APIC NHSN Webinar Janet Brooks, Cindy Gross, Denise Leaptrot, & Eileen Scalise Subject Matter Experts September 9, 2015 National Center for Emerging and Zoonotic Infectious Diseases Place Descriptor Here Topic Overview 2015 HAI vs. POA NHSN Infection Criterion Determination Secondary Bloodstream Infection Catheter-Associated Urinary Tract Infection Surgical Site Infection ICD-10-PCS Transition PATOS MDRO/ CDI LabID Event Reporting Common Misconceptions Ventilator Associated Events (VAE) CDC/CMS Communique on Adherence to CDC/NHSN Infection Definitions and Criteria Overall Learning Objectives Participants will apply NHSN definitions to secondary bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated events Participants will review SSI and MRDO/CDI LabID event reporting Participants will explain the ICD-10-PCS transition 1
Cindy Gross 2015 HAI vs. POA NHSN INFECTION CRITERION DETERMINATION Learning Objectives Participants will be able to explain the basic concepts in determining the infection window period, date of event, repeat infection timeframe, and secondary bloodstream infection attribution period. Participants will be able to explain the process in determining an HAI vs. POA infection definition determination Question Can you review the basic concepts in making an HAI vs. POA NHSN infection definition determination, the RIT and the Secondary BSI Attribution Period? 2
Steps to determine if an NHSN definition is met 1. Infection is suspected 2. Determine the infection window period using a diagnostic test or localized sign or symptom 3. Determine if all elements of the infection definition are found within the infection window period 4. Determine the date of event 5. Determine (based on the date of event) if the infection is POA or HAI 6. Determine (based on the date of event) the location of attribution and the device association if applicable 7. Determine the 14 day Repeat Infection Timeframe and Secondary BSI Attribution Period (for all events except Primary BSI) Steps to determine if an NHSN definition is met 1. Infection is suspected 2. Determine the infection window period using a diagnostic test or localized sign or symptom 3. Determine if all elements of the infection definition are found within the infection window period 4. Determine the date of event 5. Determine (based on the date of event) if the infection is POA or HAI 6. Determine (based on the date of event) the location of attribution and the device association if applicable 7. Determine the 14 day Repeat Infection Timeframe and Secondary BSI Attribution Period (for all events except Primary BSI) Remember. The diagnostic test or localized sign or symptom that defines the Infection Window Period must be an element used to meet the NHSN site-specific criterion. Infection Window Periodis the 7-days during which all site-specific infection criteria must be met. It includes the day the first positive diagnostic test that is an element of the site-specific infection criterion, was obtained, the 3 calendar days before and the 3 calendar days after. 3
Remember. Date of Event is the date the firstelement used to meet an NHSN site-specific infection criterion occurs for the first time within the seven-day infection window period. The Repeat Infection Timeframe (RIT) is 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 RIT. Additional eligible pathogens identified during the RIT from the same type of infection are added to the event. The RIT applies to a POA or an HAI determination Remember. The Secondary BSI Attribution Period is the period in which a positive blood culture must be collected to be considered as a secondary bloodstream infection to a primary site infection. Infection Window Period + the Repeat Infection Timeframe It is 14-17 days in length depending upon the date of event One of the following must occur (Secondary BSI Guide): The blood culture must contain at least one organism that matches an organism found in a site-specific infection culture used to meet the site-specific infection criterion OR The blood culture must be an element used to meet the sitespecific infection criterion. 1 4 3 2 UTI-POA w/ Secondary BSI, Not catheter associated IWP: 7/5 7/11 Date of event: 7/6 RIT: 7/6 7/19 Secondary BSI: 7/5 7/19 Pathogens reported: E.coli, Enterococcus *Patient is < 65 yrs. with Foley catheter placed on admission 4
2 3 4 CAUTI-HAI w/ Secondary BSI- Attributed to ICU IWP: 7/5 7/11 Date of event: 7/8 RIT: 7/8 7/21 Secondary BSI: 7/5 7/21 Pathogens reported: E.coli, Enterococcus *Patient is < 65 yrs. with Foley catheter placed on admission Questions If a bloodstream infection (BSI) is determined to be secondary to another primary site of infection, does this create a BSI repeat infection timeframe (RIT)? Can I exclude from BSI surveillance all positive blood cultures from the same patient in the next 13 days? Repeat Infection Timeframe (RIT) The RIT is 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 RIT Additional pathogens recovered during the RIT from the same type of infection (the primary site of infection) are added to the event 5
