Training VAE 2014 Case Studies2

VAEQuestionsandCaseStudies
CindyGross,MT,SM(ASCP),CIC
IPConsultant
March14,2014
National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion
Thefollowingexamplesareforillustration
purposesonlyandarenotintendedtorepresent
actualclinicalscenarios.
WhenshouldIusePNEU/VAPinsteadofVAE?
A.
B.
C.
D.
E.
Never alwaysuseVAE
Whensurveillanceistobeconductedinmechanically
ventilatedchildrenwhoareinpediatriclocations
Whensurveillanceistobeconductedforhealthcare
associatedpneumoniathatisnotassociatedwith
mechanicalventilation
B andC
Noneoftheabove
NHSN Lower Respiratory Events in 2014
VAP protocol is in use for in-plan surveillance in

pediatric locations (pedVAP)
In-plan neonatal VAP surveillance is no longer available as of
January 2014
PNEU definitions are still available for off-plan

surveillance of VAP in adults , children, neonates or
non-ventilated PNEU in adults, children or neonates.
WhenevaluatingpatientdatatoseeiftheIVAC
definitionismet,Ishouldfocusonly on
antibioticsthatareusedtotreatrespiratory
infections
A. Yes
B. No
IVACandAntimicrobialAgents
MeetingInfectionrelatedVentilatorAssociated
Complication(IVAC)definitiondoesnotmeanthatthe
infectionrelatedeventisnecessarilyrespiratoryinorigin.
TheIVACantimicrobiallistwasrefinedbyremovingselected
antimicrobialagentsthatwouldnotbeused,orwouldbe
unlikelytobeused,intreatingalowerrespiratoryinfection
inacriticallyillpatient.
Stillpossiblethatanexistingagentmayhavedualpurposes
andnotnecessarilybetreatingarespiratoryinfection.
Noneedtodiscernthereasonfortheadministrationofthe
antimicrobial.
Prophylaxis,deescalation,changewithinaclassofantimicrobialsis
notareasonforexclusion
WhenselectingthedailyminimumPEEPand
FiO2 foreachcalendarday..
1. Throwoutthelowestvalue
2. Choosethemostconsistent
value
3. Selectthevalueusingany
24hourtimeperiod
4. Choosethelowestvalue
thathasbeenmaintained
foratleast1hour
Choosethelowestsettingthathasbeen
maintainedforatleast1hour
WhenchoosingthedailyminimumPEEPandFiO2,use
allsettingsthatarerecorded duringtimeswhenthe
patientisreceivingsupportfromaneligiblemodeof
mechanicalventilationandthepatientiseligiblefor
VAEsurveillance
Includesettingscollectedduringweaning/mechanical
ventilationliberationtrialsaslongasthepatientisventilated
Useconventionalmechanicalventilationsettings
IncludeconventionalMVsettingsduringtimeswhenapatientis
intermittentlyonanexcludedmodeofventilation
IncluderecordedPEEPsettingsduringtimeswhenapatientisnoton
APRVorasimilarmodeofventilation.
Useacalendardaynotsomeothercaptureperiod
orotherdesignated24hourtimeperiod
DailyMinimumValues
Thepatientisintubatedat2pm.PEEPandFiO2 are
setatthefollowingvaluesthroughtheremainderof
thecalendarday.WhatarethedailyminimumPEEP
andFiO2 valuesforthecalendarday?
Time
2 pm
4 pm
6pm
8 pm
10 pm
12 am
PEEP
(cmH2O)
10
FiO2
1.0
0.60
0.40
0.50
0.55
0.60
WhatarethedailyminimumPEEPandFiO2?
1.
2.
3.
4.
5 and 0.40
8 and 0.60
5 and 0.50
10 and 1.0
Time
2 pm
4 pm
6pm
8 pm
10 pm
12 am
PEEP
(cmH2O)
10
FiO2
1.0
0.60
0.40
0.50
0.55
0.60
DailyMinimumValues
Thepatientisintubatedat6pm. PEEPandFiO2 are
setatthefollowingvaluesthroughtheremainderof
thecalendarday.WhatarethedailyminimumPEEP
andFiO2?
Time
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
PEEP
(cmH2O)
10
FiO2
1.0
0.60
0.40
0.50
0.60
0.60
WhatarethedailyminimumPEEPandFiO2?
1.
2.
3.
4.
5 and 0.40
8 and 0.60
10 and 1.0
5 and 0.60
Time
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
PEEP
(cmH2O)
10
FiO2
1.0
0.60
0.40
0.50
0.60
0.60
MeetingVACDefinition
Whatiftheincreaseoverthebaselineperiodmeets
therequirementrelativetoonebaselineday?
MV Day
1
2
3
4
5
6
Daily minimum
PEEP
Daily minimum
FiO2
10
7
5
8
8
8
100
90
90
50
50
50
1. VAC
2. NO VAC
Whatifthereisanincreaseforonedayandthena
decrease?
MV Day
Daily minimum
PEEP
Daily minimum
FiO2
10
100
90
90
50
50
50
1. VAC
2. NO VAC
VACorNoVAC?
MV Day
1
2
3
4
5
6
Daily minimum
PEEP
Daily minimum
FiO2
10
5
5
10
8
8
100
90
90
50
50
50
1. Yes
2. No
Discrepantchanges
PEEPgoesupbutFiO2 goesdown
MV Day
1
2
3
4
5
6
Daily minimum
PEEP
Daily minimum
FiO2
8
7
7
10
10
8
100
90
90
50
50
50
ApatientinmyICUmettheIVACdefinition.OntheVAE
EventDate,therewasalsoapositivebloodculturethat
grewPseudomonasaeruginosa.Thepatienthasacentral
line.Otherthanfever,therearenoother
signs/symptomsofinfection.HowshouldIreportthis
event?
A. ReportanIVAC(nopathogen)andevaluateto
seeifthepositivebloodcultureissecondaryto
anotherHAIorifitisaCLABSI(pathogen=PA)
B. ReportanIVAC(pathogen=PA)
C. ReportanIVACandsecondaryBSI
(pathogen=PA)
D. ReportaCLABSI(pathogen=PA)
E. ReportanIVAC(nopathogen)
F. Noneoftheabove
SecondaryBSIcanonlybereportedforpossibleorprobable
VAP
Organismsisolatedfromthebloodculturemustmatchanorganism
isolatedfromanappropriaterespiratorytractspecimenthatwas
usedtomeetthepossibleorprobableVAPdefinition
Bloodculturemustbecollectedduringthe14dayeventperiod
IfthebloodcultureisnotfoundtobesecondarytoVAElook
totheotherHAIdefinitions(includingPNEUandLRI)or
reportasaCLABSI
PossibleorprobableVAPmetbutnoorganismmatchand/orblood
culturenotcollectedduring14dayeventperiod
VAC,IVACorNoVAEdetected
IfIamconductingVAEsurveillanceinplan,I
needtoassessdailyminimumandmaximum
temperaturesforthefollowingpatients:
1. AllpatientsintheICU
2. AllpatientsintheICUwhoareona
ventilator
3. PatientswhoIhavedeterminedmeet
theVACdefinition
4. PatientswhohavemettheVAC
definitionandalsohaveanabnormal
whitebloodcellcount
5. Patientswhotheclinicalcare
providershavediagnosedwithVAP
CaseStudy1
A69yearoldfemaleisseenintheERwithanadmitting
diagnosisofcommunityacquiredpneumonia(CAP).Sheis
admittedtotheICUthesamedayonaventilator. Reviewher
ventilatorsettingsanddetermineifVAEcriteriaaremet.
1
2
3
4
5
Daily minimum
PEEP
8
6
5
6
6
Daily minimum
FiO2
100
50
50
40
70
6
7
8
9
6
5
5
5
70
60
70
60
MV Day
A. Yes
B. No
Whatspecificeventshouldbereportedforthispatient?
MV
DAY
Daily
minimum
PEEP
Daily
minimum
FiO2
Temp
100
38.0
WBC
ABX
Pip /
Tazo
ABX
Pip /
Tazo
50
39.0
50
37.6
4.9
40
38.6
5.8
70
39
5.8
70
38.8
5.4
60
38.0
5.4
70
60
Pip /
Tazo
Specimen
Polys
/Epis
Organism
Sputum
Scant NF,
Many Staph.
aureus
BAL
104 cfu/ml
S. aureus
VancoIV
VancoIV
VancoIV
VancoIV
Whatspecificeventshouldbereportedforthis
patient?
A. None,thepatienthadCAP
presentonadmission
