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| {{DX tag | Infection | Medical Problem| [[:Category: Pneumonia | Pneumonia ]]| PNEUMONIA-VAP (ventilator acq'd) | 3900-Ventilator Associated Pneumonia | No | 0 |'''Critical Care and Medicine''' | Currently Collected | July 1, 2006 | |}} | | {{DX tag | Infection | Medical Problem| [[:Category: Pneumonia | Pneumonia ]]| PNEUMONIA-VAP (ventilator acq'd) | 3900-Ventilator Associated Pneumonia | No | 0 |'''Critical Care and Medicine''' | Currently Collected | July 1, 2006 | |}} |
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| For patients with VAP, [[QA Infection VAP]] may need to be entered.
| | See criteria in [[Pneumonia, ventilator-associated (VAP)]]. |
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| == Follow Criteria Strictly for this one! ==
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| <!--Dr. Robert, Olafson and Garland have advised that for VAP:-->Data collectors should '''follow criteria''' listed below regardless of what a physician writes in chart as a DX. If patient meets criteria VAP below, code as VAP. If patient does not meet all listed criteria, then '''do not code as VAP'''.
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| If a patient has a [[Acquired Diagnosis / Complication]] of VAP, consider [[#VAP Attribution Transfer Rule]] and code [[QA Infection VAP]] if applicable.
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| === Criteria ===
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| '''IF''' a patient has been on a device to assist respiration (ventilator) either continuously or intermittently through a tracheostomy or endotracheal tube (ETT) for at least '''48 hours before [[#onset of infection]], or new infection.''' Start counting the 48 hours from the time of intubation no matter where this intubation occurs '''before''' or '''during''' an admission to the ICU. <!--per Dr. Olafson.-->
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| '''AND''' if they demonstrate new, worsening or persistent infiltrate on x-ray compatible with pneumonia
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| '''AND if at least one''' of the following criteria is met:
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| * Fever (T > 38) with no other cause
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| * Leukopenia WBC(<4X10(9)) or leukocytosis (>12x 10(9)).
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| * Altered mental status with no other causes in >69 year old.
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| '''AND if at least one''' of the following criteria is met:
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| * New onset of purulent secretions
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| * Change in character of sputum
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| * Increased volume of purulent secretions
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| * Increased suction requirement
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| * New onset of worsening cough
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| * New onset of dypsnea (SOB) or tachypnea (increased Resp Rate)
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| * Increased oxygen or ventilation requirement
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| '''AND if at least one''' of the following criteria is met:
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| * Pathogen (not on the [[#Pathogen exclusion list]]) isolated from sputum in the last 48 hours
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| * Positive blood cultures not related to another infection
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| * Positive pleural fluid culture.
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| ==== Timeframe for reviewing criteria ====
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| The time frame for looking at the VAP criteria is '''within 1-3 days on either side''' of when the positive culture was '''sent'''.
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| == Additional Information==
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| === Onset of infection ===
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| The onset of an infection (pneumonia) can begin prior to the 48 hours on a ventilator. It is important to rule out these patients in the VAP criteria because often we do not have a positive culture sent until after the 48 hrs on a ventilator. If a patient has '''at least 2 symptoms from the list below''' within the first 48 hours on a ventilator, it is not a VAP because the onset of infection is prior to the 48 hour mark.
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| * CXR infiltrates (see [[#CXR implications]]
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| * increased WBC or fever (with no other infective source identified)
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| * starting to have purulent secretions
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| * increased ventilation requirements (for no other reason).
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| ==== CXR implications ====
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| Whenever a positive sputum culture is reported, the data collector should check to see if this is, first of all, a pneumonia and then, to see if it is a [[CAP]], [[HAP]] or VAP. If the CXR does not give evidence of a pneumonia, code
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| it as (old: [[Tracheobronchitis]])/(ICD10: [[Bronchitis, infectious or noninfectious]]/Respiratory disorder, postprocedure/postop NOS]]).
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| Infiltrates that are present on admission (ie CAP) need to persist/ worsen and also meet the VAP criteria to code VAP.
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| === VAP Attribution Transfer Rule ===
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| If a patient transferred from another unit first meets all criteria for VAP within the '''first 48 hrs''' on your unit, code VAP as an '''[[Admit Diagnosis]]''', not as a [[Acquired Diagnosis / Complication]].
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| '''Don't''' enter a [[QA Infection VAP]] for these patients.
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| *The ICU sending the pt would then need to code the VAP in their complications and enter the [[QA Infection VAP]] information.
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| If you code VAP as an [[Admit Diagnosis]] the [[statistician]] will track back to previous units until the one where the VAP was an [[Acquired Diagnosis / Complication]] is found.
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| If no unit has the VAP as an acquired the [[data processor]] will contact you to clarify whether this is correct.
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| ==== VAP acquired in ICU then transferred to Ward====
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| If a patient has a '''VAP''' in the '''ICU''' that is not yet resolved when the patient is transferred to a '''ward''', the ward should code the VAP in the [[Admit Diagnosis]]. If VAP was '''resolved''' in the ICU before the patient was sent to the ward, then don't code it.
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| ====VAP can't be Medicine complication====
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| VAP cannot be coded as a [[Acquired Diagnosis / Complication]] on a Medicine ward but can be used as an [[Admit Diagnosis]] if patient came from an ICU and requires ongoing treatment for this problem. If resolved in the ICU, don't code as an [[Admit Diagnosis]] to you ward.
