Ventilator-Associated Events (VAEs): Reduction and Reporting

Transcription

1 Ventilator-Associated Events (VAEs): Reduction and Reporting June 21, 2016

2 Agenda Opening Remarks Housekeeping Polling Question Presentations Q&A Closing Remarks 2

3 Introduction to the atom Alliance Multi-state alliance for powerful change composed of three nonprofit, healthcare QI consulting companies. 3

4 Objectives What we'll cover: Review VAE definitions and criteria Learn how to correctly report VAEs in NHSN Discuss best practices and quality improvement strategies to reduce VAEs 4

5 Housekeeping Items: Chat To ensure maximum sound quality, participant lines have been muted; however we welcome ALL questions and comments via the chat board on the right hand side of your screen To submit questions or comments: Use WebEx chat send messages to the panelists or all participants using the chat feature drop down menu 5

6 Housekeeping Items: Polling During today s presentations you may be asked to participate in some polling questions. These questions will come up on the right side of your screen. When you do answer a polling question, be sure to hit the submit button so we can capture your answer. 6

7 Polling Question #1 Are you currently reporting VAE into NHSN? Yes, we currently submit VAE data into NHSN. No, but we will start within the next 3 months. No, we have no plans for reporting VAE at this time 7

8 Ventilator-Associated Event (VAE) Reporting: Overview and Definitions Kathy Buechel, RN, BSN, CIC

9 Objectives NHSN Background Reporting requirements VAE Denominator data Definitions and data entry Event/Case (Numerator) data Ventilator-Associated Condition (VAC) Infection-Related Ventilator-Associated Complication (IVAC) Possible Ventilator-Associated Pneumonia (PVAP) 9

10 VAE Denominator Data

11 Daily Denominator Data Collection Patient days At the same time each day, record the number of patients in the unit/location Total number of patients on a ventilator At the same time each day, record the total number of patients on a ventilator Number of APRV Of patients on a ventilator, record how many are on Airway Pressure Release Ventilation (APRV) or a related mode of mechanical ventilation (e.g., BiLevel, Bi Vent, BiPhasic, PCV+, DuoPAP) (Optional) Number of Episodes of Mechanical Ventilation Count all patients on mechanical ventilation on the first day of the month, count each additional new patient that was started on mechanical ventilation each day. Include new episodes in previously ventilated patients. 11

12 Who Records the Denominators? Note: Whoever collects this information should receive training at regular intervals to ensure accuracy The IP can go to the unit and look at the patient or chart What about weekends? Holidays? Use unit clerk to record at same time every day Charge nurse or house supervisor can record during endof-shift report Electronic sources MUST validate for a minimum of 3 months Must be within +/- 5% of manual counts 12

13 Ventilator Definition Ventilator is defined as a device to assist or control respiration, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation Intermittent positive-pressure breathing (IPPB); nasal positive end-expiratory pressure (nasal PEEP); and continuous nasal positive airway pressure (CPAP, hypocpap) are not considered ventilators unless delivered via tracheostomy or endotracheal intubation (e.g., ET-CPAP) 13

14 Ventilator-Associated Condition (VAC)

15 VAE Definition Algorithm Summary Patient on mechanical ventilation > 2 days Respiratory status component Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC) Infection / inflammation component Additional evidence General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testing Possible VAP (PVAP) 15

16 VAE Algorithm Algorithm is progressive in terms of criteria to be met (from VAC to IVAC to PVAP), but this is not to imply that each subsequent tier is more clinically significant than the one before. IVAC is not necessarily worse than having a VAC PVAP is not necessarily worse than having an IVAC The fundamental definition within the algorithm is that VAC is defined on the basis of respiratory deterioration IVAC additional evidence that the event may be infectious vs. non-infectious PVAP additional evidence the infection may be respiratory related 16

17 Positive End-Expiratory Pressure (PEEP) A technique used in respiratory therapy in which airway pressure greater than atmospheric pressure is achieved at the end of exhalation by the introduction of a mechanical impedance to exhalation. * In patients on conventional mechanical ventilation, PEEP is one of the parameters that can be adjusted depending on the patient s oxygenation needs. A sustained increase in the daily minimum PEEP of 3 cmh 2 O following a period of stability or improvement on the ventilator is one of two criteria that can be used in meeting the VAC definition. *Stedman s Medical Dictionary, (28 th ed). (2005). Philadelphia: Lippincott, Williams, & Wilkins. 17

