Jo Henman MPH,CIC
After attending presentation and completing
case studies, attendees will be able to:
 Apply
new NHSN definitions to identify
Ventilator Associated Events (VAE)
 Create
effective surveillance methods to
detect VAE
 Ventilator-associated
penumonia
 Sepsis
 Acute
Respiratory Distress Syndrome (ARDS)
 Barotrauma
 Pulmonary edema
 Longer
time on the ventilator
 Longer hospitalization
 Increased healthcare costs
 Disability
 Mortality


24% in patient 15-19
60% for patients >85
 More
than 300,000 patients are placed on
ventilator assistance every year
 NHSN data from 2010



1,700 facilities reported data (Compared to over
3,000 for CLABSI)
3,525 VAP cases reported
Rates ranged from 0.0 – 5.8/1,000 patient days
 Research
has shown that its not sensitive or
specific
 Major drawback is reliance on chest x-ray
which is highly variable and subjective.
 Also heavily relies on subjective clinical data
which lowers validity
 Standardized,
objective definition for public
reporting
 Increased opportunities for prevention and
improvement in care
 Many proven efforts to improve outcomes
aren’t specifically targeted to prevent
infections

Only one outcome—
either patient had
VAP or didn’t
Designed
for public
reporting
and P4P
Designed
for
internal
QI
VAP

Several choices along
pathway




Ventilator Associated
Condition (VAC)
Infection-Related
Ventilator Complication
(IVAC)
Possible VAP
Probable VAP
VAE



Started with chest xray

Starts with changes in
ventilator requirements

Explicit timing
definitions for inclusion
in surveillance

Objective clinical
criteria that is clearly
defined
Unclear definitions on
when something is
hospital acquired
Subjective clinical
symptoms (increased
sputum production)
VAP
VAE
 Eligible


patients/wards
Only for patients 18 and older
Acute care, long term acute care and inpatient
rehab facilities
 Excluded



types of ventilation
High frequency ventilation (>60 breaths per
minute with small tidal volumes)
Extracorporeal life support
NOTE: patients on airway pressure release
ventilation (APRV) those in the prone position
and those receiving nitric oxide therapy should
be included in surveillance
 Date
of Event: FIRST day that the worsening
oxygenation threshold is met
 VAE Window Period: The time period when all
elements of a definition must be met. It
usually includes the 2 days before and the 2
days after the date of event.
 Episode of ventilation: Days when a patient is
on a vent for some portion of each
consecutive day. Patient must be off
ventilator for one full calendar for new
episode to begin.
 Location
of attribution- Where patient was at
date of event

Exception – If date of event occurs on the day of
or day after transfer then the event is attributed
to transferring location
 Reporting
– In 2013 MUST report all events in
the VAE algorithm
Patient has a baseline period of stability or improvement on the
ventilator, defined by ≥ 2 calendar days of stable or decreasing daily
minimum FiO2 or PEEP values. The baseline period is defined as the two
calendar days immediately preceding the first day of increased daily
minimum PEEP or FiO2.
and
After a period of stability or improvement on the ventilator, the patient has
at least one of the following indicators of worsening oxygenation:
 1) Increase in daily minimum FiO2 of ≥ 0.20 (20 points) over the daily
minimum FiO2 in the baseline period, sustained for ≥ 2 calendar days.

2) Increase in daily minimum PEEP values of ≥ 3 cmH2O over the daily
minimum PEEP in the baseline period, sustained for ≥ 2 calendar days.
Ventilator Day
FI02
PEEP
1
100%
8
2
50%
6
3
40%
5
4
40%
5
5
70%
6
6
70%
6
Ventilator Day
FI02
PEEP
1
100%
8
2
50%
6
3
35%
5
4
40%
5
5
70%
6
6
70%
6
 Is
this case a VAC?
Why? PEEP was stable or declining on
days 2 and 3, then increased by at least
3 on days 4 and 5.
Bonus: What was the Date of the Event?
 Is
this case a VAC?
Why? PEEP increased between day 2
and 3 so there wasn’t a 2 day period
of stable or increasing ventilator
requirements prior to them going up
to 10.
Patient meets criteria for VAC
And
On or after calendar day 3 of mechanical
ventilation and within 2 calendar days before
or after the onset of worsening oxygenation, the
patient meets both of the following criteria:
 1) Temperature > 38 °C or < 36°C, OR white
blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000
cells/mm3
AND

