IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013

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IPRO HAI LAN Meeting

New York City, November 6, 2013Schenectady NY, November 7, 2013

Applying NHSNProtocol Definitions

Carole Van Antwerpen, RN, BSN, CIC

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Objectives:

•Use of case studies to improve and/or validate competency in applying 2013 NHSN surveillance protocol criteria for:

Select Surgical Procedure SSI’s ICU associated CAUTI’s ICU associated CLABSI’s Inpatient Facility-Wide CDI Lab ID Events

• Utilization of surveillance definitions (not clinical), which are designed to minimize case finding subjectivity

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Applying theNHSN Surgical Site Infection (SSI)

Protocol Definitions

Surgical Site Infection (SSI) Case Studies

Adapted from CDC-NHSN Training Slides

http://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html

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Navigating NHSN SSI Reporting RulesResources

NHSN Website “Favorite” www.cdc.gov/nhsn• 2013 Reporting Protocols:

HAI Definitions (Chapter 17)SSI Criterion (Chapter 9 and April /July 2013

erratums) Table 1: Operative Procedure Categories Table 3: Procedure Categories (30/90day

surveillance) Table 4: Specific Organ space Sites Table 5: Principle Operative Priority Procedure

List

• Use 2012 NHSN SSI criteria protocols for 2012 procedures • NHSN email address ([email protected])

http://www.cdc.gov/nhsn

mailto:[email protected]

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Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG.; CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp E pidemiol 1992;13(10):606-8.

20121 yr surveillance period for deep and organ space SSI for all procedures with non-human implant

Primary incision closure excluded all procedures where a drain or other material was extruding from the incision. Skin incision completely closed

Priority list abdominal procedures- small bowel, rectal then colon

2013Surveillance period 30 day for all, plus 90 day for deep and organ space SSI for just 14 procedures (table 3)

Primary Incision closure includes procedures where a drain or other material was extruding from the incision. Gaps between skin incision closure included as an NHSN procedure (4/13 erratum)

Priority list abdominal procedures- colon above small bowel and rectal

Depth of SSI: used for both primary and secondary incisions (no changes)

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Surveillance Determination

Trumps

Clinical Determination

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SSI Case Study 1• Patient is admitted to the hospital on 4/12 for

elective surgery and active MRSA screening test is positive.

• On the same day, patient undergoes total abdominal hysterectomy (HYST).

• Postoperative course is unremarkable; patient discharged on 4/16.

• On 4/29, patient is readmitted with complaints of acute incisional pain since day before. Surgeon opened the wound into the fascial level and sent drainage specimen for culture and sensitivities.

• On 5/1, culture results are positive for MRSA

SSI Case Study 1

1. Yes2. No3. Don’t know

0 / 100

0% 0% 0%

1 2 3

0

Is this an HAI?

SSI Case Study 1

1. SSI-SIP2. SSI-SIS3. SSI-DIP4. SSI-DIS5. SSI-IAB

0%

57%

14% 14% 14%

1 2 3 4 5

What infection type should be reported?

0

SSI Case Study 1

1. A= on admission2. P= Post Discharge3. RF= Readmission to this

facility4. RO= Readmission

“other” facility

14%

71%

0%

14%

1 2 3 4

Reported as occurring:

0

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SSI Case Study 1 – AnswerDeep Incisional SSI - Criterion b

Infection occurs within 30 or 90 days after the NHSN operative (4/12-4/29) procedure according to the list in Table 3 and

involves deep soft tissues of the incision (e.g., fascial and muscle layers) and

patient has at least one of the following:a. purulent drainage from the deep incisionb. a deep incision that spontaneously dehisces or is deliberately openedby a surgeon and is culture-positive or not culturedandpatient has at least one of the following signs or symptoms: fever(>38°C); localized pain or tenderness. A culture-negative finding doesnot meet this criterion.c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during invasive procedure, or byhistopathologic examination or imaging test.d. diagnosis of a deep incisional SSI by a surgeon or attending physician

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SSI Case Study 1 - AnswerIf so, what is the date of event?

4/29, the date the last element used to meet the infection criterion occurred (i.e., date of deliberate wound opening and positive drainage specimen obtained)Reported as:

2. RF= Readmission to this facility

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SSI Case Study 2• Patient admitted on 9/10 and underwent a hemi-

colectomy. Wound class = 4 and incision primarily closed.

• 9/13: Temp up to 38.7°C, abdominal pain. Ultrasonography shows abscess along the abdominal wall.

• 9/14: Radiology fluoroscopy percutaneous I&D of the abdominal wall abscess. Abscess specimen collected for culture. Antibiotics begun.

• 9/18: Discharged from hospital on oral antibiotics. Abscess culture positive for E.coli.

SSI Case Study 2

1. SSI-SIP2. SSI-DIP3. SSI-IAB4. SSI-GIT

29% 29%

14%

29%

1 2 3 4

What type of SSI does this patient have?

0

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SSI Case Study 2 – Answer Infection occurs within 30 or 90 days after the NHSN operative procedure (9/10-9/14)according to the list in Table 3 and

involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and

patient has at least one of the following:• a. purulent drainage from a drain that is placed into the

organ/space• b. organisms isolated from an aseptically-obtained culture of

fluid ortissue in the organ/space

• c. an abscess or other evidence of infection involving the organ/spacethat is found on direct examination, during invasive procedure, orby histopathologic examination or imaging test

• d. diagnosis of an organ/space SSI by a surgeon or attendingphysician

•and meets at least one criterion of a specific organ/space infection site listed in Table 4

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SSI Case 2 Answer (continued)IAB Criterion 2:

Patient has abscess or other evidence of intraabdominal infection seen during an invasive procedure histopathologic exam

Rationale:• 2 different criteria need to be met for Organ/Space

SSI– SSI organ/space criteria AND– Those of the specific site of the organ/space operated on

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SSI Case Study 2 – Answer (continued)• Why not GIT as the specific site of SSI?

– The abscess is in the abdominal wall

– GIT focuses on organs of the GI tractEsophagusStomachSmall, Large bowel and RectumExcludes gastroenteritis and appendicitis

– Therefore, IAB is the appropriate choice site of SSI in this case

SSI Case Study 2 (Continued)

1. Yes2. No3. Don’t know

29%

57%

14%

1 2 3

Let’s change the scenario and say that at the time of the I & D, it was discovered that the patient had suffered an anastomotic leak from which the abscess developed.

Does this change your determination of an SSI-IAB?

0

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SSI Case Study 2- Answer

Let’s change the scenario and say that at the time of the I & D, it was discovered that the patient had suffered an anastomotic leak from which the abscess developed.

Does this change your determination of an SSI -IAB?

1. NoAlthough an anastomotic leak can be a complication of surgery, the fact remains that this patient meets the criterion for an SSI. If the surgery had not been performed there would not have been an anastomotic leak.

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SSI Case Study 3On 5/15 a 45-year-old female undergoes an abdominal hysterectomy (HYST) and colectomy (COLO) performed through the same incision.If both of these procedures are in your Monthly Reporting Plan in MayThe colectomy is performed as the result of a ruptured

diverticulum. The operative note states “ cloudy peritoneal fluid aspirated from the abdomen and sent for culture”. The ASA score is 2 and the operative wound class is recorded as clean contaminated (2). The surgical time (incision to incision close) is 3.10 hrs .

1. Which procedure(s) do you enter into NHSN?

2. How do you record the surgical time?

3. What about the Wound Class?

SSI Case Study 3

1. Colon only2. Hysterectomy only3. Both colon and

hysterectomy4. Not sure

14%

43%

14%

29%

1 2 3 4

Which surgical procedure is entered in NHSN?

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SSI Case Study 3

1. Enter in NHSN as 2

2. Enter in NHSN as WC 3 or 4

3. Discuss WC assignment with the Surgeon and/or OR staff

4. Answers 2 and 3

5. Not sure

29%

57%

0% 0%

14%

1 2 3 4 5

What about the assigned intraoperative wound class 2?

0

SSI Case Study 3

1. Divide in half incision to incision close time

2. Total incision to incision close time

3. Time identified for each procedure

4. Not sure

0% 0% 0% 0%

1 2 3 4

How do you record the surgical time for each procedure?

0

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SSI Case Study 3- Answer

How do you record the surgical time for each procedure?

1. Divide in half incision to incision close time

2. Total incision to incision close time

3. Time identified for each procedure.

4. Not Sure

3.10 hrs

The surgical time (incision to incision close) is 3.10 hrs .

SSI Case Study 3

1. Yes

2. No

3. Not sure

0% 0% 0%

1 2 3

• 5/15 Intraoperative cultures reported as no growth

• 5/19: Patient spikes temp to 38°C, has abdominal pain and emesis. Ultrasound shows fluid collection in abdominal cavity. Fluid specimen for culture is obtained by needle aspiration.

• 5/20: Culture positive for E. faecium, many neutrophils seen

Is this an HAI?

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SSI Case Study 3 (continued)

1. SSI-Deep Incisional Primary

2. SSI-Deep Incisional Secondary

3. SSI Organ/Space, specific site IAB

4. This is an IAB but there is no SSI infection

0% 0% 0% 0%

1 2 3 4

What type of an SSI?

0

SSI Case Study 3

1. HYST

2. COLO

3. Both HYST and COLO

4. Not sure0% 0% 0% 0%

1 2 3 4

To which procedure is the SSI attributed?

0

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SSI Case Study 3-AnswerRationale for procedure SSI attribution

• HYST

• COLO

• Both HYST and COLO

If a procedure from more than one NHSN operative procedure category was done through a single incision, attempt to determine the procedure that is thought to be associated with the infection. If it is not clear (as is often the case when the infection is a superficial incisional SSI),or if the infection site being reported Is not an SSI, use the NHSN Principal Operative Procedure Selection Lists (Table 5) to select which operative procedure to report.

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SSI Case Study 4• 1/22: Patient had a total laparoscopic abdominal

hysterectomy. Discharged 1/24

• 2/1: Abdominal pain with purulent drainage in 2 of 3 trocar sites; Temp 38.4°C

• 2/3: Surgeon opened wounds in the ER and noted purulent material in the fascial layer; specimens to lab for culture; Urine culture sent; antibiotics begun

• 2/5: Wound cultures positive for Pseudomonas aeruginosa

Urine culture >105 P. aerugensa, E. coli and CNS

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SSI Case Study 4 cont.Is this an SSI?

‒ Yes‒ No

What Type‒ SIP‒ SIS‒ DIP‒ DIS

Identified:‒ (A)Admission‒ (P)Post Discharge‒ (RO) Readmit other.

Met one of the following criteria:

Infection occurs within 30 or 90 days after the NHSN operative (1/22-2/3) according to the list in Table 3. and

involves deep soft tissues of theincision (e.g., fascial and musclelayers) of the incision and

patient has at least one of the following:

a. purulent drainage from the deepincision b. a deep incision spontaneouslydehisces… c. And abscess or other evidence ofinfection is found… d. diagnosis by surgeon or physician

Event Date: 2/3

SSI Case Study 4

1. One

2. Two

3. Three

4. Four

0% 0% 0% 0%

1 2 3 4

How many SSIs should be reported?

0

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SSI Case Study 4 -Answer

How many SSIs should be reported?

1. One

RationaleFollowing laparoscopic surgeries, if more than one of the incisions should become infected, only report as a single SSI.

If one is superficial incisional and one is deep incisional, report only as a deep incisional SSI.

What about the urine culture. UTI?

‒ NO (>3 pathogens)

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Applying the NHSN Central Line Associated

Blood Stream Infection (CLABSI) Definitions

CLABSI Case StudiesAdapted from CDC-NHSN Training Slides†

http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html †

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Navigating NHSN CLABSI Reporting Rules

Basic Resources

• NHSN Website “Favorite” www.cdc.gov/nhsn• Reporting Protocols:HAI Definitions (Chapter 17)CLABSI Criterion (Chapter 4)

Appendix 1. (Jan. 2013, pp.14-17) April/July 2013 erratum’s

• NHSN email address ([email protected])



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Surveillance Determination

Trumps

Clinical Determination

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Ms. A. CLABSI Case Study 1• April 1: Ms. A is transferred to your facility with

pancreatic cancer, ICU admission and a PICC which is first accessed on Day 1.

• April 7: Blood culture collected on April 5th is growing Providencia stuartii. No other organisms isolated. Patient started on antibiotics.

• Additional laboratory values as follows: Apr 1 Apr 2 Apr 3 Apr 4 Apr 5 Apr 6 Apr 7WBC 900 800 600 400 600 700 800ANC --- --- --- --- 400 --- 600 -Does patient meet criteria for an HAI? -What is the Event Date?

Ms. A. CLABSI Case Study 1

1. Yes, Event date 4/7

2. Yes, Event date 4/5

3. No

4. Not sure0% 0% 0% 0%

1 2 3 4

Does patient meet criteria for an HAI?

0


1. LCBI 1

2. LCBI 2

3. MBI-LCBI 1

4. MBI-LCBI 20% 0% 0% 0%

1 2 3 4

What specific type of HAI does Ms. A have?

0

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Ms. A. CLABSI Case Study 1-Answer

What specific type of HAI does Ms. A have?

1. LCBI 1

2. LCBI 2

3. MBI-LCBI 1

4. MBI-LCBI 2Yes. all elements of a CDC/NHSN site specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1).

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Ms. A. : Laboratory Values- Answer (continued)

Adm. Date Blood collection BC Report Apr 1 Apr 2 Apr 3 Apr 4 Apr 5 Apr 6 Apr 7 WBC 900 800 600 400 600 700 800 ANC --- --- --- --- 400 --- 600

Patient meets neutropenic definition: Two values of ANC or WBC < 500 on or within 3 calendar days before positive blood culture collection.

+ Eligible Pathogen (Enterobacteriaceae) + No other pathogen isolated Meets MBI-LCBI 1 Criteria 2

Day -5

Day -4

Day -3

Day - 2

Day -1

Day 1 Day 2 Day 3

ANC or WBC<500?

X X


1. Your facility since the device was accessed there

2. The transferring facility where the line was placed

3. Not sure0% 0% 0%

1 2 3

Is the CLABSI attributed to your facility or the transferring facility?

0

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Ms. A. CLABSI Case Study 1-AnswerIs the CLABSI attributed to your facility or the transferring facility?

1. Your facility since the device was accessed there.

If a patient is admitted with a pre-existing central line, the line should be included in the central line day count starting with the first day that the line is accessed and BSIs with date of event on or after Day 3 are attributed to the admitting facility

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Mr. D. CLABSI Case Study 2

• May 15: 79 year old male, admitted with gastric cancer. Central line placed day of admission for total parenteral nutrition.

• May 16: Partial gastrectomy performed.

• May 21: Patient progressing well until fever spike of 101.3. Blood cultures sent.

• May 22: Increasing abdominal pain. CT Scan of abdomen shows small fluid collection posterior to stomach. Fluid collection fully drained by ultrasound guided needle aspiration and fluid sent for culture. Blood cultures repeated

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Mr. D. CLABSI Case Study 2 (continued)

• May 23: Blood cultures from May 21: 1 of 2 positive for Staphylococcus epidermidis. Abdominal fluid growin gram positive cocci. Antibiotics begun.

• May 24: Abdominal culture of 4/22: Enterobacter cloacae. Blood cultures from May 22: 2 of 2 positive for coagulase-negative staphylococcus

Does the patient meet criteria for a CLABSI?

Mr. D. CLABSI Case Study 2

1. Yes, HAI, CLABSI with S.epidermidis

2. No, HAI, CLABSI

3. No, but HAI abdominal infection with secondary bacteremia

4. Not sure0% 0% 0% 0%

1 2 3 4

Does this patient meet the criteria for a CLABSI?

0

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Mr. D. CLABSI Case Study 2 - AnswerDoes this patient meet criteria for a CLABSI?

3. No, but HAI abdominal infection with secondary bacteremia.

CLABSI Module Appendix 1: 4-14 (January 2013)2. Blood and a site-specific specimen cultured but the organisms do not match: if the site-specific culture is an element used to meet the infection site criterion (in this case it is, IAB cr. 1) and

the blood isolate is also an element used to meet another criterion at the same infection site (in this case IAB cr 3c),then

the BSI is considered secondary to that site-specific infection. This is an SSI- IAB with both E. cloacae and CNS. Element (BC) time frame not >1 day gap.

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Ms. E. CLABSI Case Study 3

8/14: A 10 year old female presents to the ED diabetic coma and with anemia. She has a subclavian catheter inserted in the ED. The next day (8/15) in the Pediatric ICU, she has a midline catheter inserted and receives blood transfusions. 8/17: She develops fever of 39°C and shaking chills.

Two sets of blood cultures sent. 8/19: Blood cultures positive for Pseudomonas aeruginosa. Neither insertion site shows inflammation and there is no other documented infection meeting NHSN criteria.


1. No

2. Yes, ICU associated, P. aeruginosa

3. Yes, but not ICU associated

4. Not sure 0% 0% 0% 0%

1 2 3 4

Is there an LCBI?

0


1. LCBI criterion 1 – recognized pathogen cultured from 1 or more blood cultures

2. LCBI criterion 2 – with fever, chills and 2 or more skin commensal positive blood cultures

3. Not sure

0% 0% 0%

1 2 3

Which LCBI criterion apply?

0


1. The ED

2. The ICU

3. Neither location

4. Not sure

0% 0% 0% 0%

1 2 3 4

What unit should be indicated for the location of device insertion field?

0

Ms. E. CLABSI Case Study 3 (Continued).

1. No, this patient still has a CLABSI

2. Yes, this is no longer a CLABSI

3. Not sure 0% 0% 0%

1 2 3

Let’s change this scenario and say that on 8/17 the patient’s subclavian catheter site is red and has a small amount of pus present. Does this change your decision?

0

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Ms. G CLABSI Case Study 43/24: Ms. G is a 92 year old female transferred from a nursing home to the ED with respiratory distress and sepsis and unresponsive. She is a diabetic and bilateral amputee.

She is transferred to the medical ICU where she is intubated placed on a vent, a Foley catheter and right subclavian catheter are inserted. A septic workup is completed (blood, urine and sputum cultures).

She is started on antibiotics for x-ray confirmed bilateral pneumonia.

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Ms. G. CLABSI Case Study 4 (continued)

Date Temp Diagnostic Findings3/24-3/26 3/24 101.6,

3/26 99.2Preliminary chest x-ray bilateral pneumonia. Urine and blood cultures no growth

4/1-4/9 afebrile Central line (CL) present, vent present. Foley draining clear yellow urine. NG feeding tube placed 4/5. Urine blood and sputum cultures sent….all negative for pathogens

4/10 98.7-100.2 Loose stools x5. stool for C. difficile sent

4/11 101.2 max Urine clear, stool negative for C. diff toxin. Urine Culture sent

4/12 98.7 Urine culture C. albicans (no colony count recorded).4/13 101.2 Urine culture U/A, BC’s sent, CL site unremarkable.

Stool for C. difficile sent4/18 100.2 4/13 Urine culture Candida sp. U/A=LE mod. N neg.,

WBC 26-50, Blood C. tropicalis x 2, 4/14 echocardiogram report of positive vegetation mitral valve. C.diff=negative. CL discontinued.

4/19 98.0 Medical diagnosis of Candida endocarditis. Antifungal treatment initiated.

Ms. G. CLABSI Case Study 4

1. Yes

2. No

3. Not sure0% 0% 0%

1 2 3

Does the patient meet NHSN criteria for an HAI?

0

Ms. G. CLABSI Case Study 4

1. CLABSI only

2. UTI only

3. CLABSI and UTI

4. Endocarditis

5. All of the above0% 0% 0% 0% 0%

1 2 3 4 5

What is the HAI site?

