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>> Okay, we're going to get started again,
so please take your seats
and I'd like to introduce you to Cindy Gross
She's one of the new members of our NHSN team, and she's going
to walk you through some of the case studies for VAE.
>> Thanks Theresa.
All right, we're going to walk through about 6 cases here
that sounds like just a few and that's not as many as the 20
that were this morning with lab idea event, but these are going
to be tiered just like the algorithm itself is,
so each case will have multiple parts.
Just a little disclaimer,
the following examples are for illustration purposes only
and are not intended to represent actual
or clinical scenarios, so if you see something
that looks a little crazy, not to worry,
it's just for illustration purposes.
So let's get started with case 1, and you do have a handout
in your packet, and as I understand the web streaming
audience also has that handout as well now as well.
So case study 1, a 69-year-old female seen in the ER
and subsequently admitted to the ICU on a ventilator.
Review her ventilator settings and determine
if VAE criteria are met,
and if so on what mechanical ventilation day does the
event occur.
And we will take the audience response, so when you have your,
the polling is open, and as soon
as you have your answer, click it in.
[ Background Noise ]
Okay. I'm going to close the poll.
The group of you, 69%, has said A, yes,
it is met, and B, 35%.
Well the B's are right.
This is a little tricky,
but we'll start off and get the tricks out of the way.
We do have stabilization in our FiO2.
We have an increase up to 60;
however, that increase is not a greater than 20-point value
from day 3 to day 5, so you have to meet that increase in 3 cm
for PEEP or 20 points in FiO2 for both
of your days of stability.
Okay? All right.
Let's take a look at these readjusted settings now
on this same patient.
What if these are the settings.
Does this meet VAE criteria.
Do we meet IVAC?
[ Background Noise ]
Okay, we're going to close the polling
in just a few seconds here.
Last minute entries?
They're coming in fast and furious.
[ Background Noise ]
Okay, 95% of you said yes, and you are correct.
Nice job. So we clearly have, all right, we've got the patient
on the ventilator for greater than 2 days.
We have stabilization with actually improvement
and then an increase to 70 on the FiO2, or, yes,
and so then we have our window period defined by the event day
of mechanical ventilation day 5,
the 2 days prior, and the 2 days after.
Any questions on that?
Okay. Let's stay on this same patient,
but now she's developed a fever,
and she's started on antibiotics.
Does this meet the IVAC definition?
>> Quick question.
[ Background Noise ]
Excuse me.
>> Yes?
>> I have a quick question before we move on.
So this is the discussion at our table.
So if we're saying that the stability is the 50
and then you improve to 40.
>> Um hum.
>> Your 20, your increase, is going back to the 50?
For comparison not to the 40?
>> To both.
So it has to be greater than 20 for both of those stable days.
>> For the stable days, even if there's a day or 2 days
in between where they improve?
In other words, what do we,
where are we getting the 20?
That's what I want to know.
>> The 20 is.
>> Between [inaudible] and 50.
>> Between 70 and 40 and between 70 and 50.
Both have to be greater than or equal to 20.
>> Okay, thank you.
>> Okay. Does that answer your question?
>> Yes.
>> Okay, good.
[ Background Noise ]
Okay, so the polling is open.
[ Background Noise ]
You can't hear me back there?
>> No, you have to really talk in the mike [inaudible].
>> Oh, okay.
Okay.
>> [inaudible]
>> I have a big mouth, I can talk louder.
>> Project.
>> Okay.
[ Background Noise ]
Okay, a couple more seconds and then we'll close the polling.
[ Background Noise ]
All right.
We have 35% saying that yes,
this patient does meet IVAC definition,
and we have 65% saying no, and the answer is no.
Okay. So let's look at why the answer is now.
We already know that we met VAC,
so that's the sole reason we're proceeding
on to collect the temp, or white count, and antibiotics
to see if we can need IVAC.
We definitely have a temperature increase,
and we do have an antibiotic started
but note it starts outside the window period,
so even if this continued down here for 4 consecutive days,
we would have not met IVAC.
Okay? And I want to again emphasize the importance
of establishing this VAE window period.
It will assure that you reached the correct definition,
and it also limits you in what days you need to go back
and search, search for the additional criteria.
So as you reach the VAC, now you can go on and look for temp,
white count, antibiotic therapy.
If you satisfy IVAC, now you will go on and look
for your laboratory, but if either of those are not met,
there's no need to continue, or to go on to collect
that additional information.
Okay, so with this case, what we determined was we met the
temperature but the antibiotic was started outside
that VAE window period.
Okay. Same patient, a little bit different scenario,
does this meet IVAC definition?
Wow, we've got some fast ones.
[ Background Noise ]
I see a lot of you flipping back through, and that's a good sign,
because I assume you're checking the definitions.
Okay, close the polling, and we have, wow,
98% saying A and 2% saying B. Good job.
Good job. Okay, again, we want
to highlight our VAE window period.
We have increase in temp.
We do have antibiotics that have been started
in the window period, and for this demonstration purpose,
we're going to assume it's the same antibiotic.
We had 2 days of administration
within the window period and 2 days outside.
As long as it meets the new antibiotic definition,
meaning that it was not given 2 days prior to the start date
and it occurs in that VAE window period, your continuation
to meet your 4 qualifying antimicrobial days can extend
outside the window.
Okay? Good job.
Okay, we're still building on this case study 1.
Now let's assume that this same patient, and remember
that the VAE event day was mechanical ventilation day 5,
and that's how you define your window period,
2 before and 2 after.
A sputum was collected
after there was increased sputum production
on mechanical ventilation day 6.
Sputum was collected, sent for culture and sensitivity
on that same day, mechanical ventilation day 6,
and on the 8th, the report came back scant normal flora
with many Staphylococcus aureus.
Does this meet A, IVAC, B,
possible VAP, or C, probable VAP.
[ Background Noise ]
A couple more seconds.
[ Background Noise ]
All right.
Let's close the polling.
Twenty percent of you said A, 65% said B,
and 15% said C. The winner is, B. Good,
so the majority of you got it right.
Now let's look at why that is correct.
So again, the VAE window period.
Can't emphasize that enough.
We knew this patient met IVAC with a temp and the antibiotics.
There was an appropriate respiratory specimen sent
to the lab, and there was a report that came back
with many Staph aureus, which can be included as a pathogen.
So the mechanical ventilation day stays at day 5,
we have a possible VAP because we've met the
culture requirement.
Okay? So you can meet that possible VAP
with either purulent secretions, meeting the definition,
or with a qualitative, quantitative,
or semi-quantitative culture result, either or.
So we didn't have the 2 together, so we couldn't move
on to probable, we only had the culture result,
so this would be reported as a possible VAC.
Again, it's a tiered system.
You have to have a VAC to eval for an IVAC and then to move
on to look at the VAP definitions.
This would be reported as a possible VAP in NHSN.
Okay? Okay, case study 2, a 72-year-old male was seen
in the ER of hospital A
on May 2nd following a motor vehicle accident.
He sustained closed rib fractures, ruptured spleen,
and dissection of the aorta.
In the ER, central lines and a Foley catheter were replaced,
and he was admitted to trauma ICU on that same day
where he was intubated and stabilized at a PEEP setting
of 6 cm of water and an FiO2 of 0.50 or 50 points or 50%.
On mechanical ventilation day 4, he required an increase in PEEP
to 7.5 cm of water and an FiO2 to 0.80.
Utilize this information, it's going to be displayed
on the table, to evaluate for the VAE
or E's answer [background noise].
We will first determine does the patient meet criteria for a VAE?
And I've already given you a little hint here with a box.
[laughter]
[ Background Noise ]
Okay. Let's see how you do.
Ninety-seven percent said yes, 3% said no.
The yeses have it.
Let's just go back to that for a second.
Notice what's outlined here.
Is this the VAE window?
[background noise] I see some heads.
Okay. This is not the VAE window.
