Kaddam Multispeciality Hospital

(Mini Bypass, Bank Colony, Rohtak Road, Bhiwani, HR, 127021)

VAP (Ventilator-associated pneumonia) SURVELILLANCE FORM

Patient Name: UHID:

Age/Sex: D.O.A. Brought From: Home Hospital
Diagnosis: Ward/Unit:

Risk Factors
 Kaddam Multispeciality Hospital
(Mini Bypass, Bank Colony, Rohtak Road, Bhiwani, HR, 127021)

Ventilator: Yes / No Date of Endotracheal Tube/Ventilator Date of

Endotracheal

Tube/Ventilator Insertion: ….…/..…../……. Removal: ..…/……/……

For NICU Only: Birth weight: ______________ grams

Patient Details

Specific Event : PNU1 PNU2 PNU3 (PROTIENE NITROGEN UNIT)

 Kaddam Multispeciality Hospital
(Mini Bypass, Bank Colony, Rohtak Road, Bhiwani, HR, 127021)

Specific Criteria Used: (Check all that Apply)

Few or Progressive Consolidation Cavitations Pneumatoceles

and Persistent Infiltrate
Signs & Symptoms
Fever
Leukopenia or Leukocytosis
Few onset/change in sputum
Few onset/worsening cough, dyspnea,
tachpnea
(in <=1 y.o)
Signs & Symptoms
Bradycardia or Tachycardia
Temperature instability
Apnea, Tachycardia, nasal Flaring and
with retraction of chest wall or grunting
Hypothermia
 Kaddam Multispeciality Hospital
(Mini Bypass, Bank Colony, Rohtak Road, Bhiwani, HR, 127021)

Pales or Bronchial breath Sounds Wheezing, rales or rhonchi

Worsening gas Exchange Cough
Other associated parameters

Signs & Symptoms Date

TLC (Total Leukocyte

Count)
DLC (Differential
Leukocyte Count)
Fever
 Kaddam Multispeciality Hospital
(Mini Bypass, Bank Colony, Rohtak Road, Bhiwani, HR, 127021)

Culture Details

Micro-organism Date
 Kaddam Multispeciality Hospital
(Mini Bypass, Bank Colony, Rohtak Road, Bhiwani, HR, 127021)

Nosocomial Infection: YES NO

Recorded By:

Name________ _________ Signature___________________ Date ______________________