2015 NHSN Training Teresa Fox, CIC Quality Improvement Advisor [email protected].

2015 NHSN Training

Teresa Fox, CIC

Quality Improvement Advisor

[email protected]

2

Objectives

Discuss New Definitions and Modifications for 2015

Review of Reporting for LabID Events

Review of Reporting for CAUTI

3

HAI Surveillance in the Current U.S. Environment

ImplicationsChanges in NHSN’s purposes, infrastructure and operations

New scrutiny of HAI case criteria

Increasing attention to data quality

Pressure to HAI definitions and move to electronic HAI detection and reporting

EnvironmentPublic Reporting

Pay for Reporting

Pay for Performance

4

Implications of Public Reporting and Pay for Performance

New scrutiny of HAI definitions and case studies

• Updates of definitions and case criteria that reflect user’s concerns about misclassification of some events

Heightened emphasis on data validation

• Assistance to states and CMS for validation

Pressure to simplify HAI definitions and data requirements and move to electronic HAI detection and reporting

• Revise definitions and data requirements in ways to reduce complexity, maintain clinical relevance, and avoid potential case misclassification

• Accelerate use of electronic healthcare data for event detection and reporting purposes

5

NHSN Plans for 2015 and Beyond

New baseline year for ALL HAIs

• Implementation of new definitions and criteria changes for several HAIs concurrently and retaining those previously established

• Allow data from single calendar year as the new baseline for SIRs

• Provide baseline data for calculating SIRs for 2016 and the following years

• Potential to recalculate 2015 SIRs from the 2015 baseline population

Future changes (3-5 years) will be driven by increasing healthcare data availability via electronic methods and increasing EHRs

6

2015 CMS Reporting Requirements-Acute Hospitals

CLABSI

• Adult, pediatric and neonatal ICUs

• Adult and pediatric medical wards, surgical wards & med-surgical wards

CAUTI

• Adult and pediatric ICUs

• Adult and pediatric medical wards, surgical wards & med-surgical wards

SSI

• Inpatient colon and abdominal hysterectomy procedures

7

2015 CMS Reporting Requirements-Acute Hospitals (cont’d)

MRSA Bacteremia and CDI LabID Events

• Facility-wide inpatients

HCP Influenza Vaccination Summary

• Inpatient and outpatient healthcare personnel

Medicare Beneficiary Number

• All events (numerators) from Medicare patients

8

Major Definition Changes for Specific Types of Infections

UTI• Major changes to

definitions-covered in UTI presentation

Secondary BSI Attribution• Major changes to

definition for Secondary Bloodstream Infections

• Reinforced in CLABSI presentation

Clostridium difficile infection

BSI, Pneu, SSI, UTI, VAE• Removed from Chapter

17• Found in separate,

dedicated chapters• Chapters cover both

device-associated and non-device associated

BRON• Removed entirely from

NHSN surveillance

9

New Definitions and Modifications

Infection Window Period *+

Date of Event *

• Present on Admission Infections (POAs) *+

• If housed in ED prior to admission- date of Admission is date when moved to inpatient location

• Healthcare Associated Infections (HAIs) *+

Repeat Infection Timeframe (RIT) *+

Secondary BSI Attribution Period *+

Pathogen assignment (part of RIT) *+

* Does not apply to VAE, or LabID Events

# Does not apply to SSI

10

2015 Removed Criteria

Gap Days to determine criterion met

Logical pathogens to determine secondary BSI

Date of Event- when last element of criteria is met

DELETE

11

Infection Window Period

A 7-day-period which all site-specific infection criterion must be met to determine an event includes:

• Date of the first positive diagnostic test

• 3 calendar days before

• 3 calendar days after

If site-specific criterion does not include a diagnostic test, the first documented localized sign and symptom that is an element of the infection criterion will be used

-3 day -2 day -3 day Event Date 1 day 2 day 3 day

First positive diagnostic test

12


Diagnostic tests

• Laboratory specimen collection (If more than one diagnostic test, use most localized test result)

