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1 Welcome and Instructions For audio, join by telephone at , participant code: Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6. If you are having technical difficulties, or call Please ask questions through the chat box or wait to the end of each section to ask the presenter 1 NHSN Catheter-associated associated Urinary Tract Infection Surveillance in 2015 Laura Gillim, RN, BSN, CIC Infection Preventionist Kentucky Webinar Series 2015 Updates to Measures and Analysis for The National Healthcare Safety Network Users June 12, 2015 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion 1

2 Objectives Define 2015 CDC/NHSN CAUTI and key concepts used for CAUTI surveillance Identify the correct way to count indwelling urinary catheter days to determine infection association Identify the correct way to distinguish between a single UTI with sequential positive urine cultures and separate UTIs Objectives 2 Describe how to collect indwelling urinary catheter and patient day data Identify data collection form and Table of Instructions for UTI surveillance 2

3 Agenda CAUTI epidemiology and trends Changes to CAUTI definitions 2015 CAUTI Definitions Denominator collection Resources for CAUTI surveillance Healthcare Facility CAUTI Reporting Requirements to CMS via NHSN-- Current or Proposed Requirements * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN 3

4 CAUTI? Who Cares? Urinary tract infection is tied with pneumonia as the second most common type of healthcare-associated infection, second only to SSIs 1 Majority of UTIs associated with indwelling catheters Secondary BSI in 5.7% of ICU and 7.4% non-icu CAUTIs 2 in 2013 Each year, more than 13,000 deaths are associated with UTIs 3 One-third of asymptomatic bacteriuria treated with antimicrobials although in conflict with published guidelines 4 May be a proxy for quality of care 1 Magill SS, Hellinger W, et al. Prevalence of healthcare-associated infections in acute care facilities. Infect Control Hosp Epidemiol. 2012;33(3): Unpublished NHSN data 3 Klevens RM, Edward JR, et al. Estimating health care-associated infections and deaths in U.S. hospitals, Public Health Reports 2007;122: Cope M, Cavellos ME, et. al. Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.clin Infect Dis. 2009; 48(9): Things to Consider for CAUTI Surveillance All CAUTIs require a positive urine culture. Start there. Routinely generated report? Know your laboratory s urine culture reporting policies: What are the ranges of CFU reported? What minimal CFU are reported i.e. 10, ,000 CFU/mlcan the laboratory tell you this is at least 100,000 CFU/ml Are positive urine cultures reported for the unit on which they were collected or where the patient is housed at the time of report? Consider the Transfer. Account for positive cultures from the ED which may represent recently discharged patients 4

5 Spinal cord injury patients: A Caution! Reports of ffoley catheters t discontinued d without t adequate alternative bladder emptying method SCI patients may appear to be voiding voluntarily but actually retaining huge volumes Potentially serious adverse effects include bladder damage, renal damage, autonomic dysreflexia, death, etc. Use of Foley should be clinical decision providing appropriate alternatives/care Sample Worksheet to Help With Chart Review Sample Worksheet CDC form Your facility may create its own data collection form and collect additional data so long as the required NHSN data are captured. 5

6 Urinary Tract Infection Definitions There are two specific types of UTI: Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI) Urinary Tract Infection Definitions There are two specific types of UTI: Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI) 6

7 Any Age SUTI 1 UTI Overview Infant 1 yr SUTI 2 Any Age ABUTI B: Non-catheter associated A: Catheterassociated Catheterassociated Catheterassociated Noncatheterassociated Non- Catheterassociated The Logic Behind SUTI Definitions Symptoms of true UTI will vary depending on whether or not a device (i.e. Foley) is in place. Cannot use the following symptoms to identify UTI in catheterized patients for NHSN: Frequency Urgency Dysuria Infants will exhibit infection differently from patients of other ages. For infants the following additional symptoms may indicate UTI: Apnea Bradycardia Lethargy Vomiting Hypothermia <36.0 C 7

8 SUTI Definitions No more than 2 species of microorganisms Urine cultures with > 2 organisms are routinely regarded as contaminated cultures and not used for clinical care nor NHSN CAUTI surveillance. Urine culture including mixed flora or equivalent cannot be used Organisms of same genus but different species = 2 organisms. Example: Pseudomonas aeruginosa and Pseudomonas stutzeri The same organism with different antimicrobial susceptibilities = 1 organism. Example: MRSA and MSSA UTI Infection Window Period 8

