VAP - Ventilator Associated Pneumonia: Difference between revisions
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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 | |}} | ||
== Ventilator Associated Pneumonia (VAP) Criteria == | |||
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. | |||
'''Code the diagnosis VAP only if these criteria are met.''' The doctors may or may not be calling it a VAP but this has no bearing on the way we collect the information. Be sure to adhere''' strictly to these criteria '''. | '''Code the diagnosis VAP only if these criteria are met.''' The doctors may or may not be calling it a VAP but this has no bearing on the way we collect the information. Be sure to adhere''' strictly to these criteria '''. | ||
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* Positive blood cultures not related to another infection | * Positive blood cultures not related to another infection | ||
* Positive pleural fluid culture. | * Positive pleural fluid culture. | ||
=== New CDC Document === | |||
{{discussion}} | |||
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? | |||
== Additional Information== | == Additional Information== | ||
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** infiltrates that are present example CAP on admission need to persist/ worsen and also meet the VAP criteria to code VAP. | ** infiltrates that are present example CAP on admission need to persist/ worsen and also meet the VAP criteria to code VAP. | ||
== | == Onset of infection:== | ||
* Because 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. A patient must have at least 2 symptoms from the list below within the first 48 hours on a ventilator to constitute a non-VAP pneumonia: (CAP or aspiration) | * Because 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. A patient must have at least 2 symptoms from the list below within the first 48 hours on a ventilator to constitute a non-VAP pneumonia: (CAP or aspiration) | ||
*1. CXR infiltrates | *1. CXR infiltrates | ||
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*The note above refers to patients that are newly intubated who already have symptoms before the 48 hour mark. Then, it could be a CAP if the culture is only sent after 48 hours on the vent. | *The note above refers to patients that are newly intubated who already have symptoms before the 48 hour mark. Then, it could be a CAP if the culture is only sent after 48 hours on the vent. | ||
== | == Time window for VAP == | ||
You need to look for the WBC, fever, sputum and CXR signs either the '''day before, day of or up to 3 days after the positive culture. Especially the CXR because sometimes the pneumonia is slower to develop and see on the XRAY.--[[User:LKolesar|LKolesar]] 11:55, 2017 July 13 (CDT) | |||
== VAP Attribution Transfer Rule == | |||
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 complication'' | |||
'''Don't''' enter a [[QA_Infection#A._VAP]] for these patients. | |||
==[[CDC]] VAP Surveillance, PATHOGEN EXCLUSION list== | |||
*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. | *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. | ||
* | *Candida Species (specified or unspecified) | ||
*[[VAP#Yeast_in_Sputum_.26_VAP | YEAST]] not otherwise specified | *[[VAP#Yeast_in_Sputum_.26_VAP | YEAST]] not otherwise specified | ||
* | *coagulase-negative staphyllococcus species (specified or unspecified) '''except [[Staphylococcus aureus]] including [[MRSA]]''' | ||
*ENTEROCOCCUS SPECIES (specified or unspecified) | *ENTEROCOCCUS SPECIES (specified or unspecified) | ||
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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) | 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) | ||
===MRSA colonized=== | |||
= | |||
==MRSA colonized== | |||
These patients can develop VAP if all other criteria are met and MRSA is cultured in their endotracheal secretions. They are not excluded because of previous colonization. | These patients can develop VAP if all other criteria are met and MRSA is cultured in their endotracheal secretions. They are not excluded because of previous colonization. | ||
= | === [[:Category:Yeast/fungus | Yeast]] in Sputum & VAP=== | ||
== [[:Category:Yeast/fungus | Yeast]] in Sputum & VAP== | |||
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. | 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. | ||
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. | 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. | ||
[[Category:Yeast/fungus]] | [[Category:Yeast/fungus]] | ||
== VAP acquired in ICU then transferred to Ward== | == Special cases == | ||
=== VAP acquired in ICU then transferred to Ward=== | |||
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. | 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. | ||
==VAP can't be Medicine complication== | ==VAP can't be Medicine complication== | ||
VAP cannot be coded as a complication on a Medicine ward but can be used as an Admitting diagnosis if patient came from an ICU and requires ongoing treatment for this problem. If resolved in the ICU, don't code as an admitting DX to you ward. | VAP cannot be coded as a complication on a Medicine ward but can be used as an Admitting diagnosis if patient came from an ICU and requires ongoing treatment for this problem. If resolved in the ICU, don't code as an admitting DX to you ward. | ||
==Arrived with community acquired pneumonia and develops VAP== | ===Arrived with community acquired pneumonia and develops VAP=== | ||
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. | 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. | ||
==Long term ventilator patients with pneumonia== | ===Long term ventilator patients with pneumonia=== | ||
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).[[User:TOstryzniuk|TOstryzniuk]] 17:38, 15 December 2008 (CST) | 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).[[User:TOstryzniuk|TOstryzniuk]] 17:38, 15 December 2008 (CST) | ||
This was confirmed again by Dr.Garland on May 9,2013. | This was confirmed again by Dr.Garland on May 9,2013. | ||
== | == Background == | ||
*[http://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf CDC article for VAP see page 6-2]. | |||
As per [[CDC]] VAP surveillance guidelines: If all elements of a VAP are present within two (2) calendar days of transfer from one inpatient location to another in the same facility or a new facility (i.e., on the day of transfer or the next day), the infection is attributed to the transferring location or facility. If the patient was in multiple locations within the transfer rule time frame, attribute the infection to the original location initiating the transfer. | |||
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" is found. | |||
If no unit has the VAP as an acquired the [[data processor]] will contact you to clarify whether this is correct. | |||
== Alternative diagnoses == | == Alternative diagnoses == | ||
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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. | 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. | ||
*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. | *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. | ||
== See Also == | |||
* [[QA Infection Audit]] for info common to the [[QA Infection CLI]] and the [[QA Infection VAP]] project | |||
[[Category:Pneumonia]] | [[Category:Pneumonia]] | ||
[[Category:QAInfection]] | [[Category:QAInfection]] | ||