18 Fraction of Inspired Oxygen (FiO 2 ) The fraction of oxygen in inspired gas. For example, the FiO 2 of ambient air is 0.21; the oxygen concentration of ambient air is 21%. In patients on mechanical ventilation, the FiO 2 is one of the key parameters that can be adjusted depending on the patient s oxygenation needs. A sustained increase in the daily minimum FiO 2 of 0.20 (20%) following a period of stability or improvement on the ventilator is the second of the two criteria that can be used in meeting the VAC definition. 18

19 VAE Definition Algorithm Summary Patient on mechanical ventilation > 2 days Respiratory status component Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC) FiO 2 or PEEP Infection / inflammation component General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Additional evidence Positive results of microbiological testing Possible VAP (PVAP) 19

20 Daily Minimum FiO 2 and PEEP Choose the lowest FiO 2 and PEEP setting during the calendar day that was maintained for at least 1 hour If there is no value that has been maintained for at least 1 hour then select the lowest value available regardless of the period of time in which the setting was maintained Ventilation initiated late in the calendar day Ventilation discontinued early in the calendar day Ventilator settings very unstable throughout the day 20

21 Daily Minimum Values The patient is intubated at 6 pm. PEEP and FiO 2 are set at the following values through the remainder of the calendar day. What are the daily minimum PEEP and FiO 2 values for the calendar day? 1. 5 and and and and pm 7pm 8pm 9pm 10pm 11pm PEEP (cmh 2 O) FiO

22 Daily Minimum Values What are the daily minimum PEEP and FiO 2 values for the calendar day? 1. 5 and and and and pm 7pm 8pm 9pm 10pm 11pm PEEP (cmh 2 O) FiO

23 Period of Stability or Improvement Patient has a baseline period of stability or improvement on the ventilator, defined by 2 calendar days of stable or decreasing daily minimum* FiO 2 or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO 2. *Daily minimum FiO 2 and PEEP must be maintained for at least 1 hour 23

24 Period of Stability or Improvement After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: Increase in daily minimum* FiO 2 of 0.20 (20 points) over the daily minimum FiO 2 in the baseline period, sustained for 2 calendar days. Increase in daily minimum* PEEP values of 3 cmh 2 O over the daily minimum PEEP in the baseline period**, sustained for 2 calendar days. OR *Daily minimum FiO 2 or PEEP must be maintained for at least 1 hour **Daily minimum PEEP values of 0 to 5 cmh 2 O are considered equivalent for the purposes of VAE surveillance. 24

25 Operationalizing VAE Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys/ Epis Org

26 Operationalizing VAE Vent Day PEEP min FiO 2 min Temp min Temp WBC WBC 2-day maxperiod min of stability max (PEEP or FiO 2 ) Abx Spec Polys/ Epis Org

27 Operationalizing VAE Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys/ Epis Org day peri od of worsening, based on PEEP

28 Operationalizing VAE Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys/ Epis Org =VAC

29 Operationalizing VAE Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys/ Epis Org Event Date = Vent Day 5 (first day of worsening oxygenation)

30 Operationalizing VAE Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys/ Epis Org

31 Date of Event / Event Date The date of onset of worsening oxygenation (day 1 of the required 2 day period of worsening oxygenation). It is not the date on which all VAE criteria are met. It is not the date of the first day of the baseline period Earliest date of event for VAE is mechanical ventilation day 3 (first day of worsening oxygenation) First possible day that VAC criteria can be fulfilled is mechanical ventilation day 4 31

32 Why is the Event Date important? Defining the VAE Window Period Period during which criteria for other events IVAC, PVAP must be met Sets the 14 day VAE Event Period Each VAE is 14 days in duration (arbitrary to standardize). Day 1 is the Event Date so if June 1 is date of onset of worsening oxygenation and a VAC is reported, a second VAE cannot be detected and reported until June 15. May not upgrade a VAE based on data collected outside the VAE Window Period but within the 14-day event period. May not report a new VAE until that 14 day period has elapsed (keep in mind that 14 day period is event date to event date so baseline period can occur during previous event period). Blood cultures must be collected within the 14 day event period for a BSI to be secondary to VAE 32

33 VAE Window Period This is the period of days around the event date (i.e., the day of onset of worsening oxygenation) within which other VAE criteria must be met. It is usually a 5-day period and includes the 2 days before, the day of, and the 2 days after the VAE event date (i.e., the first day of worsening oxygenation, the day of VAE onset). 33

