NHSN and Public Reporting. Linda R. Greene, RN,MPS,CIC Manager Infection Prevention Highland Hospital Rochester, NY linda_

Transcription

1 1 NHSN and Public Reporting Linda R. Greene, RN,MPS,CIC Manager Infection Prevention Highland Hospital Rochester, NY linda_

2 2 Objectives Describe challenges and opportunities related to pay for performance and pay for reporting Identify changes to NHSN definitions for 2015 Apply definitions to case scenarios Interpret NHSN data and illustrate ways it can be used to drive improvement using the current evidence

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5 Reported Measures 5

6 Who Gets HAIs? 1/25 on any given day in U.S. hospitals; many are older adults Magill SS, et al. NEJM 2014

7 How Big of a Problem are Healthcare Associated Infections (HAIs) in the U.S.? Point Prevalence Survey; National Healthcare Safety Network (NHSN) N=183 hospitals, 2011 Patients at risk = 11, (4.0%) with > one HAI Distribution by site see pie chart C. difficile = 70% of GI infections Nationwide estimates: 648,000 patients with 721,800 HAIs/year Magill SS et al. NEJM 2014;370:

8 HHS Action Plan 8

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11 Challenges 11

12 12 Hospital Compare Central line-associated bloodstream infections (CLABSI) My Hospital State U.S. National Benchmark = 1

13 HAC Reduction 13

14 14 NHSN TAP Reports 5 Star System

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16 16 NHSN Data is Important Surveillance vs. Clinical Definitions Future move to algorithmic surveillance CMS validation Many changes in Will become the new baseline year.

17 17 General Changes Infection Window Period* Date of Event* Present on Admission (POA) Infections* Healthcare-Associated Infections(HAI)* Repeat Infection Timeframe (RIT)* Secondary BSI Attribution Period* Pathogen assignment* Does not apply to SSI Surveillance *Does not apply to VAE, LabID Event Surveillance

18 18 NHSN NHSN Course Slides Posted NHSN Webinar

19 19 No Longer Used Gap days Date last element was met

20 20 Infection Window Period Infection Window Period A 7 day period during which all site-specific infection criterion must be met. It includes the date of the first positive diagnostic test, that is an element of the sitespecific criterion, 3 calendar days before and 3 calendar days after For site-specific criterion that do not include a diagnostic test, the first documented localized sign or symptom that is an element of the infection criterion will be used

21 21 Example Infection Window Period Diagnostic test examples: Laboratory specimen collection Imaging test Procedure or exam Localized sign and/or symptom examples: Diarrhea Site specific pain Purulent exudate

22 22 Date of Event The date the first element used to meet the CDC NHSN site-specific infection criterion occurs for the first time within the seven day infection window period Date of Infection 2015 Fever Positive culture

23 Date of Event 23

24 24 POA Present on Admission (POA) vs. Healthcare-Associated Infection (HAI) Present on Admission - date of event* occurs on the day of admission or the day after admission. The POA time period continues to include the day of admission, 2 days before and the day after admission. Healthcare-Associated Infection - the date of event* occurs on or after the 3rd calendar day of admission.

25 25 Repeat Infection Timeframe (RIT) A 14-day timeframe during which no new infections of the same type are reported The date of event is Day 1 of the 14-day Repeat Infection Timeframe Additional pathogens identified are added to the event

26 26 RIT The RIT will apply at the level of specific type of infection with the exception of Bloodstream Infection (BSI), Urinary Tract Infection (UTI) and Pneumonia (PNEU) where the RIT will apply at the major type of infection Patients will have no more than one BSI (e.g., LCBI1, LCBI2, MBI-LCBI1etc.) Patients will have no more than one UTI (e.g., SUTI, ABUTI)

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28 28 Test Your Knowledge Mrs. X is admitted to your hospital on Oct 1 st. A urinary catheter is inserted at that time. On Oct 3 rd, she spikes a temp of The next day, a urine culture is sent which grows 100,00 ecoli. Is this an HAI? Why or why not?

