Ventilator Associated Pneumonia (VAP). Objectives VAE PNEU1 PNEU2 PNEU3.
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CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients
Infection Prevention 2VAE Surveillance Training: Infectious Ventilator-Associated Complication (IVAC)
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITYJohns Hopkins University
February 25, 2015
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2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
CUSP 4 MVP – VAP
Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia
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VAE Surveillance Training: Infectious Ventilator-Associated Complication (IVAC)Kathleen Speck, MPH
CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients
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4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Polling Question
Who is on the call? • IP – infection preventionist• RN – registered nurse• RT – respiratory therapist• PT – physical therapist• OT – occupational therapist• MD – medical doctor• Healthcare executive• Educator• National project team• Other
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5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Objectives
• Review history of VAE surveillance
• Review the definitions of VAE tiers
• Discuss case finding and determination of the second tier in VAE–IVAC
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6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Polling Question
Did you attend the CDC’s “Applying the 2015 Changes to Accurately Report HAIs” on Feb 17-19, 2015?
1. Yes – in Atlanta
2. Yes – online
3. No
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7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Former NHSN VAE Surveillance Definition
• Subjective• Not sensitive or specific1-3
• Required radiographic findings – often unclear• Required clinical signs and symptoms• Did not allow accurate validation of success of
prevention strategies4-7
• Did not allow establishment of valid benchmarks for quality improvement projects
1. Klompas M, JAMA 20022. Klompas M, Am J Infect Control 20103. Klompas M, et al, Clin Infect Dis 20084. Zilberberg MD, et al, Clin Infect Dis 20105. Girard T, et al, Lancet 20086. Strom T, et al, Lancet 20107. The Acute Respiratory Distress Syndrome
Network , N Engl J Med 2000
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8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
NHSN VAE Definition
• Objective
• Streamlined
• Potentially automatable
• Defines a broad range of conditions and complications occurring in mechanically ventilated patients
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9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Which Locations Should Use VAE Surveillance?
• Inpatient – Acute care hospitals– Long-term care hospitals– Rehabilitation facilities
• Unit type (examples)– Critical/intensive care units– Specialty care units– Step-down units– Long-term care units 8CDC NHSN Device-associated Module Ventilator-
associated Event (VAE); http://www.cdc.gov/nhsn/pdfs/pscManual/10-VAE_FINAL.pdf
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10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
VAE Definition Tiers8
Possible Ventilator-Associated Pneumonia (PVAP)
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11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
CUSP 4 MVP–VAP VAE Surveillance
Assessment must take place for all VAE tiers• VAC
Ventilator-associated Condition
• IVACInfectious Ventilator-associated Complication
• Possible VAPPossible Ventilator-associated Pneumonia
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12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
VAE Attributable Hospital Mortality10
10Klompas, Infect Control Hosp Epidemiol, 2014
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Case Finding
CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients
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14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Relationship VAC – IVAC
• VAC must be determined before IVAC can be considered
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15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
VAC Definition Criteria
• Patient intubated for >2 calendar day – Earliest day of event is calendar day 3
• Baseline stability – Stable baseline period– Two calendar days immediately preceding the
first day of increased daily minimum PEEP or FiO2
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16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Determination of VAC
After period of stability or improvement on the ventilator, the patient exhibits at least one of these indicators of worsening oxygenation
• Daily minimum FiO2 values increase ≥ 0.20 over daily minimum for preceding 2 calendar days
• Daily minimum PEEP values increase ≥ 3 cm H2O over daily minimum for the preceding 2 calendar days
• PEEP or FiO2 must be maintained for ≥ 1 hour (two consecutive hour readings) (exceptions covered in VAC call)
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17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Positive End-Expiratory Pressure (PEEP)
• Any value of PEEP ≥ 5 cm H2O
• PEEP < 5 cm H2O will be entered as 5 cm H2O
• Actual PEEP of < 5 cm H2O will be considered = to 5 cm H2O for determination of event
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18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
PEEP: Change ^ ≥ 3
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 504 6 705 5 606 5 507 8 708 9 809 6 50
10 7 50
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19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
VAC – Possible on MV Day 7
Two days of stable PEEP, followed by a change in PEEP
of ≥ 3 cm H2O. The change is
maintained or worsens for
≥ 2 days.
