Shilla Patel OD, CIC UC San Diego Health System Infection Prevention/Clinical Epidemiology

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1 Shilla Patel OD, CIC UC San Diego Health System Infection Prevention/Clinical Epidemiology

2 Name 3 adverse outcomes of VAE events Identify 4 most common causes of VAE Review latest research on VAE preventability Review updated 2014 VAE Prevention guidelines

4 VAP VAE

5 3 Large Academic Medical Centers 600 pts 300 on vent 2-6 days 300 on vent >7days VAC PEEP increase by 2.5 > or Equal to 2 days FiO2 increase by 15 > or equal to 2 days VAP IPs assessed for CDC definition

Table 2. Comparison of outcomes for ventilator-associated complication positive and negative patients and ventilator-associated pneumonia positive and negative patients.

6 Table 2. Comparison of outcomes for ventilator-associated complication positive and negative patients and ventilator-associated pneumonia positive and negative patients. Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, et al. (2011) Multicenter Evaluation of a Novel Surveillance Paradigm for Complications of Mechanical Ventilation. PLoS ONE 6(3): e doi: /journal.pone

Table 5. Qualitative analysis of 52 patients flagged with ventilator-associated complications or ventilator-associated pneumonia. Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, et al.

7 Table 5. Qualitative analysis of 52 patients flagged with ventilator-associated complications or ventilator-associated pneumonia. Klompas M, Khan Y, Kleinman K, Evans RS, Lloyd JF, et al. (2011) Multicenter Evaluation of a Novel Surveillance Paradigm for Complications of Mechanical Ventilation. PLoS ONE 6(3): e doi: /journal.pone

8 Hayashi et al. (2012)Towards improved surv: the impact of VAC on length of stay and antibiotic use in pts in ICUs. Clin Inf Dis. 56(4):471-7 Royal Brisbane and Women s Hospital (Australia) VAC signif assoc w/ increase ICU LOS, Duration of MV, antibiotic use Prospero et al. (2012) Learning from Galileo: VAP Surveillance. Am J Respir Crit Care Med. 186(12): Teaching hospital in Central Italy VAC signif assoc w/ duration of MV, hospital LOS and mortality

9 Prospective cohort study in two Dutch academic medical centers ( ). VAE surveillance was electronically implemented as well as ongoing VAP surveillance. VAC IVAC VAE VAP VAP The VAE algorithm detected at most 32% of the patients with VAP identified by prospective surveillance.

10 VAC signals were most often caused by volume overload and infections, but not necessarily VAP. The large number of VACs occurring on the third or fourth day of ventilation could be representative of ongoing clinical deterioration as opposed to insufficient quality of care IVACs appeared to detect respiratory infections not related to MV.

11 Retrospective Cohort Study Academic tertiary care center Rates VAC plus (VAE) 12.4 IVAC plus 4.7 Poss VAP 1.5 Prob VAP 1.4 Rate per 1000 vent days

14 % PVAP CDC VAP % S. aureus S. aureus 24% 14% P. aeruginosa P. aeruginosa 17% 7.9% Klebsiella spp Klebsiella spp 10% 7.9% Enterobacter spp Enterobacter spp % 8.6%

15 110 pts with VAC matched to controls Risk factors for VAC Positive fluid balance CHF was protective 1/3 less fluids given % of days on mandatory modes of vent Risk factors for IVAC (n=38) Benzodiazepines Total opioid administered Paralytic meds

17 CDC Prevention Epicenters Wake Up and Breathe Collaborative 20 ICUs from 13 academic and community hospital 12 ICUs included SAT/SBT and VAE surv 8 ICUs only did VAE surv

18 12 ICUs included SAT/SBT and VAE surv SAT 14% - 77% (when indicated) SBT 49% - 75% (when indicated) Coordinated SAT/SBT 6% - 87% Decreased MV days and hospital LOS Decreased VAE rate per 100 episodes VAE 9.7 to 5.2 IVAC 3.5 to 0.52 PVAP 0.88 to 0.52 No change in VAE risk when using vent days 8 ICUs only VAE surv No Change

19 Prospective time series study 11 North American ICUs VAP clinical practice guidelines implemented Prevention, Diagnosis and Treatment Each ICU enrolled 30 pts on vent >48 hrs Applied old VAP def Retrospectively applied VAC, IVAC def

20 Date of download: 4/14/2015 Copyright American College of Chest Physicians. All rights reserved. From: The Clinical Impact and Preventability of Ventilator-Associated Conditions in Critically Ill Patients Who Are Mechanically VentilatedImpact of Ventilator-Associated Conditions Chest. 2013;144(5): doi: /chest Figure Legend: The relationship between VAP, VAC, and ivac. ivac = infection-related ventilatorassociated complication; VAC = ventilator-associated condition; VAP = ventilatorassociated pneumonia.