29 29 Another One Mr. Y developed a CAUTI on 11/01/14 which grew 100,000 pseudomonas On 11/13/14, he has a second urine culture sent which grows 100,000 proteus. How is this classified? 1. Not a new CAUTI- no further data is added to NHSN 2. New CAUTI- Different organism 3. Not a new CAUTI, but add proteus to the pathogen list of the pre-existing infection.

30 30 Definitions Secondary Bloodstream Infection (BSI) Attribution Period The period in which a positive blood culture must be collected to be considered as a secondary bloodstream infection to a primary site infection. The period is days in length depending upon the date of event

31 Blood Culture Ecoli 31

32 32 Secondary BSI Secondary bloodstream infections may be attributed to a primary site infection as per the Secondary BSI Guide of the BSI event protocol Blood culture pathogen matches at least one organism found in the site-specific infection culture used to meet the primary site infection criterion OR The positive blood culture is an element used to meet the primary site infection criterion

33 33 Pathogen Assignment Pathogen Assignment Additional eligible pathogens identified within a Repeat Infection Window are added to the event Pathogens exclusions for specific infection definitions (e.g., UTI, PNEU)* also apply to secondary bloodstream infection pathogen assignment Excluded pathogens must be attributed to another primary site-specific infection as either a secondary BSI or identified as a primary BSI

34 34 Pathogen Assignment BSI pathogens may be assigned to more than one infection source Assigned as a secondary BSI pathogen to a site-specific infection (e.g., UTI) and assigned as an additional pathogen to a primary BSI event

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36 36 Definitional Changes: New CAUTI Definition The Urinary Tract Infections (UTI) definitions will no longer include: Symptomatic UTI (SUTI) criteria 2 and 4 due to removal of the following elements: Colony counts of less than 100,000 CFU/ml Urinalysis results Urine cultures that are positive only for yeast, mold, dimorphic fungi, or parasites Uropathogen List for Asymptomatic Bacteremic UTI (ABUTI)

37 37 CAUTI What These Changes Mean for Facilities Reporting UTIs to NHSN in 2015 Only urine cultures with a colony count of at least 100,000 CFU/ml for at least one bacteria will be used to meet NHSN UTI criteria. Only bacteria will be accepted as causative organisms of UTI. ABUTI criteria will use the same pathogen list as SUTI.

38 38 Question Mrs. X is admitted to your unit on 11/6/2014. She has a PICC line in place and a urinary catheter is inserted. On 11/10/2014 she spikes a temperature of 38.5, the physician orders blood and urine cultures. Both the blood and urine grow 1,000 candida. How do you classify this infection? 1. CAUTI with secondary BSI 2. Primary BSI and CAUTI 3. CLABSI only

39 39 SSI Definition Infection Present at Time of Surgery Infection present at time of surgery (PATOS) will be a new field on the SSI Event form. PATOS denotes that an infection is present at the start of, or during, the index surgical procedure (in other words, it is present preoperatively). PATOS doesn t apply if there is a period of wellness between the time of a preoperative condition and surgery. The infection must be noted/documented preoperatively or found intra-operatively in a pre-operative or intraoperative note.

40 40 SSI Continued The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be surgeon notation that there is evidence of infection or abscess present at the time of surgery.

41 41 PATOS Only select PATOS = YES if it applies to the depth of SSI that is being attributed to the procedure (e.g., if a patient had evidence of an intra-abdominal infection at the time of surgery and then later returns with an organ space SSI the PATOS field would be selected as a YES. If the patient returned with a superficial or deep incisional SSI the PATOS field would be selected as a NO).

