Pneumonia, ventilator-associated (VAP): Difference between revisions
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===VAP Pathogens Excluson List=== | ===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 respiratory flora | ||
*Normal oral flora | *Normal oral flora | ||
Revision as of 19:34, 2017 December 4
| 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 supercedes 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.
- The only way VAP can be coded (as an admit code)on a medicine ward is if (see criterion#1, below) the patient's Mechanical Ventilation (MV) ended that day or the prior day in an ICU AND he/she met all the criteria.
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 on the day of transfer OR the next day, 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 an 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
- meet all criteria of an Acquired Diagnosis / Complication of VAP while in your unit
- then
- Contacting Quality Officer and Manager for VAPs and CLIs;( Exception for STB_CICU & STB_CCU: do not contact the Quality Officer but need to still contact the respective manager.)
- make the following entry in tmp:
- Project: QAInf
- Item: VAP
- date_var: date (no time) positive sputum culture was sent to micro lab.
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.
- e.g: if MV is started on Tuesday, first day that that VAP can occur is Thursday.
- It can occur on the day MV ends or the day following MV ends IF the MV had been in place already for >2 calendar days before ending.
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
5. NOTE: THIS SECTION IS A NEW CDC ITEM : Must have the first 3 criteria met 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.
Alternate ICD10s to consider coding instead or in addition
| Pneumonia codes: |
Candidate Combined ICD10 codes
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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