It represents the event day when the first day of worsening
of oxygenation, day 4,
the 2 days prior, and the 2 days after.
So it's representing your stabilization, your event day,
and then the 2 days following.
But remember the patient has to be on the ventilator for 2 days.
So while you can use those first 2 days
to establish stabilization in their settings,
you cannot use those 2 days as part of the VAE window.
So, let's move forward.
This would be your VAE window.
So you can include day 2.
You can use it as part of the meeting stabilization but not
as a part of the VAE window.
So now that we have this additional information,
identify the event or events, may be more than one,
may not be, and the date or dates
for this patient using this criteria that is supplied,
or the parameters that are supplied.
[ Background Noise ]
So you all should have this same table in your packet,
so I'm going to go on to the next slide
so that you can see what your choices are.
A, IVAC on mechanical ventilation day 4,
possible VAP on mechanical ventilation day 4, probable VAP
on mechanical ventilation day 4,
and a VAC on mechanical ventilation day 16, probable VAP
on mechanical ventilation day 4.
So the poll is open.
[ Background Noise ]
>> I'm sorry?
>> [inaudible] day 16 or 6.
>> Day 16.
The question is do we mean day 16 or day 6,
and it's day 16, and remember I said event or events.
[ Background Noise ]
But be careful.
[ Background Noise ]
Okay, I'm going to close the poll here.
We'll just review.
Wow. [laughter] Seventeen percent
of you said A. Eight percent said B. Forty-two percent said
C, and 33% said D. Now we're going to walk through this one.
The answer is D. Probable VAP,
mechanical ventilation day 4, now why is that?
Okay, so we have an increase in temp,
and we do have an antibiotic started
that meets the new definition, and it was administered
and satisfies, gives us 4 qualifying antimicrobial days,
so we met IVAC.
So then we go on and we evaluate the culture results
if we have any, and in this case we do.
We have the definition met for purulent respiratory secretions,
the neutrophils seen on Gram stain were greater than 25,
and the squamous epithelials were less than 10.
And we also have a quantitative culture result from a BAL 10
to the 4th Pseudomonas aeruginosa.
So that gets us to that probable VAP definition.
[ Background Noise ]
I think I went the wrong way, woops.
Does that all make sense?
[background noise] No.
Okay. What's the question?
[ Background Noise ]
It's not on.
[background noise]
>> Is it on day 4 instead of day 5.
>> The question is why is the mechanical,
or the event day, on day 4.
It's the first day of worsening oxygenation,
not when you meet the 2 days.
>> Not when you meet the final [inaudible].
>> It's the first day of the onset of worsening oxygenation.
So the question was why is it day 4 and not 5.
>> My question is why does the event window not start
on the 4th instead of the 3rd?
If you look back at, well you probably don't have the other
slides, but page 25 of the other slides, it shows,
it says that you can't count data in the first 2 days
of mechanical ventilation.
>> Right. So, we, the window,
that stabilization period was actually day 1, 2, and 3.
>> Oh, I see now, okay.
>> You see?
>> I see that now.
>> Okay.
>> Thank you, I'm sorry.
>> Sure, sure.
Okay, so we did meet probable VAP.
Now we're going to move on with this and answer maybe some
of the other questions of why the others didn't work,
but before we do that, does
that patient have a secondary blood stream infection?
[background noise] This should be a quick one.
[ Background Noise ]
And the votes are coming in very fast.
You must have it down.
[background noise] The answer is yes.
Oh look at that, 100%.
Good job. Okay, so the blood culture was collected.
It's outside of the window; however, it was collected during
that event period, and remember your event period is day 1 being
the onset, the day of onset of worsening,
so that in this case is mechanical ventilation day 4,
and I apologize, that little green guy is scooched
up a little too high, and it continues for 14 days,
which takes us to day 17.
So our blood culture came in on day 8.
It is growing the same pathogen as the respiratory culture
that was included to meet the definition for a probable VAP.
Okay. All right.
So, why wasn't there an event on day 16.
The last slide was the hint.
