2016 National Healthcare Safety Network (NHSN) …. abscess or other evidence of intraabdominal...

Whats New?

2016 NHSN Surveillance Definition Updates

Health Services Advisory Group, Inc.

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Whats New?A Review of National Healthcare Safety

Network (NHSN) Surveillance Definitions

Renee Rush, RN, BSN, Infection Prevention Quality Improvement Specialist

May 11, 2016

Housekeeping

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Participants can ask questions at anytime via theChat function and will be answered at the end.

Q&A session will be hosted at the end of thepresentation, as time permits.

Case-specific questions will not be answered duringthe webinar.

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Webinar will be recorded and available byweeks end.

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Whats New?



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Todays Presenters

Christine Martini-BaileyRN, BSN, CSSGB

Associate Director, California/Ohio

[email protected]

614.307.2936

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Charlie ChapinMS, CHCA

Director, Arizona

[email protected]

602.801.6940

Renee RushRN, BSN

Infection Prevention Quality Improvement Specialist

[email protected]

NHSN Surveillance Definitions

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Objectives

Relate the changes in the NHSN surveillancedefinitions for 2016.

Utilize the definitions to accurately measureand report select healthcare-associatedinfections (HAIs).

Discuss impacts of changes.

Quality improvement initiatives

Pay-for-performance programs

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General Surveillance Review

Key Concepts Seven-day infection window period (IWP): Time frame in

which all infection criteria must be met.

Date of event (DOE): Date on which the first element ofinfection criterion occurs during IWP.

Present on admission (POA): Date of event two days beforeadmission until one day after admission. HAI and POA work sheet generator

HAI DOE: On or after the third calendar day of admission.

Secondary bloodstream infection (BSI) attribution period:Time-limited (1417 days)

Repeat Infection Timeframe (RIT): 14 days beginning at DOE.

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General Surveillance Review (cont.)

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http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=2*SSI = surgical site infection

General Surveillance

HAI and POA worksheet generator just released!

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http://nhsn.cdc.gov/nhsntraining/calculator/workgen.html

http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=2http://nhsn.cdc.gov/nhsntraining/calculator/workgen.html

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General SurveillancePathogen Assignment

Additional pathogens identifiedadded tooriginal event, if within an RIT and not anexcluded organism. Example

Meets catheter-associated urinary tract infection (CAUTI)definition with urine culture and symptoms: E. coli

Two days later, positive urine culture with Enterococcus, spp.

Organism may be added to more than one event. Example

Meets CAUTI definition with urine culture/symptoms: S. aureus. Meets pneumonia (PNU2) definition. Two days later, positive blood culture for S. aureus.

Secondary BSI for CAUTI and pneumonia

9http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=6http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=11

New NHSN Guidance CDC Locations

For inaccurate Center for Disease Control andPrevention (CDC) location descriptions: NHSN provides instructions to change locations and

connect data from an older location to a newlymapped location. CDC Locations and Descriptions Manual, Page 15-8

Added four new outpatient locations for ambulatorysurgery centers (ASCs).

1. Outpatient Ambulatory Surgery Center

2. Ambulatory Surgery Recovery Room

3. Outpatient Ambulatory Pediatric Surgery Center

4. Outpatient Ambulatory Plastic Surgery Center

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http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=8http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=37

http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=6http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=11http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=8http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=37

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Changes: Multiple Modules

Nonculture diagnostic testing included. Allow use of nonculture diagnostic laboratory tests in addition to

specimen cultures (PCR, ELISA). Not used in SUTI or ABUTI (requires quantified urine culture result).

Specimens from brain-dead organ donors excluded. Maintained patients awaiting organ harvest do not meet criteria

for HAI surveillance.

Specified fungal pathogens excluded from HAIsurveillance. Commonly community-acquired. Rarely HAI, but may meet NHSN surveillance criteria due to long

incubation periods. Pathogens are limited to: Blastomyces, Histoplasma,

Coccidioides, Paracoccidioides, Cryptococcus, andPneumocystis.

