APIC NHSN Webinar. May 16, National Center for Emerging and Zoonotic Infectious Diseases

Transcription

1 National Center for Emerging and Zoonotic Infectious Diseases APIC NHSN Webinar May 16, 2018 Denise Leaptrot Lindsey Weiner LaTasha Powell Dominique Godfrey

2 Disclosures The following speakers discloses no actual or potential conflict of interest in relation to this program/presentation. Denise Leaptrot Lindsey Weiner LaTasha Powell Dominique Godfrey The following planning staff report no actual or potential conflict of interest in relation to this program/presentation. Carol McLay DrPH, MPH, RN, CIC Hannah Andrews

3 Objectives Discuss CDI testing methodology Explain CDI test type impact on SIR calculation Clarify elements of Chapter 4: BSI in the NHSN manual

4 National Center for Emerging and Zoonotic Infectious Diseases Clostridium difficile(cdi) FACT or FICTION Denise Leaptrot, MSA, SM/BSMT(ASCP), CIC May 16, 2018

5 NHSN doesn t endorse or make recommendations on specific methodology used in CDI testing Each facility should choose a CDI test method that best balances the facility lab resources, clinical management, and infection prevention efforts Facilities may choose a single step test method OR a multistep test method

6 What is a multi-step testing algorithm for C. difficile? Many variations of testing qualify as multistep including, but not limited to: GDH antigen plus EIA for toxin GDH antigen plus EIA for toxin, followed by NAAT (PCR) on all specimens GDH plus EIA for toxin. If GDH and EIA results differ, followed by NAAT (by standard protocol or by physician order) NAAT first. If NAAT positive, followed by EIA toxin testing *NOTE: all testing performed on the same unformed stool specimen

7 CDI Laboratory Assay Definition:

8 Knowledge Check: Is this a CDI LabID event? Laboratory finding : GDH Antigen = Positive EIA Toxin = Negative

9 Knowledge Check: Is this a CDI LabID event? Laboratory finding : GDH Antigen = Positive EIA Toxin= Negative PCR test= Positive

10 Knowledge Check: Is this a CDI LabID event? Laboratory finding : PCR test= Positive EIA Toxin = Negative

11 Denominator Data Select CDI Test type quarterly (last month of each calendar-year quarter March; June; September; December)

12 National Center for Emerging and Zoonotic Infectious Diseases Selecting CDI Test Type in NHSN Impact on SIR Calculation Lindsey Weiner, MPH Centers for Disease Control and Prevention

13 CDI Test Type Selection CDI test type is selected once per quarter: FacWideIN(& IRF unit) denominator form You have many choices in the drop-down menu: Single tests, such as NAAT (i.e., PCR) Multi-step algorithms, such as NAAT plus EIA Accurate selection of CDI test type is crucialto an accurate SIR

14 CDI Test Type & The SIR CDI test type is used in the calculation of that quarter s # of predicted events, and hence, the SIR # of healthcare-onset CDI events SIR = # of predicted healthcare-onset CDI events Sensitive tests, such as NAAT, will detect a higher # of positive CDI specimens Sensitive tests contribute to a larger SIR denominator Less sensitive tests, such as GDH or toxigenic culture, will detect fewer positive CDI events Smaller SIR denominator Monthly CDI SIRs are not available

15 CDI Test Type & Risk Adjustment Three categories of test type are used in risk adjustment for acute care hospitals Based on finaltest in the testing algorithm EIA: EIA / GDH + EIA / NAAT + EIA Negative parameter estimate (less sensitive tests; fewer predicted events) NAAT: NAAT / GDH + NAAT / GDH + EIA + NAAT Positive parameter estimate (sensitive tests; higher number of predicted events) OTHER: all other test options and free-text entry No risk adjustment for test type is applied for this category

16 Accurate Selection of CDI Test Type in NHSN Q: I don t see PCR as an option in the drop-down. What should I do? A: If your lab is using PCR, select NAAT as your test type Hint: if you don t select NAAT in this case, your SIRs will be artificially HIGH! Q: My lab changed test methods in the middle of the quarter. A: Select the test method that was used more often during the quarter, or the test used for the majorityof the quarter

17 Accurate Selection of CDI Test Type in NHSN Q: My lab uses multiple tests, however the NHSN form will only allow me to select one option. A: Some options in the NHSN drop-down describe multi-step algorithms. Select the algorithm that matches your lab s! Q: I am not sure how to select CDI test type. My hospital s lab uses many tests! A: If unsure DON T GUESS! Hint: Contact your laboratory or the NHSN helpdesk Do not select Other as your CDI test type unless absolutely necessary

18 How Does CDI Test Type Impact the SIR? Q: My lab uses a two-step algorithm involving a GDH test, followed by a NAAT test. How will my SIR be risk-adjusted? A: SIRs are risk-adjusted based on the last step in the algorithm. Your SIR will be adjusted at the NAAT level. Q: Where can I find the risk adjustment categories for each CDI test option? A: NHSN s Guide to the SIR: A: LabID SIR Troubleshooting Guide:

19 CDI Test Type FAQ Q: My hospital is thinking about changing our CDI test type from NAAT to EIA. How will this change impact our SIR? What % change will we see? A: Selection of CDI test type/algorithm is your hospital s decision In this example, the hospital is moving to a less sensitive test Number of predicted CDI events may decrease Number of observed CDI events may also decrease Other variables in the model will be impacted (CO prevalence rate) **this assumes that all other variables (e.g., # admissions) remain constant Several moving parts! We cannot predict what % change (if any) you will see in your facility s SIR. CDC s risk adjustment models are based on the national overall experience The impact of changing CDI test type is not the same for every facility and will vary depending on the facility s own experiences, patient populations, and lab practices.