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| === Pathogen exclusion list ===
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| *Normal respiratory flora, normal oral flora, mixed respiratory flora, mixed oral flora, altered oral flora or any other similar results indicating isolation of commensal flora of the oral cavity or upper respiratory tract.
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| *Candida Species (specified or unspecified)
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| *[[VAP#Yeast_in_Sputum_.26_VAP | YEAST]] not otherwise specified
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| *coagulase-negative staphyllococcus species (specified or unspecified) '''except [[Staphylococcus aureus]] including [[MRSA]]'''
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| *Enterococcus species (specified or unspecified)
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| If the pathogen is isolated from cultures of: LUNG TISSUE or PLEURAL FLUID, these organisms '''MAY BE''' reported as Possible or Probable VAP pathogens.
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| Pathogens isolated from one of the following '''may NOT''' be listed as cause of VAP:
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| SPUTUM, ENDOTRACHEAL ASPIRATES, BRONCHOALVEOLAR LAVAGES or PROTECTED SPECIMEN BRUSHINGS then they
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| *''These organisms are excluded because they are common upper respiratory tract commensals, colonizers or contaminants, and are unusual causes of VAP''
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| NOTE: Their exclusion from the SURVEILLANCE DEFINITION should NOT be used in clinical decision-making regarding '''patient treatment.''' Providers must independently determine the clinical significance of these organisms isolated from respiratory specimen cultures and the '''need for treatment.''' -[[User:TOstryzniuk|Trish Ostryzniuk]] 18:29, 2013 October 7 (CDT)
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| ====MRSA colonized====
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| MRSA '''colonized''' can be coded VAP if all other criteria are met and MRSA is cultured in their endotracheal secretions. They are not excluded because of previous colonization.
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| ==== [[:Category:Yeast/fungus | Yeast]] in Sputum & VAP ====
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| Sputum +ve yeast: '''Do not code as a yeast associated VAP'''. This is considered to be colonization unless ''treated specifically.'''Not a VAP if yeast also at other sites; so basically don’t ever code as a cause of VAP or pneumonia.
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| As a general rule, yeast does not cause pneumonia at all except in immunosuppressed patients in which case they have disseminated infection with yeast at many sites (ie multiple sites other than lung will be positive).-Posted by [[User:TOstryzniuk|Trish Ostryzniuk]] 12:09, 2012 October 4 (CDT), on behalf of Dr. Kumar and reviewed by Dr. Olafson.
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| [[Category:Yeast/fungus]]
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| ===Arrived with community acquired pneumonia and develops VAP===
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| If a patient is admitted with a CAP and then after 48 hours of ventilation develops what looks like a VAP it is only a VAP if it is a different organism than the CAP organism and they meet the VAP criteria. Infiltrates need to be persistent or worsening and the VAP criteria needs to be met.
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| === Recurrent infection ===
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| If a patient had a 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. If it is the same original organism, then the pneumonia has not completely been resolved. Do not code these as a VAP.
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| ===Long term ventilator patients with pneumonia===
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| We are tracking '''Hospital Acquired VAP's''' & not patient's who have acquired an pneumonia while on long term home ventilators (LTV) in the community. If a LTV patient is admitted from the community with an pneumonia, they are to coded as '''C'''ommunity '''A'''cquired '''P'''neumonia ([[CAP]]). (as per Dr. Bruce Light 2008, Dr.Garland on May 9,2013)
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| {{discussion}} What if the VAP only happened after an LTV patient had been in hospital for >48hrs? (Laura and [[User:LKolesar|LKolesar]] 09:29, 2017 November 1 (CDT))
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| == Data use ==
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| Used in:
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| * [[Quarterly report]]
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| === Reporting of complication when patients move units ===
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| When the [[statistician]] links admissions in the database between ICU'a & medicine wards in the city, those patient that have VAP in [[Admit Diagnosis]] are excluded from complication statistics. The patient encounter that had the VAP coded in the [[Admit Diagnosis]] slot is the unit that is given credit for the '''complication''' occurring in that unit.
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| When coding VAP's they are coded as "complication" when they occur at a specific center. However, when these patients are transferred to other centers and the VAP is still being treated, then the VAP should be coded as part of the [[Admit Diagnosis]].
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| When Julie looks at VAP rates in ICU's she only looks for the VAP code in the complication slots. The site where the patient had the VAP occur in complication codes is the site that is given the credit. A unit where a patient has a VAP in the [[Admit Diagnosis]] is not included in stats for VAP rates.
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| When a VAP appears in the admission code slots, Julie tracks back to where patient came from and makes sure that the ICU prior to the transfer, coded the VAP in their complications, if not, you will get a query to audit the diagnosis.
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| *Collectors should remember to check the transfer tracker to see if the sending unit coded a VAP. If it is not on the transfer tracker you may need to contact the data collector from the unit sending the patient to make sure it really is VAP.
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| == See Also == | | == See Also == |
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| * alternate diagnoses [[:Category:Pneumonia]] | | * alternate diagnoses [[:Category:Pneumonia]] |
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| {{discussion}}
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| * [http://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf CDC article for VAP see page 6-2].
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| Searched for the CDC document and found [https://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf this]. The document is from January 2017. Are there any changes to what was used before that we need to integrate into our documentation?
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| [[Category:Pneumonia]] | | [[Category:Pneumonia (old)]] |
| [[Category:QAInfection]] | | [[Category:QAInfection]] |