>> [inaudible]
>> Right you are still in the same event period,
and although we do have stabilization
and we do have an increase greater than 20
in our FiO2 settings, you can only have 1 event every 14 days.
Okay, good.
Good. [background noise] All right.
So to review, we have to meet those 2 days
of ventilation before you can start assessing for VAE.
You have to have 2 days or greater of stabilization
or improvement followed by, immediately followed by greater
than 2 days' increase of either 20 FiO2 or 3 PEEP,
and that will get you to VAC, and in this case,
the mechanical ventilation day 4 was the first day of worsening.
That was the event day.
And then also in this case, it was only a 4-day window.
The 1 day before, day of,
and 2 days after for the reasons we just discussed.
We met IVAC by having a temp elevation, 4 consecutive days
of antimicrobial therapy that started within the VAE window,
and then we had a specimen collection
that had purulent secretions and met the culture requirement.
We had a secondary blood stream infection
because the same pathogen which occurred
within the 14-day event period.
We couldn't call that second one because it was still
within the 14-day event period, and just to throw in there,
it was attributed to the trauma ICU,
that's where the patient was
for the whole duration of this episode.
Okay, case study 3.
A 56-year-old male was taken directly to the
OR from the cath lab after he arrested during
angioplasty procedure.
Quadruple bypass procedure was performed, and he remains
on the ventilator following surgery.
So that would be mechanical ventilation day 1.
He has a central line and a Foley catheter in place
when he arrives in the ICU on that same day.
So he arrives in ICU on day 1, and that's his day 1
of mechanical ventilation.
Given this information on this very filled table,
identify the event or events and date or dates of the event
or events that occur for this patient.
I'll just hang here for a little bit, and then well go
to the slide that gives you the choices.
Again, you have this in your handout packet to reference.
[ Background Noise ]
So your choices are A, mechanical ventilation day 6,
probable VAP, mechanical ventilation day 6, possible VAP,
mechanical ventilation day 16, IVAC,
mechanical ventilation day 15, probable VAP.
[ Background Noise ]
And you can go ahead and enter your responses whenever you
want to.
[ Background Noise ]
Okay, I'm going to give it just a couple more seconds,
so if you have your answer,
enter it in to the response system.
[ Background Noise ]
Okay. So some of you said A, some said B, most of you said C,
and a few said D. And the answer is C. [background noise] Okay.
Before you move off of this slide,
I just want to make a note on your slide here
or on your handout that when you pick up your answer sheet
on your way out the little text box that's
around that C got shifted down before I printed,
and we printed, and the text thing
on the slides will be correct, but the box got moved,
so just make a note that you're going to have a box around D,
but really the answer is C,
and on the next slide it tells you the right answer,
it's just that the box slipped.
Okay, so why is it C?
It is C because we have stabilization.
Clearly the patient's on the vent longer than 2 days.
We have stabilization on day 13 and 14.
We have increase in the worsening of oxygenation,
increase in the FiO2 greater than 20 on 15 and 16
and then even some more on the 17th, but we met it
with the 2 days on the 15th and 16th.
So we met VAC.
So we can go on to look if we meet IVAC.
We do. We have a high white count
that exceeds the threshold, the 12.1, and we have an antibiotic,
again we'll assume it's the same antibiotic
for this demonstration purposes, and it was started
within the window period.
It was not administered 2 days before.
We do have an antibiotic 3 days before,
and maybe it could have been the same antibiotic, you can't tell
from this slide, but 2 days before this antibiotic was not
administered, so it counts as a new antibiotic, and it's given
for 4 consecutive days.
Okay. So we can't use that culture information up above
or the Gram stain information because it is not occurring
within the window period.
[background noise] Okay.
So why no event on up top there
where that culture information is?
[ Background Noise ]
Take a look at this area.
We do have stabilization here, but then we bump up to 35,
which now you're not stable or improving anymore,
you've bumped up, so now you have to start over.
You'd have to have another day of 35 here.
This would have to be 50.
So you don't.
The point is, you don't have stability so you can't evaluate
for worsening of oxygenation.
