CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
CUSP for VAP: EVAP – Low Tidal Volume Ventilation Form
Hospital ID# ___________ Unit ID#___________ Date (mm/dd/yyyy) ___________
Fill out for
all beds
Bed #
Fill out if
patient is
mechanically
ventilated
Intub/
Trach &
Mech
Vent
Vent Mode –
1, 2 or 3
Y N E
1 2 3
Y N E
1 2 3
Y N E
Y N E
Fill out if Vent Mode = 1 or 2
Height – enter
centimeters or
inches
cm
in
Gender –
M or F
Does patient have a
risk factor for ARDS?
Does the patient have
ARDS?
M F
Y N
Y N
M F
Y N
Y N
1 2 3
M F
Y N
Y N
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
Y N E
1 2 3
M F
Y N
Y N
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
Tidal Volume (mL)
– Enter value
Plateau Pressure
(cm H2O) – Enter value
or NK
Fill out if Vent Mode = 1, 2 or 3
PEEP
(cm H2O) –
Enter Value or
NK
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
Ventilator Modes:
Enter 1 – if the patient’s vent is set to one of the following Volume Cycled Modes
1. Continuous Mandatory Ventilation (CMV)
2. Assist Control (AC)
3. Synchronized Intermittent Mandatory Ventilation (SIMV)
4. Volume Support (VS)
5. Pressure Regulated Volume Controlled (PRVC)
Enter 2 – if the patient’s vent is set to one of the following Pressure Cycle Modes
1. Pressure Support (PS)
2. Continuous Positive Airway Pressure (CPAP)
3. Pressure Control (PC)
4. Airway Pressure Release Ventilation (APRV)
5. BiLevel Ventilation
Enter 3 – if the patient’s vent is set to one of the following modes
1. Proportional Assist Ventilation (PAV)
2. Adaptive Support Ventilation (ASV)
3. Inverse Ratio Ventilation
4. High Frequency Oscillatory Ventilation (HFOV)
5. Extracorporeal Membrane Oxygenation (ECMO)
6. Other
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
Instructions for CUSP4MVP-VAP – Low Tidal Volume Ventilation Form



Please complete this form once a day, every day. If possible, complete it around the same time each day, hopefully during patient rounds.
Patients are considered to be mechanically ventilated on a specific day if they were mechanically ventilated at the time of observation.
All of the vent modes are listed on the back of the data collection sheet. Please print the data collection sheet with the vent modes on the
back of the sheet for ease of data collection.
DATA FIELD
DIRECTIONS
Hospital:
Enter the name of your hospital.
ICU:
Enter the name of your unit.
Date:
Enter today’s date as MM/DD/YYYY format (e.g. 01/31/2014).
Bed #:
Enter all the bed numbers on the form, whether the patient is on mechanical ventilation or
not. Include empty beds.
Intub/Trach & Mech Vent:
Is the patient currently receiving mechanical
ventilation?
Enter for all patients. Mechanical ventilation is defined as receiving ventilator support via an
ETT or tracheostomy tube.
 Patients treated with non-invasive ventilation would be counted as ‘N’
 Enter ‘Y’ if the patient is currently intubated/trached and mechanically ventilated.
 Enter ‘N’ if the patient is not currently intubated /trached and mechanically ventilated.
 Enter ‘E’ if there is no patient in the bed.