• Imaging test

• Procedure or exam

• Physician diagnosis

• Initiation of treatment

Localized S&S

• Diarrhea

• Site specific pain

• Purulent drainage

13

Date of Event

2014 2015

Last element of criterion met

First element of criterion met

14


Hospital Day

Criterion

89

1011 Temp= 101.5˚F12 Temp= 102.3˚F13 UC: >100,000 E.coli1415161718

3 Days Before

3 Days After

Infe

ction

Win

dow

Per

iod

Diagnostic Test

15

Infection Window Period and Date of Event

Hospital Day

SUTI Criterion

89

1011 Temp= 101.5˚F12 Temp= 102.3˚F13 UC: >100,000 E.coli1415161718In

fecti

onW

ind

ow

Per

iod

Date of EVENT

Date of Event is Day 11

16

Hospital Day

SUTI Criterion

89 Temp= 100.5˚F

10 Temp= 101.5˚F1112 Temp= 102.3˚F13 UC: >100,000 E.coli1415161718In

fecti

onW

indo

w P

erio

d Date of EVENT

Infection Window Period and Date of Event

First positive Diagnostic Test

17

POA vs HAI

Present on Admission (POA)- date of event occurs on the day of admission or the day after admission to an inpatient location

• POA time period includes day of admission, 2 days before and the day after admission

Healthcare-Associated Infection (HAI)- the date of event occurs on or after the 3rd calendar day of admission

18

Determining New vs. Continuation of Infections

2014 2015

Continuation of symptoms or treatment at time of next infection SubjectiveUndocumented

treatment target

Repeat Infection Timeframe (RIT)ObjectiveNo interpretation of

treatment purposesReduces IP labor

resources

19

Repeat Infection Timeframe (RIT)

Uses date of event to determine a 14-day timeframe during which no new infections of the SAME type are reported

The date of the event is DAY 1 of the 14-day timeframe for the RIT

If date of event for subsequent potential infection is within the 14-day RIT

• Do not report new infection

• Add additional pathogens to the original event

20

Repeat Infection Timeframe (RIT)Hospital

DaySUTI Criterion

89 Temp= 100.5˚F

10 Temp= 101.5˚F1112 Temp= 102.3˚F13 UC: >100,000 E.coli Infection Window Period14151617181920212223242526

14

Day

Rep

eat

Infe

ctio

n

Tim

efra

me

(RIT

)Date of EVENT

UC >100,000Proteus Fever 100.3 F

21

Repeat Infection Timeframe (RIT)

RIT applies at the level of specific type of infection with the exception of BSIs, UTIs and PNEUs where the RIT applies at the major type of infection

• Patient will have no more than one BRST (specific type of major type SST)

VS.

• Patient will have no more than one BSI

• Patient will have no more than one UTI

• Patient will have no more than one PNEU

22

Pathogen Assignment

Additional eligible pathogens identified within the RIT are added to the event

Pathogen exclusions for specific infection definitions also apply to secondary BSI pathogen assignment

• UTI- yeast

• Pneu- yeast, coag. negative Staph, Enterococcus unless isolated from lung tissue or pleural fluid; yeast is included for PNU3 (immunocomprised patients)

• Fungal pathogens

Excluded pathogens must be attributed to another site infection to be reported as a secondary BSI or it is identified as a primary BSI

23

RIT

MAJOR TYPE SPECIFIC TYPE

Skin and Soft Tissue Infection

BRST

Burn

Circ

Decu

Skin

UTI

SUTI

ABUTIOR

May have more than one in RIT

24

Secondary BSI Attribution Period

Secondary BS

I Attribution Period =

Infection Window

Period + R

ITHospital Day SUTI Criterion

9

10 Fever 101.8 F

11

12 Fever 102.4 F

13 UC > 100,000 E.coli

14

15

16

17

18

19

20

21

22

23

24

25

Date of Event

14 days

25


Hospital Day SUTI Criterion

9

10

11

12

13UC > 100,000 E.coli; costovertebral

angle pain

14 Fever 101.5 F

15 16

17

18

19

20

21

22

23

24

25

26

Date of Event17

day

s

26

Temperature Changes for 2015

No longer require core temperatures

Used documented temperature for all surveillance

Do not convert based on site

27

Secondary Bloodstream Infection (BSI)

2014 2015

No objective time period for associating BSI to another infection


28


Period in which a positive blood culture must be collected to be considered as a secondary bloodstream infection to infection at another primary site

Period includes the Infection Window Period combined with the Repeat Time Timeframe (RIT)

Period is 14-17 days in length depending on the date of event

Primary BSIs do not have a Secondary BSI Attribution Period

29

Device-Associated Denominator Sampling

Beginning January 2015, hospitals can begin to use an alternative method of collecting CLABSI and CAUTI denominator data in eligible ICU and Ward locations

• Reduces staff time in manual collection

• Requires data collection on the number of patient days, central lines and/or catheter days on a SINGLE DAY once per week

• Requires the number of patient days for every day of month

Entry of monthly sampling of device days and NHSN will automatically calculate and use the estimated CLABSI and CAUTI denominator

