Shilla Patel OD, CIC snp006@ucsd.edu

UC San Diego Health System Infection Prevention/Clinical Epidemiology

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

VAP VAE ≠

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.

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): e18062. doi:10.1371/journal.pone.0018062 http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062

http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062

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): e18062. doi:10.1371/journal.pone.0018062 http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062

http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0018062

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):1308-9 ◦ Teaching hospital in Central Italy

◦ VAC signif assoc w/ duration of MV, hospital LOS and mortality

Prospective cohort study in two Dutch academic medical centers (2011–2012).

VAE surveillance was electronically implemented as well as ongoing VAP surveillance.

The VAE algorithm detected at most 32% of the patients with VAP identified by prospective surveillance.

VAC IVAC VAE VAP VAP

10.0 4.2 3.2 8.0

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.

Retrospective Cohort Study

Academic tertiary care center

2006-2011

Rates

Rate per 1000 vent days

VAC plus (VAE) 12.4

IVAC plus 4.7

Poss VAP 1.5

Prob VAP 1.4

% PVAP CDC VAP 2009-10

%

29% 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%

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

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

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

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

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):1453-1460. doi:10.1378/chest.13-0853

The relationship between VAP, VAC, and iVAC. iVAC = infection-related ventilator-

associated complication; VAC = ventilator-associated condition; VAP = ventilator-

associated pneumonia.

Figure Legend:

VAC IVAC OLD VAP

ICU LOS Significant Significant Significant

Hopital LOS Significant

Significant

Significant

Duration of MV Significant Significant

Significant

# Antibiotic Days

Significant

Significant

Significant

Hospital Mortality

Significant

P= 0.07 P= 0.67

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):1453-1460. doi:10.1378/chest.13-0853

Rates of VAP, VAC, and iVAC and concordance across the four data enrollment periods. See Figure 2 legend for expansion of

abbreviations.

Figure Legend:

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. 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 BNP-

driven strategy (58.6 vs. 42.4 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 fluid-management 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

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.

RESULTS Control N=152

Intervention 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

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. 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. 915-936

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.

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.

Rationale

Intervention Quality of Evidence

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 High

Manage pts w/o sedation whenever possible Mod

Interrupt sedation daily High

Assess readiness to extubate daily High

Perform SBT with sedatives turned off Mod

Facilitate early mobility Mod

Use endotracheal tubes w/subglotic secretion drainage ports for pts expected to be on vent > 48-72hrs

High

Change vent circuit only if visibly soiled or malfunctioning

Low

HOB 30-45 degrees Low

Rationale Intervention Quality of Evidence

Good evidence that it improves outcomes but insufficient data available on poss risks

Selective Oral or digestive decontamination

High

May lower VAP rates but insuff data to determine impact on Duration of vent, LOS, mortality

Regular Oral care with CHG Mod

Prophylactic probiotics Mod

Ultrathin polyurethane endotrach tube cuffs

Low

Automated control of endotrach tube cuff pressure

Low

Saline instillation before trach suctioning

Low

Mechanical tooth brushing Low

Rationale Intervention Quality of Evidence

Lowers VAP rates but ample data suggest no impact on duration of MV, LOS or mortality

Silver coated endo tubes Mod

Kinetic beds Mod

Prone positioning Mod

No impact on VAP rates, Duration of MV, LOS or mortality

Stress ulcer prophylaxis Mod

Early tracheotomy High

Monitoring residual gastric volumes Mod

Early parenteral nutrition Mod

No recommendation

Closed/in line endo suctioning Mod

HRET (Health Research & Educational Trust)

HHS (US dept of Health and Human Services)

American Hospital Association

http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286

http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=182&Itemid=286

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. • 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.

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.

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.

Passive ROM TID

Turn Q 2 hrs.

Active resistance PT

Sitting position 20 mins. TID

Passive ROM TID

Turn Q 2 hrs.

Active resistance PT

Sitting position 20 mins. TID

Sitting on edge of bed

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

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)

Able to

move arm

against

gravity

Able to

move leg

against

gravity

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

Level 2

Level 3

Level 4

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.

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

http://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdf

http://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdfhttp://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdfhttp://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdfhttp://www.cdc.gov/nhsn/PDFs/vae/VAE-pubs.pdf