VAP - Ventilator Associated Pneumonia: Difference between revisions
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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== | ||
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. | ||
Revision as of 14:13, 2017 February 9
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.Trish Ostryzniuk 17:13, 2013 May 6 (EDT)
Legacy Content
This page is about the pre-ICD10 diagnosis coding schema. See the ICD10 Diagnosis List, or the following for similar diagnoses in ICD10:Pneumonia, ventilator-associated (VAP)Click Expand to show legacy content.
| edit dx infobox | |
| Category/Organ System: |
Category: Infection (old) |
|
Type: |
[[:Category: Medical Problem (old)]][[Category: Medical Problem (old)]] |
| Main Diagnosis: | Pneumonia |
| Sub Diagnosis: | PNEUMONIA-VAP (ventilator acq'd) |
| Diagnosis Code: | 3900-Ventilator Associated Pneumonia |
| Comorbid Diagnosis: | No |
| Charlson Comorbid coding (pre ICD10): | 0 |
| Program: | Critical Care and Medicine |
| Status: | Currently Collected |
| Start Date: | July 1, 2006 |
Ventilator Associated Pneumonia (VAP) 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 .
IF a patient has been on a device to assist respiration (ventilator) either continuously or intermittently through a tracheostomy or endotracheal tube (ETT) for at least 48 hours before onset of infection, or new infection. (start counting the 48 hours from the time of intubation no matter where this intubation occurs before or during an admission to the ICU.) per Dr. Olafson.
AND if they demonstrate new, worsening or persistent infiltrate on x-ray compatible with pneumonia
AND if at least one of the following criteria is met:
- Fever (T > 38) with no other cause
- Leukopenia WBC(<4X10(9)) or leukocytosis (>12x 10(9)).
- Altered mental status with no other causes in >69 year old.
AND if at least one of the following criteria is met:
- New onset of purulent secretions
- Change in character of sputum
- Increased volume of purulent secretions
- Increased suction requirement
- New onset of worsening cough
- New onset of dypsnea (SOB) or tachypnea (increased Resp Rate)
- Increased oxygen or ventilation requirement
AND if at least one of the following criteria is met:
- Pathogen isolated from sputum in the last 48 hours
- Whenever a positive sputum culture is reported, the data collector should check to see if this is first of all, a pneumonia and then, to see if it is a CAP, HAP or VAP. (Sometimes it is an upper respiratory tract infection (URTI) and not a pneumonia at all). The time frame for looking at the VAP criteria listed below is within a day or two of when the positive culture was sent. --LKolesar 15:29, 2013 April 22 (EDT)
- Positive blood cultures not related to another infection
- Positive pleural fluid culture.
Additional Information
- Keep in mind VAP Attribution TRANSFER RULE when transferring between ICU's, in that a patient could aready have been on a ventilator for 48 hrs or more prior to transferring into to your ICU.
- If a patient had a CAP or HAP 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. If it is the same original organism, then the CAP or HAP has not completely been resolved. Do not code these as a VAP.
- checked with Dr Olafson today. Patients with other infections are not automatically excluded from the VAP criteriaGHall
- infiltrates that are present example CAP on admission need to worsen and also meet the VAP criteria to code VAP.
NOTE for clarification of 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)
- 1. CXR infiltrates
- 2. increased WBC or fever (with no other infective source identified)
- 3. starting to have purulent secretions
- 4. increased ventilation requirements (for no other reason).
- 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 CDC VAP Survellance, 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.
- CANDIDA SPECIES (specified or unspecified)
- YEAST not otherwise specified
- COAGULASE-NEGATIVE STAPHYLOCOCCUS SPECIES (specified or unspecified) EXCEPTION: Staphylococcus aureus including MRSA
- ENTEROCOCCUS SPECIES (specified or unspecified)
If the pathogen is isolated from cultures of: LUNG TISSUE or PLEURAL FLUID, these organisms MAY BE reported as Possible or Probable VAP pathogens.
If the pathogen is isolated from culture of: SPUTUM, ENDOTRACHEAL ASPIRATES, BRONCHOALVEOLAR LAVAGES or PROTECTED SPECIMEN BRUSHINGS then they may NOT be listed as cause of VAP.
- These organisms are excluded because they are common upper respiratory tract commensals, colonizers or contaminants, and are unusual causes of VAP
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. -Trish Ostryzniuk 18:29, 2013 October 7 (CDT)
Time window for VAP
You need to look for the WBC, fever, sputum and CXR signs either the day before, day of or day after the positive culture.
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.
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.
Background
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.
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. 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 Trish Ostryzniuk 12:09, 2012 October 4 (CDT), on behalf of Dr. Kumar and reviewed by Dr. Olafson.
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.
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.
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.
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 Community Acquired Pneumonia (CAP). (as per Dr. Bruce Light).TOstryzniuk 17:38, 15 December 2008 (CST)
This was confirmed again by Dr.Garland on May 9,2013.
CDC Document
Template:Discussion Searched for the CDC document and found this. The document is from January 2017. Are there any changes to what was used before?
Alternative diagnoses
Data use
Used in:
Reporting of complication when patients move units
When the statistician links admissions in the database between ICU'a & medicine wards in the city, those patient that have VAP in admitting diagnosis are excluded from complication statistics. The patient encounter that had the VAP coded in the acquired diagnosis slot is the unit that is given credit for the complication occurring in that unit.
When coding VAP's they are coded as "complication" when they occur at a specific center. However, when these patients are transferred to other centers and the VAP is still being treated, then the VAP should be coded as part of the admitting diagnosis. When Julie looks at VAP rates in ICU's she only looks for the VAP code in the complication slots. The site where the patient had the VAP occur in complication codes is the site that is given the credit. A unit where a patient has a VAP in the admitting diagnosis is not included in stats for VAP rates. 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.