It just doesn't meet the defined parameters.
Another important point to emphasize,
all of that information was collected and entered,
if this was a real person and this was your real surveillance
and data collection sheet, had you gone about and entered all
of this information, it would have been all for naught,
because you'd never really met VAC, so you couldn't go
on to use your white count or your culture results.
So just another emphasis here of there's no need to progress
on to collect that additional data until you've met VAC,
and then no need to go to the lab and get your lab results
until you've met IVAC.
[background noise] So this is just a recap.
You have to have the 2 days of stability.
The criteria for the event must all be
within that VAE window period.
We couldn't use the lab information
that occurred several days before, and you have
to have 4 days of qualifying antimicrobials, and again,
just to point out, they can, the 4 days can be accrued outside
as long as the antibiotics were started within.
So let's go back to that area
where we did have a culture result, and let's just play
with the parameters here a little bit.
So we do have some stabilization, and now we bumped
up to 50, and we do meet that criteria for a VAC.
And we already said we had a white count
and we have antibiotics.
Now, we've gone to our lab and we've gotten our enterococcus
as a culture result and a Gram stain, do we meet possible
or probable VAP for this patient?
[ Background Noise ]
Say it again?
>> [inaudible]
>> I'm hearing possible and probable.
[laughter] The answer is possible.
The reason it's possible is the only finding you can utilize
to meet the definition is the Gram stain result,
the representation of purulent respiratory secretion.
You can't use the culture results
because [background noise] enterococcus is excluded
as a pathogen unless it's recovered from pleural fluid
or a lung tissue biopsy.
Okay. And then likewise, since that organism is not used
to meet your VAP definition,
even though you have a positive blood culture, you cannot use
that and call that a secondary
because the enterococcus was not used to meet the definition
for VAP; therefore, you can't tag
on a secondary blood stream infection.
Okay? Good.
[background noise] I think I'm just going to, this, yeah.
Okay. Let's go on to case 4.
A 42-year-old female dialysis patient was intubated
and transferred from hospital A to hospital B
on mechanical ventilation day 1 for management
of severe asthma exacerbations.
The patient had been receiving vancomycin for treatment
of a blood stream infection.
Upon admission, her temperature was 37.5
and her white count was 5.6.
On mechanical ventilation day 3, during dialysis treatment,
the patient developed a temp of 39.7,
and on mechanical ventilation day 5,
she had increased respiratory secretions,
and an endotracheal aspirate was sent for culture and Gram stain.
On mechanical ventilation day 7, imipenem was started.
So here we have her laid out in a chart.
Again, you wouldn't collect any
of this past FiO2 unless you've established, so I don't want you
to get confused with you would have had to gone
and gathered all this and you'd have to do this
for every patient that's on a ventilation.
This is for demonstration purposes only
that we have this all filled out in ahead.
So does this patient meet the criteria
for VAE and if so what type?
A, VAC; B, IVAC; C, possible VAP; D, no VAE.
[ Background Noise ]
Okay, the voting is open, go ahead
and enter your answer when you get it.
[ Background Noise ]
Do you need more time?
>> [inaudible]
[ Background Noise ]
Okay, we're going to close the polling.
And we have a hodge podge here.
Forty-seven percent of you said A, 8% said B,
33 said C, and 12 said no VAE.
Okay, let's see, what is it, VAC.
It is A. [background noise] Okay.
And the reason it's A is we do have a patient
on a vent greater than 2 days.
We do have a period of stabilization
or improvement followed by an increase
in 20 points of the FiO2.
We've met VAC.
Okay. Note though the window period here, where it's the same
as the previous case study.
We can't use day 2 as part of our window because that is one
of the initial 2 days of ventilation,
so we have a 4-day window period in this example
to meet the other criteria as we move
on to see if we satisfy IVAC.
>> [inaudible]
>> Pardon me?
>> What about the change in PEEP from day 2 to day 3.
>> Day 2 to day 3.
You only need to meet the criteria in 1, 1 parameter,
so does that answer your question, I'm not sure.
