Application of the NHSN 2015 Definitions

Transcription

1 Application of the NHSN 2015 Definitions Joan N. Hebden RN, MS, CIC Clinical Program Manager Infection Prevention Wolters Kluwer Health

2 Surveillance A fast moving trajectory The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails. William Arthur Ward American writer 1

3 Application of the NHSN Surveillance Definitions How well are we doing? 2

4 AJIC Case Studies Am J Infect Control 40 (2012) S32-S40 3

5 AJIC Supplement Findings 297 unique respondents First 8 case studies published separately gathered 523 respondents on average 9 case studies at once; shortened time frame Eighty-three (83/297 or 27.9%) passed on the first attempt: passing score 80% Overall: 64.6% (5,567/8,613) correct responses (range: 13.8%- 100%) Those with 10+ years of healthcare experience answered correctly (69.7%) more often than those with fewer years of experience (64.8% p<0.001) Those with a Master s degree were more likely to pass (36.7%) than those with an associate or bachelor s degree (23.8% p=0.02)

6 Variation in Application of NHSN Definitions Cross-sectional study: sample of US-based members of the SHEA Research Network; non-pediatric hospitals Objective: Using clinical vignettes, characterize variations in the interpretation of NHSN definitions 113 responses from at least 61 unique hospitals Respondents: 79.2% infection preventionists 79.4% worked in academic hospitals 6 clinical vignettes were used piloted and vetted through two NHSN surveillance experts and experienced IPs Keller SC, Linkin DR, Fishman NO, Lautenbach E. Variations in Identification of Healthcare- Associated Infections. Infect Control Hosp Epidemiol 2013;34(7):

7 Variation in Application of NHSN Definitions 6

8 Clinical Vignette CLABSI 7

9 Variation in Application of NHSN Definitions Correct respond bolded #2 Negative control- response of NO #6 Positive control response of YES 8

10 Variation in Application of NHSN Definitions Results: Mean percentage of correct responses = 61.1% with low interrater reliability between respondents. Correct responses ranged from a high of 87.5% (CLABSI) to a low of 27.4% (C. difficile) No differences identified in HAI reporting characteristics based on: State-mandated reporting requirements Hospital characteristics IPC program characteristics Respondents with clinical background were more likely to have higher scores 9

11 Variation in Application of NHSN Definitions Conclusion: Substantial disparateness exists in the application of HAI surveillance definitions more reproducible definitions of HAIs or even new approaches to HAI surveillance, such as electronic surveillance are urgently needed 10

12 NHSN 2015 Definition Changes Goal: deliver a reliable source of high quality data for analysis and action at the facility, local, state and national levels Decrease subjectivity Maintain epidemiologic standardization and clinical relevance NO near-term plans for further revisions 2015 data will provide the baseline for calculating the SIRs for 2016 and subsequent years Future changes move to fully electronic capture of required data and determination of events : 3-5 years 11

13 General NHSN HAI Changes Acknowledgement: Some slides are from the Utah Department of Health 12

14 General NHSN HAI Changes NHSN Infection Window Period No more gap day for defining site-specific infection criterion Window is defined as the 7-day period during which all sitespecific infection criterion must be met Day 1: first positive diagnostic test was obtained, the 3 calendar days before and the 3 calendar days after. If diagnostic testing is not part of the definition, use the first date that localized signs/symptoms developed Does NOT apply to SSI, VAE, or LabID Event surveillance Site-specific criterion: laboratory specimen collection date, imaging test date, procedure or exam date, physician diagnosis, initiation of treatment 13

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16 General NHSN HAI Changes NHSN Date of Event Changed from the date of the LAST to the FIRST element of infection criteria being met Does NOT apply to VAE or LabID event surveillance Occurs for the first time within the 7-day infection window period Date of event within the POA timeframe: day of admission, 2 days prior and 1 day after Date of event on or after hospital day 3 = HA 15

