In January of this year, the National Healthcare Safety Network (NHSN) within the Centers for Disease Control and Prevention (CDC) rolled out new, more objective standards and definitions to track and report ventilator-associated events (VAE), including ventilator-associated pneumonia (VAP). Although pneumonia has been found to be the most frequently fatal healthcare-associated infection (HAI), VAP can be difficult for infection-control departments to address.
As of 2012, some 900 facilities were reporting VAP rates on the NHSN, either voluntarily or via state mandates. The Centers for Medicare & Medicaid Services (CMS) does not require this reporting, but consistent with healthcare reform’s move toward a pay-for-performance framework, this could easily change. In fact, one of the stated goals of the new VAE algorithm was to enable VAE to be included in the CMS pay-for-performance framework at some point in the future.
Prior to the January 2013 introduction of the new VAE surveillance algorithm, the NHSN’s VAP definitions were based on subjective criteria, such as the interpretation of a chest X-ray. The CDC determined that the subjectivity of the definition made it difficult to assess progress against benchmarks and identify where additional efforts were needed – both on the facility level and in terms of the goal of eliminating HAIs nationally.
Based on the new surveillance algorithm, three types of reportable events are possible:
- A ventilator-associated condition (VAC);
- An infection-related ventilator associated complication (IVAC); and
- Possible or probable VAP.
The new algorithm is much more objective, more sensitive and more specific, which also brings the added benefit of making it easier to automate surveillance and reporting. Automated surveillance helps give clinicians visibility regarding patients’ conditions relative to the new VAE algorithm, and it enables them to focus on the most at-risk patients for a reportable VAC.
But to fully leverage automated surveillance and reporting, a ventilator must first communicate with the hospital information system (HIS), so that the raw data can be collected and maintained in a way that is conducive to performing analytics. This means that a hospital’s ventilators must have interoperability with the hospital network and other health IT systems.
Case in point: The prevailing data points for the algorithm are two days of stability of daily minimum levels of positive end-expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2), followed by a period of worsening oxygenation. This data is readily available objective criteria coming straight from the ventilator, making automated collection possible (provided the ventilator is connected to the hospital IT infrastructure).
However, from an infection-control perspective, the power of automation is that, with analytical tools, it is possible to not only collect, track and report, but ultimately gain insight into the differences among a hospital’s ventilated patients.
In this scenario, the question can shift from “Who had VAP?” to “Who is likely to get it, and how can we intervene to try to improve outcomes?” Being able to pinpoint which patients have had two days of PEEP and/or FiO2 stability followed by worsening oxygenation provides actionable intelligence that clinicians can use to pinpoint which patients need intervention. Trying to track this data manually would be a much heavier burden on infection-control departments, which are already spread thin from their responsibilities for preventing many different types of HAIs, not just VAP. Automated surveillance can also help identify best practices from units within a hospital or across a hospital system that can be shared to improve overall infection rates.
Such tools help quality improvement and infection control professionals interpret ventilator data to understand when changes in PEEP and FiO2 have met the threshold of significance. Because it provides near real-time visibility into where on the VAE spectrum the patient is, it can trigger the involvement of clinicians to address deteriorating conditions earlier in the process and measure adherence to best practices.
Several healthcare systems have been early adopters of technology that automates the collection and analytics of the new VAE algorithm into a hosted dashboard application that displays patient baselines, reporting thresholds and markers of protocol anomalies in an easy-to-read format. Mission Regional Medical Center in Mission, Texas, is one of the early adopters.
“We deployed a VAE surveillance dashboard that is so easy to look at, it’s the first thing I do in the morning,” says Hector Contreras, infection prevention manager at Mission Regional. “It’s a 100 percent validation of our process, and it is objective and actionable.”
Although VAP reporting is not required in Texas, Mission Regional wanted to use all tools available to help improve care.
“It has brought us efficient and concurrent surveillance of multiple detailed reports presented in real time – a bedside view from our office,” says Susan Barlow, MHA, RRT, NPS, CPFT, CPHQ, Mission’s cardiopulmonary director. “The result is the ability to see variability in not only patient status – for example, if the FiO2 data point increases, it signals a worsening oxygenation status that is a huge red flag – but also in clinical practice, such as weaning. Both are essential in making inroads toward VAP reduction.”
Good Samaritan Hospital in Los Angeles also sought to make quality improvements in the area of VAP surveillance and is working with the new app.
“We felt we had a well-tuned weaning protocol, but we wanted more controls that could help us keep improving,” says Michael Muth, MBA, RRT, RCP, director of pulmonary, neurology and sleep lab at Good Samaritan. “We want to be ready for regulatory changes down the road.”
From an infection-control perspective, using this advanced technology has changed the game almost overnight at Good Samaritan.
“The NHSN algorithm is challenging to collect and analyze manually, but the technology has shifted our perspective,” says Joan Finney, RN, BSN, CIC, Good Samaritan’s director of infection prevention and epidemiology. “The new visibility through the VAE surveillance dashboard has also shown the infection preventionist that cross-functionality has a role to play in infection control that we didn’t previously consider, with respiratory technicians now included as part of our ICU surveillance team. Instead of working in silos, we are now working from the same playbook.”
The new NHSN VAE definitions are a welcome change to ventilated patient surveillance, thanks to their objectivity and ability to automate collection and perform analytics. With today’s advances in technology, VAE surveillance will continue to help improve clinicians’ abilities to track and perform interventions to improve outcomes.
About the author
Carlos Nunez, M.D., is chief medical officer, CareFusion. For more on CareFusion, click here.