[background noise] What?
[background noise]
>> The difference in PEEP there is just 1 cm
of water too, right?
So we wouldn't be able to count that.
>> Does that answer your question?
Okay, okay.
So we have a 4-day window period.
We do have an increase in temperature,
but we don't have a new antibiotic or 4 days
of antimicrobial therapy, consecutive days.
Vanco was given 2 days prior outside that window,
so we can't call that a new antibiotic.
If it hadn't been, we do have 4 days here,
but it was given on this day 1.
So we can't count vanco's administration days
as a antibiotic to mid the QADs, and then imipenem.
>> Just to clarify that a little bit.
You would actually have 3 days of vanc
because you can only count the day between the administration,
so if vanc had been given on day 7.
>> Oh.
>> You could have counted it.
>> Right.
>> Which would be 3.
>> Three days.
Okay, thanks Shelly.
Then imipenem is started outside the window.
So we don't meet the criteria
for IVAC even though we have some culture result info
out here.
Another example of why,
don't use your valuable time collecting information
that you may not be able to utilize.
Okay.
[ Background Noise ]
Just to review and to recap,
I think we've touched on all these.
The patient was ventilated 2 days, had stabilization,
2 days of an increase.
Though it was a 4-day window, we did meet the temp elevation
but not the antimicrobial parameter, that was not met,
and so if you don't meet IVAC you can't go on to see
if you satisfied the VAP definition.
Okay? Okay, case 5.
A hospitalized 78-year-old male returned from the
OR on the ventilator following ventral hernia repair.
So that's mechanical ventilation day 1.
On mechanical ventilation day 4 the ventilator is removed
at 1600 hours.
The next calendar day, vent day 5, he coded
and was reintubated at 1730.
The following day, vent day 6, he develops a fever.
White count increases to 14.2.
Cefepime is started and continued for 1 additional day,
and then the patient is switched to pip/tazo.
Does this patient meet VAE status
in any way, shape, or form?
A, IVAC on day 5; VAC on day 5; IVAC on day 6; or no VAE?
I'll put that back up.
Sometimes the bigger picture is easier than the piece of paper.
[ Background Noise ]
Okay, we're going to close the voting because unfortunately
when I flipped back to that slide,
it only registered the 3 people who [laughter]
but unfortunately those 3 people were wrong [laughter].
This individual meets the VAC definition
on mechanical ventilation day 5.
So what we have here is a patient,
even though he was extubated and reintubated,
there was not a full calendar day without him being
on the vent, so this counts
as 1 continuous mechanical ventilation event period.
So his stabilization is satisfied actually
on the day before extubation and the day of,
and then his worsening occurs on the day
of reintubation and the day after.
[background noise] He does have an increased temp,
but again those antibiotics just don't let us meet that 4 days
of qualifying antibiotic days.
We have a new antibiotic administered 2 days followed
by 3 more days of a different antibiotic; however,
it wasn't started within that window period.
So if pip/tazo had been started on day 7 in conjunction
with cefepime, we would have been okay.
Does that make sense?
>> Can I ask a question, I'm sorry.
>> Sure, sure.
>> In this case, we're doing a full calendar day, i.e.,
24 hours, unlike other calendar days, which are up until 11:59?
>> It is a full calendar day.
>> So it's actually a 24-hour period?
>> It's from midnight until 11:59.
So it's a date.
You know, it's, it's a.
>> Right. But we're saying this gentleman was extubated the
day before.
>> But he was on a ventilator on the day before.
>> He's mechanically ventilated for some portion of each
of those calendar days.
>> Of each day, understood now, thank you.
>> As long as you can get a minimum PEEP, an FiO2 setting
on a calendar day, then you, you can have a reading,
so you can evaluate based on that PEEP or FiO2.
Yes, go ahead.
>> Hi. Our table had a question.
>> Okay.
>> Regarding the antibiotic.
>> Uh hum.
>> Because on the slides that we were looking at earlier
on the VAEs, it says there is no requirement
that the same antimicrobial agent be given
on the 4 consecutive days.
