Developing a New, National Approach to Surveillance for Ventilator-Associated Events: Executive Summary

Clinical Infectious Diseases, Dec 2013

Shelley S. Magill, Michael Klompas, Robert Balk, Suzanne M. Burns, Clifford S. Deutschman, Daniel Diekema, Scott Fridkin, Linda Greene, Alice Guh, David Gutterman, et al.

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Developing a New, National Approach to Surveillance for Ventilator-Associated Events: Executive Summary

Shelley S. Magill () 0 1 2 3 4 Michael Klompas 0 1 2 3 4 Robert Balk 0 1 2 3 4 Suzanne M. Burns 0 1 2 3 4 Clifford S. Deutschman 0 1 2 3 4 Daniel Diekema 0 1 2 3 4 Scott Fridkin 0 1 2 3 4 Linda Greene 0 1 2 3 4 Alice Guh 0 1 2 3 4 David Gutterman 0 1 2 3 4 Beth Hammer 0 1 2 3 4 David Henderson 0 1 2 3 4 Dean Hess 0 1 2 3 4 Nicholas S. Hill 0 1 2 3 4 Teresa Horan 0 1 2 3 4 Marin Kollef 0 1 2 3 4 Mitchell Levy 0 1 2 3 4 Edward Septimus 0 1 2 3 4 Carole VanAntwerpen 0 1 2 3 4 Don Wright 0 1 2 3 4 Pamela Lipsett 0 1 2 3 4 0 Clinical Infectious Diseases 2013;57(12):1742-6 The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions , please 1 motion, Centers for Disease Control and Prevention , 1600 Clifton Road, MS A-24, Atlanta, GA 30329 2 In September 2011, the Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance De 3 rithm, which is referred to as the ventilator-associated 4 The Working Group's surveillance de patients (Table 1). The charges to the Working Group were to: 1. Critically review a draft, streamlined VAP surveillance definition developed for use in adult patients; 2. Suggest modifications to enhance the reliability and credibility of the surveillance definition within the critical care and infection prevention communities; 3. Propose a final adult surveillance definition algorithm, to be implemented in the CDC's National Healthcare Safety Network (NHSN), taking into consideration the potential future use of the definition algorithm in public reporting, interfacility comparisons, and pay-forreporting and pay-for-performance programs. Table 1. Ventilator-Associated Pneumonia Surveillance Definition Working Group Organizations, Representatives, and Federal Participants American Association of Critical Care Nurses American Association for Respiratory Care American College of Chest Physicians American Thoracic Society Association of Professionals in Infection Control and Epidemiology Council of State and Territorial Epidemiologists Healthcare Infection Control Practices Advisory Committee Surveillance Working Group Infectious Diseases Society of America Society for Healthcare Epidemiology of America Society of Critical Care Medicine U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion National Institutes of Health Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion Representative(s) Suzanne Burns and Beth Hammer Dean Hess Gutterman Linda Greene Carole VanAntwerpen Daniel Diekema Edward Septimus Michael Klompas Clifford Deutschman, Marin Kollef, and Pamela Lipsett Don Wright David Henderson Scott Fridkin, Alice Guh, Shelley Magill, Teresa Horan, others events or VAE surveillance definition algorithm, represents a purposeful departure from VAP toward more general, objective measures of conditions and complications occurring in patients on mechanical ventilation (Figure 1; VAE surveillance protocol available at: http://www.cdc.gov/nhsn/acute-care-hospital/vae/ index.html). The VAE surveillance definition algorithm uses a tiered approach, moving from measures of ventilator-associated conditions (VAC), to infection-related ventilator-associated complications (IVAC), to possible and probable VAP. The first tier of VAE surveillance, VAC, seeks to identify episodes of sustained respiratory deterioration, and will capture both infectious and non-infectious conditions and complications occurring in mechanically ventilated patients. VAC is defined by a sustained period of worsening oxygenation that immediately follows a baseline period of stability or improvement on the ventilator. To meet the VAC definition, a mechanically ventilated patient must have at least 2 calendar days of stable or decreasing daily minimum positive end-expiratory pressure (PEEP) or fraction of inspired oxygen FIO2 , followed by at least 2 days of increased daily minimum PEEP or FIO2 , where the increase in the daily minimum PEEP is 3 cm H2O greater than the daily minimum PEEP during the baseline period, or where the increase in the daily minimum FIO2 is 0.20 (or 20 percentage points in oxygen concentration) greater than the daily minimum FIO2 during the baseline period. For example, if a patients daily minimum FIO2 requirement on days 4 and 5 of mechanical ventilation is 0.40, then the patients daily minimum FIO2 requirement would need to be at least 0.60 on days 6 and 7 of mechanical ventilation for the VAC definition to be met. The Working Groups decisions to set specific thresholds of 3 cm H2O and 0.20 (20 points) for the increases in PEEP and FIO2 , respectively, and to define a sustained increase as an increase persisting for at least 2 calendar days, were based on expert opinion of what criteria would likely identify clinically important events, while minimizing inadvertent incl (...truncated)


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Shelley S. Magill, Michael Klompas, Robert Balk, Suzanne M. Burns, Clifford S. Deutschman, Daniel Diekema, Scott Fridkin, Linda Greene, Alice Guh, David Gutterman, Beth Hammer, David Henderson, Dean Hess, Nicholas S. Hill, Teresa Horan, Marin Kollef, Mitchell Levy, Edward Septimus, Carole VanAntwerpen, Don Wright, Pamela Lipsett. Developing a New, National Approach to Surveillance for Ventilator-Associated Events: Executive Summary, Clinical Infectious Diseases, 2013, pp. 1742-1746, 57/12, DOI: 10.1093/cid/cit577