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Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients

Ventilator-Associated Event Surveillance

Slide 2: Learning Objectives

After this session, you will be able to—

• Discuss the ramifications of ventilator-associated events (VAEs).
• Describe methods to evaluate VAEs.
• Understand the implications of objective VAE surveillance.
• Identify ways to use data to drive improvement.

Slide 3: Why Collect VAE Data?

• Collecting VAE data can be used to—
  • Connect the dots to harm.
  • Avoid failure of infection prevention efforts due to "silo mentality."
  • View interventions under the larger context of patient safety.

Slide 4: Why Do I Want To Know Â鶹´«Ã½ VACs and IVACs?

• A retrospective cohort study examining 20,356 episodes of mechanical ventilation (MV):¹
  • VAEs:
    • 1,141 ventilator-associated conditions (VACs).
    • 431 infection-related VACs (IVACs).
    • 266 possible cases of ventilator-associated pneumonia (PVAP).
  • Patients with a VAE have—
    • More days to extubation.
    • More days to discharge.
    • Higher mortality rate.

^1. Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol 2014 May;35(5):502-10. PMID: 24709718.

Slide 5: Connect the Safety Dots

Image: Graphic showing the various harms that can result from mechanical ventilation.

Slide 6: Why Use the New VAE Surveillance Definitions?

• Screening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance but is faster, more objective, and a superior predictor of outcomes.²
• Objective surveillance definitions that include quantitative evidence of respiratory deterioration after a period of stability strongly predict increased LOS and hospital mortality.³

^2. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One 2011 Mar 22;6(3):e18062. PMID: 21445364.

^3. Klompas M, Magill S, Robicsek A, et al. Objective surveillance definitions for ventilator-associated pneumonia. Crit Care Med 2012 Dec;40(12):3154-61. PMID: 22990454.

Slide 7: Why the Change?

• Results from a study on inter-rater reliability among infection preventionists (IP).⁴
• 50 ventilated patients with respiratory deterioration.
• Kappa = 0.40.
• Criteria is subjective leading to disagreement between reviewers.

Image: A Venn diagram showing the interrater reliability for adjudicating traditional VAP surveillance.

^4. Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control 2010 Apr;38(3):237-9. PMID: 20171757.

Slide 8: Why the Shift?

• Broaden the focus:
  • Shifting focus of surveillance from pneumonia alone to complications in general emphasizes the importance of preventing all complications of MV, not just pneumonia.
  • When definitions are objective, caregivers can focus on what went wrong rather than debate the definition.

Slide 9: Applying the National Healthcare Safety Network Definition⁵

Image: Rogers' diffusion of innovation adoption lifecycle.

Image designed by Wikipedia user "" and used with permission.

^5. Rogers E. Diffusion of innovation, 5^th ed. New York, NY: Simon and Schuster; 2003.

Slide 10: Broadening the Surveillance

• The definition of VAE is intentionally broader than traditional VAP surveillance.
• Common VACs:
  • ARDS.
  • PE.
  • Thromboembolic disease.
  • Sepsis.
• Clinical ramifications?
  • Respiratory deterioration in previously stable patients is a risk factor for increased morbidity and mortality.

Slide 11: Analysis of VAC vs. VAP²

• Multicenter, retrospective study.
• Evaluated a novel surveillance paradigm for VACs: screening ventilator settings.
• Blinded critical care physician reviewed 52 randomly selected patients with VAC (defined by protocol) or VAP (determined by IPs based on VAP definition).
• Screening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance.

^2. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One 2011 Mar 22;6(3):e18062. PMID: 21445364.

Slide 12: Analysis of VAC vs. VAP²

Image: Table of patients flagged with ventilator-associated complications of ventilator-associated pneumonia.

^2. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One 2011 Mar 22;6(3):e18062. PMID: 21445364.

Slide 13: Are VAEs Preventable?

• Many providers feel some of the conditions associated with VAEs are pre-existing.
• Preliminary data from the first year of VAE data collection showed approximately 79 percent of VAEs were in patients who were either on MV for ≥5 days or in the hospital for ≥5 days at the time of VAE onset.⁶
• Time to onset data suggest that the majority of VAEs are likely hospital-associated based on previous criteria.^7,8

^6. Magill S, Gross C, Edwards JR.  Incidence and characteristics of ventilator-associated events reported to the National Healthcare Safety Network in 2013. Oral abstract presented at the meeting of IDWeek, Philadelphia, PA, October 2014.

^7. Klompas M. Complications of mechanical ventilation—the CDC’s new surveillance paradigm. N Engl J Med 2013 Apr 18;368(16):1472-5. PMID: 23594002.

^8. Muscedere J, Sinuff T, Heyland DK, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest 2013 Nov;144(5):1453-60. PMID: 24030318.

Slide 14: Prevention Strategies

• Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update:⁹
  • Contributions from—
    • Society of Healthcare Epidemiology of America.
    • Infectious Diseases Society of America.
    • American Hospital Association.
    • Association for Professionals in Infection Control and Epidemiology.
    • The Joint Commission.

^9. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 Aug;35(8):915-36. PMID: 25026607.