It is a VAC.
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 504 6 705 5 606 5 507 8 708 9 809 6 50
10 7 50
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20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
FiO2: Change ^ ≥ 20
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 504 6 505 5 706 5 707 6 708 6 809 6 50
10 7 50
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21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
VAC – Possible on MV Day 5
Two days of stable FiO2,
followed by a change in FiO2
of ≥ 0.2. The change is
maintained or worsens for ≥ 2
days.
It is a VAC.
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 504 6 505 5 706 5 707 6 708 6 809 6 50
10 7 50
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22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
FiO2: Change ^ ≥ 20 – not a VAC
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 554 6 505 5 706 5 707 6 708 6 809 6 50
10 7 50
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23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
FiO2: Change ^ ≥ 20 – not a VAC
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 454 6 505 5 706 5 707 6 708 6 809 6 50
10 7 50
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24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
FiO2: Change ^ ≥ 20 – not a VAC
MV Day Min PEEP Min FiO2
1 8 1002 7 703 6 504 6 455 5 706 5 707 6 708 6 809 6 50
10 7 50
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25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Tier 2: IVAC – 1st Part
• 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
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26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
5-Day VAE Event Window - IVAC
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
1 5 1002 5 703 6 50 12.14 7 50 36.9 37.6 12.1 16.85 5 70 38.1 39.2 14.5 15.96 5 70 38.4 38.9 12.6 13.67 6 70 36.5 37.8 11.18 6 809 6 50
10 7 50
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27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Tier 2: IVAC – 1st Part
• 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
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28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
IVAC Antimicrobial Criterion
• Can be complicated
• Standardizes assessment method of antimicrobial therapy without some information:– Dosing
– Renal function
– Indication for therapy
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29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
What Antimicrobial Drugs Are Included?
• NOW: Mostly antibacterials, antifungals, limited antivirals
• ORIGINALLY: Broad range of agents for HAIs, not just respiratory infections
• NOT INCLUDED– Anti-HIV agents– Anti-tuberculosis agents – Agents used to treat viral hepatitis – Agents used to treat herpes virus infection– Anti-parasitics
Listed in the Appendix,
10-VAE_FINAL
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30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the on either of the 2
days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
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
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32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD
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33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1Consider Levo
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD ? ? ? ? ? ? ?
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34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1Consider Mero
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD ? ? ? ?
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36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1Consider Mero
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD
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38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1Consider Vanc
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD ? ? ?
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39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1Consider Vanc
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD
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41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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42 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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43 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 1Consider Vanc
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo Levo Levo Levo Levo
Abx Mero Mero Mero Mero
Abx Vanc Vanc Vanc
QAD √ √ √ √ √ √
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44 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 2Consider Vanc
VAE Day -3 -2 -1 1 2 3 4 5
Abx Vanc -- Vanc -- Vanc -- Vanc
Abx
Abx
QAD ? ? ? ?
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45 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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46 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 2Consider Vanc
VAE Day -3 -2 -1 1 2 3 4 5
Abx Vanc -- Vanc -- Vanc -- Vanc
Abx
Abx
QAD √ √ √ √ √ √ √
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47 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 3
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo
Abx Vanc Vanc Vanc
Abx
QAD ? ? ? ? ? ? ?