2) A new antimicrobial agent(s)* is started, and is
continued for ≥ 4 calendar days.
On or after calendar day 3 of mechanical ventilation and within 2
calendar days before or after the onset of worsening oxygenation, the
patient meets both of the following criteria:
Ventilator Day
FI02
PEEP
1
100%
8
2
50%
6
3
75%
5
4
75%
5
5
70%
6
6
70%
6
This is the VAE Window Period and all elements of
definition must be met during this time period.
Ventilator Day
FI02
PEEP
1
100%
8
2
50%
6
3
40%
5
4
35%
5
5
70%
6
6
70%
6
7
40%
5
Patient meets criteria for VAC
And
On or after calendar day 3 of mechanical
ventilation and within 2 calendar days before
or after the onset of worsening oxygenation, the
patient meets both of the following criteria:
 1) Temperature > 38 °C or < 36°C, OR white
blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000
cells/mm3
AND

2) A new antimicrobial agent(s)* is started, and is
continued for ≥ 4 calendar days.
A
NEW antimicrobial that is contained in the
NHSN Appendix that is given by IV, IM,
Respiratory or Digestive tract route during
the VAE Window Period.
 NEW
means an antimicrobial that wasn’t
received in the previous 2 days and continues
for 4 “qualifying antimicrobial days” (QAD’s)
A
day when the patient received a new
antimicrobial agent.
 QAD’s must start within the VAE Window
Period and continue for four consecutive
days…..KIND OF!

In NHSN world if the SAME antimicrobial is given
on days 1 and 3 that is considered consecutive
and would count as THREE QAD’s. There can be
no more than one calendar day between doses to
count as consecutive.
 Does
this case meet the definition for IVAC?
Did your group come to the same
conclusion? Lets review the details
Assume that “increased vent requirements” meet the VAC definition for
worsening oxygenation
Ventilator
Day
4
5
6
7
8
9
VAC
Criteria
Temp
Stable Stable Increased
Increased
vent
vent
requirements requirement
s
37.5
38.9
38.0
37.5
Increased
Stable
vent
requirement
s
37.0
39.0
WBC
15.0
17.5
18.5
12.0
11.5
Antimicrobi Doxy
al Agent
Doxy
Vancomycin
None
Vancomycin Doxy
14.0
 Does
this case meet the definition for IVAC?
Did your team come up with the
answer?
Assume that “increased vent requirements” meet the VAC definition for
worsening oxygenation
Ventilator
Day
1
2
3
VAC Criteria
Stable
Stable
Increased vent Increased
Increased
Stable
requirements vent
vent
requirements requirements
Temp
37.5
38.9
38.0
37.5
37.0
39.0
WBC
15.0
17.5
18.5
12.0
11.5
14.0
Vancomyci
n
None
Vancomycin
None
Vancomyci
n
Antimicrobia Doxy
l Agent
4
5
6
 We
have now traveled half way down the VAE
Pathway!
Patient meets criteria for VAC and IVAC
and
On or after calendar day 3 of mechanical ventilation and within 2
calendar days before or after the onset of worsening oxygenation, ONE of
the following criteria is met:
1) Purulent respiratory secretions (from one or more specimen
collections)
• Defined as secretions from the lungs, bronchi, or trachea that contain >
25 neutrophils and < 10 squamous epithelial cells per low power field [lpf,
x100].
• If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds.
OR
2) Positive culture (qualitative, semi-quantitative or quantitative) of
sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or
protected specimen brushing
*Excludes the following:
• Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent
• Candida species or yeast not otherwise specified
• Coagulase-negative Staphylococcus species
• Enterococcus species
 On
or after calendar day 3 of mechanical
ventilation and within 2 calendar days before or
after the onset of worsening oxygenation, ONE of
the following criteria is met:
 1)
Purulent respiratory secretions (from one or
more specimen collections)
 Defined as secretions from the lungs, bronchi,
or trachea that contain > 25 neutrophils and <
10 squamous epithelial cells per low power
field [lpf, x100].
 If the laboratory reports semi-quantitative
results, those results must be equivalent to
the above quantitative thresholds.


