Alberta Health Services Infection Prevention and Control - Initiatives and Services Hospital Acquired Bloodstream Infections (HABSI) Hospital Wide- in Acute Care and Acute Rehabilitation Facilities Surveillance Protocol January 12, 2010 Rev. April 21, 2011
Table of Contents INTRODUCTION... 3 OBJECTIVES... 3 PATIENT POPULATION... 3 DENOMINATOR DATA... 3 CASE DEFINITION... 4 OUTCOME... 5 RISK FACTORS... 5 METHODOLOGY... 6 RATE CALCULATIONS... 7 BENCHMARKING... 7 REPORTING... 7 SURVEILLANCE PERIOD... 7 REFERENCES... 8 APPENDIX A: EXAMPLE OF LINE DAY COLLECTION FORM FOR ADULT/PEDIATRIC ICU... 9 APPENDIX B: EXAMPLE OF LINE DAY COLLECTION FORM FOR NICU... 10 APPENDIX C: CASE INCLUSION ALGORITHM... 12 APPENDIX D: EXAMPLE OF COLLECTION FORM... 15 AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 2 of 16
INTRODUCTION Hospital acquired bloodstream infections (BSIs) are an important cause of morbidity and mortality in severely ill patients. Although these infections account for less than 10% of the total of all hospital acquired infections, they contribute to increased length of stay and a higher cost of care. Surveillance is an essential component of infection prevention and control. If carried out in a uniform manner, surveillance provides a measure of the burden of illness, establishes benchmark rates for internal and external comparison, identifies potential risk factors, and allows assessment of specific interventions. Surveillance of hospital acquired BSI (HABSI) is considered a measure of quality of care 1,2. OBJECTIVES 1. To establish site-specific rates for HABSI in the acute care/acute rehabilitation patient population in Alberta Health Services (AHS) facilities. 2. To compare pooled AHS HABSI rates to appropriate established benchmarks. 3. To detect clusters of HABSI. 4. To identify areas for improvement and/or requirements for change of practice. 5. To report HABSI rates quarterly to appropriate stakeholders and provincial government. PATIENT POPULATION Any acute care/acute rehabilitation inpatient who has an organism identified in a blood culture after admission, in any acute or acute rehab site/facility in AHS. DENOMINATOR DATA Numbers of inpatient admissions and inpatient days will be obtained from Costing and Benchmarking on a quarterly basis. Central Venous Catheter (CVC) line days (as denominator in ICUs only) Count and record the number of patients with one or more CVC* at approximately the same time once each day. A patient with more than one CVC counts as only one CVC day. (see Appendix A). Denominator data is collected by ICU personnel. * A CVC is a venous access device that terminates at or close to the heart or one of the great vessels e.g. aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic, internal jugular, subclavian, external iliac and common femoral veins, and umbilical artery and vein. CVC include non-tunneled (standard) CVC, whether coated or not, peripherally inserted CVC (PIC), tunneled devices (e.g. Broviac, Hickman, tunneled hemodialysis line, etc.) and umbilical artery and vein catheters. Totally implanted devices such as Ports are NOT included. Pulmonary artery catheters are included as these are inserted via a central vein. Other arterial catheters are NOT included. Pacemaker leads and other non-infusion devices inserted into central blood vessels or the heart are NOT included.1 AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 3 of 16
Neonate Specific data stratification This population is stratified into five distinct categories base on birth weight: 1. < 750g 2. 750-1000g 3. 1001-1500g 4. 1501-2500g 5. >2500g Further, this group is risk stratified by the type of catheter used to provide patient care: 1. CVC 2. Umbilical 3. Umbilical + CVC Count and record the number of patients of each birth weight group with one or more CVC and the number with one or more umbilical catheters at approximately the same time each day. If a patient has both an umbilical catheter and CVC(s), count as an umbilical catheter day. If line type is not able to be differentiated, but line days are being collected use Umbilical + CVC (see Appendix B). CASE DEFINITION 3 Note: All infections included in surveillance must be hospital acquired (HA), therefore the BSI must not present or incubating on the time of admission and if patient has been in hospital for less than 48 hours prior to the onset of the BSI, there must be compelling evidence that the