Building Confidence in NHSN. Peg Gilbert, RN, MS, CIC, FAPIC Quality Improvement Advisor, Regional Task Lead Great Plains Quality Innovation Network

Transcription

1 Building Confidence in NHSN Peg Gilbert, RN, MS, CIC, FAPIC Quality Improvement Advisor, Regional Task Lead Great Plains Quality Innovation Network

2 Objectives Identify resources to improve reporting Examine tools and tables to streamline criteria for infection definitions Practice case studies to determine HAI events

3 Time Frames are CRITICAL! 7-day Infection Window Period (IWP): Time frame all infection criteria must be met Date of Event (DOE): Date the first element of infection criterion occurs during IWP Present on Admission (POA): Date of event 2 days before admission until 1 day after admission Healthcare-Associated Infection (HAI) DOE = day 3 or later Secondary BSI attribution period Time-limited (14-17 days) Repeat Infection Time Frame (RIT): 14 days beginning at DOE

4 Measures Affected by Time Frames

5 Example Time Frames for NHSN Surveillance Infection Window Repeat Infection Timeframe Secondary BSI Attribution Window Patient Day POA HAI Pre admit Pre admit Admit Date Admit Date Admit Date Admit Date Admit Date Admit Date Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Symptom Date of Event Date of Event Day 8 Date of Test Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21 Day 22 Discharge Day 23 Total Days 4 Days LOS minus 2 Days 7 Days 14 Days Days Note Not used Not used Not used Not used Not used with with with with with LAB ID or VAE SSI, LABID, SSI, LABID, SSI, LABID, SSI, LABID, May be used or VAE or VAE or VAE or VAE with SSI Putting it all together

6 Device Associated Module Tools CAUTI: Catheter Associated Urinary Tract Infection CLABSI: Central-Line Associated Blood Stream Infection VAE: Ventilator Associated Events

7 Tools for CAUTI and CLABSI The Worksheet Generator is a web-based tool that is designed to identify the: 7-day Infection Window Period Date of Event and POA or HAI determination 14-day Repeat Infection Time frame (RIT) Secondary Bloodstream Infection Attribution Period (if applicable) It does not determine that all NHSN infection criteria have been met

8 Location

9 Case Using the Worksheet Generator Admit date: April 6 Date of first diagnostic test: April 9 Note BSI or other event Urine culture: Staph Aureus - April 9 Urine culture: E. Coli April 15 Blood culture: E. Coli April 19 Add symptom Fever o F on April 8 Generate worksheet button What is your decision? What is missing in this scenario? What is the RIT for the Blood Culture?

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11 Case Using the Worksheet Admit date: May 1 Date of first diagnostic test: May 1 Note BSI or other Event Blood culture: Staph Coag Neg May 1 Blood culture: Staph epidermis May 2 Blood culture: Staph epidermis 1 of 2 sets May 5 Blood culture: Candida Tropicalis May 13 Add symptom Fever 101 o F on May 2 Generate worksheet button Line inserted and accessed May 1 Removed May 8 PICC inserted May 12 What is missing in this scenario?

12 What if Staph Epi culture on 5/2 was drawn on 5/3?

13 Pathogen list, located under supporting materials

14 Key Points Identify time frames use the tools! Add additional cultures to first event Secondary BSI, do not start an RIT Common Commensals must be within one calendar day Know where to locate the pathogen list Cannot convert a BSI to a CLABSI or a UTI to a CAUTI during RIT If Primary CLABSI with MRSA Event for both CLABSI and MRSA Bacteremia

15 Secondary BSI Must meet one of the NHSN site specific definitions: Chapter 17, UTI, PNEU or SSI AND An organism identified from the site specific infection is used as an element to meet the site-specific criterion AND the blood specimen contains at least one matching organism to that site specific specimen AND is collected during the secondary BSI attribution period OR

16 Second Way The positive blood specimen is an element used to meet the site-specific infection criterion (Table 5) AND is collected during the site specific infection s infection window period