9 UTI Overview Any Age SUTI 1 A: Catheterassociated B: Non-catheter associated SUTI 1a (catheter in place) Patient must meet 1, 2, and 3 below: 1. Patient t has an indwelling urinary catheter t in place for the entire day on the date of event and such catheter had been in place for >2 calendar days, on that date (day of device placement = Day 1) 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) suprapubic tenderness* costovertebral angle pain or tenderness* 3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period. * With No Other Recognized Cause 9

10 With No Other Recognized Cause *With no other recognized cause Note: Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination because they are clinically deemed due to another recognized cause. SUTI 1a (catheter recently removed) Patient must meet 1, 2, and 3 below: 1. Patient has an indwelling urinary catheter in place for greater than 2 days which was removed on the day of or the day before the date of event 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) suprapubic tenderness* costovertebral angle pain or tenderness* urinary urgency* urinary frequency* dysuria* 3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period. 10

11 Criterion Rationale- SUTI 1a Catheter removed UTIs with event date on the day of device discontinuation or the following calendar day are considered device-associated UTIs if the device had been in place already for >2 calendar days. For this criterion urgency, frequency and dysuria are symptoms. Day 1 Day 2 Day 3 Day 4 CAUTI? Foley placed Foley in place Foley in place for part of day only then removed Date of Event Yes Criterion Rationale- SUTI 1a Catheter removed UTIs with event date on the day of device discontinuation or the following calendar day are considered device-associated UTIs if the device had been in place already for >2 calendar days. For this criterion urgency, frequency and dysuria are symptoms. Day 1 Day 2 Day 3 Day 4 CAUTI? Foley placed Foley in place Foley in place for part of day only then removed Date of Event Yes Foley placed Foley in place for part of day then removed No Foley Date of Event No 11

12 Criterion Rationale- SUTI 1a Catheter removed UTIs with event date on the day of device discontinuation or the following calendar day are considered device-associated UTIs if the device had been in place already for >2 calendar days. For this criterion urgency, frequency and dysuria are symptoms. Day 1 Day 2 Day 3 Day 4 CAUTI? Foley placed Foley in place Foley in place for part of day only then removed Date of Event Yes Foley placed Foley in place for part of day then removed No Foley Date of Event No Foley placed Foley in place for part of day then removed Date of Event No SUTI 1b (Non catheter-associated) Patient must meet 1, 2, and 3 below: 1. One of the following is true: Patient has/had an indwelling urinary catheter but it has/had not been in place >2 calendar days, OR Patient did not have a urinary catheter in place on the date of event nor the day before the date of event 1. Patient has at least one of the following signs or symptoms: fever (>38 C) in a patient that is 65 years of age suprapubic tenderness* costovertebral angle pain or tenderness* urinary frequency* urinary urgency* dysuria* 2. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the SUTI criterion must occur during the Infection Window Period 12

13 UTI Overview Infant 1 yr SUTI 2 Catheterassociated Noncatheterassociated SUTI 2 ( 1-year-old) Patient must meet 1, 2, and 3 below: 1. Patient is 1 year of age (with or without an indwelling urinary catheter ) 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) hypothermia (<36.0 C) apnea* bradycardia* lethargy* vomiting* suprapubic tenderness* 3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the SUTI criterion must occur during the Infection Window Period (See Definition Chapter 2 Identifying HAIs in NHSN). If patient had an indwelling urinary catheter in place for >2 calendar days, and catheter was in place on the date of event or the previous day the CAUTI criterion is met. If no such indwelling urinary catheter was in place, UTI (non catheter associated) criterion is met. 13

14 UTI Overview Any Age ABUTI Catheterassociated Non- Catheterassociated Asymptomatic Bacteremic UTI (ABUTI) Patient must meet 1, 2, and 3 below: 1. Patient with* or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age Note: Patients t > 65 years of age with a non-catheter-associated t t ABUTI may have a fever and still meet the ABUTI criterion 2. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml 3. Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meets LCBI criterion 2 (without fever) and matching common commensal(s) in the urine. All elements of the ABUTI criterion must occur during all elements of the SUTI criterion must occur during the Infection Window Period * Patient had an indwelling urinary catheter in place for >2 calendar days, with day of device placement being Day 1, and catheter was in place on the date of event or the day before. 14