21 VAC IVAC OLD VAP ICU LOS Significant Significant Significant Hopital LOS Significant Significant Significant Duration of MV Significant Significant Significant # Antibiotic Days Hospital Mortality Significant Significant Significant Significant P= 0.07 P= 0.67

22 Date of download: 4/14/2015 Copyright American College of Chest Physicians. All rights reserved. From: The Clinical Impact and Preventability of Ventilator-Associated Conditions in Critically Ill Patients Who Are Mechanically VentilatedImpact of Ventilator-Associated Conditions Chest. 2013;144(5): doi: /chest Figure Legend: Rates of VAP, VAC, and ivac and concordance across the four data enrollment periods. See Figure 2 legend for expansion of abbreviations.

23 Oral Route of intubation (100%) Vent Circuit changes only if soiled or damaged (83%) Changing heat & moisture exchangers every 5-7 days (2%) Use closed endotracheal suctioning system and change only when indicated (100%) Subglottic Secretion Drainage (36% - 58%) HOB 45 deg (29% - 41%) CHG Oral Antiseptic (16% - 50%)

Objectives: To investigate whether fluid management guided by daily BNP plasma concentrations improves weaning outcomes compared with empirical therapy dictated by clinical acumen.

24 Objectives: To investigate whether fluid management guided by daily BNP plasma concentrations improves weaning outcomes compared with empirical therapy dictated by clinical acumen. Methods: In a randomized controlled multicenter study, we allocated 304 patients to either a BNP-driven or physician-driven strategy of fluid management during ventilator weaning. The primary end point was time to successful extubation. Measurements and Main Results: In the BNP-driven group, More negative median fluid balance during weaning. Time to successful extubation was significantly shorter with the BNPdriven strategy (58.6 vs P 0.034). The BNP-driven strategy increased the number of ventilator-free days but did not change length of stay or mortality. The two strategies did not differ significantly regarding electrolyte imbalance, renal failure, or shock. Conclusions: Our results suggest that a BNP-driven fluid management strategy decreases the duration of weaning without increasing adverse events, especially in patients with left ventricular systolic dysfunction.

Assess the impact of a depletive fluidmanagement strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation We used data from the B-type

25 Assess the impact of a depletive fluidmanagement strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization

26 RESULTS Control N=152 Interventio n N=152 Total N-304 P value VAC 27 (17.8%) 13 (8.6%) 40 (13.2%) 0.02 VAP 27 (17.8%) 14 (9.2%) 41 (13.5%) 0.03 We found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP (VAC) risk in patients who are mechanically ventilated.

27 Why is VAE BAD? Increased LOS, vent days, mortality What events is VAE detecting? Pneumonia, pulmonary edema, ARDS, atelectasis, Is VAE preventable? Some are, not sure all of them... How can we prevent them? HOB, Oral Care, Subglotic suctioning SBT, SAT, doing them together Fluid management?

Michael Klompas, MD, MPH; Richard Branson, MSc, RRT; Eric C. Eichenwald, MD; Linda R. Greene, RN, MPS, CIC; Michael D. Howell, MD, MPH; Grace Lee, MD; Shelley S. Magill, MD, PhD; Lisa L.

28 Michael Klompas, MD, MPH; Richard Branson, MSc, RRT; Eric C. Eichenwald, MD; Linda R. Greene, RN, MPS, CIC; Michael D. Howell, MD, MPH; Grace Lee, MD; Shelley S. Magill, MD, PhD; Lisa L. Maragakis, MD, MPH; Gregory P. Priebe, MD; Kathleen Speck, MPH; Deborah S. Yokoe, MD, MPH; Sean M. Berenholtz, MD, MHS Infection Control and Hospital Epidemiology, Vol. 35, No. 8 (August 2014), pp

29 Almost all of the existing literature on VAP prevention is based on traditional VAP definitions rather than VAE definitions. Little or no data at present on the impact of traditional VAP prevention strategies on VAE Of note, VAC and IVAC intentionally flag more than just pneumonia; hence, interventions directed solely against pneumonia may not be sufficient to reduce VAE rates.

30 We prioritize VAP interventions that have been shown to improve objective outcomes, duration of MV, intensive care or hospital LOS, Mortality costs in RCTs In addition, the potential benefits of different interventions are balanced against their feasibility, costs, and potential harm.