B. PossibleVAP(pathogenSA)
C. ProbableVAP(PathogenSA)
D. VAConly
MV
DAY
Daily
minimum
PEEP
Daily
minimum
FiO2
Temp
100
38.0
WBC
ABX
Pip /
Tazo
ABX
Pip /
Tazo
50
39.0
50
37.6
4.9
40
38.6
5.8
70
39
5.8
70
38.8
5.4
60
38.0
5.4
70
60
Pip /
Tazo
Specimen
Sputum
Polys
/Epis
Organism
Scant NF,
Many Staph.
aureus
VancoIV
VancoIV
BAL
VancoIV
VancoIV
104 cfu/ml
S. aureus
CASE1Recap
PatientsarenotexcludedfromVAEsurveillancedueto
admittingdiagnosis,presenceofunderlyingconditionsor
developmentofcomplications
EligiblepathogensidentifiedduringtheVAEwindowperiod
aretobeusedtodetermineifpossibleorprobableVAP
definitionscanbemetevenifthesameorsimilarpathogen
wasidentifiedpriortotheeventdetection
Daysbetweenadministrationofthesamenewantimicrobial
agentcountasQADsaslongasthereisagapofnomore
than1calendarday.
CaseStudy2
A17yearoldfemalewithcysticfibrosisisadmittedtotheadult
medicalICUwhereinplanVAEsurveillancehasbeenselected
inthemonthlyreportingplan.Sheisplacedontheventilator
onhospitalday5.Basedonthefollowingfindingsdoyouneed
toreportanythingtoNHSN.
CaseStudy2DoyouneedtoreportanythingtoNHSN?
MV Day
PEEP min
FiO2mi
n
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys /
Epis
Organism
----
----
----
--
--
--
6
6
6
50
50
50
37.0
37.9
5.4
5.4
None
None
None
7.5
80
36.5
37.3
7.2
9.2
None
1
2
7.5
80
36.3
38.9
7.4
8.4
None
BAL
25 /
10
75
75
37.2
38.5
8.5
8.8
7.5
6
Yes
Yes
---
---
104 cfu/ml
Pseudomonas
aeruginosa
---
75
Yes
Blood
--
Staph aureus
15
6
8
8
6
6
6
6
60
80
80
60
60
60
60
--------
--------
--------
16
7.5
85
Yes
Yes
Yes
Yes
Yes
Yes
No
No
--
--
--
17
7.5
85
No
--
--
--
10
11
12
13
14
CaseStudy2
1. NothingtoreporttoNHSN
2. ProbableVAPwithasecondaryBSI
(pathogensPA,SA)
3. ProbableVAP(pathogenPA)
4. ProbableVAP(pathogenPA)and
perhapsasecondaryBSItoanother
HAIsiteorCLABSI(pathogenSA)
5. ProbableVAP(pathogenPA)anda
CLABSI(pathogenPA)
MV Day
PEEP min
FiO2mi
n
Temp min
Temp max
WBC min
WBC max
Abx
Speci-men
Polys /
Epis
Organism
50
None
--
--
--
50
None
--
--
--
50
37.0
37.9
5.4
5.4
None
--
--
--
7.5
80
36.5
37.3
7.2
9.2
None
--
--
--
104 cfu/ml
80
7.5
36.3
38.9
7.4
8.4
None
BAL
25 /
Pseudomonas
10
aeruginosa
Yes
--
--
--
75
Yes
--
--
--
75
Yes
Blood
--
Staph aureus
60
Yes
--
--
--
80
Yes
--
--
--
80
Yes
--
--
--
60
Yes
--
--
--
60
Yes
--
--
--
60
Yes
--
--
--
60
No
--
--
--
16
7.5
85
--
--
--
17
7.5
85
--
--
--
7.5
75
10
11
12
13
14
15
Event Period (14 Days )
37.2
38.5
8.5
8.8
No
No
CaseStudy2Recap
AllpatientsinanadultlocationwhereVAEwasselectedin
themonthlyreportingplanareincluded
EventDay4(firstdayofonsetofworseningoxygenation)
VACmetinFiO2 parameter,donotroundupvalues
VAEWindowPeriodislimitedto4days,VACandIVAC
definitionsaremet
Bothpurulentrespiratorysecretionsandthequantitative
culturecriteriaaremettosatisfytheProbableVAP
definition
Bloodcultureiscollectedwithinthe14dayEventPeriodbut
therespiratoryandbloodculturepathogensdonotmatch
therefore,looktodetermineifanotherHAIdefinitionismet
forsecondarybloodstreaminfectionattributionandifnot
thenreportasCLABSI
CaseStudy3
AnelderlygentlemanisadmittedtothetraumaICU
followingamotorvehicleaccident.Hehadbeen
