Pneumonia, ventilator-associated (VAP)
| ICD10 Diagnosis | |
| Dx: | Pneumonia, ventilator-associated (VAP) |
| ICD10 code: | J95.88 |
| Pre-ICD10 counterpart: | VAP - Ventilator Associated Pneumonia |
| Charlson/ALERT Scale: | none |
| APACHE Como Component: | none |
| APACHE Acute Component: | none |
| Start Date: | |
| Stop Date: | |
| External ICD10 Documentation | |
This diagnosis is a part of ICD10 collection.
Additional Info
- This code supersedes the codes for bacterial, fungal and viral pneumonias. For example, if the patient qualifies for having a bacterial VAP, you code the VAP linked to the bug, and you do NOT have to code Pneumonia, bacterial.
- 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.
- A new VAP that is identified first on a medicine ward must be attributed to the ICU that sent the patient.
- The only way VAP can be coded (as an admit code)on a medicine ward is if (see criterion#1, below) and that the patient's Mechanical Ventilation (MV) ended that day or the prior day in an ICU AND patient met all the criteria.
- If the medicine collector identifies that a new pneumonia is present soon after arrival to the ward, they should let the ICU collector know to assess whether it was a VAP or not. This can be put in the Admit code of the medicine collector but the sending ICU collector would have to ensure that the VAP is a complication for them and they have done the tmp information and notification process.
Onset of infection
- If the symptoms of infection (pneumonia) are evident prior to being on MV for 48 hours, then it is not a VAP, even if the positive culture is done after the 48 hour mark.
- 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.
Attribution of the VAP to a Hospital Location
- The infection is attributed to the location where the patient was on the date the infection became clinically evident......
- EXCEPT if all elements of the infection are present within the first 48 hours of arrival, the infection is attributed to the location from which they were transferred.
- The CDC case definition explicitly states that these rules should be followed -- that the physician’s statement of where the infection was acquired should not be substituted for these rules.
Long term ventilator patients with pneumonia
- If a LTV patient is admitted from the community with a pneumonia, a Community Acquired Pneumonia (Community-acquired pneumonia (CAP) in ICD10) should be coded, not VAP, even though it is technically a VAP.
- The rationale for this is that we only are wanting to tracking Hospital Acquired VAP's, not patients who have acquired an pneumonia while on long term home ventilators (LTV) in the community.
- Of course, if the patient entered the hospital without a pneumonia, and develops one (and meets the VAP criteria), then that person would have a VAP we do want to code.
Data Collection Instructions
If a patient meets all criteria of an Acquired Diagnosis / Complication of VAP while in your unit then enter tmp as per in QA Infection VAP.
Criteria
Must meet all of #1, AND #2, AND #3, AND either #4 or #5. These are the CDC criteria.
1. VAP is an infectious pneumonia in a patient who, as of the day it was identified (“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.
2. Has at least ONE of the following 3 things:
- Fever > 38.0
- WBC<4000 or >12,000
- If >70 years old, altered mental status without another recognized cause
3. 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).
- Infiltrate
- Consolidation
- Cavitation
4. Meets both of 4 Part 1 & 4 Part 2:
- 4 Part 1: Has at least ONE of the following 4 things:
- New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
- New onset or worsening cough, or dyspnea, or tachypnea
- Rales or bronchial breath sounds.
- Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirements, or increased ventilator demand
- 4 Part 2: Must have a positive culture.
- See below for detailed list of all possible sources for cultures:
- Organism identified from blood (see pathogen exclusion list, below)
- Organism identified from pleural fluid (see pathogen exclusion list, below)
- Positive quantitative culture, performed according to accepted protocols, from bronchoalveolar lavage or protected brush specimens (see pathogen exclusion list, below)
- >5% of cells obtained from bronchoalveolar lavage contain intracellular bacteria on direct microscopic exam
- Positive culture of lung tissue (see pathogen exclusion list, below)
- Histopathologic exam of lung tissue identifies abscess formation, or foci of consoliation with intense PMN accumulation in bronchioles and alveoli
- Histopathologic exam of lung tissue identifies lung invasion of fungal hyphae or pseudohyphae
- Virus, Bordetella, Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method
- 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.