1 2 3 Oomphalitis -HAI w/ Secondary BSI (blood culture with a matching organism [S. aureus] to the site specific culture [umbilical wound]) Pathogen: S. aureus Date of Event: 8/10 3 2 Oomphalitis -HAI w/ Secondary BSI (blood culture with a matching organism [S. aureus] to the site specific culture [umbilical wound]) Pathogen: S. aureus, P. aeruginosa Date of Event: 8/10 1 2 Oomphalitis -HAI w/ Secondary BSI (blood culture with a matching organism [S. aureus] to the site specific culture [umbilical wound]) Pathogen: S. aureus Date of Event: 8/10 6
1 2 3 LCBI -HAI Pathogen: E.coli, S. aureus Date of Event: 8/10 Eileen Scalise CATHETER-ASSOCIATED URINARY TRACT INFECTION Learning Objectives Participants will apply the following NHSN rules to UTI events: Present On Admission (POA) Healthcare associated infection (HAI) Repeat Infection Timeframe (RIT) Participants will apply UTI signs/symptoms according to NHSN protocol 7
HAI or POA or??? UTI Case #1 4/15 Admit Patient age 73 for pneumonia, Fever 101, Foley Catheter (FC) inserted 4/16 Urine culture positive for 100,000 E. Coli CFU/ml 4/17 4/19 no UTI symptoms 4/20 Urine culture positive for 100,000 E. Coli, CFU/ml complains of suprapubic tenderness QUESTION: With positive urine culture on day 2, is this POA? Fever cannot be used in patient > 65 years when FC in < 2 days HAI or POA UTI Case # 1 Answer CASE SUMMARY 4/15 Admit, FC Inserted, Fever, Age 73 4/16 + urine culture IWP is 4/13 4/19 ============== 4/20 + urine culture and suprapubic Tenderness IWP is 4/17 4/23 Age 73 This does not meet POA UTI HAI or POA UTI Case # 1 Answer Continued What about the 4/20 urine culture? 8
This meets SUTI 1a: CAUTI 4/20 DOE and is HAI HAI or POA UTI Case # 1 Answer Continued CASE SUMMARY Continued 4/15 admit, FC inserted 4/20 + urine culture and Suprapubic tenderness IWP is 4/17 4/23 POA and RIT UTI Case #2 Patient transferred from nursing home to ER on 5/5 with c/o chest pain and nursing home HCW documentation of dysuria on 5/5 Admit 5/6 and Foley Catheter inserted On 5/7 urine is positive for >100,000 CFU/ml of E. Coli On 5/12 urine is positive for >100,000 CFU/ml of Acinetobacter baumannii QUESTION: What is the UTI determination? Is the 5/12 positive urine culture a second infection? This meets SUTI 1b: Non- CAUTI POA DOE 5/6 5/12 + urine in RIT is added to event POA and RIT UTI Case #2 Answer CASE SUMMARY 5/5 dysuria 5/6 admit, FC Inserted, 5/7 + Urine culture IWP is 5/4 5/10 9
Dysuria Symptom and Presence of Catheter UTI Case # 3 Admit 77 year old female on July 1 for Heart Failure, placed on Lasix, Foley inserted July 2 patient complains of dysuria July 4 urine culture is positive for E. Coli > 100,000 CFU/ml July 5 Fever > 38 0 C QUESTION: What is the UTI determination? Dysuria Symptom and Presence of Catheter UTI Case # 3 Dysuria cannot be used when FC IN PLACE This meets SUTI 1a: CAUTI 7/4 DOE HAI CASE SUMMARY 77 yr. 7/1 admit, FC inserted, 7/2 dysuria 7/4 + Urine culture 7/5 Fever > 100.4 IWP is 7/1-7/7 UTI FAQ Q. Is abdominal pain an acceptable symptom for suprapubic pain? A. No, abdominal pain is too generalized to be acceptable. However, lower abdominal pain, which is more specific, is acceptable for meeting suprapubic pain. 10
Janet Brooks SURGICAL SITE INFECTION Learning Objectives Participants will gain further understanding of the transition to ICD-10-PCS Participants will be able to explain how to answer the PATOS question on the SSI event form Question Q:Can you give a quick review of the upcoming transition to ICD-10-PCS codes that is occurring on October 1, 2015? 11
ICD-10-PCS and CPT Code Mappings are found in the Supporting Materials in the SSI Protocol section of the NHSN website Example of the ICD-10-PCS document Additional Mappings In the next couple of weeks NHSN will be providing additional ICD-10 CM/PCS mappings for: diagnosis of diabetes codes that may indicate that has HPRO or KPRO revision case is related to an infection of the joint in the 90 day period prior to the revision guidance for the details required in the application for HPRO or KPRO procedures, for example Partial Primary or Total Revision. FUSN spinal level and approach NHSN has found a few errors in the mappings and these will be updated in the next couple of weeks with a summary document to let NHSN users know what was updated or corrected. 12
Application cannot accept ICD-10-PCS or CPT codes in the application until the January 2016 release Additional Transition Information ICD-10-PCS and CPT code fields will remain as optional fields in 2016 ICD-10-PCS and CPT codes do not differentiate between the spinal fusions (FUSN) and repeat spinal refusions (RFUSN). Therefore in 2016 the NHSN procedure group FUSN will include both fusion and re-fusion procedures. NHSN Operative procedure Category OTH has not been mapped to ICD-10-PCS and CPT codes and the procedures in that group will not be considered an NHSN operative procedure, beginning January 1, 2016. PATOS INFECTION PRESENT AT THE TIME OF SURGERY 13
