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CUSP for VAP: EVAP NHSN VAE Surveillance Definition Review Call in information Phone #: 800.779.9891 Pass code: 4757941

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CUSP for VAP: EVAP NHSN VAE Surveillance Definition Review Presented by: Kathleen Speck, MPH September 13, 2012 Armstrong Institute for Patient Safety and Quality © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Our Collaborators

– Karol G. Wicker, MHS Senior Director, Quality Policy & Advocacy Maryland Hospital Association [email protected]

– Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvania [email protected]

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Learning Objectives

• To discuss the NHSN VAE definition. • To discuss the linelist generator developed by Dr. Michael Klompas

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NHSN Surveillance 2012-2013

• Assessment must take place for all VAE tiers – VAC - Ventilator-associated Condition – IVAC - Infectious Ventilator-associated Condition – Possible Ventilator-associated Pneumonia – Probable Ventilator-associated Pneumonia

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VAC Definition Criteria8

• Patient intubated for > 2 calendar days • Baseline stability – Baseline: • 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2 requirements

– Stability: • ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP requirements 6 Armstrong Institute for Patient Safety and Quality

Threshold change for VAC

• Threshold rise in daily minimum: – PEEP by ≥3 cm H2O or – FiO2 by ≥20 points – sustained ≥2 days

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Example - VAC

Stable

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Example – no VAC

Unstable

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Example – no VAC

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Subsequent VAEs

• VAEs are defined as 14 days – Starts on day 1 of worsening oxygenation – New VAE cannot be reported until 14 day period has elapsed

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VAE Outcomes

• VAE = VAC, IVAC, Possible VAP and Probable VAP • VAC = Significant respiratory deterioration after 2 or more days of stability • IVAC = VAC + abnormal temp or WBC + ≥ 4 days of new antibiotics • Possible VAP = IVAC + purulent sputum or positive sputum/BAL culture • Probable VAP = IVAC + purulent sputum AND positive sputum/BAL culture 12 Armstrong Institute for Patient Safety and Quality

Setting Up a Linelist

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Linelist Definitions

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Steps to generate linelist for VAE

• Begin with “Daily Linelist” • Enter daily minimum PEEP and FiO2 for every ventilated patient for every calendar day the patient spends any time on a ventilator • Worksheet will automatically flag events that fulfill criteria for VAC • If a patient is not identified as having VAC, don’t collect any further information for that patient. 15 Armstrong Institute for Patient Safety and Quality

Step 1 – VAC

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Determination of IVAC

• Patients where VAC has already been determined • Enter: – Tmin and Tmax – WBCmin and WBCmax – QAD – Qualifying antibiotic day • IVAC requires 4 contiguous days of a new antibiotic starting within the 5 days starting 2 days before the onset 17 Armstrong Institute for Patient Safety and Quality

Step 2 - IVAC

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New Antimicrobial Agent Qualifying Antimicrobial Day (QAD) • Any agent listed in the Appendix of the Device Associated Events: VAE (pages 10-19 through 10-21) that: – Is initiated on or after the third day of mechanical ventilation AND – is started in the 5 day period defined by • 2 days before • the day of the event • the 2 days after

AND – Was not given to the patient on either of the two days preceding the current event 19 Armstrong Institute for Patient Safety and Quality

Qualifying Antibiotic Days - Timing (VAC has already been established)

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Example Antibiotic Worksheet

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Determination of Possible VAP or Probable VAP

• Patients where IVAC has been determined • From Sputum of BAL gram stain – Enter • Polys – polys, neutrophils or WBC (semiquantitative scale) • Epis – epithelial cells or squamous cells (semiquantitative scale) • Culture – result • Quantity - threshold (10^5 for endotracheal aspirate, 10^4 for BAL, 10^3 for protected specimen brush). Semi-quantitative equivalent also acceptable. Answer Yes or No. 22 Armstrong Institute for Patient Safety and Quality

Step 3 – Possible VAP or Probable VAP

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• Questions?

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