CCMDB Wiki

Pneumonia, ventilator-associated (VAP): Difference between revisions

← Older edit
 
(26 intermediate revisions by 3 users not shown)
Line 20: Line 20:


==Regarding the Date of Onset ==  
==Regarding the Date of Onset ==  
*The incident date for a VAP should be at the onset of the infection or when you determine the VAP was first brewing.
*This guideline changed on October 15, 2024
This is determined when reviewing the chart retrospectively.  See Dr. Garland's comments below: 
*As before, the date of onset can really only be adjudicated ''in retrospect'', as to be a VAP all criteria (see section below on "VAP Criteria") must be met within a 7 day "infection window period".
*In general we want the date on which the VAP was first evident -- in retrospect.  This MAY NOT BE THE DAY it was first recognized as being present in real time by the medical team.
**This MAY NOT BE THE DAY it was first recognized as being present in real time by the medical team.
**e.g. An 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 and 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.
*Generally --- consider the date of onset of a VAP to be the date on which (assuming all criteria are met with a 7 day window period) the chest imaging study (e.g. CXR, Chest CT, etc) criterion was first met
***NOTE that IF the intubation was Tuesday or Wednesday or Thursday, then this is NOT a VAP, because the clinical onset of the pneumonia was <48 hours prior to intubation. If the intubation was Monday or prior, then it is a VAP.
**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.
*This issue of timing can be VERY tricky -- and will always require judgement and retrospective assessment of the sequence of events.
*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.
**e.g. Patient has had fever and leukocytosis for 5 days due to a septic gallbladder, and has been intubated that whole time.  Now a new infiltrate with shows up, with purulent sputum and the team believes a new pneumonia has developed.  So here you can't use the pre-existing fever and elevated WBC to identify the clinical onset, and it's the change in the CXR that makes it.
 
**e.g. Patient has ARDS from multiple trauma and so the CXR has had diffuse fluffy infiltrates for a week.  He's also had a low-grade fever the whole time.  Now the fever becomes high-grade, the sputum becomes purulent, and though it's hard to tell for sure, the CXR seems to be a bit worse in the RUL.  The team concludes a pneumonia has developed.  So here, it's a judgement that the subtle change in the CXR and the change in the fever curve and the change in sputum is due to a VAP.
 
===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==
Line 34: Line 38:
**[[#1 - Ventilated 48 hrs]] '''+'''
**[[#1 - Ventilated 48 hrs]] '''+'''
**[[#2 - Infection]] '''+'''
**[[#2 - Infection]] '''+'''
**[[#3 - CXR indicators]] '''+'''
**[[#3 - Chest imaging indicators]] '''+'''
**ONE of:  [[#4 - Respiratory indicators]] '''OR''' [[#5 - Alternative indicators]]
**ONE of:  [[#4 - Respiratory indicators]] '''OR''' [[#5 - Alternative indicators]]


Line 40: Line 44:
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.


Line 74: Line 79:
***Pleuritic chest pain
***Pleuritic chest pain


=== 3 - CXR indicators ===
=== 3 - Chest Imaging indicators ===
*Chest imaging (X-ray) study or studies showing '''at least ONE''' of the following 3 things, that must be new & ''persistent'' OR ''progressive and persistent'': (CDC WORDING CHANGE).
*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
Line 84: Line 89:
**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'''
Line 91: Line 97:


=== 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 sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
*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. 
***Increased ET tube suctioning requirements may be the sole indicator of such changes in respiratory secretions.
*New onset or worsening cough, or dyspnea, or tachypnea  
*New onset or worsening cough, or dyspnea, or tachypnea  
*Newly identified adventitia, crackles or bronchial breath sounds.
*Newly identified adventitia, crackles or bronchial breath sounds.
Line 104: Line 112:
==== List 5a ====
==== List 5a ====
(This is the same list as [[#4 - Respiratory indicators]], however, here it's '''just 1 item''' instead of 2 items)
(This is the same list as [[#4 - Respiratory indicators]], however, here it's '''just 1 item''' instead of 2 items)
*New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
*New onset of purulent respiratory secretions or change in amount or character of respiratory secretions.
*New onset or worsening cough, or dyspnea, or tachypnea  
*New onset or worsening cough, or dyspnea, or tachypnea  
*Newly identified Rales or bronchial breath sounds.
*Newly identified Rales or bronchial breath sounds.
Line 125: Line 133:
*Fourfold rise in paired sera (IgG) for pathogen (e.g., influenza viruses, Chlamydia)  
*Fourfold rise in paired sera (IgG) for pathogen (e.g., influenza viruses, Chlamydia)  
*Fourfold rise in Legionella pneumophila serogroup 1 antibody titer to ≥1:128 in paired acute and convalescent sera by indirect IFA.  
*Fourfold rise in Legionella pneumophila serogroup 1 antibody titer to ≥1:128 in paired acute and convalescent sera by indirect IFA.  
**Detection of L. pneumophila serogroup 1 antigens in urine by RIA or EIA  
**Detection of L. pneumophila serogroup 1 antigens in urine by RIA or EIA


===VAP Pathogen exclusion list===
===VAP Pathogen exclusion list===
Line 144: Line 152:


=== Sputum culture results do not qualify for VAP===
=== Sputum culture results do not qualify for VAP===
Endotracheal tube secretion / Sputum culture is '''not''' part of the CDC criteria defining a VAP because sputum is ''virtually never'' culture negative in intubated patients, even without infection.
*Endotracheal tube secretion / Sputum culture is '''not''' part of the CDC criteria defining a VAP because sputum is ''virtually never'' culture negative in intubated patients, even without infection.
You '''can use''' culture results of respiratory secretions to identify the '''[[Pathogen]] for your [[ICD10]] Diagnosis''' (though positive blood or pleural fluid culture is considered more definitive).
*However, you '''can use''' culture results of respiratory secretions to identify the '''[[Pathogen]] for your [[ICD10]] Diagnosis''' (though positive blood or pleural fluid culture is considered more definitive).


{{ICD10 Secondary infections of aspiration}}
{{ICD10 Secondary infections of aspiration}}
Line 151: Line 159:
=== No such thing as "presumed VAP" ===
=== No such thing as "presumed VAP" ===
Following CDC criteria, we will not code "presumed VAP".
Following CDC criteria, we will not code "presumed VAP".
=== '''No special rules''' for "CAP developing VAP" ===
There are no guidelines for CAP developing VAP, other than meeting the VAP criteria. For example, the idea of a CXR showing a "New and persistent" or "Progressive and Persistent" infiltrate allows for coding a second pneumonia on top of a first one.


=== VAP supersedes other pneumonia codes ===
=== VAP supersedes other pneumonia codes ===
*This code supersedes the codes for [[Pneumonia, bacterial]], [[Pneumonia, fungal/yeast]], [[Pneumonia, viral]] and [[Pneumonia, NOS]].  
*If you identify a VAP, use this code instead of the codes for [[Pneumonia, bacterial]], [[Pneumonia, fungal/yeast]], [[Pneumonia, viral]] and [[Pneumonia, NOS]].  
{{Collapsable  
{{Collapsable  
| always=Example
| always=Example
Line 162: Line 167:
*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]].


=== Recent previous pneumonia ===
*If a patient had any pneumonia previously during the same admission and then develops pneumonia again, meeting the VAP criteria, it is only a VAP if it is a new organism and has persistent or worsening infiltrates. If it is the same original organism, then the pneumonia has not completely been resolved, and you should NOT code it as a VAP.
{{DiscussTask| Does this rule still apply since we no longer require an organism for a VAP, if someone is admitted with a CAP and later meets the criteria with the same bug, with our new guidelines would this not be considered a VAP?  [[User:Lkaita|Lisa Kaita]] 11:16, 2024 July 24 (CDT)
*This will be carried over to next TASK (Sept12, 2024) [[User:Lkaita|Lisa Kaita]] 12:21, 2024 August 1 (CDT) }}


== Instructions regarding the attribution of a VAP ==
== Instructions regarding the attribution of a VAP ==
Retrieved from "https://ccmdb.kuality.ca/index.php?title=Pneumonia,_ventilator-associated_(VAP)"