34 VAE Window Period Event Date 2 days before Event Date 2 days after Event Date MV Day VAE Day Day 1 of Day 2 of Day 1 of Day 2 of Stability or stability or worsening worsening Worsening oxygenation -- improve- improve- oxygena- oxygena- VAC ment ment tion tion Temperature or WBC abnormality Antimicrobial agent IVAC Purulent respiratory secretions, positive culture, positive PVAP histopathology Documented within this shaded period Started on within this shaded period, and then continued for at least 4 days Collected within this shaded period 34

35 VAE Definition Algorithm Summary Respiratory status component Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC) Infection / inflammation component Additional evidence General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testing Possible VAP (PVAP) 35

36 Infection Related Ventilator-Associated Complication (IVAC)

37 VAE Definition Algorithm Summary Respiratory status component Infection / inflammation component Additional evidence Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC) General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testing Temperature or WBC AND New antimicrobial agent Possible VAP (PVAP) 37

38 Look for abnormal temp or white count during VAE Window Period Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys/ Epis Org

39 IVAC Antimicrobial Criterion Probably the most complicated portion of the VAE surveillance definition algorithm Rules for meeting this criterion are not perfect but there is a need to have a standardized method for assessment of antimicrobial therapy, without needing knowledge of dosing, renal function, indication for therapy, etc. could be applied 39

40 New antimicrobial agent started and continued for 4 days Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Poly/ Epis Org None None None None = IVAC Yes Yes Yes Yes 40

41 Possible Ventilator- Associated Pneumonia (PVAP)

42 VAE Definition Algorithm Summary Respiratory status component Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Infection / inflammation component Additional evidence Ventilator-Associated Condition (VAC) General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testing Purulent secretions, positive cultures, and other positive laboratory evidence Possible VAP (PVAP) 42

43 VAC and IVAC must be met Possible VAP = PVAP Laboratory test collection dates must occur On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation (VAE Window Period) Organism exclusions must be considered Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent Candida species or yeast not otherwise specified; coagulase-negative Staphylococcus species; Enterococcus species unless isolated from lung tissue or pleural fluid Community-associated respiratory pathogens: Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus, and Pneumocystis AND One of the following criteria must be met 43

44 PVAP Criterion 1 Positive culture of one of the following specimens, meeting quantitative or semi-quantitative thresholds as outlined in protocol, without requirements for purulent respiratory secretions: Endotracheal aspirate, 10 5 CFU/ml or corresponding semiquantitative result Bronchoalveolar lavage, 10 4 CFU/ml or corresponding semiquantitative result Lung tissue, 10 4 CFU/g or corresponding semi-quantitative result Protected specimen brush, 10 3 CFU/ml or corresponding semi-quantitative result 44

45 PVAP Criterion 2 Purulent respiratory secretions (defined as secretion from the lungs, bronchi, or trachea that contain 25 neutrophils and 10 squamous epithelial cells per low power field [lpf, x100]) AND A positive culture of one or the following specimens (qualitative culture, or quantitative/semi-quantitative culture without sufficient growth to meet criterion #1): Sputum Endotracheal aspirate Bronchoalveolar lavage Lung tissue Protected specimen brush 45

46 PVAP Criterion 3 One of the following positive tests: Pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube Lung histopathology Diagnostic test for Legionella species Diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneum virus, coronavirus 46

47 Pathogen Reporting Pathogens may only be reported for PVAP and according to the usual pathogen and antimicrobial susceptibility reporting methods utilized in NHSN for other events Exception: excluded pathogens Pathogens are NOT reported for VAC or IVAC 47

48 Positive quantitative or semi-quantitative ETA culture (meeting specified threshold) Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys /Epis Org None None ETA 25/ Yes Yes cfu/ml S. aureus Yes Yes = PVAP, meets Criterion 1 48

49 Purulent respiratory secretions AND ETA culture positive for S. aureus (not meeting the specified threshold) Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx None Spec None ETA Polys /Epis 25/ Yes Yes Org S. aureus Yes Yes = PVAP, Meets criterion 2 49

50 Positive pleural fluid, lung histopathology, Legionella or viral test result Vent Day PEEP min FiO 2 min Temp min Temp max WBC min WBC max Abx Spec Polys /Epis Org None None Pleural fluid Candida albicans Yes Yes Yes Yes = PVAP, Meets criterion 3 50

51 Using the Ventilator Associated Event Calculator Ver

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53 Preparing to conduct VAE Surveillance and Reporting Events Into NHSN Tips for getting started Get familiar with the protocol & review the FAQs vae_final.pdf Experiment with the VAE calculator 53