42 42 Question 19 year old patient admitted with an acute abdomen, to OR for XLAP with finding of an abscess due to ruptured appendix, and an APPY is performed. Patient returns 2 weeks later and meets criteria for an organ space IAB SSI. How would you mark the PATOS field? 1.Yes 2. No

43 43 Question Patient is admitted with a ruptured diverticulum and the surgeon notes that there are multiple abscesses in the intra abdominal space. Patient returns 3 weeks later and meets criteria for a superficial SSI? How would you mark the PATOS field? 1. Yes 2. No

44 44 SSI Diabetes Documented Along with the current NHSN definition of diabetes, assignment of the discharge ICD-9 codes in the 250 to range will be acceptable for use to answer YES to this diabetes field question. Change in Scope Field Reporting Instruction The reporting instruction for answering the SCOPE risk factor field will be updated. The instruction regarding the extension of a scope site will be removed. New instruction in the Table of Instructions will be: Check Y if the NHSN operative procedure was coded as a laparoscopic procedure performed using a laparoscope/robotic assist, otherwise check N.

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47 47 MRSA/ VRE Continued MDRO and CDI LabID Event reporting for facility-wide inpatient (FacWideIN) will also require location-specific surveillance for that same organism in each emergency department(s) (pediatric and adult) and 24-hour observation location(s). Facilities participating in FacWideIN LabID Event reporting will be required to map and report outpatient LabID Events from emergency departments and 24-hour observation locations for the same organism and LabID Event type (i.e., All Specimens or Blood Specimens only). This means facilities will no longer assign the admitting inpatient location to LabID Events when specimens are collected in the emergency department or 24-hour observation location on the same calendar day as inpatient admission.

48 48 VAE Combining possible / probable VAP Ability to enter episodes of mechanical ventilation Pathogen reporting and secondary bloodstream attribution specific to pneumonia 1 will not be allowed

49 49 VAE Surveillance Definition Algorithm Summary Respiratory status component Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation No CXR needed! Ventilator-Associated Condition (VAC) Infection / inflammation component Additional evidence General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testing Possible or Probable VAP

50 50 Case 1 54 yr old male admitted to the ICU transferred on ventilator from the ED. Review vent settings below to see if VAE criteria are met. If so, on what day? 1. No VAC 2. Day 4 3. Day 7 4. Day 8 MV Day Min PEEP Min FiO

51 51 Case 2 54 yr old male admitted to the ICU transferred on ventilator from the ED. Would the criteria be met with these settings? If so, on what day? 1. No VAC 2. Day 4 3. Day 7 4. Day 8 MV Min Min Day PEEP FiO

52 52 The Data Our job is to turn data into meaningful information which can be used by care providers to improve outcomes Let s look at this scenario:

53 53 Which answer(s) best describes this data? 1. Both the CAUTI rate and the SIR are higher statistically higher than the NHSN mean 2. The rate difference is due to chance 3. Only 14% of like ICU s reporting to NHSN have a higher infection rate

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56 56 Evidence Based Practices Look at the evidence Conduct a gap analysis Evaluate what processes are already in place

57 57 Recent Guidelines Only 2 recommendations with high level of Evidence: 1.Do not ROUTINELY use antiseptic catheters to prevent CAUTI ((quality of evidence: I). 2. Do not treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures (quality of evidence: I).

58 58 Appropriate Indications for Catheter Use Appropriate Indications Patient has acute urinary retention or obstruction Need for accurate measurements of urinary output in critically ill patients. Perioperative use for selected procedures: urologic surgery or other surgery on contiguous structures of genitourinary tract, anticipated prolonged surgery duration (removed in post-anesthesia unit), anticipated to receive large-volume infusions or diuretics in surgery, operative patients with urinary incontinence, need to intraoperative monitoring of urinary output. To assist in healing of open sacral or perineal wounds in incontinent patients. Requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine) To improve comfort for end of life care if needed. Gould C, et al. Infect Control Hosp Epidemiol 2010;31:

59 59 Driving Performance Most CAUTIs occur from day 7-10 Yeast is the primary pathogen in 30% of the CAUTIs Most patients are transferred out of the ICU with a catheter Which of the following actions would not be a first step? 1) Institute nurse driven removal protocols, automatic stop orders,etc. 2) Ensure catheters are inserted for appropriate indications 3) Develop a competency program to ensure all care providers insert urinary catheters aseptically 4) Develop culturing guidelines

