2016 National Healthcare Safety Network (NHSN) Definition Update. Peg Gilbert, RN, MS, CIC. Quality Improvement Advisor, Regional Lead.

Transcription

1 2016 National Healthcare Safety Network (NHSN) Definition Update Peg Gilbert, RN, MS, CIC Quality Improvement Advisor, Regional Lead Objectives Relate the changes in the NHSN surveillance definitions for 2016 Utilize the definitions to accurately measure and report select Healthcare-Associated Infections Quality Improvement Pay for Performance Programs 1

2 General Surveillance Review 7-day infection window period (IWP): Timeframe 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 Future HAI - POA Worksheet Generator Healthcare-Associated Infection (HAI) Date of event = day 3 or later Secondary BSI attribution period Time-limited (14-17 days) Repeat Infection Time Frame (RIT): 14 days beginning at DOE General Definition Reminder 2

3 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 General Surveillance Pathogen assignment Add on if in RIT and not an excluded organism Example Meets CAUTI definition with urine culture and symptoms: E. coli 2 days later positive urine culture with Enterococcus, sp Organism may be added to more than 1 event Example Meets CAUTI definition with urine culture and symptoms: S. aureus Meets Pneumonia 2 (PNU2) definition 2 days later positive blood culture for S. aureus Secondary BSI for CAUTI and Pneumonia 3

4 New Guidance CDC Locations "Inaccurate CDC Location Descriptions" under scenario 2 in order to provide instruction on how users can connect data from an older location to a newly mapped location. Must change before make them inactive Only for locations initially mapped incorrectly CDC Locations and Descriptions Manual, Page 15-8 Added four (4) new outpatient locations for Ambulatory Surgery Centers. Changes: Multiple Modules 1) Non-culture diagnostic testing included 2) Specimens from brain-dead organ donors excluded 3) Specified fungal pathogens excluded from HAI surveillance 4

5 Multiple Modules Allow use of non-culture diagnostic laboratory tests in addition to specimen cultures PCR, ELISA Not used in SUTI or ABUTI-requires quantified urine culture result Multiple Modules Specimens for microbiologic non-culture diagnostic testing or culture collected from patients documented brain dead AND maintained awaiting organ harvest will NOT be used for healthcare-associated infection surveillance. 5

6 Multiple Modules Certain Fungal Pathogens excluded Commonly community acquired Rarely HAI but may meet NHSN surveillance due to long incubation periods Pathogens are limited to Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus and Pneumocystis Additions: CLABSI Change in devices not considered central lines Extracorporeal membrane oxygenation (ECMO) Femoral arterial catheters Intra-aortic balloon pump (IABP) devices Hemodialysis reliable outflow (HeRO) dialysis catheters Impella heart devices (Added) If have a CL in addition to any on the excluded list (above) this does not apply Clarified that ANC/WBC levels should NOT be used to set the date of MBI-LCBI. The date the patient first meets the LCBI criteria is the date of the MBI-LCBI. 6

7 Exclusions: CLABSI Salmonella species as pathogens for primary BSI Plus fungal pathogens (earlier slide) BSI that is accompanied by a healthcare worker s documentation in the patient s medical record specifying the patient is suspected of self-injecting into a vascular access device, or is observed to self-inject into a device Enter as BSI - Report central-line: No Documentation must occur during the BSI Infection Window Period An RIT is created Page 4-4 BSI protocol manual Examples Patient seen injecting unknown medicine into child s PICC line Special medicine to save his life obtained over the internet Can this be excluded? Patient removes huber needle from port multiples times Can this be excluded? Patient on ECMO with IJ Central line Can this be excluded? 7

8 Added Guidance - CLABSI If LCBI + pus at insertion site of another vascular access device + have at least one matching organism - report LCBI. Report central line No Peripheral IV Arteriovenous fistula Arteriovenous graft Non-accessed central line Reminder must all be in Infection Window! Page 4-14 BSI Protocol Manual Example Patient originally admitted with sepsis, HD central line catheter placed and accessed. Discharged with catheter and readmitted in 24hrs after with suspected HD cath infected site. Tissue was cultured along with 2 blood cultures. 1 blood culture was negative, 1 was positive for yeast. The tissue culture of the HD cath site was positive for yeast. Answer: No, so long as the HD catheter is a central line and was in place more than 2 days during the previous hospitalization. Central lines that have been used are not eligible for this exclusion 8

9 Secondary BSI Only 2 ways Must meet one of the NHSN site specific definitions: Chapter 17, UTI,PNEU or SSI AND 1. 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 2. The positive blood specimen is an element used to meet the sitespecific infection criterion (Table 5) AND is collected during the site specific infection s infection window period. Table 5 Page 4-26, BSI Protocol Manual 9

10 Organism does not need to match Secondary BSI Review Only 2 ways Matching organism (longer time frame) Blood culture element in site specific (No match required) Be aware of time frames Only Primary BSIs create a BSI RIT. Secondary BSIs do not create a BSI RIT Removal and re-insert. Count continues unless out >1 calendar day (not 24 hours) pg

