1 Telligen Quality Innovation Network- Quality Improvement Organization Ventilator Associated Events –VAE June 26, 2015 This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-OL-C1-6/

Ventilator Associated Events (VAE) Boulos (Paul) Nassar, MD MPH Assistant Professor University of Iowa Hospitals and Clinics

Objectives Departure from the 2002 CDC definition of Ventilator Associated Pneumonia (VAP) Definition and algorithms of VAE Limitations of VAE VAE diagnosis with case studies Proven strategies to prevent VAE

Ventilator associated pneumonia (VAP) >300,000 patients receive mechanical ventilation each year in the US VAP is an important cause of morbidity, mortality, and increased health-care costs in patients who are mechanically ventilated VAP is a nosocomially acquired infection VAP is a complication of mechanical ventilation patient safety measure Incidence rates: 0-6 per 1000 ventilator-days Muscedere-Chest 13

Ventilator associated pneumonia (VAP) VAP is a hospital acquired infection (HAI) Public reporting is mandated for HAI Surveillance programs attempt to identify events and analyze the circumstances surrounding their occurrence Surveillance programs are fundamental for effective prevention of future cases

CDC VAP definition (2002) 1.New or progressive and persistent radiographic abnormality developing in a patient on mechanical ventilation 2.>=1 systemic sign (fever, leukopenia or leukocytosis, or altered mental status) 3.Selected pulmonary criteria (change in respiratory secretions, worsening oxygenation, new onset of cough, dyspnea or rales)

Illustrative case #1 57 year old male patient is admitted with acute pancreatitis He is orally intubated and started on mechanical ventilation He is receiving aggressive fluid resuscitation 72 hours into his illness, he becomes febrile and his F i O2 requirements increase from 50% to 70% A chest radiograph is obtained

Did he develop VAP?

Polling Question Did this patient develop VAP? 1)Yes 2)No 3)I don’t know

Limitations of chest radiograph Pneumonia on autopsyNo pneumonia on autopsy 2445 Air bronchograms New 02 Worsened 43 Alveolar infiltrates New 06 Worsened 715 Wunderink et.al.Chest 92

Limitations of chest radiograph A chest radiograph may demonstrate a haziness that could be pneumonia, atelectasis, or pleural effusion Chest radiograph could represent pulmonary edema or ARDS Findings are more challenging to characterize on a portable film Inter-observer variability in interpretation

Other limitations in the definition Clinical signs and symptoms are unreliable for surveillance purposes Microbiological evidence is problematic because it is difficult to distinguish between colonization and infection – 22% of 95 intensive care unit patients became colonized within 24 hours

The 2002 CDC definition was found to be neither sensitive nor specific for VAP and cannot be accurately used for surveillance Definition met through different pathways Burdensome to capture data

New definition Centers for Disease Control and Prevention’s new surveillance paradigms for patients who are mechanically ventilated This new VAE definition promotes surveillance in a uniform and consistent manner at all hospitals

New definition Uses objective data 1.deterioration in respiratory status after a period of stability or improvement on the ventilator 2.evidence of infection or inflammation 3.laboratory evidence of respiratory infection Chest radiograph is no longer part of the definition

New definition Reliable and standardize reporting 1.Public reporting 2.Comparison among institutions 3.Pay-for-performance calculations

New VAE approach VAE groups all the conditions that result in a significant and sustained deterioration in oxygenation – > than 20% increase in the daily minimum F i O 2 or – > 3 cm H 2 O in the daily minimum positive end- expiratory pressure (PEEP)

What fulfills this new VAE definition?

1.Infectious conditions (tracheitis, tracheobronchitis, and pneumonia) 2.Noninfectious conditions (atelectasis, pulmonary embolism, pulmonary edema, ventilator-induced lung injury)

Timeline for VAE The day of intubation and initiation of mechanical ventilation is day 1 Patients must be mechanically ventilated for more than 2 calendar days The earliest date of event for VAE (the date of onset of worsening oxygenation) is day 3 The earliest day on which VAE criteria can be fulfilled is day 4

