VAE Questions and Case Studies

Transcription

1 VAE Questions and Case Studies Cindy Gross, MT, SM (ASCP), CIC IP Consultant April 30, 2014 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion Review the process of detering the daily imum and FiO2 values Review the necessary criteria needed to meet the first tier of the VAE algorithm (VAC) Highlight a few FAQs Identify the VAE specific event definition that is met based on example data provided 1

2 Respiratory status component VAE Definition Algorithm Summary Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition(VAC) No CXR needed! Infection / inflammation component General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Additional evidence Positive results of microbiological testing Possible or Probable VAP Daily Minimum FiO 2 and FiO 2 and ventilator settingsdocumented across the calendar day are used to identify the daily imum FiO 2 and values FiO 2 and settings are typically recorded in the paper or electronic medical record, on respiratory therapy and/or nursing flow sheets, in the section of the flow sheet that pertains to respiratory status/mechanical ventilation Use a calendar day not some other capture period or other designated 24 hour time period Choose the lowest FiO 2 and setting during the calendar day that was maintained for at least 1 hour 2

3 Daily Minimum FiO2 and When choosing the daily imum and FiO 2, use all settings that are recorded during times when the patient is receiving support from an eligible mode of mechanical ventilation and the patient is eligible for VAE surveillance Include settings collected during weaning/mechanical ventilation liberation trials as long as the patient is receiving ventilator support during those trials Use all conventional mechanical ventilation settings Include conventional MV settings during times when a patient is intermittently on an excluded mode of ventilation throughout a calendar day Include recorded settings during times when a patient is not on APRV or a similar mode of ventilation. Daily Minimum FiO 2 and Use the daily imum FiO 2 and values when assessing for both the period of stability or improvement and the period that indicates worsening oxygenation. Do not compare values that occur within a calendar day to detere stability, improvement or worsening. 3

4 Identifying the Minimum Daily FiO 2 and (Select the lowest value recorded for each calendar day that is maintained for at least one hour) Monday 12am 3am 6am 9am 12pm 3pm 6pm 9pm MV mode ACV ACV ACV ACV ACV ACV ACV ACV FiO O Note: Documentation of FiO 2 and occurs every 3 hour Detering daily imum /FiO2 when settings are documented 1 hour intervals Specific guidance in the found in the protocol Must be sufficient documentation of consecutive recordings to meet the imum required duration of 1 hour If tracking every 15 utes, 5 consecutive recordings of a certain level would be needed (e.g., at 09:00, 09:15, 09:30, 09:45 and 10:00 If tracking every 30 utes, 3 consecutive recordings at a certain level would be needed (e.g., at 09:00, 09:30, and 10:00) If tracking every hour, 2 consecutive recordings at a certain level (e.g., at 09:00 and 10:00) Standardization 4

5 Identifying the Minimum Daily FiO 2 and (Select the lowest value recorded for each calendar day that is maintained for at least 1 hour) Monday 12am 3am 4am 6am 9am 12pm 3pm 9pm MV mode ACV ACV ACV ACV ACV ACV ACV ACV FiO O is the lowest value for the calendar day but it was not maintained for 1 hour Daily Minimum Values The patient is intubated at 2 pm. and FiO 2 are set at the following values through the remainder of the calendar day. What are the daily imum and FiO 2 values for the calendar day? Time 2 pm 4 pm 6pm 8 pm 10 pm 12 am (cmh 2 O) FiO

6 What are the daily imum and FiO2? 1. 5 and and and and 1.0 Time 2 pm 4 pm 6pm 8 pm 10 pm 12 am (cmh 2 O) FiO Daily Minimum Values The patient is intubated at 6 pm. and FiO 2 are set at the following values through the remainder of the calendar day. What are the daily imum and FiO 2? Time 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm (cmh 2 O) FiO

7 What are the daily imum and FiO2? 1. 5 and and and and 0.60 Time 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm (cmh 2 O) FiO VAC Requirements Baseline period of stability or improvement Indicators of worsening oxygenation 7

8 Define Baseline MV Day Daily imum Daily imum FiO Define Baseline MV Day Daily imum Daily imum FiO

9 Define Baseline MV Day Daily imum Daily imum FiO Meeting VAC Definition What if the increase over the baseline period meets the requirement relative to one baseline day? MV Day Daily imum Daily imum FiO 2 1. VAC 2. NO VAC