30

Denominator Sampling

Estimate denominator data, only for non-oncology ICUs and wards with ≥ 75 device days/month

Review each location’s prior year (12 months) to help determine which units or wards are eligible for sampling

More information available in the 2015 NHSN Manual

32

Updated Protocols and Clarifications

Protocols and outline of recent clarifications and UTI and SSI protocol modifications were posted to CDC/NHSN website in early April, 2015

Footers for each updated protocol will have a revision date of April 2015

UTI and SSI Surveillance will be impacted by revisions

• SSI modification should be used beginning January 1, 2015

• 2015 changes to the Inpatient and Outpatient OR procedure definition

• UTI modification should be used beginning April 1, 2015

• No requirement to edit CAUTI data for 1st quarter, 2015

33

Food for Thought

What admission and discharge date should be entered when the patient is admitted into a separately licensed CMS inpatient rehab facility (IRF) that is located inside of my acute hospital?

For NHSN purposes, if the IRF is set up as a patient care location within Hospital, movement between the acute care hospital and the IRF location should not be counted as a separate facility discharge and admission.Movements should be considered location transfers and counted as oneAdmission and one discharge from the acute care hospital.

34

Summary 2015

Surveillance definitions for specific infection types

• BRON no longer an NHSN infection

• New CDI Infection

• Other important changes

Temperatures are as documented in the chart

New alternative device day count option- weekly

• Available for certain locations

• Minimal average device days must be ≥ 75/month in prior year

35

Summary 2015 (cont’d)

GAP DAY concept no longer used

Date of Event- first date of element during infection window period

POA vs. HAI definition unchanged


• Time-limited

Secondary BSI Rules

• Simplified- blood culture matching site or part of infection definition

Pathogen assignment

• Add on if in RIT and not an excluded organism

• Organism may be added to more than one event

36

LabID Event Reporting

37

MRSA Bacteremia & C. difficile Reporting

MRSA: S. aureus testing oxacillin, cefoxition, or methicillin resistant; or positive from molecular testing for mecA and PBP2a

C. difficile: positive result for laboratory test for C. difficile toxin A and/or B or toxin-producing C. difficile detected in stool specimen by culture or by nucleic acid amplification testing by polymerase-chain reaction or PCR

• Testing should be performed ONLY on unformed stool specimens

38

MRSA Bacteremia & Clostridium difficile Reporting for 2015

Participating in CMS Inpatient Quality Reporting (IQR) Program

Acute Hospitals must report MRSA Bacteremia and C. difficile LABID Events at Facility-Wide

Inpatient Level (FacWideIN)

39

FacWideIN Reporting

Facility-wide Inpatient FacWideIN

• Includes inpatient locations

• Includes observation patients housed in an inpatient location

• All specimens or blood specimens only from each outpatient emergency department and 24-hour observation location

If facility is reporting all specimens, only Blood

Specimen data will be shared with CMS

40

FacWideIN Surveillance

41


42


43

What facility admission date should be used?

Acute Care Hospitals and CMS-IRF

• The admission date should reflect the date the patient was physically admitted to the inpatient unit in the hospital

44

LabID Events Checklist

Review location options and map locations in NHSN

Review Monthly Reporting Plan and update as needed

Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by LOCATION using the MDRO/CDI LabID Event protocol

Enter denominator data for each month under surveillance

Resolve ”ALERTS”

45

LabID Events Summary

Must be reported and monitored throughout all inpatient locations within the facility (except for locations traditionally house predominantly newborns)

Location specific reporting is required for CMS-IRF

Specimens and LabID Events collected from ED and 24-hour observation must be reported for outpatient locations regardless of whether patient is later admitted or not

Denominator counts are reported separately for each outpatient location

Specimens collected from other affiliated outpatient locations may be entered for FacWideIN ONLY if specimen collection date and admission date are the same

46

CAUTI Reporting

47

Consider for CAUTI Surveillance

All CAUTIs require a positive urine culture.

