Ventilator Associated Pneumonia Rate
Ventilator Associated Pneumonia (#VAP) Rate is the number of cases of per 1000 invasive ventilator days.
| Indicators | |
| Indicator: | Ventilator Associated Pneumonia (VAP) Rate |
| Created/Raw: | Created |
| Program: | Critical Care |
| Start Date: | Jan 1 2013 |
| End Date: | |
| Reports: | Critical Care Program Quality Indicator Report, Directors Quarterly and Annual Report (Critical Care), STB ICUs VAP Rate, CLIBSI Rate Summary, WRHA ICU Hospital-Acquired Conditions |
Used in aggregate form as "per location" and/or "per timeframe", e.g. by month/quarter/year x Ward/Unit x Hospital
QI domain
- Safe
Reported as
Number of cases of #VAP per 1000 Ventilator-days
Significance
- #VAP is a device-associated infection, the device being the artificial airway-ventilator-circuit system. #VAP is associated with worse patient outcomes and higher costs.
- Factors affecting the incidence of #VAP include those from patients (severity of illness, comorbidities, etc.) and processes of care.
- #VAP rate is a measure of the incidence of #VAP.
Sampling Plan / Procedure
Inclusion Criteria
- 100% sampling for all patients on invasive mechanical ventilation as indicated by presence of #Ventilator Days at 23 HR
- 100% sampling for all cases with VAP incidence following the criteria listed in #VAP
Exclusion Criteria
Exclude non-invasive ventilation.
Frequency
- Recording the date the #VAP occurred.
- Daily recording of dates of patient being on invasive mechanical ventilation at 2300 HR
- Total number of ventilated days are calculated and reported on a monthly, quarterly or yearly basis based on the daily data.
- Time Reference is calendar month, quarter or year.
Definition and Derivation
Numerator
Num = Total #VAP Cases in a calendar period
Denominator
Denom =Total Vent Days on the same period as the numerator
Formula
VAP Rate = Num / Denom * 1000
Example
- Time Reference: Calendar Dates from Jan 1, 2017 to March 31, 2017
- Total VAP cases = 5
- Total days patients are on invasive ventilator at 2300 HR = 688
- VAP Rate per 1000 days = (5 / 688) * 1000 = 7.3%
Data Sources
Ventilator Days at 23 HR
- Starting Oct 1, 2020, the above TISS28 element is collected as part of the CCI Collection but not at 2300HR , before this they were part of TISS28 Data.mdb. The presence of Vent at 2300 hour is imputed or assigned by inference using this method - if patient is present at 23HR and the TISS28 element T18 - Invasive Mechanical Ventilation (TISS Item) is marked, then the patient is assumed to have ventilator at 2300 hour.
- Jan 2013 to Sept 2020 - Daily data for Invasive are taken on TISS28 element T - Invasive mechanical ventilation at 2300 hrs (TISS Item). The TISS form is being marked daily by ICU bed side nurses and quality checked by the Database Data Collectors.
- June 1988 to Dec 2012 - Daily data for Invasive Mech Vent are taken on TISS76-Form elements # 29 or 30 which are saved at
- S:\MED\MED_CCMED\CCMDB\Legacy_TMS_Data\Legacy_TMS_Data.mdb
VAP
- Starting Jan 2019, VAP is part of the ICD10 collection with code J95.88 Pneumonia, ventilator-associated (VAP) under the Acquired Diagnosis / Complication. The date is the Dx Date of the VAP - Ventilator Associated Pneumonia diagnosis
- Aug 2009 to Dec 2018, the dates when VAP occurred were taken from the Tmp project QA Infection.
SAS Program
- The SAS program to get the VAP is X:\Julie\SAS_CFE\CFE_macros\Pre_ICD10_AcqDx.sas
- The SAS program to get the Ventilator Days is X:\Julie\SAS_CFE\CFE_macros\Read_TISS76_TISS28_TISSinCCI.sas
- macro %tisscci23hr shows the generation of Vent present at 23 HR
- The SAS program to get the VAP rate is X:\Julie\SAS_CFE\CFE_macros\VAPCLICAM.sas
Report Users
- Critical Care Directors, Critical Care Unit Managers and WRHA Outcome Improvement Team Committee
- St Boniface Cardiac Sciences Program (STB site only)
- HSC Infection Prevention & Control (HSC site only)
- WRHA Infection Prevention & Control
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