Form
Approved
OMB No.
Exp. Date:
www.cdc.gov/nhsn
Ventilator-Associated Event (VAE)
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Facility ID: |
Event #: |
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*Patient ID: |
Social Security #: |
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Secondary ID: |
Medicare #: |
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Patient Name, Last: |
First: |
Middle: |
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*Gender: F M Other |
*Date of Birth: |
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Sex at Birth: F M Unknown |
Gender Identity (Specify): |
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Ethnicity (Specify): |
Race (Specify): |
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*Event Type: VAE |
*Date of Event: |
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Post-procedure VAE: Yes No |
Date of Procedure: |
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NHSN Procedure Code: |
ICD-10-PCS or CPT Procedure Code: |
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*MDRO Infection Surveillance: |
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□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module |
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□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module |
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*Date Admitted to Facility: |
*Location: |
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* Location of Mechanical Ventilation Initiation: ______________ |
*Date Initiated: __ /__ /_____ |
APRV: Yes No |
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Event Details |
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*Specific Event: |
□ VAC |
□ IVAC |
□ PVAP |
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*Specify Criteria Used: |
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STEP 1: VAC (≥1 REQUIRED) |
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□ Daily min FiO2 increase ≥ 0.20 (20 points) for ≥ 2 days† |
OR □ Daily min PEEP increase ≥ 3 cm H2O for ≥ 2 days† |
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†after 2+ days of stable or decreasing daily minimum values. |
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STEP 2: IVAC |
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□ Temperature > 38°C or < 36° OR □ White blood cell count ≥ 12,000 or ≤ 4,000 cells/mm3 |
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AND |
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□ A new antimicrobial agent(s) is started, and is continued for ≥ 4 days |
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STEP 3: PVAP |
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□ Criterion #1: Positive culture of one of the following specimens, meeting quantitative or semi-quantitative thresholds as outlined in protocol,‡ without requirement for purulent respiratory secretions: |
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□ Endotracheal aspirate |
□ Lung tissue |
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□ Bronchoalveolar lavage |
□ Protected specimen brush |
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OR |
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□ Criterion #2: Purulent respiratory secretions‡ (defined in the protocol) plus organism(s) identified from one of the following specimens:‡ |
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□ Sputum |
□ Lung tissue |
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□ Endotracheal aspirate |
□ Protected specimen brush |
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□ Bronchoalveolar lavage |
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OR |
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□ Criterion #3: One of the following positive tests (as outlined in the protocol):‡ |
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□ Organism(s) identified from pleural fluid |
□ Diagnostic test for Legionella species |
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□ Lung histopathology |
□ Diagnostic test for selected viral pathogens |
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‡collected after 2 days of mechanical ventilation and within +/- 2 days of onset of increase in FiO2 or PEEP. |
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*Secondary Bloodstream Infection: Yes No |
*COVID-19: Yes No |
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**Died: Yes No |
VAE Contributed to Death: Yes No |
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Discharge Date: |
*Pathogens Identified: Yes No *If Yes, specify on pages 2-3 |
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Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 28 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.112 (Front), Rev 6 v8.8 |
Ventilator-Associated Event (VAE)
Pathogen # |
Gram-positive Organisms |
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Staphylococcus coagulase-negative
(specify species if available): |
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____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level) |
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Staphylococcus aureus
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Pathogen # |
Gram-negative Organisms
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Acinetobacter (specify species) ____________ |
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Escherichia coli
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Enterobacter (specify species) ____________
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____Klebsiella pneumoniae ____Klebsiella oxytoca ____Klebsiella aerogenes |
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Pseudomonas aeruginosa
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Pathogen # |
Fungal Organisms |
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Candida (specify species if available) ______________ |
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Pathogen # |
Other Organisms |
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Organism 1 (specify) _____________ |
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Organism 1 (specify) _____________ |
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Organism 1 (specify) _____________ |
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Result Codes
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent
N = Not tested
§ GENTHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic
† Clinical breakpoints are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2 and Resistant MIC ≥ 4
Drug Codes: |
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AMK = amikacin |
CEFTAR = ceftaroline |
GENT = gentamicin |
OX = oxacillin |
AMP = ampicillin |
CEFTAVI = ceftazidime/avibactam |
GENTHL = gentamicin –high level test |
PB = polymyxin B |
AMPSUL = ampicillin/sulbactam |
CEFTOTAZ = ceftolozane/tazobactam |
IMI = imipenem |
PIPTAZ = piperacillin/tazobactam |
AMXCLV = amoxicillin/clavulanic acid |
CEFTRX = ceftriaxone |
IMIREL = imipenem/relebactam |
RIF = rifampin |
ANID = anidulafungin |
CIPRO = ciprofloxacin |
LEVO = levofloxacin |
TETRA = tetracycline |
AZT = aztreonam |
CLIND = clindamycin |
LNZ = linezolid |
TIG = tigecycline |
CASPO = caspofungin |
COL = colistin |
MERO = meropenem |
TMZ = trimethoprim/sulfamethoxazole |
CEFAZ= cefazolin |
DAPTO = daptomycin |
MERVAB = meropenem/vaborbactam |
TOBRA = tobramycin |
CEFEP = cefepime |
DORI = doripenem |
METH = methicillin |
VANC = vancomycin |
CEFOT = cefotaxime |
DOXY = doxycycline |
MICA = micafungin |
VORI = voriconazole |
CEFOX= cefoxitin |
ERTA = ertapenem |
MINO = minocycline |
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CEFTAZ = ceftazidime |
FLUCO = fluconazole |
MOXI = moxifloxacin |
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Ventilator-Associated
Event (VAE)
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.112_VAE |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-08-26 |