HAI definitions: Ventilator-associated Events. Michael Bell, M.D. Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

HAI definitions: Ventilator-associated Events Michael Bell, M.D. Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

VAP Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation But other bad things also happen to patients on ventilators No gold standard 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 not sure apples are being compared to apples

NHSN Pneumonia (PNEU) Surveillance Definitions, 2002 to Present Combination of x-ray, signs/symptoms and laboratory criteria Chest imaging findings are required Signs and symptoms of pneumonia are required Laboratory evidence is optional but should be used if available Three specific sets of PNEU criteria are available: PNU1 Clinically-defined pneumonia PNU2 Pneumonia with laboratory findings PNU3 Pneumonia in immunocompromised patients To be ventilator-associated Endotracheal tube (ETT)/ventilator must have been in place at some time during the 48 hours preceding or at time of PNEU onset No required amount of time that the ETT/ventilator must have been in place for a PNEU to count as a VAP *See NHSN Manual: Pa.ent Safety Component Protocol, h:p://www.cdc.gov/nhsn/toc_pscmanual.html, updated Jan 2012

VAP Incidence Rates All Reporting Facilities* -13% (-13 to -14%) No data -13% (-12 to -14%) -16% (-15 to -17%) -20% (-19 to -21%) *Abstract available at: h:p://shea.confex.com/shea/2010/webprogram/paper1745.html. Analysis updated since abstract submission. Numbers may vary.

Why are VAP incidence rates declining? Implementation of prevention strategies Publication of several prevention guidelines since 2002 Use of prevention bundle approach Other considerations Increased burden on infection preventionists Definitions originally developed for internal quality improvement purposes now being used for benchmarking and public reporting Potential for these definitions to be manipulated if healthcare facility reputations and compensation are linked to VAP rates

Strictly interpret clinical signs Strictly interpret chest imaging criteria Take a consensus approach to VAP determina.ons or require approval of cases Transfer pa.ents needing prolonged mechanical ven.la.on Admit uncomplicated vented post- op pa.ents to the ICU (increase the denominator)

Goals for Modifying Current NHSN Definitions Achieve face-validity/clinical credibility Improve reliability and consistency Reduce burden and promote electronic data use

From VAP to VALORI to VAE VAP Ven'lator- Associated LOwer Respiratory Infec'on (VALORI) Streamlined VAP ( svap ) Ven'lator- Associated Events (VAE) 2009-2010 2011 2011-2012 Evaluated dra] defini.on in collabora.on with the CDC Preven.on Epicenters Defini.on based on work done by Klompas and others 2,3 Received expert feedback during HHS- sponsored mee.ngs Funded Epicenters proposal to evaluate feasibility and preventability of svap Convened VAP Surveillance Defini.on Working Group, with Cri.cal Care Socie.es Collabora.ve and other society/organiza.on representa.ves (2011-2012) 2 Klompas et al., Infect Control Hosp Epidemiol 2008;29:31-7; 3 Klompas et al., 5th Decennial Interna.onal Conference on Healthcare- Associated Infec.ons, Atlanta, GA, March 18-22, 2010, abstract #741.

Working Group Members and Participants Society/Organiza'on American Associa.on of Cri.cal- Care Nurses American Associa.on for Respiratory Care American College of Chest Physicians APIC American Thoracic Society Council of State and Territorial Epidemiologists HICPAC Surveillance Working Group Infec.ous Diseases Society of America Society of Cri.cal Care Medicine Society for Healthcare Epidemiology of America U.S. Department of Health and Human Services/Office of Healthcare Quality Na.onal Ins.tutes of Health Representa'ves Suzanne Burns, Beth Hammer Dean Hess Robert Balk, David Gu:erman Linda Greene Nicholas Hill, Mitchell Levy Carole VanAntwerpen Daniel Diekema Edward Sep.mus Clifford Deutschman, Marin Kollef, Pamela Lipse: Michael Klompas Don Wright David Henderson

Patients Eligible for VAE Surveillance 18 years of age Inpatients of acute care hospitals, long term acute care hospitals, inpatient rehabilitation facilities NOTE: rescue mechanical ventilation therapies (e.g., extracorporeal membrane oxygenation, high frequency ventilation, ventilation in the prone position) are excluded. NOT a clinical definition and not for use in the management of patients For use in NHSN, for the potential purposes of public reporting, interfacility comparisons, and pay-for-reporting and -performance programs

VAE Definition Algorithm Summary Respiratory status component Pa'ent on mechanical ven'la'on > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygena'on Infec.on / inflamma.on component Ven'lator- Associated Condi'on (VAC) General evidence of infec'on/inflamma'on Infec'on- Related Ven'lator- Associated Complica'on (IVAC) Possible Future Public Repor'ng Defini'ons Addi.onal evidence Posi've results of microbiological tes'ng Possible or Probable VAP Internal Quality Improvement

Ventilator-Associated Condition (VAC)

Infection-related Ventilator-Associated Complication (IVAC)

Possible VAP

Probable VAP VAC, IVAC plus the following

Transitioning to VAE measurement Demontrated that VAE correlates well with VAP Implementation of Prevention bundles for VAP also have a consistent impact on VAE Stakeholder adoption: Pulmonology and Critical Care subspecialties HAI community: Hospital Epi/Infection Preventionist Healthcare Executives, Hospital Associations Quality and Measurement groups Consumers Payors