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64 64 Changes 2008 Wash and clean area around incision site using appropriate antiseptic agent( A- 2) Use alcohol-containing pre-operative skin preparatory agents if no contraindication exists ( New- 1 High) Control blood glucose level during the immediate postoperative period for patients undergoing cardiac surgery (AI). Maintain post-operative blood glucose 180 mg/dl. Cardiothoracic surgical procedures (A-I; NEW=HIGH) Non-cardiac procedures [Dronge Arch Surg 2006; Golden Diabetes care 1999; Olsen MA JBoneJoint Surg Am 2008] (NEW= 2 MODERATE)

65 65 Changes Maintain normothermia (temperature higher than 36 o C) immediately after colorectal surgery previous unresolved Impervious plastic wound protectorsnot discussed Maintain normothermia(temperature > 35.5 C) during the perioperative period. (NEW= 1 HIGH) Impervious plastic wound protectors in gastrointestinal and biliary tract surgery (NEW= 1 HIGH)

66 66 Changes 2008 Maintaining oxygenation with supplemental oxygen during and after colorectal procedures (unresolved issue) 2014 Maintaining oxygenation with supplemental oxygen during and following colorectal procedures (NEW) Routine screening for MRSA or routine attempts to decolonize surgical patients with an antistaphylococcal agent in the preoperative setting (unresolved issue) Special populations: recommended for use in locations and/or populations within the hospital with unacceptably high SSI rates despite implementation of the basic SSI prevention strategies: Screen for Staphylococcus aureus and/or decolonize surgical patients with an anti-staphylococcal agent in

67 67 Changes Check list- not discussed Use the WHO check list (1) Not addressed Optimize tissue oxygenation by administering supplemental oxygen during and immediately following procedures requiring mechanical ventilation

68 68 Changes - Antibiotics Administer prophylaxis within 1 hour before incision Discontinue prophylaxis within 24 hours after surgery Although guidelines suggest stopping the antimicrobial agent within 24 hours of surgery, there is no evidence that agents given after closure contribute to efficacy, and they do contribute to increased resistance Weight dose antibiotics

69 69 CMS Final Rule for Value Based Purchasing 2017: Remove from measure set the following process measures as toppedout : SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients SCIP-Inf-3: Prophylactic Antibiotic Discontinued Within 24 Hours After Surgery End Time SCIP-Inf-9: Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2

70 70 Unresolved Issues 1. Preoperative bathing with chlorhexidine-containing products. Preoperative bathing with agents such as chlorhexidine has been shown to reduce bacterial colonization of the skin. Several studies have examined the utility of preoperative showers, but none has definitely proven that they decrease SSI risk. Six randomized controlled trials evaluating the use of 4% chlorhexidine gluconate were included in a Cochrane review, with no clear evidence of benefit noted. It should be noted that several of these studies had methodological limitations and were conducted several years ago. Thus, the role of preoperative bathing in SSI prevention is still uncertain. To gain the maximum antiseptic effect of chlorhexidine, adequate levels of CHG must be achieved and maintained on the skin. Typically, adequate levels are achieved by allowing CHG to dry completely.

71 71 Safety More than a Model Leadership System Design Communication Patient Organizational Learning Teamwork Managing Behavioral Choices 71

72 72 Different Direction Contextual Journey INSIDE OUT Observe then define Observation for understanding Anthropology foundation Solutions are uncovered, guided by insiders, those directly involved-creates ownership Our New Journey Traditional Journey OUTSIDE IN Define, then observe Observation for compliance Manufacturing foundation Solutions are pre-defined, guided by outsiders, those indirectly involved-buy-in

73 73 The Bottom Line Many changes for 2015 Moving toward clearer definitions and data that can easily be retrieved from the medical record Surveillance data is important to drive performance improvement and assure the accuracy of reported data

74 74 Difficult Job