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2015 NHSN Training
Teresa Fox, CIC
Quality Improvement Advisor
teresa.fox@area-g.hcqis.org
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
Infection Window Period
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
Infection Window Period
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
Secondary BSI Attribution Period
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
Secondary BSI Attribution Period
28
Secondary BSI Attribution Period
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
31
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
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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
Secondary BSI Attribution Period
• 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
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LabID Event Reporting
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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
FacWideIN Surveillance
42
FacWideIN Surveillance
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
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
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
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
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
57
SUTI 2 (≤ 1-year-old)
Patient must meet 1, 2 and 3 below:
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)
Patient must meet 1, 3 and 3 below:
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 7 Foley in place
Day 8 Foley in place
Day 9 Foley in place
Day 10 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
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