>25 neutrophils = 4+ OR Heavy
<10 epis = 1+ or 2+ OR Rare, Occasional or Few
Patient meets criteria for VAC and IVAC
and
On or after calendar day 3 of mechanical ventilation and within 2 calendar
days before or after the onset of worsening oxygenation, ONE of the
following criteria is met:
1) Purulent respiratory secretions (from one or more specimen collections)
• Defined as secretions from the lungs, bronchi, or trachea that contain >
25 neutrophils and < 10 squamous epithelial cells per low power field [lpf,
x100].
• If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds.
OR
2) Positive culture (qualitative, semi-quantitative or quantitative) of
sputum*, endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or
protected specimen brushing
*Excludes the following:
• Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent
• Candida species or yeast not otherwise specified
• Coagulase-negative Staphylococcus species
• Enterococcus species
2) Positive culture (qualitative, semi-quantitative or
quantitative) of sputum*, endotracheal aspirate*,
bronchoalveolar lavage*, lung tissue, or protected
specimen brushing
*Excludes the following:
• Normal respiratory/oral flora, mixed respiratory/oral
flora or equivalent
• Candida species or yeast not otherwise specified
• Coagulase-negative Staphylococcus species
• Enterococcus species
NOTE:
• Candida species or yeast not otherwise specified
• Coagulase-negative Staphylococcus species
• Enterococcus species
That is isolated from lung tissue or pleural fluid cultures
may be reported and will count as meeting criteria for a
possible VAP
 Secondary
BSIs may be reported for possible
VAP given the following:



At least one organism isolated from blood
cultures matches an isolate from the respiratory
culture that was used to meet the possible VAP
criteria
The blood culture was drawn during a 14 day
event period, with the event date for VAC
counting as day 1.
If no positive culture or only organisms that can’t
be used to meet possible VAP criteria are isolated
then a secondary BSI may not be reported.
Ventilator
4
Day
VAC Criteria Stable
5
6
7
8
9
Stable
38.9
17.5
Doxy
Increased
vent
requirements
37.5
12.0
None
Increased
vent
requirements
37.0
11.5
Vancomycin
Stable
Temp
WBC
Antimicrobi
al Agent
Gram Stain
Increased
vent
requirements
38.0
18.5
Vancomycin
Sputum
Culture
37.5
15.0
Doxy
39.0
14.0
Doxy
Few Epi
Many Wbc
Mod GPC
Few GNB
Heavy
Coagulase
Negative
Staphylococc
us
Does this meet criteria for possible VAP
If yes, which of the criteria does it meet
If the patient had a blood culture with coagulase negative Staphylococcus on Day 9 would this
count as a secondary BSI?

On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or
after the onset of worsening oxygenation, ONE of the following criteria is met:

1) Purulent respiratory secretions (from one or more specimen collections—and defined as
for possible VAP)
AND one of the following (see Table 2):


• Positive culture of endotracheal aspirate*, ≥ 105 CFU/ml or equivalent semi-quantitative
result

• Positive culture of bronchoalveolar lavage*, ≥ 104 CFU/ml or equivalent semi-quantitative
result

• Positive culture of lung tissue, ≥ 104 CFU/g or equivalent semi-quantitative result

• Positive culture of protected specimen brush*, ≥ 103 CFU/ml or equivalent semiquantitative result

*Same organism exclusions as noted for Possible VAP.

OR

2) One of the following (without requirement for purulent respiratory secretions):

• Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial
placement of chest tube and NOT from an indwelling chest tube)

• Positive lung histopathology

• Positive diagnostic test for Legionella spp.

• Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial









On or after calendar day 3 of mechanical ventilation and within
2 calendar days before or after the onset of worsening
oxygenation, ONE of the following criteria is met:
1) Purulent respiratory secretions (from one or more specimen
collections—and defined as for possible VAP)
AND one of the following (see Table 2):
• Positive culture of endotracheal aspirate*, ≥ 105 CFU/ml or
equivalent semi-quantitative result
• Positive culture of bronchoalveolar lavage*, ≥ 104 CFU/ml or
equivalent semi-quantitative result
• Positive culture of lung tissue, ≥ 104 CFU/g or equivalent
semi-quantitative result
• Positive culture of protected specimen brush*, ≥ 103 CFU/ml
or equivalent semi-quantitative result
*Same organism exclusions as noted for Possible VAP.
equivalent semi-quantitative result = 2+, 3+ or 4+ OR Moderate
or Heavy Growth
Ventilator
4
Day
VAC Criteria Stable
5
6
7
8
9
Stable
38.9
17.5
Doxy
Increased
vent
requirements
37.5
12.0
None
Increased
vent
requirements
37.0
11.5
Vancomycin
Stable
Temp
WBC
Antimicrobi
al Agent
Gram Stain
Increased
vent
requirements
38.0
18.5
Vancomycin
Sputum
Culture
37.5
15.0
Doxy
39.0
14.0
Doxy
Many Epi
Many Wbc
Mod GPC
Few GNB
Moderate
growth of
MRSA
Would this case meet the criteria for probable VAP?
OR
2) One of the following (without requirement for purulent respiratory
secretions):
• Positive pleural fluid culture (where specimen was obtained during
thoracentesis or initial placement of chest tube and NOT from an indwelling
chest tube)
• Positive lung histopathology
• Positive diagnostic test for Legionella spp.
• Positive diagnostic test on respiratory secretions for influenza virus,
respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus,
human metapneumovirus, coronavirus
This section of the definition does NOT require that a gram stain meet the
purulent criteria.
Acceptable tests for Legionella include:
Urinary antigen
Respiratory culture
4 fold rise in titer between acute and convalescent antibody tests
PCR done on respiratory specimens
Special fluorescent and immunohistochemical stains
Acceptable tests for respiratory virus:
PCR
Antigen detection
Viral cell culture
4 fold rise in titer between acute and convalescent antibody tests
Now that you’ve learned the theory
behind the new VAE surveillance
definitions….here is the calculator
instead of pencil and paper
determination
 Manual
vs. Electronic
 Only need to look at patients who are on the
vent for at least 4 days
 Probably need to partner with RT and IS
 Can capture from electronic charting if used
 Can be set up in IC software programs to run
initial algorithm if used
9999999999
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1/4/2013
1/5/2013
1/6/2013
1/7/2013
1/8/2013
1/9/2013
1/10/2013
1/11/2013
1/12/2013
1/13/2013
1/14/2013
1/15/2013
1/16/2013
1/17/2013
1/18/2013
1/19/2013
1/20/2013
1/21/2013
1/22/2013
1/23/2013
100
50
50
70
60
50
40
50
50
40
40
30
30
30
30
30
30
30
30
30
flag
diff
daily_min_FIO2
last_day_of_month
result_date
Medical_Record_Nu
mber
Patient_Id
Patient_Name
Patient A
-50
0
20
-10
-10
-10
10
0
-10
0
-10
0
0
0
0
0
0
0
0
1
My Contact Information:
Jo Henman MPH,CIC
lhenman2@ohiohealth.com
614-566-5793










1) Behrendt CE. Acute respiratory failure in the United States: incidence and 31-day
survival. Chest 2000;118:1100-5.
2) Kahn JM, Goss CH, Heagerty PJ, et al. Hospital volume and the outcomes of
mechanical ventilation. N Engl J Med 2006;355:41-50.
3) Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The
epidemiology of mechanical ventilation use in the United States. Crit Care Med
2010;38:1947-53.
4) Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute
lung injury. N Engl J Med 2005;353:1685-93.
5) Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult
patients receiving mechanical ventilation: a 28-day international study. JAMA
2002;287:345-55.
6) Dudeck MA, Horan TC, et. al. National Healthcare Safety Network (NHSN) Report,
Data Summary for 2010, Device-associated Module. Available at
http://www.cdc.gov/nhsn/PDFs/dataStat/NHSNReport_DataSummaryfor2010.pdf.
7) Klompas M. Does this patient have ventilator-associated pneumonia? JAMA
2007;297:1583-93.
8) Klompas M. Interobserver variability in ventilator-associated pneumonia
surveillance. Am J Infect Control 2010;38:237-9.
9) Klompas M, Kulldorff M, Platt R. Risk of misleading ventilator-associated
pneumonia rates with use of standard clinical and microbiological criteria. Clin
Infect Dis 2008;46:1443-6.
NHSN VAE Definition Jan 2013. http://www.cdc.gov/nhsn/PDFs/pscManual/10VAE_FINAL.pdf.