AHRQ Safety Program for

Mechanically Ventilated Patients

Ventilator-Associated Event Surveillance

AHRQ Pub. No. 16(17)-0018-41-EF

AHRQ Safety Program for Mechanically Ventilated Patients January 2017
VAE Surveillance 1
 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

AHRQ Safety Program for Mechanically Ventilated Patients

VAE Surveillance 2
 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

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VAE Surveillance 3
Why Do I Want To Know About 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 1. Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and
attributable morbidity of ventilator-associated events. Infect Control
• Higher mortality rate Hosp Epidemiol. 2014 May;35(5):502-10. PMID: 24709718.

AHRQ Safety Program for Mechanically Ventilated Patients

VAE Surveillance 4
 Connect the Safety Dots

Immobility Morbidity Mortality

Cost
Increased
length of stay
Ventilator (LOS)

Atelectasis Harm

Pulmonary IVAC VAP

edema (PE) VAC
Acute respiratory
distress syndrome Antibiotic Clostridium
(ARDS) difficile colitis
resistance

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VAE Surveillance 5
 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.

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VAE Surveillance 6
 Why the Change?

IP 1 IP 2

53
(11 VAPs) (20 VAPs)
• Results from a study on inter-
rater reliability among infection
preventionists (IP)4
• 50 ventilated patients with
0 7 3
respiratory deterioration
• Kappa = 0.40
• Criteria are subjective, leading to
1 7
disagreement between reviewers IP 3
(15 VAPs)

4. Klompas M. Interobserver variability in ventilator-associated

pneumonia surveillance. Am J Infect Control. 2010 Apr;38(3):237-9.
PMID: 20171757.

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 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

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VAE Surveillance 8
 Applying the National Healthcare Safety Network Definition 5

Image designed by Wikipedia user “

pnautilus” and used with permission

5. Rogers E. Diffusion of innovation, 5th ed. New York, NY: Simon and
Schuster; 2003.
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VAE Surveillance 9
 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
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 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.

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 Analysis of VAC vs. VAP2
CONDITION ETIOLOGY OF ETIOLOGY OF
VAC (N=44) VAP (N=18)
Any pulmonary complication 26 (59%) 11 (61%)
Pneumonia 10 (23%) 6 (33%)
Pulmonary edema 8 (18%) 4 (22%)
Acute respiratory distress syndrome 7 (16%) 2 (11%)
Atelectasis 5 (11%) 2 (11%)
Mucous plugging 1 (2%) 0
Abdominal compartment syndrome 1 (2%) 0
Pulmonary embolus 1 (2%) 0
Radiation pneumonitis 1 (2%) 0
Sepsis syndrome 1 (2%) 0
Poor pulmonary toilet 1 (2%) 0
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.

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 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 onset6
• Time to onset data suggest that the majority of VAEs are likely
hospital-associated based on previous criteria7,8

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.

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VAE Surveillance 13
 Prevention Strategies

• Strategies to Prevent Ventilator-Associated

Pneumonia in Acute Care Hospitals: 2014 Update9
– 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.

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VAE Surveillance 14
 Intervention Bundle Checklist

PROCESS MEASURE DATE Y/N COMMENTS

Continuous subglottic suctioning

Assess readiness to extubate with Paired SBTs and SATs

spontaneous breathing trials (SBTs)
Interrupt sedation daily with Note contradictions here
spontaneous awakening trials (SATs)
Ambulate according to protocol Note level here

Regular mouth care (without

chlorhexidine)
Elevate head of bed (HOB) 30–450

Conservative fluid management

Blood transfusions given Rationale:

Low tidal volume Identify:

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 Best Practices for VAE Reduction
RECOMMENDATION INTERVENTION
Basic practice • Use noninvasive positive pressure ventilation in selected
populations
• Manage patients without sedation whenever possible
• Interrupt sedation daily
• Assess readiness to extubate daily
• Perform SATs with sedatives turned off
• Facilitate early mobility
• Use endotracheal tubes with subglottic secretion drainage
ports for patients expected to require greater than 48 or
72 hours of MV
• Change the ventilator circuit only if visibly soiled or
malfunctioning
• Elevate HOB to 30– 45°
Special approaches •
•
Select oral or digestive decontamination
Regular oral care with chlorhexidine
• Prophylactic probiotics
• Ultrathin polyurethane endotracheal tube cuffs
• Automated control of endotracheal tube cuff pressure
• Saline instillation before tracheal suctioning
• Mechanical tooth brushing
Generally not recommended •
•
Silver-coated endotracheal tubes
Kinetic beds
• Prone positioning

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 What About Oral Care With Chlorhexidine?

• Routine oral care with chlorhexidine10

– 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.

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VAE Surveillance 17
 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

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VAE Surveillance 18
 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?

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 How Can We Evaluate the Data?

EVENT TYPE GENDER LOCATION PATIENT ID FIRST NAME LAST NAME EVENT
VAE M ICU 1234 Mickey Mouse PVAP
VAE M ICU 5678 Donald Duck PVAP
VAE M ICU 2222 Charlie Brown VAC
VAE F ICU 1333 Minnie Mouse VAC
VAE M ICU 4444 Bugs Bunny VAC
VAE M ICU 5555 Super Man VAC
VAE F ICU 6666 Spider Woman VAC

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 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?

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 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

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 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

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VAE Surveillance 23
 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?

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 Case Review 3

• In an example ICU, many VAEs are PVAPs

• Evaluation
– Head of bed monitoring
– Suctioning frequency
– SATs
– Endotracheal tubes with subglottic suctioning

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 Case Review 3 – Outcomes

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

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 Opportunities for Improvement

• Hardwire ambulation protocols

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

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VAE Surveillance 27
 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

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 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

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VAE Surveillance 29
 Questions?

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 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, 5th ed. New York, NY: Simon and Schuster; 2003.

AHRQ Safety Program for Mechanically Ventilated Patients

VAE Surveillance 31
 References

6. Magill S, Gross C, Edwards JR. 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.

AHRQ Safety Program for Mechanically Ventilated Patients

VAE Surveillance 32