11 IAB-Intraabdominal Infection Definition Change Sections 2b and 3b 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* CDC Surveillance Definitions (Chapter 17) IAB-Intraabdominal infection definition has been updated: Criterion 2b was added abscess or other evidence of intraabdominal infections on gross anatomic or histopathological exam AND limited organisms in the blood The organism(s) identified in the blood must contain at least one: Bacteroides spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae Address rising CLABSI rates (Scenario 2) 11

12 Enterobacteriaceae Salmonella E. Coli Proteus Enterobacteriaceae Family Klebsiella Shigella Yersinia Pestis IAB Definition Change Criterion 3b clarified, if the imaging test evidence of infection is equivocal, it is supported by clinical correlation Definition of clinical correlation from Key Term supplement Physician documentation of antimicrobial treatment for site-specific infection 12

13 CAUTI Updates SUTI 1a CAUTI page 7-5 and SUTI 1b Non- CAUTI page 7-6 and Flowchart 7-12 Protocol updated to clarify that urinary urgency, frequency and dysuria cannot be used as symptoms when catheter is in place. Protocol updated to clarify that Candida species or yeast not otherwise specified, mold, dimorphic fungi or parasites are excluded as organisms in the UTI definition. (page 7-8). 13

14 SUTI ABUTI Flowchart Fever cannot be attributed to another cause! Present On Admission - CAUTI If positive urine culture on admission is this POA? Must also have symptom during infection window period If positive signs and symptoms on admission, is this POA? Must also have positive urine culture during infection window period Date of event must be in for POA timeframe If symptoms prior to admit, when is the date of event? Day of admission 14

15 2016 Updates VAE Added the definition for matching organism Same as other modules Added guidance for Episode of Mechanical Ventilation (EMV) denominator data collection (10-11) Break 1 full calendar day starts new EMV Added the following 6 new antimicrobial agents to the Appendix "List of Antimicrobials Agents Eligible for IVAC, PVAP" CEFTAZIDIME/AVIBACTAM, CEFTOLOZANE/TAZOBACTAM, DALBAVANCIN, ISAVUCONAZONIUM, ORITAVANCIN and PERAMIVIR Ventilator Associated Events Reminder, most of the time only need to record PEEP and FiO2 levels (don t over document) Do not upgrade a VAE during repeat time frame. Reminder, VAE uses own window period and time frames Secondary BSIs may be reported for PVAP events, provided that at least one organism identified from the blood matches an organism isolated from an appropriate respiratory tract specimen (including respiratory secretions, pleural fluid and lung tissue). During VAE infection window 15

16 Extra Pneumonia BSI secondary to PNEU blood culture as an element of the definition Blood culture collection date occurs within the 7 day infection window period Pathogen exclusions apply [exception: Candida species exclusion does not apply to PNU3 when blood and lower respiratory specimen are both growing Candida species (Footnote 8)] Can only be PNU 2 or PNU3 (Element of the definition) If meet both PNU 1 and PNU 2: Report PNU 2 if met in RIT Identification of matching Candida spp. from blood and respiratory specimen now includes Bronchoalveolar Lavage (BAL) and protected specimen brushing in addition to sputum, and endotracheal aspirate (2016 change) 2016 Changes Surgical Site Infections Table 1 deleted (Operative procedures with ICD-9) ICD-10-PCS codes and CPT codes SSI Section of the NHSN website "Supporting Materials" section Link to the new documents is on page 3 in the protocol manual New code listing coming Spring? 16

17 Appendix 1: SSI protocol (Link on Page 9-12) SSI Secondary BSI Timeframe 17-day period that includes the date of SSI event, 3 days prior and 13 days after, is still used to attribute a BSI as secondary to an SSI Secondary BSI period can fall out of your surveillance period (30 or 90 days) If a (+) blood culture occurs after the SSI secondary BSI attribution period, it should be fully evaluated to see if at that time it is meeting criteria to be secondary to an ongoing SSI. 17

18 Resources Tennessee Checklist Link /health/topic/hai 18

19 Quick Learns 2016 Changes MDRO Guidance on Conditional Questions "Last physical overnight location of patient immediately prior to arrival into facility" "Has the patient been discharged from another facility in the past 4 weeks? For 2016 LabID Event Reporting Provide the most accurate information available. Use Unknown if identifying the required information presents undue burden Be working on a new process 19

20 New Reporting Instruction for CDI Date of Event Location is attributed to where the specimen was collected If specimen collected in an outpatient location other than ED or a 24 hour observation unit it can be reported to the inpatient admitting location if collected on the same day MDRO Reporting Plan Must add data for all locations in your plan 20

21 Key Points Quarterly select your CDI Test Type Rare to select Other Enter all specimens unless duplicates Your Community Onset rate is a factor in the risk adjustment Select No Events on Denominator screen Duplicates From last positive test 21

22 MDRO and LabID Event Calculator ov/nhsn/labidcalculator/index.h tml Contact Information Peg Gilbert, RN, MS, CIC Quality Improvement Advisor, Regional Lead 402/ Nadyne Hagmeier, RN QI Project Manager , ext 374 Nancy McDonald, RN, BSN, CPHQ Quality Improvement Specialist 605/ Jean Roland, RN, BSN, CPHQ Quality Improvement Specialist 701/ This material was prepared by 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. 11SOW-GPQIN-NE-C1-45/