15 ABUTI NOTE: Only events with catheters in place for >2 calendar days prior to date of event are catheterassociated. Key Terms 15

16 Key Terms Healthcare-associated infection (HAI): ~Not to be used in the SSI, VAE, or LabID Event protocols An infection is considered an HAI if all elements of a CDC/NHSN sitespecific infection criterion were not present during the POA time period and date of event occurred on or after the 3rd calendar day of admission to the facility (the day of admission to an inpatient unit is calendar day 1) Date of Event: ~Not to be used in the VAE, or LabID Event protocols 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 Key Term: Present on Admission (POA) An infection is considered Present on Admission (POA) if the date of event of the NHSN site-specificspecific infection criterion occurs during the POA time period, which is defined as the day of admission to an inpatient location (calendar day 1) the 2 days before admission the calendar day after admission 16

17 Key Term: UTI Repeat Infection Timeframe 14-day timeframe No new UTIs are reported. Date of event = Day 1 Additional pathogens recovered during the RIT from urine cultures are added to the event. Patients will have no more than one UTI in an RIT The RIT applies during a patient s single admission, including the day of discharge and the day after Key Term: Indwelling Catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a collection system. This includes a collection system that is used for irrigation of any type or duration (e.g., intermittent, continuous). Also called a Foley catheter Does not include (among others): Straight in and out catheters Suprapubic catheters Nephrostomy tubes 17

18 Key Term: Indwelling Catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a collection system. This includes a collection system that is used for irrigation of any type or duration (e.g., intermittent, continuous). Also called a Foley catheter Does not include (among others): Straight in and out catheters Suprapubic catheters Nephrostomy tubes NOTE: If a patient has a Foley and a suprapubic catheter or nephrostomy tube they meet the criteria for having a Foley. Key Term: CAUTI Device-associated Infection Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement being Day 1, -andan indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for >2 calendar days and then removed, the date of event for the UTI criteria must be the day of discontinuation or the next day. 18

19 Discontinuation and Reinsertion If a Foley catheter is discontinued, and a full calendar day passes before a Foley is reinserted, then the day count for determining catheter-associated UTI begins anew. Otherwise the day count continues from the previous catheter. t March 31 (Hospital day 3) April 1 April 2 April 3 April 4 April 5 April 6 Foley Foley Example A Foley Day 3 Foley Day 4 removed replaced Foley Day 7 Foley Day 8 Foley Day 9 (Foley Day 5) (Foley Day 6) Example B Discontinuation and Reinsertion If a Foley catheter is discontinued, and a full calendar day passes before a Foley is reinserted, then the day count for determining catheter-associated UTI begins anew. Otherwise the day count continues from the previous catheter. t March 31 (Hospital day 3) April 1 April 2 April 3 April 4 April 5 April 6 Foley Foley Example A Foley Day 3 Foley Day 4 removed replaced Foley Day 7 Foley Day 8 Foley Day 9 (Foley Day 5) (Foley Day 6) Foley Foley Example B Foley Day 3 Foley Day 4 removed No Foley replaced Foley Day 2 Foley Day 3 (Foley Day 5) (Foley Day 1) 19

20 Location of Attribution The location where the patient was assigned on the date of the UTI event, which is further defined as the date that the first element used to meet the UTI infection criterion occurred for the first time in the infection window period. Exception to Location of Attribution Transfer : If the date of event for the UTI is the day of transfer or the next day, the UTI is attributed to the transferring location or facility. Likewise, if the date of event is the day of discharge or the next day, the infection is attributed to the discharging location. Receiving facilities should share information about such HAIs with the transferring location or facility to enable reporting 20

