Pneumonia, ventilator-associated (VAP): Difference between revisions
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**The one exception is when, for whatever reason, a chest imaging study was quite delayed -- and in that case consider the date of onset of the VAP to be the earliest date on which any of the other VAP criteria was met. | **The one exception is when, for whatever reason, a chest imaging study was quite delayed -- and in that case consider the date of onset of the VAP to be the earliest date on which any of the other VAP criteria was met. | ||
*Example: intubated patient had a CXR on Thursday showing a little wispy infiltrate on the CXR. In the absence of other signs or symptoms, on that day the team did NOT think it was infectious. But Friday the patient developed fever, leukocytosis and purulent sputum, AND the wispy infiltrate was now a big, dense consolidation. A sputum culture was sent on Friday for the first time. At this point the team began antibiotics for pneumonia. The thing here is that only in RETROSPECT did it become clear that the wispy infiltrate seen on Thursday WAS the start of the VAP. Thus, in this case the VAP appears to have clinically begun on Thursday, not Friday. | *Example: intubated patient had a CXR on Thursday showing a little wispy infiltrate on the CXR. In the absence of other signs or symptoms, on that day the team did NOT think it was infectious. But Friday the patient developed fever, leukocytosis and purulent sputum, AND the wispy infiltrate was now a big, dense consolidation. A sputum culture was sent on Friday for the first time. At this point the team began antibiotics for pneumonia. The thing here is that only in RETROSPECT did it become clear that the wispy infiltrate seen on Thursday WAS the start of the VAP. Thus, in this case the VAP appears to have clinically begun on Thursday, not Friday. | ||
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===Infection Window Period=== | |||
*The infection window period (IWP) is defined as the 7-days during which all site-specific infection criteria must be met. It includes the collection date of the first positive chest imaging study (date of onset), that is used as an element to meet the site-specific infection criterion, the 3 calendar days before and the 3 calendar days after. | |||
{{Template:ICD10 Recent Previous Pneumonia}} | |||
==Data Collection Instructions== | ==Data Collection Instructions== | ||
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VAP is an infectious pneumonia in a patient who, as of the day it showed itself (“day of event”) had been on mechanical ventilation (MV), either continuously or intermittently for at least 48 hours before onset of infection. | VAP is an infectious pneumonia in a patient who, as of the day it showed itself (“day of event”) had been on mechanical ventilation (MV), either continuously or intermittently for at least 48 hours before onset of infection. | ||
*The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy. | *The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy. | ||
* While the CDC excludes patients that are on ECMO, we will '''include''' patients that are on ECMO | |||
*Although it is arbitrary, for this purpose we will consider "intermittent ventilation" to mean this: Over the 48 hours prior to the identification of the VAP, that the patient had been on the ventilator, via an ETT or trach, at least twice for periods of at least 1 hour each. | *Although it is arbitrary, for this purpose we will consider "intermittent ventilation" to mean this: Over the 48 hours prior to the identification of the VAP, that the patient had been on the ventilator, via an ETT or trach, at least twice for periods of at least 1 hour each. | ||
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=== 3 - Chest Imaging indicators === | === 3 - Chest Imaging indicators === | ||
*Chest imaging (X-ray, CT, etc | *Chest imaging (X-ray, CT, etc) study or studies showing '''at least ONE''' of the following 3 things, that must be '''new & persistent''' OR '''progressive and persistent''': (CDC WORDING CHANGE). Note: If the pt has had an ABD CT or AXR the radiologist will often comment on the lung fields. | ||
**Infiltrate -- note that there are alternative words used for infiltrates, including "airspace opacities" | **Infiltrate -- note that there are alternative words used for infiltrates, including "airspace opacities" | ||
**Consolidation | **Consolidation | ||
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**But, of course, ICU patients who are believed to have significant lung pathology, including pneumonia, typically DO have followup CXRs that will allow for identification of persistence of the changes seen. | **But, of course, ICU patients who are believed to have significant lung pathology, including pneumonia, typically DO have followup CXRs that will allow for identification of persistence of the changes seen. | ||
**In the (relatively rare situation) in which a ventilated patient qualifies for a VAP ''except'' that NO CXR was done during the next couple of days to demonstrate persistence, you could point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. If there is severe resistance to this from the ICU team, you could refer them to Drs. Garland or Paunovic. | **In the (relatively rare situation) in which a ventilated patient qualifies for a VAP ''except'' that NO CXR was done during the next couple of days to demonstrate persistence, you could point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. If there is severe resistance to this from the ICU team, you could refer them to Drs. Garland or Paunovic. | ||
*Regarding the use of chest imaging interpretation ie. radiologist vs clinical team | |||
** It is important to consider the overall clinical picture, if all of the VAP criteria are present use the interpretation of chest imaging that aligns with the clinical picture. ie If the radiologist interprets a CXR as atelectasis but the bedside team documents it as an opacity consistent with pneumonia, and the patient meets the VAP criteria then code it as a VAP. | |||
'''AND''' | '''AND''' | ||
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=== 4 - Respiratory indicators === | === 4 - Respiratory indicators === | ||
Has '''at least TWO''' of the following 4 things: | Has '''at least TWO''' of the following 4 things (from separate bullets) : | ||
*New onset of purulent respiratory secretions or change in amount or character of respiratory secretions. | *New onset of purulent respiratory secretions or change in amount or character of respiratory secretions. | ||
**In general it is secretions from the lungs (tracheal secretions, BAL sampling) that is relevant here. In intubated patients, sputum secretions mainly represent the status of the oral, orophayngeal and upper tracheal mucosa, not the lungs. | **In general it is secretions from the lungs (tracheal secretions, BAL sampling) that is relevant here. In intubated patients, sputum secretions mainly represent the status of the oral, orophayngeal and upper tracheal mucosa, not the lungs. | ||
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*Data collectors should '''follow criteria''' listed below regardless of what a physician writes in chart. If patient meets criteria VAP below, code as VAP. If patient does not meet all listed criteria, then '''do not code as VAP'''. It may qualify as a [[HAP]] or [[CAP]]. | *Data collectors should '''follow criteria''' listed below regardless of what a physician writes in chart. If patient meets criteria VAP below, code as VAP. If patient does not meet all listed criteria, then '''do not code as VAP'''. It may qualify as a [[HAP]] or [[CAP]]. | ||
== Instructions regarding the attribution of a VAP == | == Instructions regarding the attribution of a VAP == | ||