For any specific patient, if the patient is not currently intubated/trached AND on mechanical
ventilation, STOP. Do not enter any more information regarding that bed for this date.
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
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Ventilator Mode
DATA FIELD
DIRECTIONS
Enter for all patients receiving mechanical ventilation.
Enter 1, 2, or 3 on the form depending on which type of vent mode is being used at
the time of observation.
Enter 1 – if the patient’s vent is set to one of the following Volume Cycled Modes
6. Continuous Mandatory Ventilation (CMV)
7. Assist Control (AC)
8. Synchronized Intermittent Mandatory Ventilation (SIMV)
9. Volume Support (VS)
10. Pressure Regulated Volume Controlled (PRVC)
Vent Mode: What mode of ventilation is
being used at the time of observation?
Enter 2 – if the patient’s vent is set to one of the following Pressure Cycle Modes
6. Pressure Support (PS)
7. Continuous Positive Airway Pressure (CPAP)
8. Pressure Control (PC)
9. Airway Pressure Release Ventilation (APRV)
10. BiLevel Ventilation
Enter 3 – if the patient’s vent is set to one of the following modes – If your answer is
3, skip to “Does patient have a risk factor for ARDS?”
7. Proportional Assist Ventilation (PAV)
8. Adaptive Support Ventilation (ASV)
9. Inverse Ratio Ventilation
10. High Frequency Oscillatory Ventilation (HFOV)
11. Extracorporeal Membrane Oxygenation (ECMO)
12. Other
For any specific patient, if the numerical value equals 3, skip to “Does patient have a
risk factor for ARDS?” AND “Does the patient have ARDS?”
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
Height
FIELD
DIRECTIONS
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1 or 2.
Don’t enter both centimeters and inches.
Height: How tall is the patient?


Enter the patient’s height in centimeters in the “cm”column if your unit uses
centimeters.
Enter the patient’s height in inches in the “in” column if your unit uses inches.
Gender
FIELD
DIRECTIONS
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1 or 2.
Gender


Enter “M”, if the patient is male.
Enter “F”, if the patient is female.
For transgender patients, please enter their birth gender.
For transsexual patients, please enter their current gender.
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
Tidal Volume
FIELD
DIRECTIONS
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1 or 2.
Enter the Tidal Volume in milliliters (mL). Use the Preset tidal (prescribed) volume if the mode is
one of the Volume Cycled Modes (from Vent Mode question above).
Tidal Volume: What is the Tidal Volume at
the time of observation?
If the modes is one of the Pressure Cycle Modes (from Vent Mode question, above), enter the
approximate expired tidal volume.
If the vent mode for the patient is in the third group of vent modes (from Vent Mode question,
above), you should not be collecting this data. (Please read instructions for Vent Mode,
above.)
Plateau Pressure
FIELD
DIRECTIONS
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1 or 2.
Enter the Plateau Pressure at or nearest to the time of observation.
Plateau Pressure: What is the Plateau
Pressure at or nearest to the time of
observation?
If it is not available or unknown, please enter “NK”.
For APRV/BiLevel modes, this is the Plow value.
If the vent mode for the patient is in the third group of vent modes (from Vent Mode question,
above), you should not be collecting this data. (Please read instructions for Vent Mode,
above.)
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
PEEP (Positive End-Expiratory Pressure)
FIELD
DIRECTIONS
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1 or 2.
Enter the PEEP value at or nearest to the time of observation.
PEEP: What is the PEEP (Positive EndExpiratory Pressure at or nearest to the time
of observation?
If it is not available or unknown, please enter “NK”.
For APRV/BiLevel modes, this is the Plow value.
If the vent mode for the patient is in the third group of vent modes (from Vent Mode question,
above), you should not be collecting this data. (Please read instructions for Vent Mode,
above.)
ARDS
FIELD
DIRECTIONS
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1, 2
AND 3.
ARDS Risk Factors: Does the patient have a
Risk Factor for ARDS?
If the patient has one or more of the following, enter “Y”, otherwise enter “N”.
1. Pneumonia
2. Sepsis, Severe Sepsis or Septic Shock, not secondary to pneumonia
3. Aspiration
4. Trauma
Remember to answer this question even if your Vent Mode = 3. (Please read instructions for
Vent Mode, above.)
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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CUSP 4 VAP:EVAP – Low Tidal Volume Ventilation
Version 14.04.28
Evaluate daily for patients receiving mechanical ventilation and whose vent mode equals 1, 2
AND 3.
ARDS: Does the patient of the diagnosis of
ARDS at the time of the observation?
If the patient has a diagnosis of ARDS at the time of observation, enter “Y”, otherwise enter “N”.
Remember to answer this question even if your Vent Mode = 3. (Please read instructions for
Vent Mode, above.)
Please enter data from this paper-based data collection form in the CECity web-based reporting system at least once per
week.
CUSP 4 VAP: EVAP – Low Tidal Volume Ventilation_14.04.28
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
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