33 Rationale Intervention Quality of Evidenc e Good evidence the intervention decreases the ave duration of mechanical ventiliation, LOS, mortalily a/o costs; benefits likely outweigh risks Use NIPPV in select populations Manage pts w/o sedation whenever possible Interrupt sedation daily Assess readiness to extubate daily Perform SBT with sedatives turned off Facilitate early mobility Use endotracheal tubes w/subglotic secretion drainage ports for pts expected to be on vent > 48-72hrs Change vent circuit only if visibly soiled or malfunctioning HOB degrees High Mod High High Mod Mod High Low Low

34 Rationale Intervention Quality of Evidenc e Good evidence that it improves outcomes but insufficient data available on poss risks Selective Oral or digestive decontamination Regular Oral care with CHG High Mod May lower VAP rates but insuff data to determine impact on Duration of vent, LOS, mortality Prophylactic probiotics Ultrathin polyurethane endotrach tube cuffs Automated control of endotrach tube cuff pressure Saline instillation before trach suctioning Mechanical tooth brushing Mod Low Low Low Low

35 Rationale Intervention Quality of Evidence Lowers VAP rates but ample data suggest no impact on duration of MV, LOS or mortality No impact on VAP rates, Duration of MV, LOS or mortality Silver coated endo tubes Kinetic beds Prone positioning Stress ulcer prophylaxis Early tracheotomy Monitoring residual gastric volumes Early parenteral nutrition Mod Mod Mod Mod High Mod Mod No recommendation Closed/in line endo suctioning Mod

36 HRET (Health Research & Educational Trust) HHS (US dept of Health and Human Services) American Hospital Association oad&view=category&id=182&itemid=286

37 HOB 30-45deg Peptic Ulcer Disease Prophylaxis (PUD) Venous Thromboembolism Prophylaxis (VTE) Oral Care ABCDE Bundle

Use visual cues so that it is easy to identify when the bed is in the proper position. Designate one person to check for visual cues every 1-2 hours in the entire unit.

38 Use visual cues so that it is easy to identify when the bed is in the proper position. Designate one person to check for visual cues every 1-2 hours in the entire unit. Establish procedures for head-of-bed elevation as tolerated in non-icu areas, such as the Emergency Department (ED), during transport within the hospital, and during transport via ambulance between hospitals. Patient and family engagement in head of bed elevation.

39 Educate the RN staff about the rationale Create visual cues to demonstrate compliance with oral care. Examples include keeping empty holders of oral care products by the bedside or dating and timing oral care products used. Engage Respiratory Therapy in the performance of oral care; make it a joint RN and RT function. Use a whiteboard to document the delivery of oral care; omissions will make missed interventions more obvious.

40 A Awakening trials for ventilated patients B Spontaneous Breathing trials C RN and respiratory therapist Coordination to perform spontaneous breathing trials by reducing or stopping sedation so as to awaken the patient D Standard Delirium assessment program, including treatment and prevention options E Early mobilization and ambulation of critically ill patients.

Safety Screening (Patient must meet all criteria) M Myocardial stability No evidence of active myocardial ischemia x 24 hrs.

6 PEEP < 10 cm H2O V - Vasopressor(s) minimal No increase of any vasopressor x 2 hrs.

TID Able to move arm against gravity Level 2 Passive ROM TID Turn Q 2 hrs. Active resistance PT Sitting position 20 mins.

41 Safety Screening (Patient must meet all criteria) M Myocardial stability No evidence of active myocardial ischemia x 24 hrs. No dysrhythmia requiring new antidysrhythmic agent x 24 hrs. O Oxygenation adequate on: FiO2 < 0.6 PEEP < 10 cm H2O V - Vasopressor(s) minimal No increase of any vasopressor x 2 hrs. E Engages to voice Patient responds to verbal stimulation Level 1 Passive ROM TID Turn Q 2 hrs. Active resistance PT Sitting position 20 mins. TID Able to move arm against gravity Level 2 Passive ROM TID Turn Q 2 hrs. Active resistance PT Sitting position 20 mins. TID Sitting on edge of bed Able to move leg against gravity Level 3 Passive ROM TID Turn Q 2 hrs. Active resistance PT Sitting position 20 mins. TID Sitting on edge of bed Active transfer to chair 20 mins./day Level 4 Passive ROM TID Turn Q 2 hrs. Active resistance PT Sitting position 20 mins. TID Sitting on edge of bed Active transfer to chair 20 mins./day Ambulation (marching in place, walking in halls)

42 Summary of the Infection-Related Provisions in CMS FY 2015 Prospective Payment System Long-Term Care Hospital Quality Reporting (LTCHQR) Program Final Rules for Inpatient Settings CMS finalized the addition of the NHSN VAE Outcome Measure to the LTCHQR Program for FY2018 payment determination and future years as proposed.

43 VAEs are mostly caused by pneumonia, ARDS, pulmonary edema, atelectasis Traditional VAP prevention methods still likely to lower the VAE rate May consider adding SAT, SBT, early mobility and fluid management to future VAE bundle VAE will be publicly reported in the future

VAP Prevention bundles

VAP Prevention bundles Dr. Shafiq A.Alimad MD Head of medical department at USTH YICID workshop, 15-12-2014 Care Bundles What are they & why use them? What are Care Bundles? Types of Care Bundles available