infection is attributable to the hospital. Primary BSI: 1. Recognized pathogen cultured from one or more blood cultures, unrelated to infection at another site. OR 2. At least one of: fever greater than 38 C, chills, hypotension or signs of infection of catheter insertion site, tunnel or pocket. AND Common skin contaminant (e.g. diphtheroids, Bacillus spp, Propionibacterium spp, coagulase negative staphylococci or micrococci) cultured from two or more blood cultures drawn from separate sites or on separate occasions (i.e. from different venipunctures, no minimal time interval). Please refer to the CDC/NHSN surveillance definition of health care associated infection and criteria for specific types of infections in the acute care setting to as guidance in identifying infections at another site. http://www.cdc.gov/ncidod/dhqp/pdf/nnis/nosinfdefinitions.pdf Symptoms of systemic infection for patients 1 year: one of the following with no other recognized cause: fever (>30 C core), hypothermia (<36 C core), apnea, or bradycardia AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 4 of 16
Secondary BSI: Bloodstream infection which is bacteriologically, temporally and clinically related to an infection with the same pathogen at another body site of the patient. CVC-associated BSI: If CVC in use at onset of BSI or within the 48 hours before the onset of BSI If CVC has been in situ for less than 48 hours prior to the onset of BSI, as there is no minimum time that the CVC must be in place in order for the BSI to be considered CVC related, there must be compelling evidence that the infection is CVC-associated If CVC removed greater than 48 hours before onset there must be compelling evidence that the infection was associated with the CVC ICU-associated BSI: BSI not present or incubating on admission to ICU If patient has been in ICU for less than 48 hours prior to the onset of BSI, there must be compelling evidence that the infection is attributable to the ICU BSI onset during ICU stay or within 48 hours of leaving ICU Relapse vs. New Infection Same microorganism (as best as can be determined by the data available - e.g. species, antibiotic sensitivity, etc.) isolated from a subsequent blood culture: Relapse - if less than 10 days from a negative culture OR less than 10 days from completion of appropriate antibiotic therapy, consider as a relapse and DO NOT REPORT. New Infection - if more than 10 days from a negative culture (if culture was done) and more than 10 days from completion of appropriate antibiotic therapy REPORT AS A NEW INFECTION. OUTCOME Thirty days following positive blood culture determine if patient is: discharged deceased still in health care facility RISK FACTORS Certain factors may be associated with blood stream infections in specific patient populations. Information about these factors may be documented as additional data for these patients. These data points are included on the surveillance form for healthcare facilities that choose to document these details for the relevant patient groups. These factors include: 1. Premature rupture of membranes (maternal) for neonates (PROM>24 hrs) 2. Total parenteral nutrition (TPN) 3. Intra-aortic balloon pump (IABP) 4. Extracorporeal membrane oxygenation (ECMO) AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 5 of 16
METHODOLOGY Identification of patients with BSI: Daily (or, as a minimum, two to three times weekly) review of microbiology laboratory results by Infection Control Practitioner. An algorithm for case inclusion is available in Appendix C For each positive blood culture: determine if patient is an inpatient or was an inpatient within the 48 hours prior to the time the specimen was obtained. Special: if a patient, upon admission, is blood culture positive and has been in hospital within the last 48hrs include in surveillance as hospital acquired if other case criteria is met. If the organism cultured in blood sample is a common skin contaminant ensure clinical criteria (symptoms of infection) are met. If criteria for infection are not present, this sample should be considered a contaminated blood culture and the case is not included in surveillance data. Information may be obtained from a variety of sources including: patient or family members, patient hospital charts, nurses logs, laboratory reports, nursing and medical staff. Determine if case definition for HABSI is met. Determine if HABSI meets