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Welcome !!!

Please join us via phone for the audio portion of the webinar, you will be connected by the operator when the meeting begins.

Conference Line : • Line: 888-847-9717• Code: 2402919

Please complete the EMR Surveillance Assessment

at your convenience : https://www.research.net/s/HospitalEMR

https://www.research.net/s/HospitalEMR

VAE Surveillance Definition & Electronic Capture Webinar Hosted by Armstrong Institute of Patient Safety and Quality

July 31st & August 2nd

Sean Berenholtz , MD, MPH, FCCM

Kathleen Speck , MPH

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Sponsors and Affiliate Partners

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Agenda

• 1:00 pm – 1:10pm - Welcome and Introduction – Sean Berenholtz MD, MHS

• 1:10 pm - 1:30pm - Surveillance for Ventilator- Associated Events in Adults: A new Approach for the National Healthcare Safety Network (NHSN) – Shelley Magill MD, PhD,

• 1:30 pm – 1:50pm – Improving Surveillance Definitions for Ventilator- Associated Events: Better Surveillance, Better Care – Michael Klompas, MD, MPH

• 1:50pm- 2:00pm- Question and Answer Session

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Learning Objectives

• To introduce the new surveillance definition of Ventilator Associated Event (VAE)

• To gain insights into your perceptions about the new VAE definition and existing infrastructure to capture VAE data using Electronic Medical Records (EMR)

Armstrong Institute for Patient Safety and Quality

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Expert Panel & Presenters

• Dr. Magill will be discussing the new NHSN surveillance definitions.

• Dr. Klompas will be discussing techniques for implementing electronic surveillance focusing on experience with the CDC’s Epicenters for Excellence group.


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Shelley S. Magill, MD, PhDDivision of Healthcare Quality Promotion

Centers for Disease Control and PreventionAtlanta, GA

Surveillance for Ventilator-Associated Events in Adults: A New Approach for the National Healthcare Safety

Network (NHSN)

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

The Problem

Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation But other bad things also happen to patients on ventilators

No valid, reliable definition for VAP Need more accurate diagnostics … Until those are available, how do we conduct surveillance and track

prevention progress? Commonly used definitions include subjective elements and

are neither sensitive nor specific for VAP Not ideal in an era of public reporting of healthcare-associated

infection (HAI) rates, comparisons among facilities, pay-for-performance programs

Need a new approach

At least one of the following:

Fever (> 38 C/100.4 F) with no other cause

Leukopenia (< 4,000 WBC/mm³) or leukocytosis (> 12,000 WBC/mm³)

Altered mental status with no other cause, in > 70 y.o.

PNU2: Pneumonia with common bacterial or

filamentous fungal pathogens and specific lab findings

PNU2: Pneumonia with viral, Legionella, Chlamydia,

Mycoplasma, and other uncommon pathogens and

specific lab findings PNU1: Clinically

defined pneumonia

PNU3: Pneumonia in immunocompromised

patients


New onset of purulent sputum, 3

or change in character of sputum, or respiratory secretions, or suctioning requirements4

New onset or worsening cough, or dyspnea, or tachypnea5

Rales6 or bronchial breath sounds

Worsening gas exchange (e.g., O2 desats [e.g., PaO 2/FiO2

< 240],7 O2 req, or ventilation demand)

At least two of the following:

New onset of purulent sputum, 3

or change in character of sputum, or respiratory secretions, or suctioning requirements4



Worsening gas exchange (e.g., O2 desats [e.g., PaO 2/FiO2

< 240],7 O2 req, or ventilation demand)

At least one of the following10-12:

Positive culture of virus or Chlamydia from respiratory secretions

Positive detection of viral antigen or antibody from respiratory secretions (e.g., EIA, FAMA, shell vial assay, PCR)

4-fold rise in paired sera (IgG) for pathogen (e.g., Influenza viruses, Chlamydia)

Positive PCR for Chlamydia or Mycoplasma

Positive micro-IF test for Chlamydia

Positive culture or micro-IF of Legionella spp from respiratory secretions or t issue

Detection of Legionella pneumophila serogroup 1 antigens in urine by RIA or EIA

4-fold rise in L. pneumophilaantibody titer to > 1:128 in paired acute and convalescent sera by indirect IFA


Positive blood culture not related to another infection8

Positive pleural fluid culture

Positive quantitative culture9

from minimally contaminated LRT specimen (e.g., BAL or protected specimen brushing)

> 5% BAL-obtained cells contain intracellular bacteria on direct microscopic exam

Histopathologic exam shows one of the following:

At least one of following:

Matching positive blood and sputum cultures with Candida spp14,15

Evidence of fungi or Pneumocytis carinii from minimally contaminated LRT specimen (e.g., BAL or protected specimen brushing) from one of the following:

La

bo

rato

ryS

ign

s a

nd

Sym

pto

ms

X-R

ay

PNEUMONIA FLOW DIAGRAM

Patient with underlying diseases1,2 has 2 or more serial X-rays with one of the following:

New or progressive and persistent infiltrate

Consolidation

Cavitation

Pneumatoceles, in 1 y.o.