10 Meeting VAC Definition What if there is an increase for one day and then a decrease? MV Day Daily imum Daily imum FiO 2 1. VAC 2. NO VAC Meeting VAC Definition VAC or No VAC? MV Day Daily imum Daily imum FiO Yes 2. No

11 Discrepant changes goes up but FiO 2 goes down MV Day Daily imum Daily imum FiO When should I use PNEU/VAP instead of VAE? A. Never always use VAE B. When surveillance is to be conducted in mechanicallyventilated children who are in pediatric locations C. When surveillance is to be conducted for healthcareassociated pneumonia that is not associated with mechanical ventilation D. Band C E. None of the above 11

12 NHSN Lower Respiratory Events in 2014 VAE is the only in-plan option available for ventilated patients in adult locations as of January Current VAP protocol is available for in-plan surveillance in pediatric locations ONLY. In-plan neonatal VAP surveillance is no longer available as of January 2014 In 2014, the current PNEU definitions are still available for off-plan surveillance of VAP in adults, children, neonates or off-plan surveillance for non-ventilated PNEU in adults, children or neonates. If a patient is admitted with a community acquired pneumonia (CAP), they are excluded from VAE surveillance for 14 days. A. True B. False 12

13 FALSE All patients who are eligible for VAE surveillance are to be included There are no exclusions for specific admitting diagnoses or underlying illnesses Algorithm requires a period of stability on the ventilator typically should not be capturing events that represent ongoing worsening If patient stabilizes or improves then worsens again, this is a possible indication of a new HAI Patients with CAP, may experience complications related to mechanical ventilation that are preventable If temperature, WBC or laboratory criteria are present prior to detection of a VAE and also present within the VAE Window Period, they canbe used to meet IVAC and possible or probable VAP definitions. A. True B. False 13

14 TRUE All abnormal temperature and white blood cell count values documented during the VAE Window Period are to be utilized Eligible laboratory findings (Gram stain, culture, other laboratory test results) that have a collection date during the VAE Window Period are to be utilized When evaluating patient data to see if the IVAC definition is met, I should focus onlyon antibiotics that are used to treat respiratory infections A. Yes B. No 14

15 IVAC and Antimicrobial Agents Meeting Infection-related Ventilator Associated Complication ( IVAC) definition does not mean that the infection related event is necessarily respiratory in origin. The IVAC antimicrobial list was refined by removing selected antimicrobial agents that would not be used, or would be unlikely to be used, in treating a lower respiratory infection in a critically ill patient. Still possible that an existing agent may have dual purposes and not necessarily be treating a respiratory infection. No need to discern the reason for the adistration of the antimicrobial. Prophylaxis, de-escalation, change within a class of antimicrobials is not a reason for exclusion When selecting the daily imum and FiO 2 for each calendar day.. 1. Throw out the lowest value 2. Choose the most consistent value 3. Select the value using any 24 hour time period 4. Choose the lowest value that has been maintained for at least 1 hour 15

16 A patient in my ICU met the IVAC definition. On the VAE Event Date, there was also a positive blood culture that grew Pseudomonas aeruginosa. The patient has a central line. Other than fever, there are no other signs/symptoms of infection. How should I report this event? A. Report an IVAC (no pathogen) and evaluate to see if the positive blood culture is secondary to another HAI or if it is a CLABSI (pathogen=pa) B. Report an IVAC (pathogen=pa) C. Report an IVAC and secondary BSI (pathogen=pa) D. Report a CLABSI (pathogen=pa) E. Report an IVAC (no pathogen) F. None of the above Secondary BSI can only be reported for possible or probable VAP Organisms isolated from the blood culture must match an organism isolated from an appropriate respiratory tract specimen that was used to meet the possible or probable VAP definition Blood culture must be collected during the 14 day event period If the blood culture is not found to be secondary to VAE look to the other HAI definitions (including PNEU and LRI) or report as a CLABSI VAC, IVAC or No VAE detected Possible or probable VAP met but no organism match and/or blood culture not collected during 14 day event period 16

17 If I am conducting VAE surveillance in-plan, I need to assess daily imum and maximum temperatures for the following patients: 1. All patients in the ICU 2. All patients in the ICU who are on a ventilator 3. Patients who I have detered meet the VAC definition 4. Patients who have met the VAC definition and also have an abnormal white blood cell count 5. Patients who the clinical care providers have diagnosed with VAP Key Things to Remember about Data Collection For most patients will only need to record daily imum and FiO 2 while on ventilator. Nothing else! Only need to assess temperature and white blood cell count information for patients who fulfill VAC criteria And only need to look at these values during the VAE Window Period (3-5 days) Only need to look at antimicrobial adistrations for patients with VAC AND abnormal temp or white count New during the VAE Window Period (3-5 days) Only need to assess lab/microbiology/pathology data for patients that meet the IVAC definition Collection dates during the VAE Window Period (3-5 days) 17