definition for primary or secondary bacteremia If patient meets definition for primary BSI, that is, no evidence of infection at another body site with the same pathogen at the same time. If primary BSI, determine is it attributable to the CVC or not. Review patient s chart to determine if a CVC was in place or removed within the preceding 48 hours. If CVC associated primary BSI determine if attributable to the ICU or not. Determine if they were an admitted patient in an ICU or discharged from the ICU within the preceding 48 hours. For secondary BSI, identify site of infection causing the BSI. Note: Please refer to the CDC/NHSN surveillance definition of health care associated infection and criteria for specific types of infections in the acute care setting as guidance in identifying infections at another site. http://www.cdc.gov/ncidod/dhqp/pdf/nnis/nosinfdefinitions.pdf Fill in the data collection form (Appendix D) Follow-up at 30 days to determine outcome and finalize data collection form. AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 6 of 16
RATE CALCULATIONS HABSI rates will be calculated quarterly for each acute care/acute rehabilitation facility participating in surveillance. Technical Definitions HABSI rate Number of HABSIs Number patient admissions Number of HABSIs Number patient days X 1,000 X 10,000 Note using the above definition rates may be further analyzed to derive rates for primary, primary CVC, and secondary HABSI. CVC-associated BSI rate (ICU Only) Number of CVC associated HABSIs Number of CVC line days X 1,000 Note using the above definition rates may be further analyzed to derive rates for neonates by birth weight and line type. BENCHMARKING Pooled Alberta Health Services HABSI rates will be compared with rates from appropriate Canadian Nosocomial Surveillance Program (CNISP) comparators. REPORTING HABSI rates will be reported quarterly to appropriate stakeholders within 60 days following the end of each quarter. SURVEILLANCE PERIOD AHS-HABSI surveillance commenced with a protocol trial September, 2009 with full implementation October, 2009. AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 7 of 16
REFERENCES 1. Canadian Nosocomial Infection Surveillance Program (CNISP) Central Venous Catheter-Associated Blood Stream Infections in Intensive Care Units and in Recipients of Haemapoeietic Steam Cell Transplants. Protocol. December 22, 2005. 2. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR 2002; 51 (No. RR-10):1-32. 3. Canadian Nosocomial Infection Surveillance Program (CNISP), Surveillance for Central Venous Catheter Associated Blood Stream Infections (CVC-BSI) in Intensive Care Units, Revised April 15 th, 2009. 4. CDC/NHSN surveillance definition of health care associated infection and criteria for specific types of infections in the acute care setting. AJIC June, 2002; Vol. 36. No.5:309-332 AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 8 of 16
APPENDIX A: Example of Line day Collection Form for Adult/Pediatric ICU Intensive Care Unit Central Line Bloodstream Infection Surveillance Number of Line Days Please indicate the number of patients with central lines in place by bed number (i.e. count only one central line, even if the patient has more than one central line). A central line is one that enters a central vein either directly e.g. subclavian, jugular or femoral vein; or is inserted via a peripheral vein and is threaded into a central vein e.g. umbilical artery/venous catheters, PICC lines, Broviac catheters. Arterial lines are excluded. Lines in place should be documented at the same time each day. If a patient is discharged from a bed and a new patient admitted, do not revise count. Month of Unit Hospital Bed# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
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APPENDIX B: Example of Line Day Collection Form for NICU SURVEILLANCE FOR CVC-ASSOCIATED BSI IN NEONATAL INTENSIVE CARE UNITS Daily denominator collection form for Neonatal Intensive Care Unit (NICU) Month Year Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth weight 750 g # # Pts UC #CVC Birth weight 751-1000 g # # Pts UC #CVC Birth weight 1001-1500 g # # Pts UC #CVC Birth weight 1501-2500 g Birth weight >2500 g # # # # Pts UC #CVC Pts UC #CVC Total # Pts=number of infants # UC=number of infants with umbilical catheter # CVC=number of infants with 1 or more central venous lines If infant has both a UC & CVC, count as UC day AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 11 of 16