17 Page 4-26, BSI Protocol Manual Table 5 Reminder the blood specimen must be in the IWP

18 HAI? 3/17 to ER. Treated for an upper respiratory infection last 10 days. Complains of severe abdominal pain. In the ER became unresponsive, bradycardic and arrested. Coded and placed on ventilator. 3/17 Day of admission - WBC CXR - Bronchiectasis and infiltrates, both lungs. Central line inserted 3/18 WBC CXR-bilateral interstitial infiltrates, unchanged. Temp /19- WBC 21.9, temp /20 - CXR bilateral diffuse interstitial and alveolar infiltrates, increased in bases. Blood cultures x 2, Candida albicans. Dialysis catheter inserted and started on dialysis 3/21 Temp 101 Pulmonologist documents: lungs sounds harsh vesicular breath sounds bilaterally with tachypnea and rales bilaterally at the bases. Sputum CX, Candida albicans.

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20 Table 5 What Are the Options?

21 IAB 2b (Blood source only) Intraabdominal infections must meet at least one of the following criteria: 2. Patient has: b. abscess or other evidence of intraabdominal infection on gross anatomic (seen in surgery) or histopathologic exam (pathology report) and organism(s) identified from blood by a culture or non-culture based microbiologic testing method, which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). The organism(s) identified in the blood must contain at least one of the following organisms: Bacteroides spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae

22 PNEU Immunocompromised patients include those with neutropenia (absolute neutrophil count or total white blood cell count (WBC) <500/mm3), leukemia, lymphoma, HIV with CD4 count <200, or splenectomy; those who are early posttransplant, are on cytotoxic chemotherapy, or are on high dose steroids (e.g., >40mg of prednisone or its equivalent (>160mg hydrocortisone, >32mg methylprednisolone, >6mg dexamethasone, >200mg cortisone) daily for >2weeks).

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24 Exclusions

25 Key Points Note pathogen exclusions Note source of culture exclusions Note timeframe for each 2 o BSI option Pneumonia 1 does not use a culture in definition Pneumonia 2 note exclusions Pneumonia 3 patient must be immunocompromised

26 So What Was the Answer?

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28 Surgical Site Infection Meets criteria for a surgery Meets 30- or 90-day surveillance All superficial are 30 day Determine depth Look at ICD-10 or CPT code to determine Operative Code Go to Operative Code section of Appendix 1 Picture from NHSN SSI Training, 2016

29 Appendix 1: SSI protocol (Link on Page 9-12)

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31 SSI? 3/1 Patient admitted to the hospital with colon perforation. Severe abdominal pain and vomiting. To OR for an exploratory laparotomy, sigmoid resection. Culture of the fluid in the abdomen during the procedure grew E. coli. Patient was dismissed from the hospital on 3/12. 3/22 Readmitted for nausea and unable to eat. A CT scan was done and showed a pelvic fluid collection containing a small amount of gas, suspicious for abscess. 3/23 Patient had drainage of fluid collection the radiologist noted thin yellow fluid and sent fluid for culture. There were no organisms seen on the culture. Patient was also given IV Invanz. Temperature did not elevate over degrees F. during the stay. Criteria for Organ Space SSI Infection occurred within 30 days of the procedure AND involved part of the body deeper that then fascial muscle layers that was opened or manipulated during the operative procedure. AND An abscess or other evidence of infection involving the organ/space was detected on imaging test AND Meets at least 1 criterion for a specific organ/space infection site listed in table 3 (Specific Sites of Organ Space SSI)

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33 Appendix 1 First Limit the Options