20 National Center for Emerging and Zoonotic Infectious Diseases BSI Clarifications and Lightbulb Moments 2018 Chapter 4: LCBI Protocol Dominique Johnson, MPH, CPH, CIC LaTasha Powell RN, BSN, MPH, CIC

21 What is a Device Day? The count of central lines on an inpatient unit that will be recorded in the monthly denominator summary data Denominator counts performed Manually and Electronically Device Day = Denominator Counts

22 What Central Lines Are Included in the Device Day Counts (Denominator)? In 2018, ALLcentral lines present on an inpatient unit should be counted regardless of access. These central lines include but are not limited to the following: PICC s Ports HD catheters

23 What are Central Line (CL) Days? The number of days a central line has been accessed for deviceassociated (CLABSI) determinations. Begin with line placement For central lines present on admission 1 st day of access (use for infusion, blood draws or hemodynamic monitoring). Example: Patient A: Central line placed on current admission. Date of central line insertion = CL Day 1 Patient B: Admitted with HD catheter on 5/4 1 st HD treatment, 5/8 5/8 = CL Day 1 Central Line Day = CLABSI

24 Denominator Counts and Central Line Day CountsnExample Aug 5 Aug 6 Aug 7 Aug 8 Aug 9 Aug -10 Aug -11 3A 3A 3A 3A 3A 3A 3A Patient A CL Inserted CL In Place CL In Place CL In Place CL In Place CL In Place CL In Place Device Days for Denominator Counts Central Line Days for Device Attribution

25 Denominator Counts and Central Line Day Counts Example (cont.) Dec-31 Jan-1 Jan-2 Jan-3 Jan-4 Jan-5 Jan-6 Patient B, Admitted with HD central line in place. ED MICU MICU MICU MICU MICU MICU CL in place CL in place CL in place HD CL Accessed HD CL Accessed HD CL Accessed HD CL Accessed Device Days for Denominator Counts Central Line Days for Device Attribution

26 Where Can I Find Guidance on Device Day Counts?

27 Where Can I Find Guidance on Central Line Counts? Table 3. Page 4-16

28 Timing is Everything!!! IVDA CLABSI Exclusion IVDA -Observed or suspected injectioninto their vascular access Within the BSI IWP of the positive blood culture Documentation must indicate INJECTION Manipulated, tampered, picked, sucked cannot be used for this exclusion Remember: IF INJECTED WAS JUST SUSPECTED, THE EXCLUSION MUST BE REJECTED

29 Timing is Everything!!! ECMO and VAD CLABSI Exclusions Presence of extracorporeal life support (ECMO) or Ventricular assist device (VAD) Device must be in place > 2 consecutive calendar days on the BSI DOE and is still in place on the DOE or day before ECMO and VAD fields are optionalfields in 2018 Central Line = No ECMO and VAD fields are requiredfields in 2019 Central Line = Yes

30 Munchausen Syndrome by Proxy (MSBP): Timing is Everything MSBP -diagnosis during the current admission Central line in place >2 days on BSI date of event (DOE) Events are LCBIs but NOTcentral line associated MSBP added to the BSI event form in 2019 and required fields in 2020

31 Epidermolysis bullosa (EB): Timing is Everything EB -diagnosis during the current admission Central line in place >2 days on BSI date of event (DOE) Events are LCBIs but NOTcentral line associated EB added to the BSI event form in 2019 and required fields in 2020

32 Secondary BSI Attribution: VASC Criteria

33 Secondary BSI Attribution: VASC Criteria Report intravascular infections with organism(s) identified from blood and meeting LCBI criteria as BSI-LCBI NOTE: If BSI meets CLABSI criteria & BOTH of the following are present within the infection window period (IWP), Central line field equals No : Pus Matching culture at the vascular site to the blood

34 Secondary BSI Attribution: VASC Criteria

35 CLABSI Exclusions: Do You Remember the Times? CLABSI Exclusion 2018 Field Status 2018 Central Line Field 2019 Field Status 2019 Central Line Field Documentation Timeframe IVDA Protocol only NO Optional NO During the IWP ECMO Optional NO Required YES VAD Optional NO Required YES MSBP Protocol only NO Optional NO > 2 calendardays on BSI DOE, still presenton DOE, or day before > 2 calendardays on BSI DOE, still presenton DOE, or day before During the current admission EB Protocol only NO Optional NO During the current admission

36 Thank you!! Questions? For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

37 To obtain your certificate, please click the Evaluation Link: and enter the certificate code below: ESPJ5343