Clinical Uses and Ramifications of VAE Data Linda R.Greene,RN,MPS,CIC Manager of Infection Prevention Highland Hospital Rochester, NY Affiliate of University of Rochester Medical Center linda_greene@urmc.rochester.edu

Objectives Discuss the ramifications of VAE Describe methods to evaluate VAE Identify ways to use data to drive improvement

Why Collect VAE Data ? Infection Prevention efforts may fail due to silo mentality Need to view interventions under the larger context of patient safety Connect the dots to harm

Multicenter Evaluation of a Novel Surveillance Paradigm for Complications of Mechanical Ventilation PLoS ONE | www.plosone.org 5 March 2011 | Volume 6 | Issue 3 | e18062

Analysis

Outcomes of VAE Conclusions: Objective surveillance definitions that include quantitative evidence of respiratory deterioration after a period of stability strongly predict increased length of stay and hospital mortality

Connect the Safety Dots Immobility Ventilator Harm VAP VAC Morbidity Mortality ARDS Pulmonary Edema IVAC Delays, LOS Atelectasis Antibiotic Resistance Cost$ C Diff infection

Broadening the Surveillance Intentional Associated Conditions: ARDS Pulmonary Edema Thromboembolic disease Sepsis Respiratory deterioration in previously stable patients is a risk factor for increased morbidity and mortality

Why the Shift ? 1. inter-rater reliability Variations in Chest X-Ray Interpretation Poor Inter-rater reliability

Why the Shift? Broaden the Focus Shifting the focus of surveillance from pneumonia alone to complications in general emphasizes the importance of preventing all complications of mechanical ventilation, not just pneumonia. When definitions are objective, care givers can focus on what went wrong rather than debate the definition.

Retrospective Cohort Study 2006-2011 20,356 episodes of mechanical ventilation 1,141 VACs 431 IVACs 266 Combined Pneumonias VAEs More days to extubation More days to discharge Higher Mortality Rate Conclusion Prevention Strategies are needed

Is VAC Preventable ? . Magill et.al 2014 ID Week : approximately 79% of VAEs were in patients who were either on MV for ≥5 days or in the hospital for ≥5 days at the time of VAE onset. Conclusion: Characteristics of patients with VAEs in 2013 differ from those with tVAP in 2012. Time to onset data suggest that the majority of VAEs are likely hospital-associated.

What Else do we Know About VAE Prevention? . The existing VAP prevention literature is the best available guide to improving outcomes for ventilated patients. VAP interventions that have been shown to improve objective outcomes, such as duration of mechanical ventilation, intensive care or hospital length of stay, mortality, and/or costs in randomized controlled trials.

Getting Started 2. Do we see improvements? Where to Start ? 1. Look at both process and outcome measures 2. Do we see improvements? 3. Important to track you own performance over time

How can we Evaluate the Data? eventType gender location patID patgname patsurname spcEvent VAE F ICU 1234 Mickey Mouse POVAP 5678 Donald Duck 2222 Charlie Brown VAC 1333 Minnie M 4444 Bugs Bunny 5555 Super Man 6666 Spider Woman

Bundle Process Measure Date Y/N Comments Continuous Subglottic Suctioning Assess readiness to extubate ( Spontaneous breathing trials) Paired SBT’s and SATs Interrupt sedation daily ( Spontaneous awakening trials) If contraindications – note here Ambulate according to protocol* Note level Regular Mouth care (without chlorhexidine )* Elevate HOB 35-400 Conservative fluid management Blood Transfusions Given Rationale: Low Tidal Volume Identify:

What about Oral Care?

Findings Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. 16 studies meeting criteria – 3,630 patients There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine No significant difference in ventilator-associated pneumonia risk in double-blind studies of non–cardiac surgery patients

Your VAC Rates

Early Comparison Data Comparative data should be available early next year Incidence rates of ventilator-associated events and ventilator-associated pneumonia in the National Healthcare Safety Network, 2012-2013

VAE Rates in Published Studies

How will I use my data to drive improvement? Review both individual cases and system level issues Do we have policies and procedures in place ? Do we follow evidence based guidelines? Are we consistent with our practices?

Reviewing Cases Patient who develops a VAC Chronic vent Ambulation protocols not implemented Dehydrated Sputum not documented Nursing and respiratory not communicating

Opportunities Hardwire ambulation protocols Ensure documentation of secretions Work collaboratively with respiratory therapy to identify subtle changes Daily huddle

Another Case Mrs. X is a 76 y.o. woman admitted to the ICU with septic shock requiring large volume fluid resuscitation. She is intubated and placed on the ventilator She is stable on the ventilator until day 6 when she has progressing oxygenation demands She has developed a VAC

Case evaluation No fever No increased white count No new antibiotics Diagnosis: Pulmonary Edema Opportunities for improvement ?

Another one In another ICU, a large proportion of VAC’s are possible or probable pneumonia Evaluation: HOB monitoring? Suctioning frequency? SATs? ET tubes with Subglottic suctioning?

Analysis of Data The team analyzes their data During the first quarter they had 20 VAC’s 16 of these meet criteria for IVAC They recognize that the usual ratio for ICU’s is 1/3 to 1/2

IVAC Analysis Not PVAPS Most are other HAIs Considerations?

Prevention Thoughts Prevention of Pneumonia- HOB Pulmonary- fluid conservation Atelectasis – manage sedation Acute lung injury-low tidal volume

Execute- Applying the NHSN Definition

“If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. … We need not wait to see what others do” -Gandhi

Know your Data Surveillance is a critical component of every quality improvement effort; you cannot prevent it if you cannot measure it.

The Bottom Line VAE associated with mortality and LOS (my experience supports this) Continue to monitor processes of care and outcomes Give feedback to providers and assess potential for preventable events