Timeline for VAE D2D1D3D4

VAE Ventilator associated condition (VAC) Patient develops hypoxemia for a sustained period of >2 days The etiology of the hypoxemia is not considered Infection-related ventilator- associated complication (IVAC) Hypoxemia develops in the setting of generalized infection or inflammation, and antibiotics are instituted for a minimum of 4 days Probable or possible ventilator-associated pneumonia (VAP) Additional lab evidence of WBC on Gram stain of respiratory secretions of acceptable quality, or presence of respiratory pathogens on quantitative cultures, in patients with IVAC

Possible or Probable VAP Positive results of microbiological testing IVAC General evidence of infection/inflammation VAC Baseline period of stability or improvement, followed by sustained period (>2 days) of worsening oxygenation Patient on mechanical ventilation > 2 days Respiratory status Infection/ Inflammation Micro data

Tier 1: Ventilator associated condition (VAC) VAC is defined by a sustained period of worsening oxygenation that immediately follows a baseline period of stability or improvement Captures both infectious and non-infectious condition and complication occurring in mechanically ventilated patients Detects variety of conditions, not all of which are preventable; hence they are called conditions not complications

Tier 2:Infection-related ventilator-associated complication (IVAC) Identifies the subset of VACs that are potentially related to infection 1.Abnormal WBC 2.Abnormal Temperature 3.Initiation of a new antimicrobial agent IVAC will likely capture patients with pulmonary infections and extrapulmonary infections of sufficient severity to trigger respiratory deterioration

Tier 3: Probable or possible ventilator associated pneumonia (VAP) Patient who met 1 and 2 with respiratory infections as manifested by objective evidence of purulent respiratory secretions and/or positive results of microbiological tests performed on respiratory specimens

Tier 3: Probable or possible ventilator associated pneumonia (VAP) Possible VAP – presence of purulent secretions or a positive lower respiratory tract culture Probable VAP – purulent secretions in addition to a positive lower respiratory tract culture meeting certain quantitative or semiquantitative thresholds of pathogen growth – presence of a positive pleural fluid culture, lung tissue with histopathological evidence of infection, or positive diagnostic tests for Legionella or respiratory tract viruses

Limitations Limited science to truly define VAP Surveillance definitions don’t always align with clinical events Only 21% of “traditional” VAP are detected by VAC and 17% by IVAC – Definition criteria – VAC does not equal VAP Minimum of duration of mechanical ventilation could miss a fraction of patients Lilly et.al.Chest 13

Limitations Measure physician behavior rather than physiologic parameters or pathologic patient conditions – The measure can improve with changes in behavior to game the system that do not reflect improvement in the condition of the patient Lilly et.al.Chest 13

Pointers Acknowledge the limitations of the current definition Cost of this surveillance program might be less Avoid “manipulating” data to avoid detection of events and lower the rates without improving delivery of care Opportunity of partnership between infection preventionist and other stakeholders – Tumor board model? Use VAC flag to make sure all VAP preventive measures are in place

Example 1: VAC or no VAC? MV dayDaily minimum PEEP Daily minimum FiO % 2050%

Polling Question Does this case represent VAC? 1) VAC 2) No VAC

Example 2: VAC or no VAC? MV dayDaily minimum PEEP Daily minimum FiO % 2650% 3535% 4540% 5670% 66

Polling Question Does this case represent VAC? 1) VAC 2) NO VAC

How do we prevent VAP? High to moderate evidence Use non invasive positive pressure ventilation! Early discontinuation of mechanical ventilation Minimize sedation Daily interruption of sedation Assess readiness to extubate daily Early mobilization Change the ventilator circuit only if visibly soiled Utilize endotracheal tubes with subglottic secretion drainage port Head-of-bed elevation (30º to 45º)

How do we prevent VAP? Less evidence Oral decontamination and care with chlorhexidine Mechanical tooth brush

How do we prevent VAP? Generally not recommended Early tracheostomy Early parenteral nutrition Monitoring residual gastric volumes Stress ulcer prophylaxis Silver coated endotracheal tubes

Take home points New definition is a surveillance algorithm and not a clinical definition There is an opportunity to involve multiple stakeholders in addressing VAP Surveillance program is an opportunity to signal to the clinician when a VAC has occurred Anticipate changes as more data is being collected on the performance of this new algorithm

Questions

40 Contacts Karen Boland Sr. Quality Improvement Facilitator Phone: Debbie Camacho Senior QI Manager Phone: Meghan Foley Project Assistant II Phone: