Shelley S. Magill, MD, PhD

July 16, 2015

Ventilator-Associated Event Surveillance:CDC Updates

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

Overview

� Review the current status of National Healthcare Safety

Network (NHSN) Ventilator-Associated Event (VAE)

surveillance

� Discuss VAE data reported to NHSN in 2013-2014

� Provide definition and IT updates

STATUS OF NHSN VAE SURVEILLANCE

VAE

Ventilator-Associated Condition (VAC):

Based on changes in PEEP and

FiO2

Infection-related Ventilator-Associated Complication (IVAC):

VAC with general evidence of

infection

Possible Ventilator-Associated Pneumonia

(PVAP):

IVAC with lab evidence

of pneumonia

VAE Surveillance Timeline

1/2013 1/20151/20148/2013

VAE

implemented

in NHSN

PEEP criterion

changes

Changes to

eligible

antimicrobials

Additional

guidance for

microbiological

criteria

Additional

organism

exclusions

Addition of new,

optional

denominator

(“EMV”)

Consolidation of

Possible and

Probable VAP into

single “PVAP”

definition

1/2016

CMS reporting

requirement for

LTCH QRP

VAE DATA REPORTED TO NHSN

Facilities Reporting In-Plan VAE to NHSN, 2013-2014*

� 1615 facilities in 2013

� 1893 facilities in 2014

� 2017 facilities in 2013

and/or 2014

*Includes any facility indicating in-plan VAE surveillance in 2013 or 2014, regardless of whether data submission is complete for all location-months of reporting. Preliminary and subject to change.

83%

7%

6%

4%N=2017

General

hospital

LTAC hospital

Critical access

hospital

Other

Locations Reporting In-Plan VAE Data to NHSN, 2013-2014*

� Total of 68,695

location-months

of VAE

surveillance data

reported in 2013-

2014

� 3927 unique

locations

*Includes any facility indicating in-plan VAE surveillance in 2013 or 2014, regardless of whether data submission is complete for all location-months of reporting. Preliminary and subject to change.

42%

11%6%

6%

5%

5%

4%

4%

3%

2% 2% 10%

N=3927

Med/surg ICU

Medical ICU

Cardiothoracic ICU

Med/surg ward

Cardiac ICU

Surgical ICU

Stepdown

LTAC ward

Neurosurg ICU

Medical ward

Trauma ICU

Other

Selected Critical Care Location VAE Rates, 2014**preliminary**

Data are preliminary, unpublished, subject to change. *Unit no. in parentheses are those reporting >50 vent days per year and included in rate distributions.

VAEs per 1000 ventilator days

Location No. units*

Pooled

mean 10%ile 50%ile 90%ile

LTAC 18 2.00 -- -- --

Med/surg 1478 (1325) 5.60 0 3.09 11.51

Cardiothoracic 232 (231) 6.16 0 4.93 12.79

Cardiac 185 (181) 6.41 0 5.45 13.61

Burn 36 (34) 6.55 0 6.52 18.07

Medical 383 (354) 7.37 0 5.17 13.06

Surgical 186 (183) 7.71 0 6.28 15.73

Neurosurgical 99 8.29 0 6.66 19.44

Trauma 83 (82) 11.79 2.07 10.95 21.45

Distribution of VAE Specific Sites (N=35,040)

VAC only, 63%

IVAC,

21%

Po/Pr VAP,

16%

Preliminary, unpublished data, subject to change.

“IVAC-plus”

Criteria Used to Report VAEs (N=35,038)

Preliminary, unpublished data, subject to change.

Excludes 2 events with incomplete criteria reporting.

PEEP only,

68%

FiO2 only,

22%

Both PEEP

and FiO2,

10%

What’s the breakdown of VAEs in different ICUs?

67% 65% 65%60% 59% 59%

56% 54%

33% 35% 35%40% 41% 41%

44% 46%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Cardiac Medical Med/surg Surgical Cardiothor Neurosurg Burn Trauma

Pro

po

rtio

n o

f V

AE

s

VAC

IVAC-plus

Preliminary, unpublished data, subject to change.

