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Developing a New, National Approach to Surveillance for Ventilator-Associated Events*

Magill, Shelley S. MD, PhD1; Klompas, Michael MD, MPH2,3,4; Balk, Robert MD5,6; Burns, Suzanne M. RN, ACNP, MSN, RRT6,7; Deutschman, Clifford S. MS, MD6,8; Diekema, Daniel MD9,10; Fridkin, Scott MD1; Greene, Linda RN, MPS11,12; Guh, Alice MD, MPH1; Gutterman, David MD6,13; Hammer, Beth RN, MSN, ANP-BC6,14; Henderson, David MD15; Hess, Dean PhD, RRT16,17,18; Hill, Nicholas S. MD6,19; Horan, Teresa MPH1; Kollef, Marin MD6,20; Levy, Mitchell MD6,21; Septimus, Edward MD22,23; VanAntwerpen, Carole RN, BSN24,25; Wright, Don MD, MPH26; Lipsett, Pamela MD, MHPE6,27

Critical Care Medicine:
doi: 10.1097/CCM.0b013e3182a262db
Special Point of View Article
Abstract

Objective: To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients.

Design: The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011. Working Group members included representatives of stakeholder societies and organizations and federal partners.

Main results: The Working Group finalized a three-tier, adult surveillance definition algorithm for ventilator-associated events. The algorithm uses objective, readily available data elements and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP. The first tier definition, ventilator-associated condition (VAC), identifies patients with a period of sustained respiratory deterioration following a sustained period of stability or improvement on the ventilator, defined by changes in the daily minimum fraction of inspired oxygen or positive end-expiratory pressure. The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature or white blood cell count, and be started on a new antimicrobial agent. The third tier definitions, possible and probable VAP, require that patients with IVAC also have laboratory and/or microbiological evidence of respiratory infection.

Conclusions: Ventilator-associated events surveillance was implemented in January 2013 in the CDC’s National Healthcare Safety Network. Modifications to improve surveillance may be made as additional data become available and users gain experience with the new definitions.

Author Information

1Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

2Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.

3Infection Control Department, Brigham and Women’s Hospital, Boston, MA.

4Society for Healthcare Epidemiology of America, Arlington, VA.

5Division of Pulmonary and Critical Care Medicine, Rush University School of Medicine, Chicago, IL.

6Critical Care Societies Collaborative–American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine.

7School of Nursing, Critical and Acute Care, University of Virginia, Charlottesville, VA.

8Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

9Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA.

10Healthcare Infection Control Practices Advisory Committee Surveillance Working Group, Atlanta, GA.

11Infection Prevention and Control Department, Rochester General Health System, Rochester, NY.

12Association for Professionals in Infection Control and Epidemiology, Washington, DC.

13Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.

14Department of Cardiology, Zablocki VA Medical Center, Milwaukee, WI.

15Hospital Epidemiology and Quality Improvement, The Clinical Center, National Institutes of Health, Bethesda, MD.

16Department of Respiratory Care, Massachusetts General Hospital, Boston, MA.

17Department of Anesthesia, Harvard Medical School, Boston, MA.

18American Association for Respiratory Care, Irving, TX.

19Division of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA.

20Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO.

21Division of Pulmonary, Critical Care, and Sleep, Warren Alpert Medical School at Brown University, Rhode Island Hospital, Providence, RI.

22Department of Internal Medicine, Texas A&M Health Science Center, College Station, TX.

23Infectious Diseases Society of America, Arlington, VA.

24New York State Department of Health, Bureau of Healthcare-Associated Infections, Albany, NY.

25Council of State and Territorial Epidemiologists, Atlanta, GA.

26Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Washington, DC;

27Department of Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

* See also p. 2641.

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, the American Association for Respiratory Care, the Association of Professionals in Infection Control and Epidemiology, the Council of State and Territorial Epidemiologists, or the Infectious Diseases Society of America.

The work described herein was supported by the Centers for Disease Control and Prevention (CDC).

Dr. Klompas received grant support from the Centers for Disease Control (CDC), U.S. Food and Drug Administration, and the Office of the National Co-ordinator for Health IT. Dr. Balk received grant support from the CDC and bioMérieux for participation in the EPIC CAP study (CDC) and the Procalcitonin in ICU antibiotic stewardship study (CDC and bioMérieux). Dr. Deutschman received grant support from the National Institute of General Medical Sciences. Dr. Diekema received grant support from Merck, Cerexa, bioMériuex, PurThread Technologies, and Pfizer.

Dr. Klompas received support for travel from the CDC, Society of Healthcare Epidemiologists of America, Association of Professionals in Infection Control, and the Duke University Infection Control Outreach Network. Dr. Balk received support for travel from the CDC and Critical Care Societies Collaborative. Dr. Burns received support for travel from the American Association of Critical-Care Nurses (AACN; meeting unrelated to this study). Drs. Deutschman and Lipsett received support for travel from the Society of Critical Care Medicine. Ms. Greene received support for travel from the Department of Health and Human Services/CDC.

Ms. Greene consults for INC. Dr. Hess consulted for Philips Respironics, ResMed, Pari, and Breathe. Ms. Greene lectured for Premier, Advanced Sterilization Products, and APIC. Dr. Burns lectured for AACN (annual national conference). Ms. Greene presented speeches for Covidien and Maquet. Dr. Septimus received an honorarium for a lecture. Dr. Klompas received support from the Society of Healthcare Epidemiologists of America for the development of educational presentations.

Ms. Greene is employed by the Rochester General Hospital. Dr. Lipsett has board membership with the Society of Critical Care Medicine. Dr. Deutschman received a stipend for his Presidency with the Society of Critical Care Medicine.

Dr. Deutschman received royalties from Elsevier for the textbook, Evidence-based Practice of Critical Care Medicine. Dr. Burns receives royalties from McGraw-Hill for books endorsed by AACN. Ms. Greene receives royalties from Up-To-Date, Jones and Bartlett, and McGraw-Hill.

The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, Email: smagill@cdc.gov

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins