Implementation Guide

for Ventilator-Associated
Pneumonia and Ventilator-
Associated Events

January 22, 2014

 Contents
1. Introduction ............................................................................................................................. 3
2. Ventilator-Associated Pneumonia and Ventilator-Associated Events Surveillance Evidence-
Based Practices......................................................................................................................... 3
2.1 Background Information .................................................................................................. 3
2.2 VAE Definitions and Algorithms…………………………………………………………………………….4

2.3 Burden of Illness……………………………………………………………………………………………………6

2.4 Risk Factors ..................................................................................................................... 66

2.5 Evidence-Based Practice Guidelines and Bundles……………………………………………….......7
2.6 MHS VAP and VAE Prevention Performance Measures8……………………………………………8
3.0 References…………………………………………………………………………………………………………………...8

4.0 Appendix .................................................................................................................................. .9

Attachment A: VAP/VAE Bundle Compliance Form ............................................................ ..9

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 1. Introduction
This implementation guide was created to support the Partnership for Patients, a national initiative
sponsored by the Department of Health and Human Services to reduce harm in health care facilities.
Military Health System leadership has pledged its support to the PfP, and has made a commitment to
specific, identified aims. Improving the quality and safety of health care in all Department of Defense
facilities will only be possible with universal support at every level in the MHS.

This guide is one of 10 harm-specific guides designed to assist you as you implement identified
evidence-based practices to improve patient care. Common to all guides are resources that
support efforts to educate the health care team by providing MHS-selected EBPs and quality
improvement strategies.

In addition, implementation strategies and tools relevant to all harm categories are included in a guide
titled “Practical Applications for Process Improvement and Change Management.” This guide supports
efforts to equip the health care team with rapid-cycle process improvement methods and engage the
health care team through the use of change management strategies.

2. Ventilator-Associated Pneumonia and Ventilator-

Associated Events Surveillance
Evidence-Based Practices
2.1 Background Information
Ventilator-Associated Pneumonia (VAP) and Ventilator-Associated Events (VAE) are nosocomial lung
infections that occur in patients receiving mechanical ventilation. Pneumonia and events are
considered ventilator-associated if the patient is intubated and ventilated at the time or within 48
hours before the onset of infection. The CDC notes there is no minimum period of time that the
ventilator must be in place for the infections to be considered ventilator-associated (National
Healthcare Safety Network Manual: Patient Safety Component Protocol).

In January 2013, CDC recommended that VAP protocol be used for neonatal and pediatric patients
ONLY. At that time, the CDC modified the definitions for VAP for those patients on mechanical
ventilation for patients 18 years of age or older. Ventilator Associated Events (VAE) represents a new
approach that is focused on standardized methods, objectivity, and reliability. VAE identifies a broad
range of events in patients on mechanical ventilation, not limited to VAP. Criteria for patients eligible
for VAE Surveillance:

 ≥18 years of age

 Inpatients of acute care hospitals, long term acute care hospitals, inpatient rehabilitation
facilities
 NOTE: Patients on high frequency ventilation or extracorporeal life support are EXCLUDED from
VAE surveillance

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 2.2. VAE Definitions and Algorithms
While the definition of VAP in patients <18 years of age remains the same, the definition of VAE has
changed. A summary of the definition algorithms and tiers follows:

Ventilator-Associated Events Definition Algorithm Summary

Patient on mechanical ventilation > 2 days

 Respiratory No CXR
Status. Baseline period of stability or improvement, needed
Component
followed by sustained period (>2 days) of worsening oxygenation

Ventilator-Associated Condition (VAC)

 Infection/
Inflammation
Component General evidence of infection/inflammation

Infection-related Ventilator-Associated Complication (IVAC)

 Additional
Evidence
Positive results of microbiological testing

Possible or Probable VAP

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 Figure 1: Ventilator-Associated Events (VAE) Surveillance Algorithm
Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum* FiO or PEEP
2
values. The baseline period is defined as the two calendar days immediately preceding the first day of increased minimum PEEP or FiO *Daily minimum
2.
defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour.

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 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 periodϯ, sustained for ≥ 2 calendar days
*
Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour.
ϯ
Daily minimum PEEP values of 0-5 cmH2O are considered equivalent for the purposes of VAE surveillance.