Slide 15: Intervention Bundle Checklist

Image: Table listing items in the Intervention Bundle Checklist.

Slide 16: Best Practices for VAE Reduction

Image: Table with best practices for VAE reduction.

Slide 17: What Â鶹´«Ã½ Oral Care With Chlorhexidine?

• Routine oral care with chlorhexidine:¹⁰
  • Prevents nosocomial pneumonia in cardiac surgery patients.
  • May not decrease VAP risk in noncardiac surgery patients.
  • Does not affect—
    • Mortality.
    • Duration of MV.
    • Intensive care unit (ICU) LOS.

^10. Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med 2014 May;174(5):751-61. PMID: 24663255.

Slide 18: VAE Prevention Techniques

• Prevent pneumonia by implementing HOB elevation.
• Avoid pulmonary complications through fluid conservation.
• Protect against atelectasis by managing sedation.
• Combat acute lung injury by following a low tidal volume ventilation strategy.

Slide 19: Getting Started on Prevention

Where to start?

1. Look at both process and outcome measures.
2. Track your own performance over time.
3. Do we see improvements?

Image: Photo of a large "start" button.

Slide 20: How Can We Evaluate the Data?

Image: Table (line list) of fictional example patient information regarding VAEs.

Slide 21: How Will I Use My Data To Drive Improvement?

• Review both individual cases and system level issues.
• Develop a form to help analyze individual cases.
• Do we have policies and procedures in place?
• Do we follow evidence-based guidelines?
• Are we consistent with our practices?

Slide 22: Review All VAC Cases—Case Review 1

• Patient develops a VAC:
  • Chronic ventilator dependency.
  • Ambulation protocols were not implemented.
  • Not monitored for dehydration.
  • Presence of sputum not documented.
  • Lack of communication between nursing and respiratory groups.

Slide 23: Case Review 2

• Ms. X is a 76-year-old woman, admitted to the ICU with septic shock requiring large volume fluid resuscitation:
  • Intubated and placed on ventilator.
  • Stable until day 6 when she has progressive oxygenation demands.
  • Increased demands last for 72 hours.

Slide 24: Case Review 2—Outcomes

• Patient has a VAC:
  • No fever.
  • No increased white blood cell count.
  • No new antibiotics.
• Diagnosis: Pulmonary edema.
• Opportunities for improvement?

Slide 25: Case Review 3

• In an example ICU, many VAEs are PVAPs.
• Evaluation:
  • Head of bed monitoring.
  • Suctioning frequency.
  • SATs.
  • Endotracheal tubes with subglottic suctioning.

Slide 26: Case Review 3—Outcomes

• Analysis:
  • Quarter 1: 20 VACs:
    • 4 VACs.
    • 16 IVACs.
    • 0 PVAPs.
    • Most are other healthcare-acquired infections.

Slide 27: Opportunities for Improvement

• Hardwire ambulation protocols.
• Ensure documentation of secretions.
• Work collaboratively with respiratory therapists to identify subtle changes.
• Daily huddles.

Slide 28: Know Your Data

"Surveillance is a critical component of every quality improvement effort; you cannot prevent it if you cannot measure it."

—Linda Greene, R.N., M.P.S., CIC
Infection Prevention Manager
University of Rochester Medical Center, Highland Hospital

Slide 29: The Bottom Line

• VAEs are associated with increased mortality and ICU and hospital LOS.
• In randomized controlled trials, VAP interventions have been shown to improve objective outcomes, such as duration of MV, ICU or hospital LOS, mortality, and costs.
• The existing VAP prevention literature is the best available guide to improving outcomes for ventilated patients.
• It is important to continue monitoring the processes of care and the outcomes for mechanically ventilated patients.
• Always give feedback to providers and assess the potential for preventable events.

Slide 30: Questions?

Image: Colored hanging tags with questions marks on them.

Slide 31: References

^1. Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol 2014 May;35(5):502-10. PMID: 24709718.

^2. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One 2011 Mar 22;6(3):e18062. PMID: 21445364.

^3. Klompas M, Magill S, Robicsek A, et al. Objective surveillance definitions for ventilator-associated pneumonia. Crit Care Med 2012 Dec;40(12):3154-61. PMID: 22990454.

^4. Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control 2010 Apr;38(3):237-9. PMID: 20171757.

^5. Rogers E. Diffusion of innovation, 5^th ed. New York, NY: Simon and Schuster; 2003.

Slide 32: References

^6. Magill S, Gross C, Edwards JR.  Incidence and characteristics of ventilator-associated events reported to the National Healthcare Safety Network in 2013. Oral abstract presented at the meeting of IDWeek, Philadelphia, PA, October 2014.

^7. Klompas M. Complications of mechanical ventilation—the CDC’s new surveillance paradigm. N Engl J Med 2013 Apr 18;368(16):1472-5. PMID: 23594002.

^8. Muscedere J, Sinuff T, Heyland DK, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest 2013 Nov;144(5):1453-60. PMID: 24030318.

^9. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 Aug;35(8):915-36. PMID: 25026607.

^10. Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med 2014 May;174(5):751-61. PMID: 24663255.