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APPENDIX C: Case Inclusion Algorithm AHS-HABSI Surveillance Protocol -revapril 2011.doc Page 13 of 16
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NAME PHN# MED REC# APPENDIX D: Example of Collection Form 1. PATIENT DEMOGRAPHICS / Admission Details PHN: NAME: Last name: First Name Gender: M F Admit Date: MM/DD/YY DOB: MM/DD/YYYY Med.Rec./Hosp # Site/Facility D/C Date: MM/DD/YYYY Birth weight (BWT) <750g 751-1000g 1001 1500g 1501 2500g > 2500g Gestational Age: (weeks) 2. BSI PROM>24 hrs TPN IABP ECMO Date of Infection: (MM-DD-YYYY) (Date 1 st +) Hemodialysis Dialysis Line CVC Associated BSI ICU Associated BSI Central Perm Graft Central Temp Fistula FACILITY: UNIT/Bed #: SERVICE: PROGRAM: 3. Infection Date of Infection: (MM-DD-YYYY) (Date 1 st +) Primary Bacteremia CVC Related Non CVC Related Maternal IV Device Arterial Line Peripheral Line No line CVC PICC Line Type CVC Umbilical Umbilical + CVC Secondary Bacteremia (see criteria for infection on reverse side of form) Burn Skin GI Not endoscopy related Superficial Incision GI endoscopy related Deep Incision Respiratory Tract Organ Space Pneumonia Other Urinary Tract ICU Admission Date MM/DD/YYYY ICU Discharge Date: MM/DD/YYYY Outcome: (Patient disposition 30 days following BSI) Discharged Deceased Alive, in hospital (inpatient) 4. Pathogen (Organism Isolated) 1. 2. 3. Additional Comments: Total Time Expended on Data Collection: (in minutes) Entered in Data Base AHS-HABSI Data Collection Form January 2010
Guideline for Completing Blood Stream Infection Surveillance Form BSI must not present or incubating on the time of admission and if patient has been in hospital for less than 48 hours prior to the onset of the BSI, there must be compelling evidence that the infection is attributable to the hospital. Primary BSI 1. Recognized pathogen cultured from one or more blood cultures, unrelated to infection at another site. OR 2. At least one of: fever greater than 38 C, chills, hypotension (if aged less than 1 year: one of fever greater than 38 C, hypothermia, apnea or bradycardia), or signs of infection of catheter insertion site, tunnel or pocket. AND Common skin contaminant (e.g. diphtheroids, Bacillus spp, Propionibacterium spp, coagulase negative staphylococci or micrococci) cultured from two or more blood cultures drawn from separate sites or on separate occasions (i.e. from different venipunctures, no minimal time interval). OR 3. At least one of: fever greater than 38 C, chills, hypotension (if aged less than 1 year: one of fever >38 C, hypothermia < 36 C, apnea or bradycardia), or signs of infection of catheter insertion site, tunnel or pocket. AND Common skin contaminant (as above) cultured from one blood culture from a patient with an intravenous line and the physician institutes appropriate antimicrobial therapy. Secondary BSI: A bloodstream infection which is bacteriologically, temporally and clinically related to an infection (CDC definition for guidance) with the same pathogen at another body site of the patient. Relapse vs New Infection Same microorganism (as best as can be determined by the data available- e.g. species, antibiotic sensitivity, etc) isolated from a subsequent blood culture: Relapse - if less than 10 days from a negative culture OR less than 10 days from completion of appropriate antibiotic therapy, consider as a relapse and DO NOT REPORT. New Infection - if more than 10 days from a negative culture (if culture was done) and more than 10 days from completion of appropriate antibiotic therapy REPORT AS A NEW INFECTION. ICU-associated BSI BSI was not present on admission to ICU. BSI onset during ICU stay or within 48 hours of leaving ICU CVC-associated BSI CVC-associated if catheter in use at onset of BSI or within the 48 hours before the onset of BSI (if CVC removed 48 hours before onset there must be compelling evidence that the infection was associated with the CVC) Signs/Symptoms Infection General: Chills Fever Pus Respiratory: Dr. s Dx Inflammation WBC >10 x 10/L Cough Chest X-Ray Resp Assist Signs Sputum Trach Urinary: Dysuria/Frequency/Urgency Hematuria Pyuria Flank Pain CVA/SP Tenderness Straight Cath Foley Instrumentation Stents Neonates Alter Resp Poor Feed Diarrhea WCB < 4x 10L GI Diarrhea AHS- HABSI Data Collection Form January 2010