Hospital-acquired pneumonia (HAP) in ICD10: Difference between revisions

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== Coding instructions ==

*HAP, Hospital-acquired pneumonia, is a category of nosocomial pneumonia that is contracted by a '''~~non-ventilated~~''' ~~patient after~~ at least 48 hours of being admitted to a hospital.

*HAP, Hospital-acquired pneumonia, is a category of nosocomial pneumonia that is contracted by a patient '''after''' at least 48 hours of being admitted to a hospital. In ventilated patients see [[Pneumonia, ventilator-associated (VAP)|Pneumonia, ventilator-associated]] to decide if it is a VAP or a HAP.

*To code HAP, you must [[Combined ICD10 codes | combined coding]] 3 separate ICD10 codes:

*To code HAP, you must use [[Combined ICD10 codes | combined coding]] of 3 separate ICD10 codes:

** (1) '''[[~~Iatrogenic~~, ~~complication of medical or surgical care~~ NOS]]''' ''PLUS''

** (1) '''[[Nosocomial infection, NOS]]''' ''PLUS''

** (2) One of the codes for SPECIFIC TYPES OF PNEUMONIAS:

***[[Pneumonia, bacterial]]

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===Attribution of the HAP to a Hospital Location===

*The infection is attributed to the location where the patient was on the date the infection became clinically evident -- EXCEPT if all

*The infection is attributed to the location where the patient was on the date the infection became clinically evident -- EXCEPT if all elements of the infection are present within the first 48 hours of arrival, the infection is attributed to the location from which they were transferred.

elements of the infection are present within the first 48 hours of arrival, the infection is attributed to the location from which they were transferred.

==Alternate ICD10s to consider coding instead or in addition==

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== Additional Info ==

* If there is insufficient criteria for a [[Pneumonia, ventilator-associated (VAP)]] in ventilated patients with positive cultures, the patient may still have HAP.

* Patients from [[Grace Nursing Home Ward]] - even though this is considered a nursing home type ward, for patients who acquire a pneumonia and meet the HAP criteria '''code HAP'''.

==~~RE:A Patient with CAP on Admission~~==

=== Don't need to follow VAP Guidelines for this ===

~~{{Discussion}}~~

Do you need to follow the same guidelines for acceptable sources for cultures like for the VAP cultures?

*AG REPLY -- for HAP, no. Indeed, the main thing that distinguishes a CAP from a HAP is whether the patient has been in a LOCATION that qualifies for it being a HAP.

===RE:A Patient with CAP on Admission===

Can a patient with unresolved CAP ever be coded as HAP if ETC cultures become positive for a new [[Pathogens|pathogen]] or is it always going to be CAP?

*AG REPLY -- this is a very difficult clinical determination. Since our ability to identify the lung pathogen in ANY type of pneumonia isn't that good (even WITH bronchoscopy and quantitative BAL or protected specimen brush, which is almost NEVER done in Winnipeg) it is very very difficult to tell whether a new pathogen is a new infection. This is especially true since it is well known that hospitalized and intubated patients quickly get colonized in their airways with bugs that don't usually live there (e.g. gram negative rods) -- thus again just identifying a new bug in sputum that is a POTENTIAL pathogen is far from a diagnosis that that potential pathogen is actually the bug for an actual pneumonia or bronchitis. Thus, there can be no real rule here. It IS possible to get a new HAP/VAP after being admitted for a CAP, and even without cure of the CAP, but that determination requires things like: 1-A new potential pathogen PLUS 2-chest imaging that shows infiltrates in an area that was virtually COMPLETELY clear before PLUS 3-a clinical decision about this whole thing.

~~Do you need to follow the same guidelines for acceptable sources for cultures like for the VAP cultures?~~

If a patient with CAP on admission that hasn't cleared but isn't ventilated for days then has to go on a ventilator less than 48 hour ventilated develops a positive culture (quantitive bronchoscopically obtained) and a change in respiratory status can this be called HAP? Or are you saying it's CAP the whole admission? It seems according to the VAP quidelines patients with CAP can develop VAP under the right conditions so couldn't they also get HAP? Are you saying patients with CAP can never get HAP?