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48 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Definition:New Antimicrobial Agent
Any agent listed in the Appendix that is initiated in the VAE window period: • New indicates it was not given to the patient on either of
the 2 days preceding the current start date• Must be continued for ≥ 4 consecutive days• Does not need to be the same antimicrobial agent for the 4
days• Must be administered IV, IM, via digestive tract or via
respiratory tract• Can be considered continuous if a single day is skipped
between two doses of the same agent
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49 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
QAD – Example 3
VAE Day -3 -2 -1 1 2 3 4 5
Abx Levo Levo Levo
Abx Vanc Vanc Vanc
Abx
QAD
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50 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
5-day VAE Event Window - IVAC
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
1 5 100 No2 5 70 No3 6 50 12.1 No4 7 50 36.9 37.6 12.1 16.8 No5 5 70 38.1 39.2 14.5 15.9 No6 5 70 38.4 38.9 12.6 13.6 Yes7 6 70 36.5 37.8 11.1 Yes8 6 80 Yes9 6 50 Yes
10 7 50 No
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51 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
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 37.62 5 50 38.1 39.2 12.1 13.63 8 50 38.4 38.9 12.5 14.5 No4 8 50 36.5 37.8 12.6 16.8 No5 7 60 11.1 15.9 Yes6 5 70 11.2 Yes7 6 70 Yes8 6 80 Yes9 6 50 No
10 7 50 No
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52 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
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 37.62 5 50 36.5 39.2 12.1 13.63 8 50 37.5 37.9 14.0 14.94 8 50 37.9 37.8 11.6 12.85 7 60 11.1 11.96 5 70 11.27 6 708 6 809 6 50
10 7 50
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53 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
5-day VAE Event Window – Not IVAC
MV Day
Min PEEP
Min FiO2
Temp min
Temp max
WBC min
WBC max
Abx
1 5 100 39.92 5 70 38.0 13.13 6 50 11.94 7 50 36.9 37.6 10.1 11.55 5 70 36.5 37.2 11.5 11.66 5 70 37.0 37.9 11.2 11.37 6 70 36.5 37.8 11.18 6 809 6 50
10 7 50
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54 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 1
A 69-year old female is seen in the ER with an admitting diagnosis of community acquired pneumonia (CAP). She is admitted to the ICU the same day on a vent.
Review her ventilator settings and, if necessary, her temperature, white blood count (WBC) and antibiotic (ABX) information, and determine whether VAE criteria have been met and, if so, whether she meets VAC or IVAC criteria.
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55 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 1:Is this a VAE? Find the Event DayMV Day Min
PEEPMin FiO2
Temp max
WBC max
Abx Abx
1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 809 6 50 Vanc IV
10 7 50
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56 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 1:Event Day and WindowIs this really a VAE? VAC? IVAC?MV Day Min
PEEPMin FiO2
Temp max
WBC max
Abx Abx
1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 809 6 50 Vanc IV
10 7 50
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57 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Polling Question
Is this a VAE?
If so, is it a VAC or IVAC?
1. No VAE, the patient had a CAP present on admission
2. VAC only
3. IVAC
MV Day
Min PEEP
Min FiO2
Temp max
WBC max
Abx Abx
1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 80
9 6 50 Vanc IV10 7 50
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58 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Polling Question
Is this a VAE?
If so, is it a VAC or IVAC?
1. No VAE, the patient had a CAP present on admission
2. VAC only
3. IVAC
MV Day
Min PEEP
Min FiO2
Temp max
WBC max
Abx Abx
1 8 100 38.0 Pip/Tazo2 6 50 39.0 Pip/Tazo3 5 50 37.6 3.0 Vanc IV Pip/Tazo4 6 40 38.6 3.15 6 70 39.0 3.0 Vanc IV6 6 70 38.8 4.97 6 70 38.0 5.0 Vanc IV8 6 80
9 6 50 Vanc IV10 7 50
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59 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 1: Discussion
• Patients are not excluded from VAE surveillance due to admitting diagnosis, symptoms existing before the VAE Window Period, presence of underlying conditions, or development of complications from admission criteria
• FiO2 change is 20 points
• Temp >38C°• WBC is ≤4,000• Days between administration of the same new Abx count
as QADs as long as there is a gap of no more than 1 calendar day
• Vanc meets Abx criteria, Pip/Tazo does not
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60 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2
A 27-year old male is admitted to the neuro ICU following a motorcycle accident. He was intubated in the field and there was concern of aspiration upon intubation.
