Ventilator Associated Pneumonia Rate
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|Indicator:||Ventilator Associated Pneumonia (VAP) Rate|
|Start Date:||Jan 1 2013|
Number of cases of VAP - Ventilator Associated Pneumonia per 1000 Ventilator-days
- VAP is a device-associated infection, the device being the artificial airway-ventilator-circuit system. VAPis associated with worse patient outcomes and higher costs.
- Factors affecting the incidence of VAPinclude those from patients (severity of illness, comorbidities, etc.) and processes of care.
- VAPrate is a measure of the incidence of VAP.
Sampling Plan / Procedure
- 100% sampling for all patients on invasive mechanical ventilation as indicated by presence of T48 - Invasive mechanical ventilation at 2300 hrs (TISS Item)
- 100% sampling for all cases with VAP incidence following the criteria listed in VAP - Ventilator Associated Pneumonia
Exclude non-invasive ventilation.
- 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
Num = Total VAP Cases in a calendar period
Denom =Total Vent Days on the same period as the numerator
VAP Rate = Num / Denom * 1000
- 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%
- Daily data for Invasive are taken on TISS28 element T48 - 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.
- Starting 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
- Before 2019, the dates when VAP occurred were taken from the Tmp project QA Infection.
- 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\CFE_tiss28.sas
- 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