Five years ago the CDC replaced its ventilator-associated pneumonia (VAP) surveillance definitions with ventilator-associated event (VAE) definitions.
In a paper published in the November edition of Respiratory Care, Michael Klompas, MD, MPH, from the department of population medicine at Harvard University, attributed the change to the complexity and subjectivity of the VAP definitions, their narrow focus and limited association with adverse outcomes, the burden they place on surveyors, and the lack of comparability between institutions.
According to Dr. Klompas, the new VAE definitions address those concerns and broaden the focus of safety surveillance to encompass any event severe enough to require a sustained increase in ventilator support, including non-infectious events.
How are respiratory care departments incorporating VAE surveillance into their operations? AARC members share their processes.
Evidence based bundle
Gwen Hesselman, BS, RRT, director of respiratory care services at Mercy Medical Center in Dubuque, IA, says her hospital has a VAE team that reports to the Critical Care Committee on a quarterly basis.
RTs in her department follow an evidence based bundle that includes a ventilator bundle, hi-low evacuation endotracheal tubes to optimize suctioning, chlorhexidine gluconate rinse with oral care, head of bed elevation, and oral care prior to intubation.
She collects all the ventilator data for their VAE team.
“Should we have an event, then the infection prevention nurse and I review data to make sure that the bundle was followed,” Hesselman said. They use the Learning from Defects tool in their investigation and present all their findings to the Critical Care Committee.
At Midland Memorial Hospital in Midland, TX, Troy Ward, MSHA, RRT, says VAEs are tracked by infection prevention practitioners through RT documentation. Therapists employ a standard VAP bundle to minimize the occurrence of VAEs.
“We virtually own the process,” said Ward, the division director of cardiopulmonary and neurology. “If a VAE does occur, we perform a root cause analysis to include all those involved in the patient’s care – nursing, RT, pharmacy, infection control, etc.”
They look at factors that could have contributed to the VAE and they also schedule the root cause analysis, assure its completion, write action plans, and perform any additional education that might be necessary to prevent another occurrence.
The process is working well. Over the past 18 months, the hospital has only had one VAE/VAP incident.
VAEs are tracked by the infection control department at Palos Health in Palos Heights, IL, says Respiratory Care Services Manager Anna Molsen, RRT.
“When a VAE is identified, respiratory leaders and ICU leaders review the chart,” Molsen said.
Each of the leaders is assigned a different part of the chart to assess and they take their findings to the medical director, who reviews the chart with them again to see if the VAE could have been avoided or if any improvements can be made to avoid a similar VAE in the future.
EMR facilitates the process
Gary Stone, MS, RRT, and his department at Mount Sinai Medical Center in Miami Beach, FL, are responsible for quality tracking for the prevention of VAPs and they work with their infection control department on VAEs.
“We track VAEs via our EPIC electronic medical record,” said Stone, the director of respiratory/pulmonary services. “We devised a report that highlights all PEEP changes and FIO2 changes.”
All identified VAEs are forwarded to the infection control department, which tracks patients going forward.
Stone says the advent of the electronic medical record has made surveillance much easier for his facility.
Monthly meetings held with nursing, infection prevention, respiratory, and quality help everyone stay on track with efforts to prevent VAEs at Capital Health in Pennington, NJ, says Laura Zesski, BS, RRT.
“The nurses monitor all vent patients for compliance with the bundle, with the exception of the minimum PEEP and FiO2,” said Zesski, respiratory care manager. RTs monitor those factors, and the quality department runs the data and presents the results to multiple committees within the facility.
Zesski says her hospital has used subglottic ETTs for most patients for years and believes they are responsible for the significant drop seen in the hospital’s VAP rate. When they do see a VAP, it is generally in a patient without a subglottic.
The RT department is now looking at subglottic trachs as well, and they drove the use of Endoclear to clear the biofilm from the ETTs last August.
“While we are seeing a decrease in LOS, since our VAE rates are low it is too early to validate if we have a drop in VAEs from the Endoclear,” Zesski said.
One change that didn’t pan out was moving the mouth care kits from the counter to the IV pole in the patient rooms. Nursing noted a drop in compliance and is now moving them back to their original spot.
You can learn more about VAE surveillance in the AARC’s 2018 VAP to VAE: Implications for the Respiratory Therapist online course. The course covers ventilator-associated pneumonia, ventilator-associated conditions, and infection-related ventilator-associated complications, along with an overview of the opportunities VAE prevention offers to respiratory therapists.