At least one of the following in an immunocompromised patient 13:

Fever (> 38 C/100.4 F) with no other cause

Altered mental status with no other cause, in > 70 y.o.

New onset of purulent sputum, 3 or change in character of sputum, or respiratory secretions, or suctioning requirements4



Worsening gas exchange (e.g., O 2

desats [e.g., PaO 2/FiO2 < 240],7

O2 req, or ventilation demand)

Hemoptysis

Pleurit ic chest pain

Facility ID # _____________ Event # _____________ Event Date _ ___/___ _/_________

Ins tructions : Complete form only if x -ray criteria are met

• Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli

• Positive quantitative culture9 of lung parenchyma

• Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae

• Direct microscopic exam

• Positive culture of fungi

Patient without underlying diseases1,2 has 1 or more serial X-rays with one of the following:

New or progressive and persistent infiltrate

Consolidation

Cavitation

Pneumatoceles, in 1 y.o.

Current PNEU Definitions• Three sets of criteria• Chest x-ray evidence required• Signs/symptoms required• Lab evidence used if available

from acceptable specimen type

• VAP is a PNEU event that meets the “ventilator-associated” criterion—

Endotracheal tube (ETT)/ventilator must have been in place at some time during the 48 hours preceding the onset of PNEUNo required amount of time that the ETT/ventilator must have been in place for a PNEU to count as a VAP

Limitations of Current VAP Definitions

References include but are not limited to the following:1Wunderink R, et al., Chest 1992;101;458-63; 2Young M, et al., Arch Intern Med 1994;154:2729-32; 3Fabregas N, et al., Thorax 1999;54:867-73; 4Kirtland SH, et al., Chest 1997;112:445-57; 5Berton DC, et al., Cochrane Database Syst Rev 2008; 6Ruiz M, et al., Am J Respir Crit Care Med 2000;162:119-25.

Goals for Modifying Current NHSN Definitions

Achieve face validity/clinical credibility Improve reliability Reduce burden

2009-2010 2011 2011-2012

Ventilator-Associated LOwer Respiratory Infection (VALORI)

Streamlined VAP (“sVAP”)

Ventilator-Associated Events (VAE)

• Evaluated draft definition in collaboration with the CDC Prevention Epicenters

• Definition based on work done by Klompas and others1,2

• Received expert feedback during HHS-sponsored meetings

• Funded Epicenters proposal to evaluate feasibility and preventability of “sVAP”

• Convened VAP Surveillance Definition Working Group, with Critical Care Societies Collaborative and other society/organization representatives (2011-2012)

From VAP to VAE

1Klompas et al., Infect Control Hosp Epidemiol 2008;29:31-7; 2Klompas et al., 5th Decennial International Conference on Healthcare-Associated Infections, Atlanta, GA, March 18-22, 2010, abstract #741.

Working Group Members and ParticipantsSociety/Organization RepresentativesAmerican Association of Critical-Care Nurses Suzanne Burns, Beth HammerAmerican Association for Respiratory Care Dean HessAmerican College of Chest Physicians Robert Balk, David GuttermanAssociation of Professionals in Infection Control and Epidemiology

Linda Greene

American Thoracic Society Nicholas Hill, Mitchell LevyCouncil of State and Territorial Epidemiologists Carole VanAntwerpenHICPAC Surveillance Working Group Daniel DiekemaInfectious Diseases Society of America Edward SeptimusSociety of Critical Care Medicine Clifford Deutschman, Marin

Kollef, Pamela LipsettSociety for Healthcare Epidemiology of America Michael KlompasU.S. Department of Health and Human Services/Office of Healthcare Quality

Don Wright

National Institutes of Health David Henderson

Working Group Objectives

Critically review CDC’s draft, streamlined VAP surveillance definition for use in adult patients;

Suggest modifications to enhance reliability and credibility within the critical care community;

Propose final adult definition algorithm that will be implemented for use in NHSN for the potential purposes of public reporting, inter-facility comparisons, and federal pay-for-reporting and -performance programs.

Working Group Progress

Kick-off meeting 9/2011, multiple follow up calls Revised definition algorithm—tiered approach

Definitions suitable for potential use in public reporting: objective, general measures of ventilator-associated conditions and complications

• Similar definitions evaluated by Klompas et al. identified events associated with longer duration of mechanical ventilation, longer ICU stay, and increased mortality—and were more efficient to apply than current VAP definitions (PLoS One 2011;6:e18062, Crit Care Med 2012; in press)

Internal use definitions: possible and probable VAP, incorporating laboratory evidence

Research agenda items Mechanism for intensive care unit-level risk adjustment or

stratification (to account for differences in severity of illness) Denominator data collection

VENTILATOR-ASSOCIATED EVENTS (VAE) SURVEILLANCE DEFINITION ALGORITHM

***Note that this is NOT a clinical definition algorithm and is not intended for use in the management of patients.***

Patients Eligible for VAE Surveillance

≥18 years of age Inpatients of acute care hospitals, long term acute care

hospitals, inpatient rehabilitation facilities

NOTE: Patients receiving high frequency ventilation or extracorporeal life support are excluded from surveillance.

VAE Definition Algorithm Summary

Ventilator-Associated Condition (VAC)

Infection-related Ventilator-Associated Complication (IVAC)

Possible VAP

Probable VAP

VAC, IVAC plus the following…

Key Operational Details*

In 2013, in-plan surveillance for ventilator-associated PNEU may still be conducted for neonatal and pediatric patients ONLY.

In 2012 and 2013, the PNEU definitions are still available for those units seeking to conduct off-plan PNEU surveillance for mechanically-ventilated adults or non-ventilated adults or children.

Conducting in-plan VAE surveillance means assessing patients for the presence of ALL events included in the algorithm—from VAC to IVAC to Possible and Probable VAP. A unit participating in in-plan VAE surveillance cannot decide, for example, that only surveillance for VAC (and not for IVAC or Possible or Probable VAP) will be performed.

*Preliminary and subject to change.

More Key Operational Details*

“New” antimicrobial agent How to determine whether a new antimicrobial agent has

been given for at least 4 days (including in patients with renal insufficiency)

Single doses of vancomycin Multiple VAEs during a single hospitalization VAEs in patients who’ve been recently extubated Pathogens and secondary BSIs Lung histopathology Diagnostic tests for viruses and Legionella spp. Time frame within which VAE criteria must be fulfilled

*Preliminary and subject to change.

Next Steps

Options for Tracking VAP/VAE Rates, 2012-2013

Implement VAE early Forms and protocol Training Data management

Continue VAP surveillance into 2013 Will remain available off-plan in NHSN application—but probably only

until end of CY 2013 Do both

Acknowledgments

Patients and staff in NNIS and NHSN facilities VAP Surveillance Definition Working Group Other subject matter experts HHS Office of Healthcare Quality CDC Prevention Epicenters CDC VALORI/draft sVAP project facilities, Premier, Inc.,

expert reviewers CDC/DHQP colleagues

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Thank you!

[email protected]

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: [email protected] Web: www.cdc.gov

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.

mailto:[email protected]

Expert Panel & Presenters

• Dr. Magill will be discussing the new NHSN surveillance definitions.

• Dr. Klompas will be discussing techniques for implementing electronic surveillance focusing on experience with the CDC’s Epicenters for Excellence group.


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IMPROVING SURVEILLANCE DEFINITIONS FOR VENTILATOR-ASSOCIATED EVENTSBETTER SURVEILLANCE, BETTER CARE

JULY 31, 2012

MICHAEL KLOMPAS MD, MPH, FRCPC

HARVARD MEDICAL SCHOOL DEPT OF POPULATION MEDICINE

BRIGHAM AND WOMEN’S HOSPITAL, BOSTON, MA

OUTLINE

• CDC Prevention Epicenters’ studies of objective surveillance

• Operationalizing the new definitions

Multicenter Evaluation Of A Novel Surveillance Paradigm For Complications Of Mechanical Ventilation

• Retrospective comparison of VAC surveillance versus conventional surveillance in medical and surgical patients ventilated ≥48 hours in 3 university hospitals

• Brigham and Women’s Hospital (Boston, MA)

• Ohio State University Medical Center (Columbus, OH)

• LDS Hospital (Salt Lake City, UT)

• 597 patients ventilated for 6,347 days

LENGTH OF STAY: VAP VERSUS VACModel adjusted for vent days prior to event, age, sex, hospital, unit, and co-morbidities

5 10 15 200

Ventilator days

ICUdays

Hospitaldays

VAP

VAC

Days

VAP or VAC positive

VAP or VAC negative

VAP

VAC

VAP

VAC

******

******

**

PLoS ONE 2011;6: e18062

MORTALITY: VAP VERSUS VAC

PLoS ONE 2011;6: e18062

Model adjusted for vent days prior to event, age, sex, hospital, unit, and co-morbidities