Ventilator-Associated Condition (VAC)

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:
◦ ◦ 3 3
1) Temperature > 38 C, or < 36 C, OR white blood cell count ≥ 12,000 cells/mm or ≤ 4,000 cells/mm .

AND
2) A new antimicrobial agent/s is started, and is continued for >4 calendar days.

Infection-Related Ventilator-Associated Complication (IVAC)

On or after day 3 of mechanical ventilation and within 2 calendar days On or after calendar day 3 of mechanical ventilation and within 2 calendar
before or after the onset of worsening oxygenation, ONE of the days before or after the onset of worsening oxygenation, ONE of the
following criteria is met: following criteria is met:
Purulent respiratory secretions (from one or more specimen collections –
and defined as for possible VAP)
1. Purulent respiratory secretory secretions (from one or more
AND one of the following:
specimen collections 5

 Defined as secretions from the lungs, bronchi, or  Positive culture of endotracheal aspirate*, ≥ 10 CFU/ml or
equivalent semi-quantitative result
trachea that contain ≥ 25 neutrophils and ≤ 10 4

squamous epithelial cells per low power field [lpf,  Positive culture of bronchoalveolar lavage*, ≥ 10 CFU/ml or
x100] equivalent semi-quantitative result
4
 If the laboratory reports semi-qualitative, those  Positive culture of lung tissue, ≥ 10 CFU/g or equivalent semi-
results must be equivalent to the above quantitative result
3
quantitative thresholds  Positive culture of protected specimen brush*, ≥ 10 CFU/ml or
 See additional instructions on page 10-4 of 2014 equivalent semi-quantitative result
NHSN Manual, Patient Safety Component *Same organism exclusions as noted for Possible VAP.
Protocol
2. Positive culture (qualitative, semi-qualitative or quantitative) 2. One of the following (without requirement for purulent respiratory
secretions):
of sputum*, endotracheal aspirate*, bronchoalveolar
 Positive pleural fluid culture (where specimen was obtained during
lavage*, lung tissue or protected specimen brushing*. thoracentesis or initial placement of chest tube and NOT from an
indwelling chest tube)
*Excludes the following:  Positive lung histopathology
 Normal respiratory/oral flora, mixed respiratory/oral flora or  Positive diagnostic test to Legionella spp.
equivalent  Positive diagnostic test on respiratory secretions for influenza virus,
 Candida species or yeast not otherwise specified respiratory syncytial virus, adenovirus, parainfluenza, rhinovirus,
 Coagulase-negative Staphylococcus species human metapneumovirus, coronavirus
 Enterococcus species

Possible Ventilator-Associated Pneumonia Probable Ventilator-Associated Pneumonia

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 2.3. Burden of Illness
According to the Institute for Healthcare Improvement, VAP and VAE are the leading cause of death
amongst hospital-acquired infections, exceeding the rate of death due to central line infections, severe
sepsis, and respiratory tract infections in the non-intubated patient. Perhaps the most concerning
aspect of VAP is the high associated mortality. Hospital mortality of ventilated patients who develop
infection is 46 percent compared to 32 percent for ventilated patients who do not develop VAP or VAE.

VAP and VAE Burden of Illness

 Increases ventilators support and ICU stay by an average of 4.3 days
 Increases hospital length of stay by 4 to 9 days
 Increases cost by more than $40,000 per episode of hospital stay
 Is estimated to cost more than $1.2 billion nationally each year
 Is the leading cause of death among hospital-acquired infections

Sources:
1. IHI, How to Guide: Prevent Ventilator-Associated Pneumonia, Cambridge, MA, IHI: 2012.
2. Heyland, et al, American Journal of Respiratory and Critical care Medicine, (1999).
3. Craven, Epidemiology of Ventilator-Associated Pneumonia, CHEST Journal: 2000.
4. Rello, et al, Epidemiology and Outcomes of Ventilator-Associated Pneumonias in a Large US Database, CHEST Journal:
202.
5. Safder, et al, Clinical and Economic Consequences of Ventilator-Associated Pneumonias: A Systematic Review,
Critical Care Review: 2005.