18 The following examples are for illustration purposes only and are not intended to represent actual clinical scenarios. Case Study 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 ventilator. Review her ventilator settings and detere if VAE criteria are met. MV Day Daily imum Daily imum FiO A. Yes B. No 18

19 What specific event should be reported for this patient? MV DAY Daily imum Daily imum FiO 2 Temp WBC ABX ABX Pip / Tazo Pip / Tazo Pip / Tazo Specimen Vanco- IV Vanco- IV Sputum Polys /Epis Organism Scant NF, Many Staph. aureus BAL Vanco- IV 10 4 cfu/ml S. aureus Vanco- IV What specific event should be reported for this patient? A. None, the patient had CAP present on admission B. Possible VAP (pathogen SA) C. Probable VAP (Pathogen SA) D. VAC only 19

20 MV DAY Daily imum Daily imum FiO 2 Temp WBC ABX ABX Pip / Tazo Pip / Tazo Pip / Tazo Specimen Vanco- IV Vanco- IV Sputum BAL Vanco- IV Polys /Epis Organism Scant NF, Many Staph. aureus 10 4 cfu/ml S. aureus Vanco- IV CASE 1 Recap Patients are not excluded from VAE surveillance due to admitting diagnosis, presence of underlying conditions or development of complications Eligible pathogens identified during the VAE window period are to be used to detere if possible or probable VAP definitions can be met even if the same or similar pathogen was identified prior to the event detection Days between adistration of the same new antimicrobial agent count as QADs as long as there is a gap of no more than 1 calendar day. 20

21 Case Study 2 A 17 year old female with cystic fibrosis is admitted to the adult medical ICU where in plan VAE surveillance has been selected in the monthly reporting plan. She is placed on the ventilator on hospital day 5. Based on the following findings do you need to report anything to NHSN. Case Study 2 Do you need to report anything to NHSN? FiO MV Day 2mi Polys / Temp Temp max WBC WBC max Abx Speci-men n Epis Organism None None None None None BAL 25 / cfu/ml Pseudomonas aeruginosa Yes Yes Yes Blood -- Staph aureus Yes Yes Yes Yes Yes Yes No No No

22 Case Study 2 1. Nothing to report to NHSN 2. Probable VAP with a secondary BSI (pathogens PA, SA) 3. Probable VAP (pathogen PA) 4. Probable VAP (pathogen PA) and perhaps a secondary BSI to another HAI site or CLABSI (pathogen SA) 5. Probable VAP (pathogen PA) and a CLABSI (pathogen PA) MV Day FiO 2mi n Temp Temp max WBC WBC max Abx Speci-men Polys / Epis Organism None None None None None BAL 25 / cfu/ml Pseudomonas aeruginosa Yes Yes Event Period (14 Days ) Yes Blood -- Staph aureus Yes Yes Yes Yes Yes Yes No No No

23 Case Study 2 Recap All patients in an adult location where VAE was selected in the monthly reporting plan are included Event Day 4 (first day of onset of worsening oxygenation) VAC met in FiO 2 parameter, do not round up values VAE Window Period is limited to 4 days, VAC and IVAC definitions are met Both purulent respiratory secretions and the quantitative culture criteria are met to satisfy the Probable VAP definition Blood culture is collected within the 14 day Event Period but the respiratory and blood culture pathogens do not match therefore, look to detere if another HAI definition is met for secondary bloodstream infection attribution and if not then report as CLABSI Case Study 3 An elderly gentleman is admitted to the trauma ICU following a motor vehicle accident. He had been intubated in the field and there was some concern of aspiration upon intubation. Given the following information, identify all events. 23

24 Case Study 3 Identify event(s) and MV day of event(s) MV Day FiO 2m in Temp Temp max WBC WBC max Abx Specimen Polys / Epis Organism None None None None None Yes BAL 25 / C. albicans Yes BC x2 -- C. albicans Yes Yes Yes Yes Yes None None Yes Yes Yes PATIENT EXPIRES Identify the event(s) and MV day 1. MV Day 6 - Probable VAP and MV Day 15 -VAC 2. MV Day 6 - Possible VAP 3. MV Day 15 - VAC 4. MV Day 6 -Probable VAP 24

