/23 Patient on PCV, SBT/PAV, A/C modes 00:11   4:42 5:30 5:32 5:34 5:48 7:44 MV Mode PCV SBT/PAV FiO2 40 30 PEEP 5   15:51 20:10 21:49 23:36 MV Mode A/C FiO2 30 PEEP 5 7 Patient on PCV, SBT/PAV, A/C modes FiO2 for MV day 12 = 30 PEEP for MV day 12 = 5 February 28, 2019

MV Day 13, 11/24 MV Day 14, 11/25 Patient on PCV, SBT/PAV, A/C modes FiO2 for MV day 13 = 30 PEEP for MV day 13 = 5 MV Day 13, 11/24 11/24 04:38 4:47   4:48 8:20 16:34 22:35 MV Mode A/C SBT PCV FiO2 30 PEEP 5 MV Day 14, 11/25 Patient on A/C, SBT, and CPAP/pr sup modes FiO2 for MV day 14 = 30 PEEP for MV day 14 = 5 11/25 4:18   4:32 4:37 7:23 17:14 20:44 MV Mode A/C SBT CPAP/pr sup FiO2 30 PEEP 5 February 28, 2019

Patient on SBT/PAV, A/C FiO2 for MV day 17 = 30 PEEP for MV day 17 = 5 MV Day 15, 11/26 11/26 5:33   5:38 7:35 11:25 17:22 17:30 18:00 20:54 MV Mode SBT A/C FiO2 30 100 PEEP 5 MV Day 16 and 17, 11/27 and 11/28 11/27 5:10   9:19 14:26 21:00 MV Mode A/C PAV FiO2 30 PEEP 5 11/28 5:59   8:03 MV Mode PAV FiO2 30 PEEP 5 Patient on PAV, A/C FiO2 for MV day 16 = 30 PEEP for MV day 16 = 5 Patient on PAV FiO2 for MV day 17 = 30 PEEP for MV day 17 = 5 February 28, 2019

Longitudinal PEEP and FiO2 MV Day FiO2 PEEP 1 100 - 2 70 3 50 14 4 12 5 40 6 7 8 9 MV Day FiO2 PEEP 10 40 7 11 - 12 30 5 13 14 15 16 17 After digging and combing through all those data - There is no VAE! February 28, 2019

Surveillance data can be complicated Determining which values to use for your PEEP and FiO2 minimums can be time consuming Before you use the calculator or make your final determination Set up your own tables Check the vent modes Check the duration of the settings (≥ 1 hour) February 28, 2019

CDC VAE Calculator http://www.cdc.gov/nhsn/VAE-calculator/ February 28, 2019

VAE Rates Registry Allison Ord - CECity Entering Data and Accessing Reports February 28, 2019

Going forward Collect PEEP and FiO2 for your patients on mechanical ventilation Determine whether they qualify as a VAC, IVAC, PoVAP or PrVAP Use the IP site Send in questions CUSP4MVP@jhmi.edu February 28, 2019

Next Step – If you have been using NHSN defined VAE surveillance We are asking for 6 months baseline data If you ARE using the NHSN system, please confer rights to your CE if you haven’t already done so CEs can download your data from NHSN and upload to the CECity platform February 28, 2019

Next Step – If you have been using NHSN defined VAE surveillance If you AREN’T using the NHSN surveillance system, or you choose not to confer rights, this data can be entered into the CECity system manually February 28, 2019

Would you like to continue these calls? Establish a community to discuss Interesting cases Confusing cases Invite guest speakers Changes in VAE surveillance as they arise February 28, 2019

Poll 4 – Do you want to continue to have IP calls? No more IP calls Monthly calls Every other month calls Only when there are changes in VAE surveillance definitions February 28, 2019

Next Steps Complete the registration form so you can enter data into the data platform and view data reports. Enter baseline VAE rates and Feb ‘14 rates. February 28, 2019

Additional Resources CUSP 4 MVP-VAP website https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx NHSN VAE Surveillance Resources February 28, 2019

Email address: CUSP4MVP@jhmi.edu February 28, 2019