1. Ahmed Al Gahtani, BSRC, RRT
Associate Director, Clinical Education
Chairman, RTS Scheduling Committee
Dept. of Respiratory Therapy
Inaya Medical College
Central Chapter Member, Saudi Society for Respiratory Care

2.  Clear distinction between surveillance and clinical case definitions
based on:
Maryland Hospital Association

3.  Lacked objectivity and reliability
 Included three components
 An radiographic component (required)
 A signs and symptoms component (required)
 A laboratory component (optional)
 Included situations where pneumonia could not be diagnosed with a
reasonable degree of certainty

4.  The CDC's NHSN has been working since 2009 to develop a more
objective, reliable approach to VAP surveillance, convening a VAP
Surveillance Definition Working Group in collaboration with
 Nationally recognized experts
 Several professional societies and organizations
 Other federal partners
 The CDC’s new approach centers on ventilator-associated conditions
and complications in an attempt to limit diagnostic inaccuracies.
 The new approach, surveillance for Ventilator-Associated Events (VAE),
was implemented for use in NHSN in January 2013.

5.  Step ways approach (VAC, IVAC, possible or probable VAP)
 Simple and focuses on readily available, objective clinical data
 Requires a minimum period of time on the ventilator
 Does not include chest radiograph findings
 Detects ventilator-associated conditions and complications, including (but not
limited to) VAP
 Captures important complications, most cases due to:
 Pneumonia
 Pulmonary edema
 ARDS (Acute Respiratory Distress Syndrome)
 Atelectasis
 Allows clinicians to identify and manage care complications that lead to VAP earlier
and more effectively than in the past

6.  Routine bedside evaluation coupled with radiographic information
provides suggestive but not definitive evidence that VAP is present or
absent. Given the severity of VAP and the frequency of serious
conditions that can mimic VAP, clinicians should be ready to consider
additional tests that provide further evidence for VAP or that establish
another diagnosis.
Klompas, et el: JAMA, April 11, 2007—Vol 297, No. 14

7.  Objective: The objective of this study was to compare the observed rates of
ventilator-associated pneumonia when using the National Healthcare Safety
Network vs. the American College of Chest Physicians criteria.
 Design: Prospective, observational cohort study.
 Setting: A 1250-bed academic tertiary care medical center.
 Patients: Adult medical and surgical intensive care unit patients requiring
mechanical ventilation for >48 hrs.
 Interventions: None.

8.  The clinical characteristics of VAP and VAT are similar and include fever,
leukocytosis, and purulent sputum. An infiltrate on chest radiograph is consistent
with VAP but lacks diagnostic precision, so it is not a criterion in the proposed
surveillance definition and should be interpreted cautiously by clinicians.
Microbiologically, quantitative and semiquantitative endotracheal aspirate cultures
may be employed to diagnose VAP and VAT. Positive bronchoalveolar lavage and
protected specimen brush cultures are useful only for the diagnosis of VAP. Experts
should collaborate to develop consensus definitions for VAP and VAT that can be
applied in practice

9.  Evaluated a novel surveillance paradigm for ventilator-associated
complications (VAC) defined by sustained increases in patients’
ventilator settings after a period of stable or decreasing support.
 Assessed 600 mechanically ventilated medical and surgical patients
from three hospitals
 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.
Clinical Infectious Diseases 2011: Klompas et al

10.  The complexity and subjectivity of ventilator-associated pneumonia (VAP)
surveillance limit its value in assessing and comparing quality of care for
ventilated patients. A simpler, more quantitative VAP definition may
increase utility.
 A streamlined version of the VAP definition was faster, more objective, and
predicted patients’
 outcomes almost as effectively as the conventional definition. VAP
surveillance using the streamlined method may facilitate more objective and
efficient quality assessment for ventilated patients.
Clinical Infectious Diseases 2012;54(3):370–7

11.  VAEs were associated with more days to extubation (relative rate, 3.12
[95% confidence interval (CI), 2.96–3.29]), more days to hospital
discharge (relative rate, 1.46 [95% CI, 1.37–1.55]), and higher hospital
mortality risk (odds ratio, 1.98 [95% CI, 1.60–2.44]). Conclusions.
VAEs are common and morbid. Prevention strategies targeting VAEs
are needed.
Infection Control and Hospital Epidemiology, 2014

12. VAP VAE
 Only one outcome—
either patient had
VAP or didn’t
 Several choices along
pathway
 Ventilator Associated
Condition (VAC)
 Infection-Related
Ventilator Complication
(IVAC)
 Possible VAP
 Probable VAP
Designed
for public
reporting
Designed
for internal
QI
VAE: Learning Your way through the new ventilator event pathway, Jo Henman

13. VAP VAE
 Started with chest x-ray
 Unclear definitions on
when something is
hospital acquired
 Subjective clinical
symptoms (increased
sputum production)
 Starts with changes in
ventilator requirements
 Explicit timing
definitions for inclusion
in surveillance
 Objective clinical criteria
that is clearly defined
VAE: Learning Your way through the new ventilator event pathway, Jo Henman

14.  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
VAE: Learning Your way through the new ventilator event pathway, Jo Henman

15.  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.

16.  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
VAE: Learning Your way through the new ventilator event pathway, Jo Henman

18. 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.
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.
and

19. Ventilator Day FI02 PEEP
1 100% 8
2 50% 6
3 35% 5
4 35% 5
5 60% 6
6 60% 6

20. Patient meets criteria for 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:
 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.
And

21.  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)

22.  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.

23. 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

24. Ventilator Day 1 2 3 4 5 6
VAC Criteria Stable Stable Increased vent
requirements
Increased vent
requirements
Increased vent
requirements
Stable
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
Antimicrobial
Agent
Doxy GENTAMICIN GENTAMICIN None GENTAMICIN GENTAMICIN
Another Example

27. Now that you’ve learned the theory
behind the new VAE surveillance
definitions….here is the calculator
instead of pencil and paper
determination

28.  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

30.  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/10-
VAE_FINAL.pdf.