34 GIT-Gastrointestinal tract infection (esophagus, stomach, small and large bowel, and rectum) excluding gastroenteritis, appendicitis, and C. difficile infection Gastrointestinal tract infections, excluding, gastroenteritis and appendicitis, must meet at least one of the following criteria: 1. Patient has an abscess or other evidence of infection on gross anatomic or histopathologic exam of gastrointestinal tract. 2. Patient has at least two of the following localized signs or symptoms compatible with infection of the organ or tissue involved: fever (>38.0 C), nausea*, vomiting*, pain*or tenderness*, odynophagia*, or dysphagia* And at least one of the following: a. organisms identified from drainage or tissue obtained during an invasive procedure or from drainage from an aseptically-placed drain by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). b. organisms seen on Gram stain or fungal elements seen on KOH stain or multinucleated giant cells seen on microscopic examination of drainage or tissue obtained during an invasive procedure or from drainage from an aseptically-placed drain c. organisms identified from blood by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST) in a patient with imaging test evidence suggestive of gastrointestinal infection (e.g., MRI, CT Scan), which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for gastrointestinal tract infection). d. imaging test evidence suggestive of infection (e.g., MRI, CT scan), which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for gastrointestinal tract infection). e. evidence of infection on endoscopic examination (e.g., Candida esophagitis, proctitis, etc.)

35 IAB-Intraabdominal infection, not specified elsewhere including gallbladder, bile ducts, liver (excluding viral hepatitis), spleen, pancreas, peritoneum, subphrenic or subdiaphragmatic space, or other intraabdominal tissue or area not specified elsewhere Intraabdominal infections must meet at least one of the following criteria: 1. Patient has organisms identified from an abscess or from purulent material from intraabdominal space by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). 2. Patient has: a. abscess or other evidence of intraabdominal infection on gross anatomic or histopathologic exam b. abscess or other evidence of intraabdominal infection on gross anatomic or histopathologic exam and organism(s) identified from blood by a culture or non-culture based microbiologic testing method, which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). The organism(s) identified in the blood must contain at least one of the following organisms: Bacteroides spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae 3. Patient has at least two of the following signs or symptoms: fever (>38.0 C), nausea*, vomiting*, abdominal pain*, or jaundice* And at least one of the following: a. organisms seen on Gram stain or identified from drainage or tissue obtained during invasive procedure or from an aseptically-placed drain (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage)by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). b. organisms identified from blood by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST) and imaging test evidence suggestive of infection (e.g., ultrasound, CT scan, MRI, radiolabel scans [gallium, technetium, etc.] or on abdominal x-ray), which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for intraabdominal infection). The organism(s) identified in the blood must contain at least one of the following organisms: Bacteroides spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae*

36 OREP-Other infection of the male or female reproductive tract (epididymis, testes, prostate, vagina, ovaries, uterus, chorioamnionitis, or other deep pelvic tissues, excluding endometritis or vaginal cuff infections) Other infections of the male or female reproductive tract must meet at least one of the following criteria: 1. Patient has organisms identified from tissue or fluid from affected site (excludes urine) by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). 2. Patient has an abscess or other evidence of infection of affected site on gross anatomic (not seen) or histopathologic exam. 3. Patient has suspected infection of one of the listed OREP sites and two of the following localized signs or symptoms: fever (>38.0 C), nausea*, vomiting*, pain or tenderness*, or dysuria* And at least one of the following: a. organisms identified from blood by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). No blood culture b. physician initiates antimicrobial therapy within two days of onset or worsening of symptoms INVANZ

37 Surgical Site Infection Tools Tennessee checklist link tn.gov/healt h/topic/hai

38 MDRO & CDI Event Calculator

39 Calculate

40 Resources l

41 Ask NHSN Put measure type in subject line Include Org ID Put cases on graph Print Screen Alt Print Screen if 2 monitors Control V (Paste) Send question to: nhsn@cdc.gov Website Training:

42 Summary Time frames are critical Use the tools Worksheets Calculators Checklists Complete the online training Don t be afraid to ASK!

43 Where Are Your Struggles?

44 Contact Information Peg Gilbert, RN, MS, CIC, FAPIC Great Plains Quality Innovation Network P: This material was prepared the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11S0W-GPQIN-NE-C1-53/0616