- Detection of L. pneumophila serogroup 1 antigens in urine by RIA or EIA
- In an immunocomprimised patient: identification of matching Candida from blood and sputum, endotracheal aspirate, BAL or protected specimen brushing. (NOTE: THIS IS A NEW CDC ITEM)
- In an immunocomprimised patient: Evidence of fungi from BAL or protected specimen brushing)(NOTE: THIS IS A NEW CDC ITEM). Be aware that fungi is not the same as yeast (do not use candida spp).https://www.cdc.gov/fungal/diseases/index.html
- Template:Discussion The above list of possible sources does not seem to include the obvious which would be the respiratory secretions obtained by suctioning an ETT or Trach. I would assume we need to include this. --LKolesar 08:45, 2018 June 15 (CDT)
5. NOTE: THIS SECTION IS A NEW CDC ITEM : Must have met the first 3 criteria above AND have at least TWO of the following 4 things (this criteria does not require a positive culture):
- New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
- New onset or worsening cough, or dyspnea, or tachypnea
- Rales or bronchial breath sounds.
- Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirements, or increased ventilator demand
- This section is only used if a VAP is being suspected and no positive culture is available. If the first 3 criteria is met and you have two of the items off the list above, this can still be considered a VAP.
VAP Pathogens Excluson List
NEW CDC LIST (does not include candida b/c can be a valid pathogen in immunocompromised pts who have candida in both blood and ETT cultures (see above list of sources)
- Normal respiratory flora
- Normal oral flora
- Mixed respiratory flora
- coagulase-negative staph species (includes S. epidermidis, does not include S. aureus)
- Enterococcus species
- Blastomyces species (blasto)
- Histoplasma species
- Coccidioides species
- Paracoccidioides species
- Cryptococcus species
- Pneumocystis species
- Patients might be treated for infection with these pathogens, but we should still not code them as VAP. In that case you might be able to code it as a Hospital-acquired pneumonia (HAP) in ICD10 or Community-acquired pneumonia (CAP) in ICD10.
MRSA colonized
Is this still valid? It is cut and pasted below and taken from the old guidelines.Template:Discussion Template:DiscussAllan
- 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.
CXR's
- Some VAP can be occasionally missed because the doctors are not always doing the follow up CXR's after the intial infiltrate and identification of pathogen. If the infiltrate need to be new and persistent or progressive and persistent, if those follow up CXR's are not done we can't code a VAP even if it is a probable VAP. If the QA people want to improve VAP recording by data collectors than maybe attendings need to be reminded to do those follow up CXR's on the cases that they think have VAP? Just a thought.GHall 10:42, 2018 April 5 (CDT)Template:Discussion
CAP patients developing VAP
Template:Discussion We had guidelines for this that didn't get moved yet.
Possible sources of cultures listed
What about regular endotracheal tube aspirates?
Alternate ICD10s to consider coding instead or in addition
| Pneumonia codes: |
Candidate Combined ICD10 codes
Infections
Infections in ICD10 have combined coding requirements for some of their pathogens. Any that have antibiotic resistances would store those as Combined ICD10 codes as well. If the infection is acquired in the hospital, see Nosocomial infection, NOS. See Lab and culture reports for confirmation and details about tests. See Infections in ICD10 for more general info.
Possible Simultaneous Presence of Multiple Different Types of Infection in a Single Site
- This refers to the situation where there may be simultaneous infection with multiple types of organisms -- e.g. 2 of bacteria, virus, fungus. While a classic example is a proven viral pneumonia (e.g. influenza) with a suspected/possible bacterial pneumonia superimposed, this kind of thing can occur in places other than the lungs, e.g. meningitis.
- The "signature" of this is typically the patient being treated simultaneously with antimicrobial agents for multiple types of organisms. BUT don't confuse this with there being infections at DIFFERENT body sites.
- As per our usual practice, we will consider a diagnosis as present if the clinical team thinks it's present and are treating it, with the exception that the team initially treated for the possible 2nd type of infection but then decided it likely was NOT present and stopped those agents.
- And remember that Infectious organism, unknown is used when the the specific organism is unknown (this could be not knowing the TYPE of organism, or suspecting the type but not having identified the specific organism of that type), while when the organism has been identified but it's not in our bug list, THEN use Bacteria, NOS, Virus, NOS or Fungus or yeast, NOS.
Attribution of infections
Related CCI Codes
Data use
Used in:
Reporting of complication when patients move units
The Ventilator Associated Pneumonia Rate we report are based only on Acquired Diagnosis / Complication occurring in a unit. If VAP is coded as an Admit Diagnosis, we check if the patient came from one of the ICUs where we collect data, and if so, make sure that the VAP is coded as a Acquired Diagnosis / Complication and QA Infection VAP there.
If a VAP Admit Diagnosis doesn't have a corresponding Acquired Diagnosis / Complication in the previous unit, the data processor will ask the collector to audit.
Criteria change
The update in criteria in 2017-11 will likely lead to a higher rate of identifying VAPs. This needs to be noted in reports.
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