0.5 1.0 2.0 2.50

Odds Ratio

1.5 3.0

VAC

VAP

QUALITATIVE ANALYSIS OF CASESCritical care MD blinded to VAC or VAP status

20

15

10

5

0Pneumoni

a

Pe

rce

nt

of

Pa

tien

ts

PulmEdem

a

ARDS LobarCollapse/Atelectasi

s

PEMucous Plug

VAC VAP

25

Sepsis

XRTpneumonitis

30

PLoS ONE 2011;6: e18062

Objective surveillance definitions for ventilator-associated pneumonia

Retrospective analysis of all patients on mechanical ventilation in 8 different U.S. hospitals

• Community, academic, VA hospitals• 8,123 patients• 8,735 ventilation episodes• 50,324 ventilator-days

VAC patients matched to non-VAC patients. Regression analyses adjusting for age, sex, comorbidities, APACHE score, unit, hospital, pre-morbid time on ventilator

Klompas et al. 2012; Critical Care Medicine; in press

RESULTS

VAC versus non-VAC

Mortality odds ratio 2.4 (95% CI 1.6-3.6)

Excess ventilator days 4.2 days (95% CI 3.8-5.6)

Excess hospital days 3.8 days (95% CI 2.7-6.0)


SENSITIVITY & PPV OF SURVEILLANCE DEFINITIONS FOR HOSPITAL DEATH


VAC SUMMARY• Simple and objective measure

• Captures important complications, most cases due to:

• Pneumonia• Pulmonary edema• ARDS• Atelectasis

• Associated with prolonged mechanical ventilation, length of stay, and hospital mortality

VAE SURVEILLANCEIN PRACTICE

Sustained increase in ventilator support after≥2 days of stable or decreasing settings

VAC + (abnormal temp or WBC count) ANDnew antibiotic for 4 days or more

VACventilator-associated condition

iVACinfection-relatedventilator-associated complication

VAPpossible

probable

iVAC + positive respiratory culture ORgram stain with ≥25 polys and ≤10 epis

iVAC + positive respiratory culture ANDgram stain with ≥25 polys and ≤10 epis

HOW ON EARTH DO WE APPLY THESE DEFINITIONS?

BEGIN WITH VAC

Criteria

• ≥2 days of stable or decreasing daily minimum PEEP or FiO2

followed by

• Rise in daily minimum PEEP by ≥3 cm H2O or FiO2 by ≥20 points sustained ≥2 days

OPERATIONALIZING THE DEFINITIONCREATE A DAILY LINELIST

DatePEEP(min)

FiO2(min)

Jan 1 10 100


DatePEEP(min)

FiO2(min)

Jan 1 10 100

Jan 2 5 50

CHECK FOR IVAC:ADD TEMP, WBC, & ABX TO THE LINELIST

DatePEEP(min)

FiO2(min)

Tmin

Tmax

WBCmin

WBCmax

Antibiotic Antibiotic

Jan 1 10 100

Jan 2 5 50

Jan 3 5 40

Jan 4 5 40

Jan 5 8 60

Jan 6 8 50

Jan 7 8 40

Jan 8 5 40

Jan 9 5 40

CHECK FOR IVAC:ADD TEMP, WBC, & ABX TO THE LINELIST

CHECK FOR VAP:ADD GRAM STAIN & CULTURE RESULTS

TIPS FOR SUCCESS

Use the linelist approach

Explore your hospital’s IT environment

• Definitions are amenable to complete automation• …but if IT can only offer semi-automation, still a substantial help

• e.g. automatic linelists with daily vent settings for manual review• Linelists of vent settings PLUS temp / wbc / abx / micro • Linelists + automatically flag VAE

Does respiratory therapy already have an electronic tracking system for vented patients?

• Vent settings sometimes stored electronically but outside the EMR• If not currently tracking vented pts electronically, do they want to start?

If automation not possible, ask respiratory therapy and / or nursing for help collecting daily vent settings

• Upcoming project: CUSP for VAP – Maryland – Pennsylvania

• VAP Program Overview – August 7th at 1 pm – August 8th at 11 am

• Complete the EMR Surveillance Assessment


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Next steps:

VAE - EMR Surveillance

• To gain insights into your perceptions about the new VAE definition and existing infrastructure to capture VAE data using Electronic Medical Records (EMR)

– EMR Surveillance Assessment • Survey Monkey https://www.research.net/s/HospitalEMR• 10 minutes to complete


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https://www.research.net/s/HospitalEMR

welcome !!! please join us via phone for the audio portion of the webinar, you will be connected by...

Documents

pm surveillance

vap slide

electronic surveillance

new approach slide

better surveillance

ga surveillance

ventilator associated

ventilatorassociated