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
Only code VAP if the #VAP Criteria are met completely. If they are met, also enter tmp as per QA Infection VAP.
Data Collection Instructions
VAP Criteria
Must meet the CDC criteria: (all of #1 - Ventilated + #2 - Infection + #3 - CXR indicators) + (EITHER OF #4 - Respiratory indicators OR #5 - Alternative indicators)
1 - Ventilated
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 - Infection
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 - CXR indicators
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
Criteria 3 clarifications
- Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients, #3 - CXR indicators requires that the listed changes be either "New and Persistent" or "Progressive and Persistent". This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".
- If, in real time, you are seeing that a ventilated patient qualifies for a VAP except that a followup CXR wasn't done to demonstrate persistence, you should point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. Refer them to Dr. Garland if there's resistance to this.
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what would the resistance be to, to taking another CXR just to prove VAP, or to not calling it VAP in absence of that CXR? |
4 - Respiratory indicators
Has at least two 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
- Newly identified Rales or bronchial breath sounds.
- Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240, arterial blood gas or pulse oximetry), increased oxygen requirements, or increased ventilator demand
5 - Alternative indicators
Has at least one item in both of #List 5a and #List 5b
List 5a
(Yes, this is the same list as #4 - Respiratory indicators, but here it's just 1 item instead of 2 items)
- 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
- Newly identified Rales or bronchial breath sounds.
- Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240, arterial blood gas or pulse oximetry), increased oxygen requirements, or increased ventilator demand.
List 5b
- Organism identified from blood (see #VAP Pathogen exclusion list)
- Organism identified from pleural fluid (see #VAP Pathogen exclusion list)
- Virus, Bordetella, Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method
- In an compromised patient: identification of matching Candida from blood and sputum, endotracheal aspirate, BAL or protected specimen brushing. (This is a new CDC item)
- In an compromised patient: Evidence of fungi (i.e. mycelia, not yeast) from BAL or protected specimen brushing)(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
- Positive quantitative culture, performed according to accepted protocols, from bronchoalveolar lavage or protected brush specimens (see#VAP Pathogen exclusion list)
- Regarding the "quantitative culture", Dr. Garland says this is not done very often if ever and he has actually never seen one done at HSC. Most bronchoscopies are not "quantitative" so for most intents and purposes a BAL culture is not valid for use in the VAP criteria unless candida is cultured in immunocompromised patients only and only if the patient also has a matching blood culture. --LKolesar 09:55, 2018 July 26 (CDT)
- >5% of cells obtained from bronchoalveolar lavage contain intracellular bacteria on direct microscopic exam
- Positive culture of lung tissue (see #VAP Pathogen exclusion list)
- Histopathologic exam of lung tissue identifies abscess formation, or foci of consolidation with intense PMN accumulation in bronchioles and alveoli
- Histopathologic exam of lung tissue identifies lung invasion of fungal hyphae or pseudohyphae
- 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
- (ETT secretion(sputum) culture is NOT part of the criteria -- the reason is that sputum is virtually never culture negative in intubated patients, even without infection. We will still enter the ETT pathogen as ICD10 pathogen if it is available, even though the positive culture is not part of the criteria.)
what is this?
- See below for detailed list of all possible sources for cultures:
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where is that list of sources, did it get lost in an edit? |
VAP Pathogen exclusion 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 list 5B, above)
- Normal respiratory flora
- Normal oral flora
- Mixed respiratory flora
- Cagulase-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.
- Some Notes:
- Prior colonization with MRSA does not exclude it from causing VAP, if they meet the listed criteria.
Sputum cultures
Sputum culture is not part of the CDC criteria defining a VAP because sputum is virtually never culture negative in intubated patients, even without infection. You can use culture results of respiratory secretions to identify the Pathogen for your ICD10 Diagnosis (though positive blood or pleural fluid culture is considered more definitive).
No such thing as "presumed VAP"
Following CDC criteria, we will not code "presumed VAP".
No special rules for "CAP developing VAP"
There are no guidelines for CAP developing VAP, other than meeting the VAP criteria. For example, the idea of a CXR showing a "New and persistent" or "Progressive and Persistent" infiltrate allows for coding a second pneumonia on top of a first one.
VAP supersedes other pneumonia codes
- This code supersedes the codes for Pneumonia, bacterial, Pneumonia, fungal/yeast, Pneumonia, viral and Pneumonia, NOS.
| Example |
|
If the patient qualifies for having a bacterial VAP, you code the VAP linked to the pathogen, 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.
VAPs on medicine wards
- The only way VAP can be coded (as an Admit Diagnosis) on a medicine ward is if -- as per criterion #1 below -- 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 Diagnosis 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 mechanical ventilation for 48 hours, then it is not a VAP, even if the positive culture is done after the 48 hour mark.
Recent previous pneumonia
- 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.
- An important consequence of this is that if on admission to the current unit it was NOT recognized that the patient has a VAP, but by these rules it is then figured out to be so --> THEN the correct coding of this VAP is as an Admit Diagnosis, not an acquired diagnosis -- Tina please put this in for CLI too.
- 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.
- A new VAP that is identified first on a medicine ward must be attributed to the ICU that sent the patient.
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.
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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