>> That's correct.
>> So we're confused as to why that wouldn't count.
>> Okay, good question.
The reason is because although it's not required
that the antibiotic be the same to meet the qualifying,
all the antibiotics must be started
within that window period.
So, as I was saying with pip/tazo, had it been started
on day 7 and administered in conjunction with cefepime
on day 7 and then continued for another several days,
we could have met the antibiotic criteria.
Okay?
>> And this is one of those circumstances
that clinically may just not make much sense to you.
>> Right.
>> But it's a side effect of having to try to be practical
about implementation, so I know it's not perfect
and it doesn't sit quite right, but we're trying to keep things
as simple as we can [inaudible].
>> Okay, so to recap on this one.
The points we touched upon was the mechanical ventilation
for some portion of each consecutive day,
and that will qualify for 1 episode
of mechanical ventilation.
The period of stability is established the day before
and the day of extubation,
and the worsening was established the day
of reintubation and the following day.
The event day actually happens to be that day of reintubation,
mechanical ventilation day 5, and while we had an increase
in the white count and we did have 1 new antibiotic started,
it wasn't continued for 4 days, and there wasn't another one
that could tag along to meet the 4 days.
Okay? Okay, the last case study.
This is a 30-year-old female with a history
of cerebral palsy, seizures, and diabetes and was admitted
to MICU with respiratory failure.
She was ventilated on admission and stabilized.
On mechanical ventilation days 3 through 6, her PEEP was stable
at 4 cm of water, and on mechanical ventilation day 7,
her minimum PEEP was 8 cm of water and remained
at 8 for the next 5 days.
A fever of 40.1 was documented on mechanical ventilation day 8
and 9, and antibiotics were started
on mechanical ventilation day 9 and it continued
until mechanical ventilation day 15.
So let's get a little bit more here.
On mechanical ventilation day 8,
and endotracheal aspirate was collected.
The Gram stain revealed many neutrophils,
rare epithelial cells, many gram-positive cocci, few yeast,
and many gram-negative rods.
The laboratory's semiquantitative evaluation
of this Gram stain was indicative
of purulent respiratory, purulent respiratory secretions.
So here's a little hint again.
So check with your laboratory how they define.
On mechanical ventilation day 9, a bronchoscopy was performed
at which time a transbronchial biopsy was collected.
The biopsy subsequently was reported
to be growing Candida albicans greater than 10
to the 4th colony-forming units per gram.
How would you report these findings in NHSN?
Here's a little display of what was just spelled
out in the word part.
And again, you have this in your packet.
[ Background Noise ]
Your choices are A, possible VAP with a vent day of 7;
probable VAP with an event day of 7; IVAC on day 7; or no VAE.
[background noise] And the responses can come
in anytime you're ready.
[ Background Noise ]
All right.
For the sake of time, so we can wrap it up,
I'm going to close out the polling.
We'll see how, whoa.
We have all kinds of responses.
The answer is B. [background noise] So 34% of you, 38%,
I don't know, but it's understandable.
Okay, so the answer is probable VAP.
We meet the 2 days of patient is on the vent for 2 days,
then stabilizes, and we were looking
at the PEEP setting on this one.
The PEEP setting had an increase of greater than 3 cm of water,
and the event day would be day 7.
The increase in temp is established
within that window period.
We do have 4 consecutive days of antibiotic therapy.
We have a Gram stain result, which in the text it said
that the lab said that was representative
of purulent secretions.
And that's on 1 type of a specimen.
And then we have another specimen
that grew Candida albicans, and Candida albicans is excluded
as a pathogen unless it's from a lung tissue or a pleural fluid.
So we do meet probable VAP.
And do you have any questions?
[ Background Noise ]
Yeah. [background noise] One other note.
On your handout, you're, the answer sheet,
you will have some screen shots of the tool that,
the calculator tool that Shelly demonstrated,
so just for demonstration purposes.
>> Awesome.
>> And questions can come into the NHSN mailbox.
Thanks.