Ventilator Associated Event(VAE) Surveillance

Adapted from CDC Aisa Jensen Lee

Objectives

• Define Ventilator Associated Event• Identify background of previous evidence

based critical care practice guidelines• Identify and apply most recent evidence

based guidelines for critical care practice • Be able to identify areas in which critical care

practice may be impacted by most recent guidelines

Introduction• VAP is the 2nd most common nosocomial

infection = 15% of all hospital acquired infections

• Incidence = 9% to 70% of patients on ventilators

• Increased ICU stay by several days• Increased avg. hospital stay 1 to 3 weeks• Mortality = 13% to 55%• Added costs of $40,000 - $50,000 per stay

Centers for Disease Control and Prevention, 2003. Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of

Respiratory Disease, 21 (5), p. 321;

Probable Causes of VAP

Old Definition of VAP

• VAP is a Nosocomial Pneumonia = Hospital acquired

• Diagnosis is imprecise and usually based on a Combination of:–Clinical factors - fever or hypothermia; change in

secretions; cough; apnea/bradycardia; tachypnea

–Microbiological factors - positive cultures of blood/sputum/tracheal aspirate/pleural fluids

–CXR factors - new or changing infiltratesAmerican Thoracic Society, Infectious Diseases Society of America: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005, 171:388-416.

Ventilator Associated Event

• Background :• Formerly known as VAP (Ventilator

Associated Pneumonia); last updated in 2002

• VAEs reported to National Healthcare Safety Network (NHSN); the CDC ’s Healthcare Associated Infection (HAI) surveillance system; newly updated in 2011

• Previous reports too subjective and variable across institutions based on resources and lack of standardization

Ventilator Associated Events in Adults

• New Algorithm for Surveillance :• Patients >/= 18 years of age• Patients who have been

intubated/mechanically ventilated for at least 3 calendar days

New Algorithim vs Old Algorithm: What’s Different? :

• Xray: – No radiographic reporting is required due to

inconsistency in ordering practices and variability in resources/techinique. Do not adequately identify patients with VAP

• Will detect ventilator associated conditions and complications

• Focuses on readily available, objective clinical data

• Requires a minimum period of time on the ventilator

Define Ventilator

• Ventilator – a device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation

Define Ventilators• Intermittent positive-pressure breathing

(IPPB), nasal positive end-expiratory pressure (nasal PEEP) and continuous nasal positive airway pressure (CPAP, hypoCAP) are NOT ventilators unless delivered via tracheostomy or ET

Temperature, WBC

And New Antimicrobial

agent

Purulent secretions

and/or other positive lab

evidence

Possible or Probable Ventilator Associated Pneumonia (VAP):

• Definition:• On or after calendar day 3 of mechanical ventilation

within 2 calendar days of onset of worsening oxygenation, ONE of the following criteria is met:

• Purulent respiratory secretions (>25 neutrophils and <10 squamous epithelial cells per lpf) or be above quantitative thresholds

• Positive culture of sputum, BAL, lung tissue, histopathology, + pleural fluid

Break Down:

• IVAC: Temp, signs of infection, lab data of infection, new antimicrobial agent >4 days

• Possible / Probable VAP : The above with the addition of positive cultures from lungs, lung tissue, purulent secretions

• More objective data• VAP no longer used as the event; it is the result of

the event

Reference: 2011. Improving surveillance for ventilator-associated events in adults. Centers for Disease Control and Prevention

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