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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=6

Central Line-Associated Bloodstream Infection (CLABSI) Event

Following devices are NOT considered central lines

Extracorporeal membrane oxygenation (ECMO)

Femoral artery catheters

Intra-aortic balloon pump (IABP) devices

Hemodialysis Reliable Outflow (HeRO) dialysis catheters

Impella heart devices

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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=26http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=34

http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=6http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=26http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=34

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CLABSIAccession of Central Lines

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Documentation of observed or suspected patient accession into vascular access lines, within the BSI IWP, will be considered a laboratory-confirmed bloodstream infection (LCBI) but NOT a CLABSI.

BSI RIT will be created.

Documentation must occur during the BSI IWP.

If reporting the BSI to NHSN, answer NO tothe risk factor event field Central line


CLABSIMucosal Barrier Injury (MBI)-LCBIs

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Absolute neutrophil count/white blood celllevels should not be used to set IWP oridentify DOE.

Only a subset of LCBI.

Date the patient first meets the LCBI criteria is thedate of the MBI-LCBI.


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CLABSIMBI-LCBI (cont.)

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Remember: To meet any criterion, blood culturesmust only have the organisms specified for each of thethree criteriawith no other organisms isolated.

No other isolated pathogen or two matching commoncommensals collected on separate occasions thatwould otherwise meet LCBI criteria.

A single common commensal does not exclude frommeeting MBI-LCBI criteria.

CLABSIMBI-LCBI (cont.)

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Organisms that meet criteria:

MBI-LCBI 1: Bacteroides spp., Candida spp.,Clostridium spp., Enterococcus spp.,Fusobacterium spp., Peptostreptococcus spp.,Prevotella spp., Veillonella spp., orEnterobacteriaceae (intestinal organisms)

MBI-LCBI 2: Viridans group streptococci

Patient of any age

MBI-LCBI 3: Viridans group streptococci

Patient 1 year of age

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Determination of Secondary BSI to Another Site

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Exception: Assigning a BSI secondary to Necrotizing Enterocolitis.Excluded: Salmonella spp. as pathogen for LCBI; these organisms may be

secondary BSIs, but not reported as sole pathogens in a primary BSI.

CLABSISecondary BSI

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CLABSISecondary BSI: VASC

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Criteria must be met for LCBI.

Once LCBI has been confirmed, clear evidenceof vascular site is needed. This must include: Pus AND

A culture of that pus (must be collected during thatLCBI IWP) AND

At least one organism that matches the bloodspecimen

LCBI will not be considered associated with thecentral line.

CLABSISecondary BSI: VASC (cont.)

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Reporting to NHSN

Report as LCBI

Enter NO for the field Central Line

Enter the patients central line days in the summary denominator count

Vascular access devices included Peripheral IV

Arteriovenous fistula

Arteriovenous graft

Non-accessed central line (not accessed/inserted during hospitalization [e.g., non-accessed port])

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CLABSISecondary BSI: PNEU

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PNEU definition Site-specific infection for secondary BSI attribution

when conducting CLABSI surveillance, even foradult patients

Secondary BSIs Only reported for specific events related to PNU2

and PNU3 (for immunocompromised patients)

CLABSISecondary BSI: IAB

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Intraabdominal infections (IABs) must meet at least one of the following criteria:1.Patient has organisms identified from an abscess or from purulent material from intraabdominal space by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing [ASC/AST]).

2. Patient has:

a. abscessor other evidence of intraabdominal infection on gross anatomic or histopathologic exam

b. abscess or other evidence of intraabdominal infection on gross anatomic or histopathologic exam and organism(s) identified from blood by a culture or non-culture-based microbiologic testing method, which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing [[ASC/AST]). The organism(s) identified in the blood must contain at least one of the following organisms: Bacteroides spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae

3. Patient has at least two of the following signs or symptoms: fever (>38.0C), nausea*, vomiting*, abdominal pain*, or jaundice*

and at least one of the following:

a. organisms seen on Gram stain or identified from drainage or tissue obtained during invasive procedure or from an aseptically-placed drain (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage)by a culture or non-culture-based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing [ASC/AST]).

b. organisms identified from blood by a culture or non-culture-based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing [ASC/AST]) and imaging test evidence suggestive of infection (e.g., ultrasound, CT scan, MRI, radiolabel scans [gallium,

technetium, etc.] or on abdominal x-ray) which, if equivocal is supported by clinical correlation (i.e., physician documentation ofantimicrobial treatment for intraabdominal infection. The organism(s) identified in the blood must contain at least one of thefollowing organisms: Bacteroides spp., Candida spp., Clostridium spp., Enterococcusspp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., orEnterobacteriaceae.*

* With no other recognized cause

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CLABSISecondary BSI

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Central Line Insertion Practices (CLIP)

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The only skin prep allowed to meet CLIPbundle adherence is chlorhexidine gluconate(CHG) for patients 60 days old.

Documented contraindications to use CHGrecorded in NHSN upon CLIP event entry

Patient less than two months of age.

Patient has a documented/known allergy/reaction toCHG-based products that would preclude its use.

Facility restrictions or safety concerns for CHG use inpremature infants preclude its use.

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CAUTI

Indwelling urinary catheter in place could cause patient complaints of frequency, urgency, or dysuria.

Symptoms cannot be used to meet HAI criteria when catheter is in place.

Fever is a nonspecific symptom of infection and cannot be excluded from UTI determination because it is clinically deemed due to another recognized cause.


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Pathogen Exclusion: CAUTI

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Excluded as organisms in the UTI definition: Candida species or yeast not otherwise

specified, mold, dimorphic fungi, parasites

Acceptable urine specimen may include these organisms as long as one bacterium of100,000 colony-forming units (CFUs)/ml isalso present.


Whats New?



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Pathogen Exclusion: VAE/VAP

Apply to both Ventilator-Associated Event (VAE)/Ventilator-Associated Pneumonia (VAP) Candida species or yeast not otherwise specified;

coagulase negative Staphylococcus and Enterococcusspecies, unless isolated from lung tissue or pleural flare Indication of isolation of commensal flora (e.g., normal

respiratory/oral flora or mixed respiratory/oral flora) of the oral cavity or upper respiratory tract.

Candida species will continue to be included as a pathogen for meeting PNU3 (immunocompromised patients).

Cryptococcus, Histoplasma, Coccidioides, Paracoccidioides, Blastomyces, Pneumocystis Community-associated fungal pathogens.

Rarely cause or are not known to cause HAIs.http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=142http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=148http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=15227

VAE: Antimicrobials

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Six new antimicrobial agents have been addedto the List of Antimicrobials Agents Eligible forIVAC, Possible and Probable VAP

1. Ceftazidime-avibactam

2. Ceftolozane/tazobactam

3. Dalbavancin

4. Isavuconazonium

5. Oritavancin

6. Peramivir

http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=142http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=148http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=152

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VAE With Secondary BSI

May only be reported for probable ventilator-associated pneumonia (PVAP) including both of: At least one eligible organism from the blood

culture specimen matches an eligible organism from an appropriate respiratory tract specimen collected during the VAE window period.

Blood culture collected within the 14-day event period.

Are not reported for ventilator-associated condition (VAC) or infection-related VAC (IVAC).

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VAE With Secondary BSI (cont.)

May not be reported for PVAP when a respiratory culture was not performed. PVAP met with histopathology criterion.

Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, human metapneumovirus, rhinovirus, or coronavirus.

No PVAP definition can be met to determine a secondary BSI. Determine if the BSI is secondary to another site-

specific infection including the PNEU definitions.

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Whats New?



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VAE/VAP

Identification of matching Candida spp. from blood and respiratory specimen now includes BAL (bronchoalveolar lavage) and protected specimen brushings in addition to sputum and endotracheal aspirate (Page 6-9).

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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=84#page=71

Surgical Site Infection (SSI)

NHSN uses ICD-10-PCS and CPT codes. Transition complete

from ICD-9.

ICD-10-PCS Guidance was provided for spinal level and approach for FUSN procedures.

Updated supporting materials.

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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=84#page=71

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SSI (cont.)

Superficial SSI criterion c Updated to reflect a

symptomatic patient whose incision opened but for whom no culture was obtained. Note: (+) culture is obtained if

the patient meets SSI criterion b.

Addition of Appendix 1 Contains a list of all NHSN

operative procedure groups.

Site-specific SSIs are available as events for each group.

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Multi-drug Resistant Organism (MDRO)/ Clostridium difficile Infection (CDI) Module

Two conditionally required questions will move to required status in 2016: "Last physical overnight location of patient immediately prior

to arrival into facility"

"Has the patient been discharged from another facility in the past four weeks? Questions are not intended to be excessively burdensome to

facilities.