*AG REPLY -- for HAP, no. Indeed, the main thing that distinguishes a CAP from a HAP is whether the patient has been in a LOCATION that qualifies for it being a HAP.

~~{{Discuss | who = Allan | question =~~ If a patient with CAP on admission that hasn't cleared but isn't ventilated for days then has to go on a ventilator ~~then~~ less than 48 hour ventilated develops a positive culture(quantitive bronchoscopically obtained) and a change in respiratory status can this be called HAP? Or are you saying it's CAP the whole admission? It seems according to the VAP quidelines patients with CAP can develop VAP under the right conditions so couldn't they also get HAP? Are you saying patients with CAP can never get HAP?

I will give an example cases:

*The pt has CAP no culture is sent. The patient is in the ICU for 8 days not on a ventilator. The ventilation status gets worse. The CXR continues to have persisent infiltrates. The pt gets intubated and less than 48 hours on a ventilator a bronchoscopy is done and both ETC and quantitive cultures grow aspergillos. Is this still CAP or can it be called HAP?

*Same ~~scenerio~~ as above occurs but a patient isn't treated for what ever [[Pathogens|pathogen]] grows in the cultures. Do we code the [[Pathogens|pathogen]] or not. Do we call it colonization or ignore the culture?

*Same scenario as above occurs but a patient isn't treated for what ever [[Pathogens|pathogen]] grows in the cultures. Do we code the [[Pathogens|pathogen]] or not. Do we call it colonization or ignore the culture?

*AG REPLY -- as I've said above, it IS possible to get a VAP or HAP superimposed on a CAP -- but making that diagnosis is very difficult, requires clinical judgement and SHOULD require the 3 items I've listed above.

}}

== Aspiration and development of pneumonia less than 48 hours==

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[[Category: Pneumonia]]

[[Category:Pneumonia]]

[[Category: Respiratory]]

[[Category:Respiratory]]

[[Category: Iatrogenic]]

[[Category:Iatrogenic]]