2.4 Risk Factors

There are a number of factors that can put a patient at risk for a VAP or VAE. The CDC has identified
important risk factors including:

 Mechanical ventilation
 Pre-existing pulmonary conditions
 Large number of previous intubations

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 2.5 Evidence-Based Practice Guidelines and Bundle
To reduce the prevalence of VAP and VAE, best practices have been developed. They focus on
three components: staff education, colonization and aspiration reduction and prevention

 Staff education
 Colonization reduction
o Handwashing
o Oral hygiene
o Common suction protocol
o Avoid saline lavage
o Closed suction system
o Stress ulcer prophylaxis (involve pharmacists)
 Aspiration reduction and prevention
o Regular oral and subglottic suction
o Elevation of head > 30 degrees
o Early extubation
 Daily assessment of extubation readiness
 Daily interruption of sedation

Source:
1. Theron Van Hooser, D. (2002) Ventilator-Associated Pneumonia (VAP) Best Practice Strategies for
Caregivers. Kimberly-Clark Health Care.
National Guideline Clearinghouse. (2009) Strategies to prevent ventilator-associated pneumonia in acute
care

In an effort to prevent infection, care management bundles have been created. A care bundle is
a set of evidence-based interventions that, when used together, significantly improve
patient outcomes.

The MHS has selected the Institute for Healthcare Improvement VAP bundle for implementation at
Military Treatment Facilities:
MHS VAP and VAE Bundle (IHI)

 Elevate the head of the bed at least 30 degrees.

 Perform daily sedation interruption and daily assessment
of readiness to extubate.
 Perform peptic ulcer disease prophylaxis.
 Perform deep venous thrombosis prophylaxis.
 Perform daily oral care with chlorhexidine.

Source:
IHI. How-to Guide: Prevent Ventilator-Associated Pneumonia. Cambridge, MA:
IHI; 2012.

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 2.6 MHS VAP and VAE Prevention Performance Measures
MTFs are expected and encouraged to report facility-wide VAP data with the understanding that this
will be limited to ICUs unless there is a long-term ventilator unit. The MHS has selected the following
process and outcome measures to track performance:

Descriptions Data Source Metric

 Observation / Check list for bundle compliance Essentris Process Measure

 Ventilator-Associated Pneumonia Rate: [Incidence of VAP CDC/NHSN Outcome Measure

in each ICU] / [Number of ventilator days] x 1000

3.0 References
Centers for Disease Control and Prevention (2003). Guidelines for Preventing Health-Care-Associated
Pneumonia. Center for Disease Control.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm Accessed 7/10/12.

Coffin, S. (2008). Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals.

SHEA/IDSA Practice Recommendation.

Cook, J. (1994). Risk Factors for GI Bleeding in Crticially Ill Patients. New England Journal of Medicine.

Institute for Healthcare Improvement. (2012, February). How-to Guide: Prevent Ventilator-Associated
Pneumonia. Institute for Healthcare Improvement.
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventVAP.aspx Accessed 7/10/12.

Kress, J. (2003). The Long-term Psychological Effects of Daily Sedation Interruption on Critically Ill
Patients. American Journal of Respiratory and Critical Care Medicine.

Munro, C., Grap, M., Jones, D., McClish, D., & Sessler, C. (2011). Chlorhexidine, Toothbrushing, and
Preventing Ventilator-Associated Pneumonia in Critically Ill adults. American Journal of Critical Care,
428-437.

NHSN Manual: Patient Safety Component Protocol,

http://www.cdc.gov/nhsn/PDFs/pscManual/pcsManual_current.pdf Accessed 1/8/2014.

Ventilator-Associated Events (2013, January)

www.cdc.gov/nhsn/psc_da_vae.html.

Ventilator-Associated Pneumonia (VAP) . (2012, January).

www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf Accessed 7/10/12.

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 4.0 Appendix: Attachment A: VAP/VAE Bundle
Compliance Form
VAP Bundle – Compliance

Objective: To provide documentation of compliance with implementation of VAP/VAE prevention

bundle.
Instructions: Assess guideline compliance on patients receiving mechanical ventilation.

Ventilator-Associated Pneumonia Prevention EBP Compliance Checklist Yes No Identified Barriers/

Plans to Overcome
Barriers
1. Elevation of the head of the bed at least 30 degrees.
2. Perform daily sedation interruption and assessment of need to
extubate patient.
3. Perform peptic ulcer disease prophylaxis.
4. Perform deep venous thrombosis prophylaxis.
5. Perform daily oral care with chlorhexidine.