Time from Intubation/Mechanical Ventilation Initiation to VAE (N=35,021)*

Preliminary, unpublished data, subject to change; *19 records excluded due to data entry error.

19%

16%

13%

9%7%

6%4%

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10+

Nu

mb

er

of

VA

Es

Mechanical Ventilation Day

35% 39% 25%

Time from Hospital Admission to VAE, Among Patients with VAEs on Mechanical Ventilation Days 3-4

(N=12,361)*

Preliminary, unpublished data, subject to change. *One record excluded due to data entry error; 2 records excluded due to missing data.

28%

32%

10%

6%4%

3% 2%

15%

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10+

Nu

mb

er

of

VA

Es

Hospital Day

40%

60%

Timing of VAE Onset

Preliminary, subject to change.

VAEs in patients

in the hospital OR

on the ventilator

for at least 5 days

= 68% of all VAEs

VAEs in patients in

the hospital <5 days

AND on the

ventilator <5 days

= 32% of all VAEs

Summary

� Majority of VAEs occur on/after mechanical ventilation day 5

or hospital day 5

� Suggests most are healthcare-associated

� Distribution of VAC vs. IVAC-plus differs by ICU type

� Reflects capture of a variety of conditions that may be more or less

common depending on the patient population

� Additional work needed to:

� Describe VAEs in different patient populations

� Understand reasons for differences in VAE specific event distributions

� Understand clinical correlates of early-onset VAEs

� Consider whether VAC definition can be modified to exclude events

where oxygenation has not worsened but rather PEEP is being

increased to allow for reduction in FiO2

VAE DEFINITION AND IT UPDATES

Definition Updates

� Minor changes for 2016—adding recently approved

antimicrobial drugs to the list of drugs eligible for meeting

IVAC and PVAP definitions

� Pediatric VAE

� Recent work exploring potential pediatric VAE-like definitions

presented at SHEA 2015

� Reconvening the work group in September 2015

� Goal to implement in NHSN in 2017

Synthetic Data Set

� An EHR vendor seeking to automatically detect VAEs within

their data will first read and interpret the definitions from

written description/VAE protocol

� Need a way to electronically confirm that the vendor is

applying the VAE definitions accurately

� Creation of a synthetic data set

Modified from slide courtesy of Cindy Gross and Barry Rhodes

Use of Synthetic Data Set

Two XML files available to vendors:

� XML File 1 : Sample patient records that have embedded in

them, various VAE event types

� Vendors import sample set into their system and run their

implementation of the VAE algorithm against it

� The data elements and definitions map directly to the VAE protocol

which may be found here.

http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf

� XML File 2: The result set with the expected VAE

determinations

� Vendors compare the results their algorithms generate against the

result set

Slide courtesy of Cindy Gross and Barry Rhodes

Web Service

� A service for vendor systems to submit de-identified data

automatically or for individual users to submit de-identified

datasets through a web page

� XML or CSV file format

� Data elements

� Patient index (de-identified)

� Ventilator day

� Daily minimum PEEP

� Daily minimum FiO2

� Min temp / max temp

� Antimicrobial agent

� Assumes daily min PEEP and FiO2 are determined accurately

Slide courtesy of Cindy Gross and Barry Rhodes

Current Status

� Synthetic data sets:

� Provided to the vendor community

� Available upon request to nhsncda@cdc.gov

� Web service

� Available on request for beta testing

� Working to move into a production environment in fall 2015

Slide courtesy of Cindy Gross and Barry Rhodes

Acknowledgments

� DHQP staff, including Qunna Li, Cindy Gross, Barry Rhodes,

Jonathan Edwards, Maggie Dudeck, Kathy Bridson, Susan

Hocevar

� NHSN facilities and users

� VAP/VAE Surveillance Definition Working Group and

Neonatal/Pediatric Working Group

� CDC Prevention Epicenters

� Many subject matter experts

� Federal partners

The findings and conclusions in this presentation are those of the author and do not necessarily

represent the views of the Centers for Disease Control and Prevention.

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.

Questions?

smagill@cdc.gov

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion