IPRO
HAI LAN Meeting
New York City, November 6, 2013
Schenectady NY, November 7, 2013
Applying NHSN
Protocol Definitions
Carole Van Antwerpen, RN, BSN, CIC
1
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
2
Applying the
NHSN 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
3
Navigating NHSN SSI Reporting Rules
Resources
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 (nhsn@cdc.gov)
4
Depth of SSI: used for both
primary and secondary
incisions (no changes)
2012
1 yr surveillance period
for deep and organ
space SSI for all
procedures with nonhuman implant
Primary incision closure
excluded all procedures
where a drain or other
material was extruding
from the incision. Skin
incision completely
closed
2013
Surveillance 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
Priority list abdominal
procedures- small bowel, procedures- colon above
small bowel and rectal
rectal then colon
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.
5
Surveillance Determination
Trumps
Clinical Determination
6
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
7
SSI Case Study 1
Is this an HAI?
1. Yes
2. No
3. Don’t know
0%
0%
0%
1
2
3
0
0 / 100
SSI Case Study 1
What infection type should be reported?
57%
1. SSI-SIP
2. SSI-SIS
3. SSI-DIP
4. SSI-DIS
5. SSI-IAB
14%
14%
14%
3
4
5
0%
1
2
0
SSI Case Study 1
Reported as occurring:
71%
1. A= on admission
2. P= Post Discharge
3. RF= Readmission to this
facility
4. RO= Readmission “other”
facility
14%
14%
0%
1
2
3
4
0
SSI Case Study 1 – Answer
Deep 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 incision
b. a deep incision that spontaneously dehisces or is deliberately opened
by a surgeon and is culture-positive or not cultured
and
patient has at least one of the following signs or symptoms: fever
(>38°C); localized pain or tenderness. A culture-negative finding does
not meet this criterion.
c. an abscess or other evidence of infection involving the deep incision is
found on direct examination, during invasive procedure, or by
histopathologic examination or imaging test.
d. diagnosis of a deep incisional SSI by a surgeon or attending physician
11
SSI Case Study 1 - Answer
If 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
12
SSI Case Study 2
• Patient admitted on 9/10 and underwent a hemicolectomy.
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.
13
SSI Case Study 2
What type of SSI does this patient have?
29%
29%
29%
1. SSI-SIP
2. SSI-DIP
14%
3. SSI-IAB
4. SSI-GIT
1
2
3
4
0
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 or
tissue in the organ/space
•c. an abscess or other evidence of infection involving the organ/space
that is found on direct examination, during invasive procedure, or
by histopathologic examination or imaging test
•d. diagnosis of an organ/space SSI by a surgeon or attending
physician
•and
meets at least one criterion of a specific organ/space infection site listed in
Table 4
15
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
16
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 tract
Esophagus
Stomach
Small, Large bowel and Rectum
Excludes gastroenteritis and appendicitis
– Therefore, IAB is the appropriate choice site of SSI in
this case
17
SSI Case Study 2 (Continued)
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.
57%
Does this change your determination of an SSI-IAB?
1. Yes
29%
2. No
14%
3. Don’t know
1
2
3
0
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. No
Although 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.
19
SSI Case Study 3
On 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 May
The 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?
20
SSI Case Study 3
Which surgical procedure is entered
in NHSN?
43%
1. Colon only
29%
2. Hysterectomy only
3. Both colon and
14%
14%
hysterectomy
4. Not sure
1
2
3
4
0
SSI Case Study 3
What about the assigned
intraoperative wound class 2?
1.
57%
Enter in NHSN as 2
2. Enter in NHSN as WC 3 or 4
3. Discuss WC assignment with
29%
the Surgeon and/or OR staff
14%
4. Answers 2 and 3
5. Not sure
1
2
0%
0%
3
4
5
0
SSI Case Study 3
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
0%
0%
0%
0%
1
2
3
4
0
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
3.10 hrs
3. Time identified for each procedure.
4. Not Sure
The surgical time (incision to incision close) is 3.10 hrs .
24
SSI Case Study 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?
1.
Yes
2. No
3. Not sure
0%
0%
0%
1
2
3
0
SSI Case Study 3 (continued)
What type of an SSI?
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
0
SSI Case Study 3
To which procedure is the SSI attributed?
1.
HYST
2. COLO
3. Both HYST and COLO
4. Not sure
0%
0%
0%
0%
1
2
3
4
0
SSI Case Study 3-Answer
Rationale 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.
28
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
29
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 the
incision (e.g., fascial and muscle
layers) of the incision and
patient has at least one of the following:
a. purulent drainage from the deep
incision
b. a deep incision spontaneously
dehisces…
c. And abscess or other evidence of
infection is found…
d. diagnosis by surgeon or physician
Event Date: 2/3
30
SSI Case Study 4
How many SSIs should be reported?
1.
One
2. Two
3. Three
4. Four
0%
0%
0%
0%
1
2
3
4
0
SSI Case Study 4 -Answer
How many SSIs should be reported?
Rationale
1. One
Following 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)
32
Applying the NHSN Central Line Associated
Blood Stream Infection (CLABSI) Definitions
CLABSI Case Studies
Adapted from CDC-NHSN Training Slides†
http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html †
33
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 (nhsn@cdc.gov)
34
Surveillance Determination
Trumps
Clinical Determination
35
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 7
WBC 900
800
600
400
600
700 800
ANC
--------400
--- 600
-Does patient meet criteria for an HAI?
-What is the Event Date?
36
Ms. A. CLABSI Case Study 1
Does patient meet criteria for an HAI?
1.
Yes, Event date 4/7
2. Yes, Event date 4/5
3. No
4. Not sure
0%
0%
0%
0%
1
2
3
4
0
Ms. A. CLABSI Case Study 1
What specific type of HAI does Ms. A
have?
1.
LCBI 1
2. LCBI 2
3. MBI-LCBI 1
4. MBI-LCBI 2
0%
0%
0%
0%
1
2
3
4
0
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 2
Yes. 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).
39
Ms. A. : Laboratory Values- Answer (continued)
Adm. Date
ANC
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
--------400
--600
Day 5
Day 4
Day
-3
Day
-2
ANC or
WBC<500?
Day 1
X
Day 1
Day 2
Day 3
X
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
40
Ms. A. CLABSI Case Study 1
Is the CLABSI attributed to your
facility or the transferring facility?
1.
Your facility since the
device was accessed there
2. The transferring facility
where the line was placed
3. Not sure
0%
0%
0%
1
2
3
0
Ms. A. CLABSI Case Study 1-Answer
Is 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
42
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
43
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?
44
Mr. D. CLABSI Case Study 2
Does this patient meet the criteria for a
CLABSI?
1.
Yes, HAI, CLABSI with
S.epidermidis
2. No, HAI, CLABSI
3. No, but HAI abdominal
infection with secondary
bacteremia
4. Not sure
0%
0%
0%
0%
1
2
3
4
0
Mr. D. CLABSI Case Study 2 - Answer
Does 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.
46
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.
47
Ms. E. CLABSI Case Study 3
Is there an LCBI?
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
0
Ms. E. CLABSI Case Study 3
Which LCBI criterion apply?
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
0
Ms. E. CLABSI Case Study 3
What unit should be indicated for the
location of device insertion field?
1.
The ED
2. The ICU
3. Neither location
4. Not sure
0%
0%
0%
0%
1
2
3
4
0
Ms. E. CLABSI Case Study 3 (Continued).
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?
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
0
Ms. G CLABSI Case Study 4
3/24: 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.
52
Ms. G. CLABSI Case Study 4 (continued)
Date
3/24-3/26
4/1-4/9
Temp
3/24 101.6,
3/26 99.2
afebrile
4/10
98.7-100.2
Diagnostic Findings
Preliminary chest x-ray bilateral pneumonia. Urine and blood
cultures no growth
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
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
4/18
100.2
4/19
98.0
Urine culture U/A, BC’s sent, CL site unremarkable. Stool for
C. difficile sent
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.
Medical diagnosis of Candida endocarditis. Antifungal
treatment initiated.
53
Ms. G. CLABSI Case Study 4
Does the patient meet NHSN
criteria for an HAI?
1.
Yes
2. No
3. Not sure
0%
0%
0%
1
2
3
0
Ms. G. CLABSI Case Study 4
What is the HAI site?
1.
CLABSI only
2. UTI only
3. CLABSI and UTI
4. Endocarditis
5. All of the above
0%
0%
0%
0%
0%
1
2
3
4
5
0
Ms. G. CLABSI Case Study 4-Answer
Endocarditis 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 echocardiogram
AND MD initiates appropriated antimicrobial therapy
CLABSI Module Appendix 1: pp. 4-15
3. 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.
56
Ms. G. CLABSI Case Study 4-Discussion
NO 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
•
57
Applying
NHSN CAUTI Definitions
CAUTI Case Studies
Adapted from CDC NHSN Training Slides†
†
http://www.cdc.gov/nhsn/acute-care-hospital/CAUTI/index.html
58
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 (nhsn@cdc.gov)
•Friends in Medical Records and Laboratory
59
Remember
Surveillance 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
60
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, Afebrile
4/11: 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
61
UTI Case Study 1
Is 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
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
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.
63
UTI Case Study 2
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 CFU
4/20: 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?
64
UTI Case Study 2
Is this a UTI and if so what type?
1.
No UTI
2. Yes, CAUTI Criterion 1a,
Report NHSN
3. Yes, CAUTI Criterion 2a,
Report NHSN
4. Not sure
0%
0%
0%
0%
1
2
3
4
0
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
66
UTI Case Study 2
Does the Patient also have a CLABSI?
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
0
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 CFU
4/20: 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
68
UTI Case Study 2
Is this a UTI and if so what type?
1.
No UTI
2.
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
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
70
UTI Case Study 3
POD 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
71
UTI Case Study 3
Is this a UTI and if so what type?
1.
No UTI
2. Yes, CAUTI Criterion 1b,
Report NHSN
3. Yes, CAUTI Criterion 2a,
Report NHSN
4. Yes, SUTI but not ICU
associated
5. Don’t know
0%
0%
0%
0%
0%
1
2
3
4
5
0
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
73
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.
74
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 no
Date of UTI?
75
UTI Case Study 4
Does this patient have a UTI? If so,
what type?
1.
No, UTI
2. Yes, ABUTI, Report NHSN
3. Yes, SUTI 2a, Report
NHSN
4. Yes, SUTI 1a, Report NHSN
5. Don’t know
0%
0%
0%
0%
0%
1
2
3
4
5
0
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.
77
UTI Case Study 4
What is the date of the UTI?
1.
9/7
2. 9/8
3. 9/9
4. Don’t know
0%
0%
0%
0%
1
2
3
4
0
UTI Case Study 4
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
2. No
3. Not sure
0%
0%
0%
1
2
3
0
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
80
UTI Case Study 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?
1.
No UTI
2. Yes, SUTI 1a, Report NHSN
3. Yes, ABUTI, Report NHSN
4. Don’t know
0%
0%
0%
0%
1
2
3
4
0
Applying the
NHSN Clostridium difficile (CDI)
LabID Event Protocols
CDI LabID Event Case Studies
Adapted from CDC NHSN Training Slides†
†http://www.cdc.gov/nhsn/acute-care-hospital/cdiff-mrsa/
82
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
83
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, relieved
with 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.
84
CDI LabID Event Case Study 1
Does this meet NHSN criteria for a CDI LabID
Event
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
0
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)
86
CDI LabID Event Case Study 1
What Location is CDI Attributed?
1.
ICU
2. 2E
3. Lab
4. FacWideIn
5. Don’t know
0%
0%
0%
0%
0%
1
2
3
4
5
0
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
88
CDI LabID Event Case Study 2
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
89
CDI LabID Event Case Study 2
For FacWideIN LabID reporting. Can this result be entered as a
LabID Event and, if so, what location would be entered?
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
0%
1
2
3
4
5
CDI LabID Event Case Study 2
What if the patient was symptomatic on admission, but the
toxin was negative on admission and positive on day 4 of
admission?
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
0
CDI LabID Event Case Study 2 -Answer
What 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.
92
CDI LabID Event Case Study 3
3/1: 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
93
CDI LabID Event Case Study 3
For FacWideIN LabID reporting, would you enter this as a
CDI LabID Event?
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
0
CDI LabID Event Case Study 3
How will NHSN Categorize the CDI Event?
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
0
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
96
CDI LabID Event Case Study 3 (continued)
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?
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
0
CDI LabID Event Case Study 3- Answer
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?
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
98
CDI LabID Event Case Study 4
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.
CDI LabID Event Case Study 4
For FacWideIN LabID reporting, would you enter this as a CDI
LabID Event?
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%
1
2
3
0%
04
CDI LabID Event Case Study 4-Answer
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.
For FacWideIN LabID reporting, would you enter this as a
CDI LabID Event?
3. No, not a reliable C.difficile test
Only positive C.difficile tests on liquid stools (conforming to
the collection container) qualify for NHSN CDI LabID event
101
CDI LabID Event Case Study 4 (continued)
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?
1.
Yes, positive and HO to SICU
2.
Yes, positive and HO to 4 West
3.
No, not reliable C.difficile test
4.
No, the previous test (4/15) was
positive
5.
Don’t know
0%
0%
0%
0%
1
2
3
4
0%
05
CDI LabID Event Case Study 4-Answer
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?
2. Yes, positive and HO to 4 West
Transfer rule does not apply to LABID Event surveillance
103
Questions
104