@@ Line 2: / Line 2: @@
 == Coding instructions ==
-*HAP, Hospital-acquired pneumonia, is a category of nosocomial pneumonia that is contracted by a '''non-ventilated''' patient after at least 48 hours of being admitted to a hospital.
+*HAP, Hospital-acquired pneumonia, is a category of nosocomial pneumonia that is contracted by a patient '''after''' at least 48 hours of being admitted to a hospital. In ventilated patients see [[Pneumonia, ventilator-associated (VAP)|Pneumonia, ventilator-associated]] to decide if it is a VAP or a HAP.
-*To code HAP, you must [[Combined ICD10 codes | combined coding]] 3 separate ICD10 codes:
+*To code HAP, you must use [[Combined ICD10 codes | combined coding]] of 3 separate ICD10 codes:
-** (1) '''[[Iatrogenic, complication of medical or surgical care NOS]]''' ''PLUS''
+** (1) '''[[Nosocomial infection, NOS]]''' ''PLUS''
 ** (2) One of the codes for SPECIFIC TYPES OF PNEUMONIAS:
 ***[[Pneumonia, bacterial]]
@@ Line 16: / Line 16: @@
 ===Attribution of the HAP to a Hospital Location===
-*The infection is attributed to the location where the patient was on the date the infection became clinically evident -- EXCEPT if all
+*The infection is attributed to the location where the patient was on the date the infection became clinically evident -- EXCEPT if all elements of the infection are present within the first 48 hours of arrival, the infection is attributed to the location from which they were transferred.
-elements of the infection are present within the first 48 hours of arrival, the infection is attributed to the location from which they were transferred.
 ==Alternate ICD10s to consider coding instead or in addition==
@@ Line 25: / Line 24: @@
 == Additional Info ==
 * If there is insufficient criteria for a [[Pneumonia, ventilator-associated (VAP)]] in ventilated patients with positive cultures, the patient may still have HAP.
-* Patients from [[Grace Nursing Home Ward]] - even though this is considered a nursing home type ward, for patients who acquire a pneumonia and meet the HAP criteria '''code HAP'''.
-==RE:A Patient with CAP on Admission==
+=== Don't need to follow VAP Guidelines for this ===
-{{Discussion}}
+Do you need to follow the same guidelines for acceptable sources for cultures like for the VAP cultures?
+*AG REPLY -- for HAP, no.  Indeed, the main thing that distinguishes a CAP from a HAP is whether the patient has been in a LOCATION that qualifies for it being a HAP.
+{{ICD10 Guideline Pneumonia|}}
+===RE:A Patient with CAP on Admission===
 Can a patient with unresolved CAP ever be coded as HAP if ETC cultures become positive for a new [[Pathogens|pathogen]] or is it always going to be CAP?
 *AG REPLY -- this is a very difficult clinical determination.  Since our ability to identify the lung pathogen in ANY type of pneumonia isn't that good (even WITH bronchoscopy and quantitative BAL or protected specimen brush, which is almost NEVER done in Winnipeg) it is very very difficult to tell whether a new pathogen is a new infection.  This is especially true since it is well known that hospitalized and intubated patients quickly get colonized in their airways with bugs that don't usually live there (e.g. gram negative rods) -- thus again just identifying a new bug in sputum that is a POTENTIAL pathogen is far from a diagnosis that that potential pathogen is actually the bug for an actual pneumonia or bronchitis.  Thus, there can be no real rule here.   It IS possible to get a new HAP/VAP after being admitted for a CAP, and even without cure of the CAP, but that determination requires things like:  1-A new potential pathogen PLUS 2-chest imaging that shows infiltrates in an area that was virtually COMPLETELY clear before PLUS 3-a clinical decision about this whole thing.
-Do you need to follow the same guidelines for acceptable sources for cultures like for the VAP cultures?
+If a patient with CAP on admission that hasn't cleared but isn't ventilated for days then has to go on a ventilator less than 48 hour ventilated develops a positive culture (quantitive bronchoscopically obtained) and a change in respiratory status can this be called HAP? Or are you saying it's CAP the whole admission? It seems according to the VAP quidelines patients with CAP can develop VAP under the right conditions so couldn't they also get HAP? Are you saying patients with CAP can never get HAP?
-*AG REPLY -- for HAP, no.  Indeed, the main thing that distinguishes a CAP from a HAP is whether the patient has been in a LOCATION that qualifies for it being a HAP.
-{{Discuss | who = Allan | question = If a patient with CAP on admission that hasn't cleared but isn't ventilated for days then has to go on a ventilator then less than 48 hour ventilated develops a positive culture(quantitive bronchoscopically obtained) and a change in respiratory status can this be called HAP? Or are you saying it's CAP the whole admission? It seems according to the VAP quidelines patients with CAP can develop VAP under the right conditions so couldn't they also get HAP? Are you saying patients with CAP can never get HAP?
 I will give an example cases:
 *The pt has CAP no culture is sent. The patient is in the ICU for 8 days not on a ventilator. The ventilation status gets worse. The CXR continues to have persisent infiltrates. The pt gets intubated and less than 48 hours on a ventilator a bronchoscopy is done and both ETC and quantitive cultures grow aspergillos. Is this still CAP or can it be called HAP?
-*Same scenerio as above occurs but a patient isn't treated for what ever [[Pathogens|pathogen]] grows in the cultures. Do we code the [[Pathogens|pathogen]] or not. Do we call it colonization or ignore the culture?
+*Same scenario as above occurs but a patient isn't treated for what ever [[Pathogens|pathogen]] grows in the cultures. Do we code the [[Pathogens|pathogen]] or not. Do we call it colonization or ignore the culture?
 *AG REPLY -- as I've said above, it IS possible to get a VAP or HAP superimposed on a CAP -- but making that diagnosis is very difficult, requires clinical judgement and SHOULD require the 3 items I've listed above.
-}}
 == Aspiration and development of pneumonia less than 48 hours==
@@ Line 54: / Line 55: @@
 {{Related Articles}}
-[[Category: Pneumonia]]
+[[Category:Pneumonia]]
-[[Category: Respiratory]]
+[[Category:Respiratory]]
-[[Category: Iatrogenic]]
+[[Category:Iatrogenic]]