PATOS Infection Present at the time of surgery Q:If I find that an infection meets criteria for a PATOS SSI do have to report this as an SSI event to NHSN? A:SSI Events with the PATOS field = YES are reported to NHSN if they are attributable to an NHSN operative procedure which you are following in your monthly reporting plan. PATOS Infection Present at the time of surgery Q: If a patient has infection present at the time of surgery does that mean that any subsequent SSI will be a PATOS = YES? A: Only select PATOS = YES if it applies to the depth of SSI that is being attributed to the procedure. Example: If a patient had evidence of an intraabdominal 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. PATOS Infection Present at the time of surgery Q: Are SSI events with the PATOS =Yes included in the SIR, and for COLO and HYST, are these events reported to CMS? A: All of the SSI SIRs that use the 2006-2008 SSI baseline will include SSIs that are reported as present at time of surgery if the wound closure method was a primary closure. As stated in the analysis section of the SSI protocol, procedures with closure method other than primary are not included in SIR analysis and are not reported to CMS. In 2016 the SSI events that are PATOS = Yes will be excluded from SIR analysis and from reporting to CMS. 14
PATOS Infection Present at the time of surgery Q: Can you give a few examples of what would and would not be a PATOS = Yes on an SSI event? What can be a PATOS? The evidence of infection or abscess must be noted/documented preoperatively or found intraoperatively in a pre-operative or intraoperative note (immediate postoperative note). Some examples: Abscess(s) noted Mention of infection in OR note. Does not have to meet SSI infection criteria. Purulence/pus noted Septic/feculent peritonitis noted Ruptured appendix If found alone without the finding of infection the following do not meet PATOS = YES Some examples: Positive culture or path report from surgical specimen Mention of rupture or perforation of colon Fecal spillage\nicked bowel during procedure Note of just inflammation, necrosis or gangrene Contaminated trauma cases (e.g. gunshot wound to abdomen) Note: PATOS is not diagnosis driven (e.g., diverticulitis; peritonitis; appendicitis) 15
Denise Leaptrot COMMON MISUNDERSTANDINGS FOR MDRO/ CDI LABID EVENT REPORTING Learning Objectives Participants will be able to identify monthly reporting plan requirements for locations contributing to FacWideIN LabID event reporting as prescribed for CMS required reporting Participants will be able to identify correct entry for LabID events Participants will be able to identify correct denominator summary data entry Cindy Gross VENTILATOR ASSOCIATED EVENT (VAE) 16
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Learning Objective Participants will be able to understand the purpose of the date of mechanical ventilation initiation and location of mechanical ventilation. 19
Question If a patient is admitted to my facility with a ventilator in place and subsequently a VAE is identified, when reporting the event to NHSN, what date should I enter for date mechanical ventilation initiatedand what location should I enter for location of mechanical ventilation? Date Mechanical Ventilation Initiated Enter the actual date of the initiation of mechanical ventilation NOT the date of admission to the facility (unless, of course, they are the same) Estimate if necessary MV initiation date impacts the VAE window period determination for VAEs detected early on in the hospitalization MV initiation date may impact the determination of HAI attribution when daily minimum PEEP and FiO2 ventilator data is available from a transferring location 20
VAE Window Period Admission Date 8/1 MV Initiation Date 8/1 Date of Event 8/3 Admission Date 8/1 MV Initiation Date 7/26 Date of Event 8/3 HAI Attribution Admission Date 8/1 MV Initiation Date 7/26 Date of Event 8/1 Per the transfer rule this would be attributed to the transferring location as the date of event is the day of transfer Janet Brooks CDC/CMS COMMUNIQUE ON ADHERENCE TO INFECTION DEFINITIONS AND CRITERIA 21
Background Response developed jointly by CDC/CMS Reports of 1) purposeful non-reporting of healthcare-associated infection data 2) deviations from standards of medical practice to avoid reporting HAI data to NHSN, and 3) coercion of Infection Perfectionists to alter HAI data submitted to NHSN Content Reminds facilities of the importance of reporting accurate and complete HAI data For compliance with CMS Quality Reporting requirements For reliability and comparability of data used to determine the success of HAI prevention efforts and federal reimbursements Provides pathways for healthcare staff to address concerns CDC/NHSN infection definitions and criteria Incomplete or inaccurate HAI data reporting to NHSN Status/Distribution Plans Reviewed by Office of Inspector General, hospital associations, APIC Undergoing final review by agencies signatories Email to all NHSN Users Posted on CMS website Distributed by hospital associations 22
NHSN Frequently Asked Questions Topic-specific documents can be found in a dedicated section on the topic specific page of the NHSN website Other pertinent FAQs are also available on each page, e.g. locations questions, analysis questions, etc. Questions? NHSN@cdc.gov Additional Training Materials Are Posted to the NHSN Training Webpage Go to: http://www.cdc.gov/nhsn/training/ 23