Provide the most accurate information available.

Use Unknown if identifying the required information is an undue burden.

Continue building processes that support the most information (recorded and extracted) from the patient record.

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http://www.cdc.gov/nhsn/forms/instr/57_128.pdf#page=4

http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=102http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=118http://www.cdc.gov/nhsn/forms/instr/57_128.pdf#page=4

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New Reporting Instructions for CDI DOE

Location is attributedto where thespecimen wascollected.

For specimenscollected in anoutpatient locationother thanemergencydepartment or 24-hour observation unit Report to the

inpatient admittinglocation if collectedon the same day.*

MDRO Reporting Plan

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*Must add data for all locations in your plan.

http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=21http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=37

Key Points: CDC and CMS Joint Reminder on NHSN Reporting

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http://www.cdc.gov/nhsn/pdfs/cms/nhsn-reporting-signed.pdf

http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=21http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=37http://www.cdc.gov/nhsn/pdfs/cms/nhsn-reporting-signed.pdf

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Key Points: Summary Data Examples

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Summary Data:Device-Associated Module

Summary Data:MDRO

Key Points: No Events/No Procedures Examples

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Device-Associated ModuleNo Events

MDRONo Events

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Key Points: Every Journey Begins With a Good Map!

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Avoids incorrect reporting to CMS

x

Accurate mapping is critical

http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf*standardized infection ratio

Find NHSN Reporting Resources!

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http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf

Whats New?



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Thank you!Renee L. Rush, RN, BSN

Infection Prevention Quality Improvement Specialist614.653.5445 | [email protected]

Question and Answer Session

mailto:[email protected]

Whats New?



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How to Use Chat Function

1. To submit a question,click on the Chat optionat the top right.

2. The Chat panel will open.

3. Indicate that you want to send aquestion to the Host & Presenter.

4. Type your question in thebox at the bottom of the panel.

5. Click Send.

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More Questions? Contact an HSAG Team Member

State Project Lead

Arizona Charlie Chapin 602.801.6940 [email protected]

California Laurie Hensley 818.265.4643 [email protected]

Florida/U.S. Virgin Islands

Rick Welsh 813.549.9920 [email protected]

Ohio Renee Rush 614.653.5445 [email protected]

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mailto:[email protected]:[email protected]:[email protected]:[email protected]

Whats New?



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Thank you!

For More NHSN Resources and a Recording of Todays Webinar

www.hsag.com/NHSN

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health

and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-C.1-05112016-01.

http://www.hsag.com/NHSN

Structure BookmarksWhats New?A Review of National Healthcare SafetyNetwork (NHSN) Surveillance Definitions HousekeepingTodays Presenters NHSN Surveillance DefinitionsObjectivesGeneral Surveillance Review General Surveillance Review (cont.) General SurveillanceGeneral SurveillancePathogen AssignmentNew NHSN Guidance CDC LocationsChanges: Multiple ModulesCentral Line-AssociatedBloodstream Infection (CLABSI) EventCLABSIAccession of Central LinesCLABSIMucosal Barrier Injury(MBI)-LCBIsCLABSIMBI-LCBI (cont.)CLABSIMBI-LCBI (cont.)Determination of Secondary BSI to Another SiteCLABSISecondary BSICLABSISecondary BSI: VASCCLABSISecondary BSI: VASC(cont.)CLABSISecondary BSI: PNEUCLABSISecondary BSI: IABCLABSISecondary BSICentral Line Insertion Practices (CLIP)CAUTIPathogen Exclusion: CAUTI Pathogen Exclusion: VAE/VAPVAE: AntimicrobialsVAE With Secondary BSIVAE With Secondary BSI(cont.)VAE/VAP Surgical Site Infection (SSI)SSI (cont.)Multi-drug Resistant Organism (MDRO)/ Clostridium difficile Infection (CDI) Module New Reporting Instructions for CDI DOEKey Points: CDC and CMS Joint Reminder on NHSN ReportingKey Points: Summary Data ExamplesKey Points: No Events/No Procedures ExamplesKey Points: Every Journey Begins With a Good Map! Find NHSN Reporting Resources!How to Use Chat FunctionMore Questions? Contact an HSAG Team Member

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