Given the following information, identify event(s).
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61 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2 Polling QuestionIs this VAE? VAC only? IVAC?
MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None
2 6 30 36.8 37.2 4.6 4.6 None
3 5 30 37.0 37.9 5.4 5.4 None
4 6 30 36.5 37.3 7.2 9.2 None
5 6 35 36.3 37.2 7.4 12.5 None
6 6 50 37.2 37.9 8.5 13.0 Yes
7 6 50 37.8 37.3 Yes
8 6 40 37.2 37.9 Yes
9 6 50 37.5 37.9 9.7 11.7 Yes
10 7 50 37.4 37.1 9.6 10.9 Yes
11 7 40 37.2 37.9 9.4 9.4 Yes
12 8 30 37.0 37.5 9.5 9.5 Yes
13 8 30 37.2 39.8 8.2 8.2 None
14 7 30 37.3 38.7 8.6 8.6 None
15 7 60 37.2 38.9 9.4 12.1 Yes
16 6 60 37.1 39.8 13.0 13.5 Yes
17 6 85 37.0 40.0 Yes
18 Patient Expires
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62 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2
MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None
2 6 30 36.8 37.2 4.6 4.6 None
3 5 30 37.0 37.9 5.4 5.4 None
4 6 30 36.5 37.3 7.2 9.2 None
5 6 35 36.3 37.2 7.4 12.5 None
6 6 50 37.2 37.9 8.5 13.0 Yes
7 6 50 37.8 37.3 Yes
8 6 40 37.2 37.9 Yes
9 6 50 37.5 37.9 9.7 11.7 Yes
10 7 50 37.4 37.1 9.6 10.9 Yes
11 7 40 37.2 37.9 9.4 9.4 Yes
12 8 30 37.0 37.5 9.5 9.5 Yes
13 8 30 37.2 39.8 8.2 8.2 None
14 7 30 37.3 38.7 8.6 8.6 None
15 7 60 37.2 38.9 9.4 12.1 Yes
16 6 60 37.1 39.8 13.0 13.5 Yes
17 6 85 37.0 40.0 Yes
18 Patient Expires
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63 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2: Discussion
• Event is not on day 6, even though there is a 20 point increase in FiO2 from day 4
• The FiO2 rates for days 4 and 5 aren’t stable: they are worsening
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64 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2 Polling QuestionIs this VAE? VAC only? IVAC?
MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None
2 6 30 36.8 37.2 4.6 4.6 None
3 5 30 37.0 37.9 5.4 5.4 None
4 6 30 36.5 37.3 7.2 9.2 None
5 6 35 36.3 37.2 7.4 12.5 None
6 6 50 37.2 37.9 8.5 13.0 Yes
7 6 50 37.8 37.3 Yes
8 6 40 37.2 37.9 Yes
9 6 50 37.5 37.9 9.7 11.7 Yes
10 7 50 37.4 37.1 9.6 10.9 Yes
11 7 40 37.2 37.9 9.4 9.4 Yes
12 8 30 37.0 37.5 9.5 9.5 Yes
13 8 30 37.2 39.8 8.2 8.2 None
14 7 30 37.3 38.7 8.6 8.6 None
15 7 60 37.2 38.9 9.4 12.1 Yes
16 6 60 37.1 39.8 13.0 13.5 Yes
17 6 85 37.0 40.0 Yes
18 Patient Expires
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65 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2 Polling QuestionIs this VAE? VAC only? IVAC?