21 Transfer Examples Admit Day Key Terms Day Day Day Day Day Day Day Transfer Transfer ICU ICU ICU- Date of event for an HAI HAI is attributable to the ICU Transfer Multi transfer * Page 7-4 of January 2015 NHSN manual Transfer Examples Admit Day Key Terms Day Day Day Day Day Day Day Transfer Transfer Transfer ICU ICU ICU- ICU ICU ICU- Date of event for an HAI Date of event for an HAI HAI is attributable to the ICU HAI is attributable to the Multi transfer * Page 7-4 of January 2015 NHSN manual 21

22 Transfer Examples Admit Day Key Terms Day Day Day Day Day Day Day Transfer Transfer Transfer Multi transfer ICU ICU ICU- ICU ICU ICU- Date of event for an HAI - Discharge d Home Date of event for an HAI Admit to ED meeting infection criterion HAI is attributable to the ICU HAI is attributable to the Attributable to * Page 7-4 of January 2015 NHSN manual Transfer Examples Admit Day Key Terms Day Day Day Day Day Day Day Transfer Transfer Transfer ICU ICU ICU- ICU ICU ICU- Date of event for an HAI - Discharged Home Date of event for an HAI Admit to ED meeting infection criterion HAI is attributable to the ICU HAI is attributable to the Attributable to Multi ICU ICU ICU- CCU CCU HAI is transfer - Date of event attributable CCU for an HAI to the ICU * Page 7-4 of January 2015 NHSN manual 22

23 Entering CAUTI Events into NHSN (Numerator) Risk Factors Required Field: Three options: CAUTI INPLACE- If catheter was in place >2 calendar days for the entire day on the date of event REMOVE If Foley catheter was in place >2 calendar days but was removed day of or day before the date of event NEITHER if no urinary catheter was in place on the day of or the day before the date of event OR not in place >2 calendar days on the date of event 23

24 Risk Factors CAUTI Optional: Patient location where indwelling urinary catheter inserted. Risk Factors CAUTI Optional: Date indwelling urinary catheter inserted. 24

25 Collecting Summary Denominator Data -Manual Collection- For all locations, count at the same time each day Number of patients on the unit Number of patients with an indwelling urinary catheter Collecting Summary Denominator Data Optional alternatives Electronically collected For any location, when denominator data are available from electronic sources (e.g., urinary catheter days from electronic charting) Following validation of the electronic method against the manual method The validation of electronic counts should be performed for each location separately 3 months concurrent data collection with both methods Difference between methods must be within +/- 5% of each other 25

26 Documenting Summary Data or No Events Collecting Summary Denominator Data Optional alternatives: Weekly Sampling To reduce time spent collecting surveillance data, once weekly sampling of denominator data to generate estimated urinary catheter days may be used as an alternative to daily collection in non-oncology ICUs and wards The number of patients in the location (patient-days)and the number of patients with an indwelling urinary catheter (urinary catheter days) is collected on a designated day each week (e.g., every Tuesday), at the same time during the month 26

27 Denominator Sampling Summed sampling data for month Alert Screen Report No Events 27

28 6/11/2015 Also Worth Considering in Your Facility Culturing practices Change long-dwelling catheters before collecting urine? exclude colonization urine? Reflex urine cultures?- send U/A along with culture and only perform culture if U/A is positive Indications for urine cultures? Improving diagnostic practices can: improve patient safety improve CAUTI rates increase staff moral Resources for NHSN 28

29 Resources for Surveillance NHSN Forms : Monthly Reporting Plan : Urinary Tract Infection : Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA) Available Resources and Training Resource CDC/HICPAC Guideline for Prevention of Catheter- associated Urinary Tract Infections 1 Training Device-Associated Module Pre-recorded Webinars Lectoras (interactive ti with knowledge checks) 1 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections Infect Control Hosp Epidemiol. 2010;31(4):

30 Available Training NHSN Enrollment & Facility Set-up Overview of the Patient Safety Component, Device-associated module Data Entry, Surveillance, Analysis, Import, and Customization Introduction to the Device-associated Module (Training Course with quiz) Catheter-associated associated Urinary Tract Infection (CAUTI) (Training Course with quiz) NHSN Catheter-associated associated Urinary Tract Infection Surveillance in 2015 Thank you to the author of these slides ~ Katherine Allen-Bridson, BSN, RN, MScPH, CIC Nurse Consultant NHSN Training 2015 February 17, 2015 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion 30

31 Questions: user support NHSN Website: 31