Know you laboratory’s urine culture policies:

• Ranges for CFU reported

• Positive urine cultures are reported for the unit where they were collected

• Minimal CFUs are reported

48

CMS Hospital Inpatient Quality Reporting Program 2015

Acute Care Hospitals

Unless a “Hospital IQR Program Healthcare-Associated Infection (HAI) Exception Form” is submitted

2015 added adult and pediatric medical, surgical and medical/surgical wards to all ICUs except NICUs

49

Urinary Tract Infection Definitions

Two Types of UTIsSymptomatic UTI- SUTI

Asymptomatic Bacteremic UTI-ABUTI

Both types, if catheter asso

ciated, must b

e reported

as part of th

e CMS CAUTI required reportin

g

50

UTI Overview

SUTI 1

A

Catheter-Associated

B

Non-catheter-Associated

Non-Catheter-Associated

Catheter-Associated

SUTI 2 ABUTI

Catheter-Associated

Non-catheter- Associated

Any Age Infant ≥ 1 year Any Age

CMS Reporting

51

SUTI Definition

Infants will exhibit symptoms differently from other ages

For infants the following additional symptoms may be used• Apnea• Bradycardia• Lethargy• Vomiting• Hypothermia < 36.0 C

Symptoms of a true UTI will vary depending on whether or not a device is present

CANNOT use the following symptoms to determine an UTI in a catheterized patient for NHSN:• Frequency• Urgency• Dysuria

52

UTI Infection Window Period


33 Days Before2

1

Date of Urine Culture Collection

1st Positive Diagnostic Test

1

3 Days After2

3

53

SUTI 1a (catheter in place)

Patient must meet 1, 2 and 3 below

1. Patient has an indwelling urinary catheter in place for the entire day on the date of event and such catheter has been in place >2 calendar days, on the that date

2. Patient has at least one of the following signs or symptoms

• Fever (> 38.0˚C) or

• Suprapubic tenderness

• Costovertebral angle pain or tenderness

3. Patient has a UC with no more than two species of organisms, and at least one of which has a colony count of ≥105 CFU/ml and all elements of UTI criterion occurs during the Infection Window Period

54

SUTI 1a (catheter recently removed)

Patient must meet 1, 2 and 3 below:

1. Patient has indwelling urinary catheter in place for greater than 2 days which was removed on the day of or day before date of event

2. Patient has a least one of the following signs or symptoms

Fever (>38.˚C)Urinary urgency

Suprapubic tenderness Urinary frequency

Costovertebral angle pain or tenderness Dysuria


55

Criterion SUTI 1a

UTIs with event date on the day of device removal and the following calendar day are considered device-associated UTIs,if the device has been in place already > 2 calendar days For this criterion urgency, frequency and dysuria are symptoms

Catheter Removed

Day 1 Day 2 Day 3 Day 4 CAUTI?

Foley placed Foley in place Foley in place for part of day, then removed

Date of Event Yes

Foley placed Foley in place for part of day, then removed

No Foley Date of Event No

56

SUTI 1 b (Non-catheter-associated)

Patient must meet 1, 2, and 3 below:1. One of the following is true:

• Patient has/had an indwelling catheter but it has/had not been in place> 2 calendar days

OR

• Patient did not have a urinary catheter in place on the date of event or the day before the date of event

2. Patient has at least ONE of the following S&S

Fever (>38.˚C)Urinary urgency

Suprapubic tenderness Urinary frequency

Costovertebral angle pain or tenderness Dysuria


57

SUTI 2 (≤ 1-year-old)


1. Patient is ≤ 1-year-old (with or without an indwelling urinary catheter)

2. Patient has at least one of the following signs or symptoms:Fever (>38.˚C) Lethargy

Hypothermia (<36.0˚ C) Vomiting

Apnea Suprapubic tenderness

Bradycardia

3. Patient has a UC with no more than two species of organisms, and at least one of which has a colony count of ≥105 CFU/ml and

all elements of SUTI criterion occurs during the Infection Window Period

58

No more than 2 Species of Bacteria

UC with >2 organisms are not used for NHSN definition

“Mixed Flora” or equivalent cannot be used to meet definition

Organisms of the same genus but different species = 2 organisms

Same organism with different antimicrobial susceptibilities = 1 organism Ex. MRSA = MSSA

59

Asymptomatic Bacteremic UTI (ABUTI)


1. Patient with or without indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age (Note: Patients > 65 years of age with a non-catheter-associated UTI may have a fever and still meet the ABUTI criterion)

2. Patient has urine culture with no more than 2 species of organisms and at least one which has a colony count of ≥ 105 CFU/ml

3. Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meet LCBI criterion 2 (without fever) and matching common commensal(s) in the urine. All elements of ABUTI criterion must occur during Infection Window Period

60

Identifying SUTI and ABUTI Flowchart

http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

61

No other Recognized Cause

Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination because they are clinically deemed due to another recognized cause.

http://phil.cdc.gov/phil/advancedsearchresults.asp

62

UTI Repeat Infection Timeframe (RIT)

14- day timeframe

No new UTIs are reported

Date of Event = Day 1

Additional pathogens from urine culture are added to the event

63

Applying CAUTI RIT

Patient is admitted to 5W on 1/15/2015 with a positive UC >100,000 of E. coli. No S&S present. Foley is inserted on admission. 7 days later (1/22/15), patient has fever (38.5˚C) and is culture positive from E. coli, >100,000.