54 Preparing for VAE Surveillance Establish relationships with Respiratory Therapy and/or Critical Care colleagues Share the protocol Discuss options for collection of minimum daily PEEP and FiO 2 for each MV day (IP, RT, electronically generated) Inquire about frequency with which excluded therapies (HFV, ECLS) and APRV are used Determine your laboratory s approach to Gram Stain and culture result reporting How does your hospital laboratory report Gram stain results? Does your hospital laboratory report culture results quantitatively? What quantitative ranges correspond to the semi-quantitative reports? 54

55 Preparing for VAE Surveillance Develop a plan for organizing the data elements needed to identify VAEs PEEP and FiO 2 WBC/Temperature Antimicrobial agents (administration, not orders) Laboratory results Explore use of tools for data collection 55

56 Thank you for time and participation! For questions:

57 Ventilator Associated Events (VAEs) Prevention Best Practices Manoj Jain MD MPH atom Alliance Medical Director

58 Objectives Understand the Causes of VAEs Avoid VAEs through Evidence Based Approaches Learn about the Barriers and Solutions to VAE Prevention Implement a Quality Improvement Strategy to prevent VAEs 58

59 How to Avoid VAEs Avoid Intubation Minimize Duration of Mechanical Ventilation Target Specific Conditions that Trigger VAEs 59

60 What are the Root Causes of VAEs? Pneumonia Atelectasis ARDS Fluid Overload 60

61 Strategy 1: Minimize Sedation Choice, depth and duration of sedation matters Sedation leads to delirium, immobility, infection, VAEs, prolonged mechanical ventilation, increased length of stay and death Benzodiazepine and opioids independent risk factors for IVACs No sedation lead to 4.2 more ventilator-free days compared with sedation However no sedation requires intensive nursing care such as 1:1 61

62 Strategy 2: Daily Spontaneous Awakening Trials and Breathing Trials SAT (Spontaneous Awakening Trails) and SBT (Spontaneous Breathing Trials) can decrease extubation by 1.5 to 2.5 days Combining SAT and SBT is synergistic SAT and SBT leads to less use of sedation CDC trial Wake Up and Breathe Collaborative 12 ICUs 7 hospitals over 19 months VAEs reduced from 9.7 to 5.2 events per 100 episodes of mechanical ventilation IVAC reduced from 3.5 to day reduced of hospital length of stay 62

63 Strategy 3: Early Exercise and Mobility Immobility is risk factor for increase LOS, pneumonia, atelectasis, and delirium Quality initiative: ABCDE Awakening and Breathing Coordination, Delirium monitoring and management, Early exercise and mobility 3 more ventilator-free days Early mobility lead to: 2.4 more ventilator-free days 2.0 fewer days of delirium 63

64 Strategy 4: Low Tidal Volume Ventilation Lower tidal volumes lead to lower mortality and complications Increased in tidal volume by each milliliter above 6ml/kg predicted body weight increased odds of VAE by 21 percent 64

65 Strategy 5: Conservative Fluid Management Key question each day Is my patient wet or dry? percent of VAE due to fluid overload FACTT (Fluid and Catheter Treatment Trial) showed conservative fluid management lead to more ventilator free days in patients with ARDS Daily BNP level leads to better fluid control 65

66 Strategy 6: Conservative Blood Transfusion Threshold Transfusions increase risk fro pulmonary edema and ARDS Conservative transfusion thresholds are safe Further studies needed 66

67 Other Strategies Limited Success Elevating the Head of Bed Oral Care Subglottic secretions drainage Choosing the Right Denominator for VAE Surveillance 67

68 68 Putting It Together ( Klompas, AJRCCM 2015)

69 69 Crosswalk of Best-Practices( Klompas, AJRCCM 2015)

70 Common Barriers to VAE Prevention VAP guidelines require time on part of doctors. Also require greater nursing and physical therapy care Higher level of monitoring and testing Practice change and culture change Monitoring process and outcome indicators 70

71 Workable Solutions to VAE Barriers Staff Education about sedation, ventilator support, mobility, and VAE Staff buy-in on data Initiate Quality Improvement Process 71

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84 VAE Definition Algorithm Summary FIO2 or Peep Patient on Mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator Associated Condition (VAC) Respiratory Status Component General evidence of infection/inflammation Infection-related Ventilator-Associated Complication Infection Inflammation Component Positive results of microbiological testing Possible Ventilator Associated Pneumonia (PVAP) Additional evidence 84

85 85 Questions?

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