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| ==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 below) 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) 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.
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| **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.
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| ==Data Collection Instructions== | | ==Data Collection Instructions== |