Is this a POA?

• No, did not meet criteria of POA on admission

Is this an HAI?

• Yes, what type?

CAUTI, Event Date of 1/22/15

64

Discontinuation and Reinsertion

If Foley catheter is discontinued, and a full calendar day passes before a Foley is reinserted, then the day count for determining catheter-associated UTI begins anew. Otherwise the day count continues from the previous catheter.

Mar 31 (hospital Day 3

April 1 April 2 April 3 April 4 April 5 April 6

Patient A Foley Day 3 Foley Day 4 Foley Day 5; Foley removed

Foley Replaced; Foley Day 6

Foley Day 7 Foley Day 8 Foley Day 9

Patient B Foley Day 3 Foley Day 4 Foley Day 5; Foley removed

No Foley Foley Replaced; Foley Day 1

Foley Day 2 Foley Day 3

65

Location of Attribution

The location where the patient was assigned on the date of the UTI Event, which is further defined as the date that the first element used to meet the UTI infection criterion occurred for the first time in the Infection Window Period

Exception - Transfer Rule

• If the date of the UTI event is the day of transfer or the next day, the UTI is attributed to transferring location or facility. Likewise, if the date of event is the day of discharge or the next day, the infection is attributed to the discharging location

Receiving facility should share information about HAIs with the transferring location or facility to enable complete reporting

66

UTI Case Study 1

Day 1: 58 year old male patient is admitted via ED with GI bleed and indwelling catheter is inserted

Day 2: Patient spikes temp of 38.6˚ C. Indwelling catheter remains in place

Day 3: UC collected

Day 4: Culture report is 100,000 CFU/ml of Pseudomonas aeruginosa. Antibiotics started

Day 5: Patient is asymptomatic and afebrile

Is this an HAI? If so, what type?

a. Yes, HAI- UTI but not CAUTI, catheter had not been in place > 2 days

b. No, it is a UTI that is POA

c. Yes, CAUTI, SUTI Criterion 1a

67

CAUTI Case Study 1 (cont’d)

Day 15: Foley remains in place. Patient completed treatment for UTI on hospital day 11 and has been afebrile since. Hospitalization has been complicated by development of DVT. Temp today is 38.1˚C. Cough is productive of yellow phlegm. Rhonchi present.

Day 16: Urine cloudy. Fever 37.9˚C, continued cough. Sputum collected

Day 17: Urine Culture collected

Day 18: Urine and sputum cultures are both positive for S. aureus, > 100,000 CFU/ml

Should another CAUTI be reported?

68

UTI Case Study 1

Day 1 Foley inserted

Day 2 Foley in place; fever

Day 3 UC collected

Day 4 100,000 Ps. aeruginosa; Antibiotics started

Day 5 no S&S

Day 6 Foley in place





Day 11 Antibiotics completed

Day 12 abrile

Day 13 abrile

Day 14 abrile

Day 15 fever; productive cough and rhonchi

Day 16 Urine cloudy; fever 37.9; cough continues; SPT collected

Day 17 UC collected

Day 18UC and Spt Cultures positive for S. aureus; >100,000 in urine

No, the date of event for a UTI relatedto this culture occurs during the RIT of previous UTI

What is the date of event?Day 15, which is in the RIT for the POA From Day 2

Rationale:Unlike CLABSI, CAUTIs may NOTbe excluded as secondary to another Site-specific infection

If the first UTI had been an HAI, then the S. aureus would have been added to that event

RIT

69

CAUTI Summary

All CAUTIs require a positive urine culture

Minimal CFU/ml > 100,000 of no more than 2 species

Account for positive UC from the ED which may represent recently discharged patients

Infection Window Period is a 7-day period (3 days before positive diagnostic test and 3 day after)

RIT period uses the date of event to determine a 14-day timeframe during which no new infections of the same type are reported. Date of event is Day 1 of the timeframe.

If date of event of subsequent infection is within the 14 day period, additional organisms are added to the original event.

70

Thank You

Slides and information adapted from CDC/NHSN Training slides and materials

2015 NHSN Training Teresa Fox, CIC Quality Improvement Advisor [email protected].

Documents

Transcript of 2015 NHSN Training Teresa Fox, CIC Quality Improvement Advisor [email protected].