1. 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

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

3. 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

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

5. Analysis

6. 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

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

8. 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

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

10. 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.

11. 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

12. 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 Time to onset data suggest that the majority of VAEs are likely hospital-associated.

15. 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.

16. 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

17. 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

18. 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
Conservative fluid management
Blood Transfusions Given
Rationale:
Low Tidal Volume
Identify:

19. What about Oral Care?

20. 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

21. Your VAC Rates

22. 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,

23. VAE Rates in Published Studies

24. 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?

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

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

29. 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

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

31. 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?

32. 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

33. IVAC Analysis
Not PVAPS Most are other HAIs Considerations?

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

35. Execute- Applying the NHSN Definition

36. “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

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

38. 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