25 MV Day Case Study 3 VAC MV Day 15 FiO 2m in Temp Temp max WBC WBC max Abx Specimen Polys / Epis Organism None None None None None BAL 25 / C. albicans Yes Yes BC x2 -- C. albicans Yes Yes Yes Yes Yes None None Yes -- 4 QAD Yes requirement Yes PATIENT EXPIRES not met Case Study 3 Recap Event Day 15 (first day of onset of worsening oxygenation) VAE Window Period is Day 13, 14 (two days before), Day 15 (event day), Day 16,17 (two days after) Abnormal WBC documented during VAE Window Period but only 3 QADs are observed prior to the patient expiring Baseline period of stability is not established early in mechanical ventilation episode No VAC, No IVAC, No Possible/Probable VAP 25

26 Case Study 3 Focus on identifying VAC No need to collect other parameters in advance Culture driven surveillance approach is not useful for VAE MV Day FiO PATIENT EXPIRES Case Study 4 Patient was admitted with a diagnosis of pneumonia and tested positive for Influenza A by PCR. On hospital day 3 she is placed on a ventilator. Does this patient have a VAC? A. Yes B. No Hosp Day MV Day Daily Daily Temp WBC ABX ABX ABX FiO ceftriaxone ceftriaxone ceftriaxone vancomycin vancomycin vancomycin Cefepime Cefepime vancomycin Cefepime Cefepime Cefepime 26

27 Case Study 4 After reviewing the medical record the additional data is collected. Does this patient satisfy the IVAC definition? A. Yes B. No Hosp Day MV Day Daily Daily Temp WBC ABX ABX ABX FiO ceftriaxone ceftriaxone ceftriaxone vancomycin vancomycin vancomycin Cefepime Cefepime 5 QADs vancomycin Cefepime Cefepime Cefepime Case Study 4 Recap Date of event is hospital day 5 / MV day 3 VAE Window Period is limited to 3 days Multiple antimicrobials were adistered but only one was considered to be new QADs can accumulate outside the VAE window period provided the agent is found to be new 27

28 Case Study 5 42 year old female dialysis patient was intubated and transferred from Hospital A to Hospital B on MV Day 1 for management of severe asthma exacerbation. The patient had been receiving vancomycinfor treatment of a BSI. Upon admission her temperature was 37.5⁰C and WBC count was 5.6 cells/mm. 3 On MV Day 3 during dialysis treatment the patient developed a temperature of 39.7⁰C. On MV Day 5 she had increased respiratory secretions and an endotracheal aspirate was sent for culture and Gram stain. On MV Day 7 imipenem was started. Case Study 5 Does this patient meet the criteria for VAE, and if so, what type of VAE? MV Day FiO 2 Temp Temp max WBC WBC max Abx Specimen Polys / Epis Organism Vanco None Vanco None Vanco ETA 25 / 10 Heavy K. pneumoniae None Imipenem Imipenem Imipenem Imipenem

29 Case Study 5 Does this patient meet the criteria for VAE, and if so, what type of VAE? A. VAC B. IVAC C. Possible VAP D. No VAE Case Study 5 MV Day FiO 2 Temp Temp max WBC WBC max Abx Specimen Polys / Epis Organism Vanco None Vanco day VAE Window None Vanco ETA 25 / 10 Heavy K. pneumoniae None Imipenem Imipenem Imipenem Imipenem

30 Case Study 5 Recap Event date is MV Day 4 (first day of worsening) Within the 4day window period Temperature elevation present However, no new antimicrobial agent was initiated and continued for 4 days (vancomycin is nota new antibiotic and imipenem was started outside the VAE Window Period) Specimen collection -purulent secretions AND qualifying positive culture present but if IVAC definition is not met you can not proceed to the next tier of the algorithm Event is attributable to Hospital B Preparing for VAE Surveillance Establish relationships with Respiratory Therapy and/or Critical Care colleagues: Share the protocol Discuss options for collection of imum daily and FiO 2 for each MV day (IP, RT, electronically generated) Inquire about frequency with which excluded therapies (HFV, ECLS) and APRV are used Detere 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? 30

31 Preparing for VAE Surveillance Develop a plan for organizing the data elements needed to identify VAEs and FiO2 WBC / Temperature Antimicrobials agents (adistration not orders) Laboratory results Explore use of tools for data collection

32 Questions 32

33 THANK YOU! For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion 33