0

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Ms. G. CLABSI Case Study 4-AnswerEndocarditis Rationale: (chapter 17 pg. 17) Criteria: 2 or more signs or symptoms (fever) and changing murmur, embolic phenomena, skin manifestations, CHF or cardiac conduction abnormality AND 2a: Organisms isolated from 2 or more BC’s 2e: evidence of new vegetation seen on echocardiogramAND MD initiates appropriated antimicrobial therapy

CLABSI Module Appendix 1: pp. 4-153. No site-specific specimen cultured only a positive blood culture: if the site-specific culture is an element used to meet the infection site criterion (in this case it is, endocarditis cr 2a and e) and the blood isolate is also an element used to meet another criterion at the same infection site (in this case endocarditis cr 2a and e),then the BSI is considered secondary to that site-specific infection. This is an endocarditis with Candida tropicalis. Element (BC) time frame not >1 day gap.

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Ms. G. CLABSI Case Study 4-DiscussionNO CAUTI Rationale (4/13)-criteria 2a

FC in place >2 days (Inserted 3/24) AND Fever (101.2) UA positive LE, WBC >10 (26-50) AND UC >103 and <105 (no colony count)

-Report to NHSN as ICU CAUTI - Candida ?

No, since there was no UC colony count it may not meet the final criteria and therefore not meet CAUTI criteria.

• Fever is a non-specific symptom of infection and must be applied to multiple HAI criterion. There is no SUTI criterion utilizing a blood culture as one of the elements

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ApplyingNHSN CAUTI Definitions

CAUTI Case StudiesAdapted from CDC NHSN Training

Slides†† http://www.cdc.gov/nhsn/acute-care-hospital/CAUTI/index.html

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Navigating NHSN CAUTI Reporting Rules

Basic Resources• NHSN Website “Favorite” www.cdc.gov/nhsn •Reporting Protocols:HAI Definitions (Chapter 17)CAUTI Criterion (Chapter 7)April and July 2013 erratum's• •NHSN email address ([email protected]) •Friends in Medical Records and Laboratory



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RememberSurveillance definitions work better in some patient populations than others.

Patients should be thoroughly assessed for UTI symptoms, including suprapubic (S/P) tenderness, costovertebral angle (CVA) pain or tenderness. Dialogue/education with clinicians may be warranted.

Clinical diagnosis may differ from surveillance determination.

NHSN Protocol definitions must still be applied

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UTI Case Study1

56 year old patient is admitted 4/12/13 the Medical ICU with diagnosis of stroke. A FC was inserted in the ER on 4/11.

4/11: FC inserted in ED, Afebrile4/11: Urine analysis normal, Urine culture <1000 CFU E. coli.4/13: temp 39.6 C; UC and UA sent UA=negative LE and N WBC= >25 WBC/mm3

UC=E. coli >103 CFU

-Meets all elements of SUTI criteria? Why yes or No -Report as a CAUTI? Why yes or no

UTI Case Study 1Is this a UTI and if so, what type?

1. No UTI

2. Yes, SUTI Criterion 1a, Report NHSN

3. Yes, SUTI Criterion 2a, Report NHSN

4. Yes, SUTI Criterion 2a, Not Required to Report in NHSN

5. Don’t know

0% 0% 0% 0% 0%

1 2 3 4 5

0

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HAI: All elements of the infection criterion were first present together on or after the 3rd calendar day of hospital admission. An element of the infection criterion may be present during the first 2 calendar days of admission to the facility as long as it is present on or after calendar day 3. AND all elements must occur within a time frame that does not exceed a gap of 1 calendar day between two adjacent elements.

UTI Case Study 1-Answer• 4/11 Foley catheter inserted = device day 1• 4/12 = Day 1 (first calendar day of hospital admission)• 4/13 = Day 2 (second calendar day of hospital admission)

- First day of SUTI criteria- Temp: 39.6- U/A: negative Nitrate/Leukoesterase,

wbc>25/mm3

- UC: E. coli > 103 (cfu 103 to ≤105 for criterion 2a)

• Hospital admission <3 calendar days, therefore not HAI• Foley catheter in 3 days, which = SUTI criterion but not HAI

64

UTI Case Study 256 year old patient is admitted 4/12/13 from the ED to Med. ICU with diagnosis of stroke. FC was inserted on 4/12.

4/12: UA LE-positive, N-positive, UC<1000 CFU E. coli.4/16: temp 39.6 sent UC and UA sent, IV site culture, Blood Culture UA=negative LE and N WBC= <10 WBC/mm3

4/18: UC=E. coli <103 CFU4/20: temp 38.8, UC and UA sent Result: UA; LE and N positive, WBC >10mm3 UC; >105 E. coli and P. aerugenosa

IV site: P. aerugenosa; Blood: No Growth

-Meets all elements of SUTI criteria? Why yes or No-Report as a CAUTI? Why yes or no-Date of UTI?

UTI Case Study 2

1. No UTI

2. Yes, CAUTI Criterion 1a, Report NHSN


4. Not sure0% 0% 0% 0%

1 2 3 4

Is this a UTI and if so what type?

0

66

UTI Case Study 2-Answer

• 4/12 FC inserted = device day 1• 4/12 = Day 1 (first calendar day of hospital admission)• 4/20 = Day 9 (days in Medical ICU)

- First day of SUTI criteria- Temp: 39.6- UC: E. coli and P. aerugenosa > 105 (criterion

1a)• Hospital admission >3 calendar days = HAI to MICU• FC indwelling >3 days = SUTI criteria 1a catheter associated• Event date: 4/20

UTI Case Study 2

1. Yes, P. aerugenosa, Report NHSN

2. No, but meets NHSN HAI criterion for VASC site (P. aeurgenosa)

3. No, does not meet any NHSN HAI criteria

4. Don’t know

0% 0% 0% 0%

1 2 3 4

Does the Patient also have a CLABSI?

0

68

UTI Case Study 2 (continued)56 year old patient is admitted 4/12/13 from the ED to Med. ICU with diagnosis of stroke. FC was inserted on 4/12.

4/12: UA LE-positive, N-positive, UC<1000 CFU E. coli.4/16: temp 39.6 sent UC and UA sent, IV site culture, Blood Culture UA=negative LE and N WBC= <10 WBC/mm3

4/18: UC=E. coli <103 CFU4/20: temp 38.8, UC and UA sent Result: UA; LE and N positive, WBC >10mm3 UC; >105 E. coli and P. aerugenosa

IV site: P. aerugenosa; Blood: No Growth New 5/1: New Temp 38.8, UC>105 C. albicans

-Meets all elements of SUTI criteria? Why yes or No-Report as a CAUTI? Why yes or no

UTI Case Study 2

1. No UTI2. Yes, but not reportable as <

14 days since last reported UTI (4/20 E.coli and P. aerug)

3. Yes, report C. albicans SUTI Criterion 1a

4. Yes, report C. albicans SUTI Criterian 2a

5. Don’t know

0% 0% 0% 0% 0%

1 2 3 4 5


0

70

UTI Case Study 2 - Answer• 4/12 = device day 1, FC inserted• 4/12 = Day 1 (first calendar day of hospital admission)• 4/20 = Day 9 (days in Medical ICU)

- First day of SUTI criteria- Temp: 39.6- UC: E. coli and P. aerugenosa > 105 (criterion

1a)• 4/20 /CAUTI, E. coli and P. aerugenosa > 105 = HAI to MICU• 5/1: new temp (38.8) change in organism (C. albicans >105) last symptoms 4/20:>1 day gap between infection criterion

• ICU associated, report NHSN

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UTI Case Study 3POD 3 (4/10): 66 y.o. patient in the ICU with a FC (OR insertion) s/p colon resection; patient noted to be febrile (38.9°) and complained of abdominal pain localized to the surgical area. Septic Workup initiated . Incision clean and dry.

4/10: WBC increased to 19,000. He had cloudy, foul-smelling urine and UA showed 2+ protein, +N, 2+LE , WBC =TNTC, and 3+ bacteria. Culture was >10,000 CFU/ml E. coli. The abdominal pain seemed localized to surgical area

UTI Case Study 3

1. No UTI

2. Yes, CAUTI Criterion 1b, Report NHSN


4. Yes, SUTI but not ICU associated

5. Don’t know

0% 0% 0% 0% 0%

1 2 3 4 5


0

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UTI Case Study 3-Answer

• 4/7 = device day 1, FC inserted OR • 4/10 = FC device day 4 (ICU)

- First day of SUTI criteria- Temp: 38.9- UA: LE(2+), N(+), WBC (TNTC)- UC: E. coli > 10,000 cfu (criterion 2a)

•FC indwelling >2 days = SUTI criteria 2a catheter associated

• ICU related = NHSN reporting

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UTI Case Study 4• 48 year old male involved in motorcycle accident

4/1. Closed head injury, multiple fractures. To OR for ORIFs and evacuation of subdural hematoma. FC and left subclavian catheter placed in ED. Patient remains on ventilator (placed in OR). Lungs clear bilaterally.

4/1 Transferred to Surgical ICU

• POD 5: temp. 99.8° F, rhonchii in left lung base. CXR shows possible infiltrate/atalectasis in this area. FC draining , clear yellow urine. Patient remains ventilated, sputum increased.

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UTI Case Study 4 (continued) • POD 7: temp. 100.3° F, vent settings stable. No

change to sputum production.

• POD 8: temp 101.9° F, lungs sounds clear, CXR clear. Patient on vent, with FC and central line. Pan cultures sent. Empiric antibiotic treatment begun.

• POD 9: Urine culture: 100,000 CFU/ml of P. aeruginosa. Sputum: P. aeruginosa. BC: No growth. Physical assessment normal. No patient response to suprapubic or costovertebral angle palpation Meets all elements of SUTI criteria? Why yes or No

Report as a CAUTI? Why yes or noDate of UTI?

UTI Case Study 4

1. No, UTI

2. Yes, ABUTI, Report NHSN

3. Yes, SUTI 2a, Report NHSN


5. Don’t know

0% 0% 0% 0% 0%

1 2 3 4 5

Does this patient have a UTI? If so, what type?

0

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UTI Case Study 4 - Answer

Does this patient have a UTI? If so, what type?

4. Yes, SUTI 1a., Report NHSN

Yes, this patient has a SUTI 1a. Fever, positive urine culture > 100,000 with one pathogen. Indwelling Foley catheter associated.

UTI Case Study 4

1. 9/7

2. 9/8

3. 9/9

4. Don’t know0% 0% 0% 0%

1 2 3 4

What is the date of the UTI?

0

UTI Case Study 4

1. Yes

2. No

3. Not sure0% 0% 0%

1 2 3

What if the patient’s temp. was 38.6 ° C and the patient also met the criteria for a Pneumonia including a bronchoalveolar lavage for E. faecium? Would the UTI criteria still be met?

0

80

UTI Case Study 4 - Answer

What if the patient’s temp. was 38.6 ° C and the patient also met the criteria for a Pneumonia including a bronchoalveolar lavage for E. faecium? Would the UTI criteria still be met?

1. Yes

Fever is a non-specific symptom and may be due to more than one cause

UTI Case Study 4

1. No UTI


3. Yes, ABUTI, Report NHSN

4. Don’t know

0% 0% 0% 0%

1 2 3 4

What if the patient had been afebrile, but had an elevated WBC for which they sent the cultures as reported? Would the patient have a UTI?

0

82

Applying theNHSN Clostridium difficile (CDI)

LabID Event Protocols

CDI LabID Event Case StudiesAdapted from CDC NHSN Training Slides†

†http://www.cdc.gov/nhsn/acute-care-hospital/cdiff-mrsa/

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CDI Event Reporting Reminders• Don’t over think, individual cases not reviewed for signs or symptoms

• Positive test = date specimen collected •Accurate recording of dates. location, positive test and date of last positive test for each patient location •> 14 days since Last positive test in same location across calendar months

• Need access to Laboratory inpatient CDI test results. Ensure tests performed on non-formed stool specimen

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CDI LabID Event Case Study 1• 2/1: 56 year old male admitted to ICU bed with pneumonia. Central IV inserted for antibiotics.

• 2/2: Patient voiding without difficulty. Cough with moderate sputum production. Patient complains of lower abdominal cramps, relievedwith medication.

• 2/3: Patient transfers to 2E. Later that day, patient has fever of 38.2 and complains of worsening lower abdominal pain. BM with loose unformed stool.

• 2/4: While on 2E, the patient continues to complain of lower abdominal pain and loose stools. Over the course of 24hours, the patient had three loose stools. Unformed stool specimen collected and sent for testing.

• 2/5: Lab results identified toxin positive C. difficile toxin stool samples.

CDI LabID Event Case Study 1

1. No, His symptoms started <4 days after admission

2. Yes, This is the first positive CDI isolate collected in this inpatient location within 14 days

3. No, C.difficile toxin assay is not an accurate test for CDI

4. Don’t know

0% 0% 0% 0%

1 2 3 4

Does this meet NHSN criteria for a CDI LabID Event

0

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CDI LabID Event Case Study 1 - Answer

2. Yes. This is the first positive CDI isolate collected in this inpatient location within 14 days.

A toxin positive C. difficile stool specimen for a patient in a location with no prior C. difficile specimen result within 14 days for the patient and the location

**Remember NHSN application will categorize as community-onset (CO) or healthcare-onset (HO)


1. ICU

2. 2E

3. Lab

4. FacWideIn

5. Don’t know0% 0% 0% 0% 0%

1 2 3 4 5

What Location is CDI Attributed?

0

88

CDI LabID Event Case Study 1-Answer

What Location is CDI Attributed?

2. 2E

Location attribution is based solely on where the patient is assigned when the specimen is collected. There is no thought process or subjective decisions allowed for location attribution for LabID event reporting. **NHSN “transfer rule” does NOT apply for LabID Events

89


3/1: Patient presents to the emergency department (ED) with complaints of diarrhea and lower abdominal pain for the past three days. Patient states that he has been on antibiotics for 10 days for tooth abscess. A stool specimen is collected while the patient is in the emergency department and toxin assay is positive for C. difficile.

3/1: Patient admitted to 2S medical unit for intravenous hydration and medical management


1. No, ED is an Outpatient location and I am only monitoring inpatient locations

2. Yes, Location would be the ED since specimen was collected there

3. Yes, location would be 2S, the admitting location

4. Yes, location would be FacWideIN

5. Don’t know 0% 0% 0% 0% 0%

1 2 3 4 5

For FacWideIN LabID reporting. Can this result be entered as a LabID Event and, if so, what location would be entered?

0


1. I can over-ride NHSN and categorize the event as community-onset

2. NHSN will categorize as community-onset

3. NHSN will categorize as healthcare –onset

4. Don’t know

0% 0% 0% 0%

1 2 3 4

What if the patient was symptomatic on admission, but the toxin was negative on admission and positive on day 4 of admission?

0

92

CDI LabID Event Case Study 2 -AnswerWhat if the patient was symptomatic on admission, but the toxin was negative on admission and positive on day 4 of admission?

3. NHSN will categorize as healthcare-onset

Healthcare Facility-Onset (HO): LabID Event collected > 3 days after admission to the facility (i.e., on or after day 4) regardless of when symptoms suggestive of CDI began.

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CDI LabID Event Case Study 33/1: Patient, accompanied by daughter, is transferred from local nursing home to the ED with complaints of diarrhea and lower abdominal pain off and on for the week. The patient had been hospitalized 6 weeks ago. The daughter states her mother has a C. difficile infection. An indwelling Foley is present. There is no record in the transfer documents or previous hospital stay of a CDI infection or treatment. A urine culture and stool for CDI is ordered. The patient is admitted to a 2S medical unit for dehydration and fever (>38.6 C)

3/2: Admission Urine culture E.coli >105

3/4: A liquid stool specimen is sent to the lab for C. difficile testing

3/5: Stool is positive for toxin A/B


1. No, Symptoms began in the nursing home before admission

2. Yes, This is the first positive CDI isolate collected in this inpatient location within 14 days

3. No, C.difficlie toxin assay is not accurate for test for CDI

4. Don’t know

0% 0% 0% 0%

1 2 3 4

For FacWideIN LabID reporting, would you enter this as a CDI LabID Event?

0


1. Community-onset (CO)

2. Healthcare-Facility onset (HO)

3. Community-Onset Healthcare Facility-Associated (CO-HCFA)

4. NHSN will not categorize the event, the user will need to make the decision

5. Don’t know

0% 0% 0% 0% 0%

1 2 3 4 5

How will NHSN Categorize the CDI Event?

0

96

CDI LabID Event Case Study 3-Rationale• Only documentation in the medical record by a health professional or other documentation is acceptable

•If the stool specimen was ordered but is obtained after the first 3 days of admission (i.e. day 4) and is then positive, it will be categorized in NHSN as HO (healthcare onset)

3/1=day 1, 3/4= day 4

• Date laboratory specimen obtained is entered in NHSN as the LabID event Date

•Unit Assigned the CDI Event is the unit where the laboratory specimen obtained

CDI LabID Event Case Study 3 (continued)

1. Healthcare Facility-onset (admitting hospital)

2. Community onset

3. Community healthcare facility associated (admitting hospital)

4. Community healthcare facility associated (nursing home)

0% 0% 0% 0%

1 2 3 4

What if this patient had been discharged from this hospital 3 weeks ago. No history of C. difficile infection during previous hospitalization. The stool specimen was obtained in the ED (3/1) and was positive for C. diff. by toxin A/B. How would this be reported in NHSN?

0

98

CDI LabID Event Case Study 3- AnswerWhat if this patient had been discharged from this hospital 3 weeks ago. No history of C. difficile infection during previous hospitalization. The stool specimen was obtained in the ED (3/1) and was positive for C. diff. by toxin A/B. How would this be reported in NHSN?

3. Community healthcare facility associated (admitting hospital)

Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from the facility ≤ 4 weeks prior to the date current stool specimen was collected


Mr. Smith is a 68 yrs old who underwent a colostomy on 4/13 for ruptured diverticulum. Post-op he is admitted to the SICU. 4/15 has a routine stool sent of C&S and C. difficile toxin. Stools are semi-formed and he is afebrile. He is transferred to 4 West on 4/16 and the C.difficile is reported as positive.


1. Yes, positive and HO to SICU

2. Yes, positive and HO to 4 West

3. No, not a reliable C.difficle test

4. Yes, assign to SICU and would be community onset

0% 0% 0% 0%

1 2 3 4


0

101

CDI LabID Event Case Study 4-AnswerMr. Smith is a 68 yrs old who underwent a colostomy on 4/13 for ruptured diverticulum. Post-op he is admitted to the SICU. 4/15 has a routine stool sent of C&S and C. difficile toxin. Stools are semi-formed and he is afebrile. He is transferred to 4 West on 4/16 and the C.difficile is reported as positive.

For FacWideIN LabID reporting, would you enter this as a

CDI LabID Event?

3. No, not a reliable C.difficile testOnly positive C.difficile tests on liquid stools (conforming to the collection container) qualify for NHSN CDI LabID event

CDI LabID Event Case Study 4 (continued)

1. Yes, positive and HO to SICU


3. No, not reliable C.difficile test

4. No, the previous test (4/15) was positive

5. Don’t know

0% 0% 0% 0% 0%

1 2 3 4 5

Mr. Smith is a 68 yrs old who underwent a colostomy on 4/13 for ruptured diverticulum. Post-op he is admitted to the SICU. 4/15 has a routine stool sent of C&S and C. difficile toxin. Stools are semi-formed and he is afebrile. He is transferred to 4 West on 4/16 and the C.difficile is reported as positive. On 4/18 patient has temp of 39.2 C, diarrheal stool sample is sent for C.diff. toxin testing and is positive. For FacWideIN LabID reporting, would you enter this as a CDI LabID event?

0

103

CDI LabID Event Case Study 4-AnswerMr. Smith is a 68 yrs old who underwent a colostomy on 4/13 for ruptured diverticulum. Post-op he is admitted to the SICU. 4/15 has a routine stool sent of C&S and C. difficile toxin. Stools are semi-formed and he is afebrile. He is transferred to 4 West on 4/16 and the C.difficile is reported as positive. On 4/18 patient has temp of 39.2 C, diarrheal stool sample is sent for C.diff. toxin testing and is positive.



Transfer rule does not apply to LABID Event surveillance

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Questions

IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013

Documents

Transcript of IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013