intubatedinthefieldandtherewassomeconcernof
aspirationuponintubation.Giventhefollowing
information,identifyallevents.
CaseStudy3Identifyevent(s)andMVdayof
event(s)
PEEP
FiO2m
Temp
Temp
WBC
WBC
min
in
min
max
min
max
1
2
3
4
6
6
6
8
30
30
30
30
37.1
36.8
37.0
36.5
37.6
37.2
37.9
37.3
4.3
4.6
5.4
7.2
35
36.3
37.2
50
37.2
50
8
9
10
11
12
13
14
15
16
17
18
6
6
8
8
6
6
6
6
7
7
40
40
40
40
30
30
30
60
60
85
MV Day
PATIENT
Abx
Specimen
Polys /
Epis
Organism
4.3
4.6
5.4
9.2
None
None
None
None
-----
-----
-----
7.4
12.5
None
--
--
--
37.9
8.5
13.0
Yes
BAL
25 /
10
104 Enterococcus
37.8
37.3
--
--
Yes
BC x2
--
Enterococcus
37.2
37.5
37.4
37.2
37.3
37.2
37.0
37.2
37.3
37.2
37.9
37.9
37.1
37.9
37.5
37.8
37.7
37.9
37.5
37.8
-----
-9.7
9.6
9.4
9.5
8.2
8.6
9.4
13.0
------
-11.7
10.9
9.4
9.5
8.2
8.6
12.1
13..5
-------
Yes
Yes
Yes
Yes
Yes
None
None
------------
------------
------------
EXPIRES
Yes
Yes
Yes
-----
Identifytheevent(s)andMVday
1.
2.
3.
4.
MVDay6 ProbableVAP
MVDay6 PossibleVAP
MVDay15 VAC
MVDay15 ProbableVAP
CaseStudy3
VACMVDay15
PEEP
FiO2m
Temp
Temp
WBC
WBC
min
in
min
max
min
max
1
2
3
4
6
6
6
8
30
30
30
30
37.1
36.8
37.0
36.5
37.6
37.2
37.9
37.3
4.3
4.6
5.4
7.2
35
36.3
37.2
50
37.2
50
8
9
10
11
12
13
14
15
16
17
18
6
6
8
8
6
6
6
6
7
7
40
40
40
40
30
30
30
60
60
85
MV Day
PATIENT
Polys /
Epis
Abx
Specimen
4.3
4.6
5.4
9.2
None
None
None
None
-----
7.4
12.5
None
BAL
37.9
8.5
13.0
Yes
--
--
--
37.8
37.3
--
--
Yes
BC x2
--
Enterococcus
37.2
37.5
37.4
37.2
37.3
37.2
37.0
37.2
37.3
37.2
37.9
37.9
37.1
37.9
37.5
37.8
37.7
37.9
37.5
37.8
-----
-9.7
9.6
9.4
9.5
8.2
8.6
9.4
13.0
------
-11.7
10.9
9.4
9.5
8.2
8.6
12.1
13.5
-------
Yes
Yes
Yes
Yes
Yes
None
None
------------
-------- 4 QAD
-requireme
nt
-not met
--
------------
EXPIRES
Yes
Yes
Yes
-----
---- 25 /
10
Organism
----104 Enterococcus
CaseStudy3Recap
EventDay15(firstdayofonsetofworseningoxygenation)
VAEWindowPeriodisDay13,14(twodaysbefore),Day15
(eventday),Day16,17(twodaysafter)
AbnormalWBCdocumentedduringVAEWindowPeriodbut
only3QADsareobservedpriortothepatientexpiring
Baselineperiodofstabilityisnotestablishedearlyin
mechanicalventilationepisode
NoVAC,NoIVAC,NoPossible/ProbableVAP
CaseStudy3
FocusonidentifyingVAC
Noneedtocollectother
parametersinadvance
Usingaculturedriven
surveillanceapproachisnot
usefulforVAE
MV Day
PEEP
min
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
6
6
6
8
8
8
6
6
6
8
8
6
6
6
6
7
7
PATIENT
FiO2
min
30
30
30
30
35
50
50
40
40
40
40
30
30
30
60
60
85
EXPIRES
Questions
THANKYOU!
nhsn@cdc.gov
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: cdcinfo@cdc.gov
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.
National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

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VAEQuestionsandCaseStudies

National Center for Emerging and Zoonotic Infectious Diseases

NHSN Lower Respiratory Events in 2014

VAP protocol is in use for in-plan surveillance in

PNEU definitions are still available for off-plan

Event Period (14 Days )

National Center for Emerging and Zoonotic Infectious Diseases

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