MV Day Min PEEP Min FiO2 Temp min Temp max WBC min WBC max Abx1 6 30 37.1 37.6 4.3 4.3 None
2 6 30 36.8 37.2 4.6 4.6 None
3 5 30 37.0 37.9 5.4 5.4 None
4 6 30 36.5 37.3 7.2 9.2 None
5 6 35 36.3 37.2 7.4 12.5 None
6 6 50 37.2 37.9 8.5 13.0 Yes
7 6 50 37.8 37.3 Yes
8 6 40 37.2 37.9 Yes
9 6 50 37.5 37.9 9.7 11.7 Yes
10 7 50 37.4 37.1 9.6 10.9 Yes
11 7 40 37.2 37.9 9.4 9.4 Yes
12 8 30 37.0 37.5 9.5 9.5 Yes
13 8 30 37.2 39.8 8.2 8.2 None
14 7 30 37.3 38.7 8.6 8.6 None
15 7 60 37.2 38.9 9.4 12.1 Yes
16 6 60 37.1 39.8 13.0 13.5 Yes
17 6 85 37.0 40.0 Yes
18 Patient Expires
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66 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Case 2 - Discussion
• Event is on day 15 (first day of worsening oxygenation) – FiO2 ^ 30 points
• VAE Window Period is Day 13, 14 (2 days before), Day 15 (event day), and Days 16, 17 (2 days after)
• Abnormal WBC documented during VAE Window Period – 13,000
• Abnormal Temp documented during VAE Window Period – Days 13-17 ≥ 38C
• However, only 3 QADs are documented prior to patient expiring
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67 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Remember!
Gather FiO2 and PEEP on all ventilated patients
1. Determine VAC first!
2. Then collect Temp and WBC
3. If Temp and WBC criteria for IVAC are met, then collect Abx information
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68 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Next Steps
If you ARE using the NHSN system for VAE reporting: • Upload six (6) months baseline data• Confer rights to your CE, if you haven’t already
done so• CEs can then download your data from NHSN and
upload to the CECity platform
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69 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Next Steps
If you ARE NOT using the NHSN surveillance system, or you choose not to confer rights, this data can be entered into CECity system manually.
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70 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
If You Already Perform VAE Surveillance
• Collect an interesting and/or complicated case for discussion
– 1 case
– Include case determination with APRV
• Email to [email protected] with the subject line VAE Surveillance Case
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71 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
This Is Your Time!
• We have 1 more IP-dedicated session
• Share topics you would like to discuss
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72 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Cohort 2 VAE Data Submission July 2014 – Jan 2015
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Next StepsKathleen Speck, MPH
CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients
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74 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Final IP Session: March 25VAE Surveillance: VAP (PVAP)
• Discuss solutions, barriers and ideas for data collection
• Discuss how to determine VAC if using APRV or other vent modes
• Cover determination of PVAC• Discuss your cases
Have questions or related topics of interest?Send requests to [email protected]
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75 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Login Information
Expect to receive information 10 days after you submit• Letter of Commitment (LOC)• Data Use Agreement (DUA)
– If the DUA is edited, this can be a longer process
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76 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
Data Entry: Tablets
Interface to data portal is the same as a computer• Can enter manually as you walk unit• Can use spreadsheet template to gather data and
then upload to portal• Can use our spreadsheet with dropdown menus
and skip logic for both data collection and uploading
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77 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Infection Prevention: VAE Surveillance – IVAC
1. CUSP
2. Daily Care Processes
3. Early Mobility
4. Low Tidal Volume Ventilation
CUSP 4 MVP–VAPCategories
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CUSP 4 MVP – VAP Website
Visit: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx
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What Can I Find on the CUSP 4 MVP – VAP Website?
• CUSP Tools and Guides
• HSOPS Resources
• Data Collection Tools
• Educational Materials
– Toolkits
– Literature Reviews
– Fast Fact Sheets
• Archive of webinars led by subject matter experts
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