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20 General NHSN HAI Changes Repeat Infection Timeframe (RIT) 14-day period during which repeat infections of the SAME infection type cannot be reported Day 1 of the RIT is the date of the event for the first infection Does NOT apply to SSI, VAE or LabID events If additional site-specific specimens are collected within the RIT and NEW pathogens are detected, ADD to the original infection documentation 19

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22 Adding an additional pathogen to event forms in NHSN 21

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24 NHSN Supporting Materials 23

25 NHSN Supporting Materials: Worksheet 24

26 Example Worksheet 25

27 General NHSN HAI Changes Secondary Bloodstream Attribution Time period will include the 17 days that make up the infection window for the primary infection as well as that infection s RIT Length of the attribution period will vary from days depending on where the date of event falls within the infection window period Does NOT apply to SSI, VAE, or LabID event surveillance The entire chapter of NHSN definitions has been updated to include ALL changes Chapter 17 of the NHSN Manual 26

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29 Utilizing NHSN 2015 Definitions Clinical scenarios Acknowledgement: Some of the slides represent material presented at the NHSN Training Conference: Feb 17-19,

30 Is it a CLABSI? 29

31 BSI Case Study 9/1: Mr. Jones is admitted for a COPD exacerbation and has a central line inserted 9/6: He is hypotensive and has a slightly elevated WBC. BP responds to fluids 9/7 Hypotensive with further increase in WBC- two sets of blood cultures are drawn 9/9: Blood cultures are positive from both sets: 1 st set grew CNS and the 2 nd set grew Staph epidermidis. No other source of infection is identified 30

32 BSI Case Study: 31

33 BSI Case Study: Polling Question Does this patient have a LCBSI? If so, what criterion? 1. Yes 2. No 32

34 BSI Case Study: Polling Question Does this patient have a LCBSI? YES 33

35 CLABSI Reporting in Dialysis Patients 34

36 CLABSI Reporting in Dialysis Patients 35

37 Is it a CAUTI? 36

38 Is it a CAUTI? 37

39 Is it a CAUTI? UTI 38

40 UTI Case Study 4/1: Mr. Smith is a 66 yo admitted to the CCU with a diagnosis of CHF and ventricular fibrillation. Urinary catheter and RIJ central line inserted 4/5: Temperature of C. Fever work-up performed - urine and blood cultures sent 4/6: Temperature remains C. Repeat urine and blood cultures sent 4/8: Urine and blood culture from 4/5 reported as negative; 4/6 urine culture + 100,000 cfu E. coli, blood negative. Urinary catheter and central line remains in place 4/10: Blood culture obtained for mental status change: + for E.coli 39

41 UTI Case Study: Polling Questions Does this patient meet SUTI 1a criteria? 1. Yes 2. No If so, what is the date of the event? 1. 4/6 2. 4/5 40

42 UTI Case Study: Polling Questions Does this patient meet SUTI 1a criteria? 1. Yes 2. No If so, what is the date of the event? 1. 4/6 2. 4/5 Date of first element of infection criteria met within the infection window period 41

43 4/5 T /6 42

44 UTI Case Study: Polling Questions Does this patient meet the criteria for secondary BSI attribution? 1. Yes 2. No 43

45 UTI Case Study: Polling Questions Does this patient meet the criteria for secondary BSI attribution? 1. Yes Bloodstream infection with the same pathogen responsible for the SUTI occurred within the 17 day time period 2. No 44

46 UTI Case Study: Polling Questions Is this a CAUTI? 1. Yes 2. No 45

47 UTI Case Study: Polling Questions Yes Rationale: Catheter was in place for > 2 calendar days and the date of event day 9 was the day after catheter removal 46

48 Is it a CAUTI? 47

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50 UTI Case Study 4/4: Patient admitted for emergent colectomy. Urinary catheter inserted in the OR. 49

51 UTI Case Study: Polling Question Does this patient meet SUTI 1a. Criteria? 1. Yes 2. No If NO, why? 50

52 UTI Case Study: Polling Question NO Candida not an acceptable pathogen 51

53 SSI Surveillance Changes SSI Infection Present at Time of Surgery (PATOS) New field on the SSI event form Infection is present PREOPERATIVELY There must be a surgeon notation of evidence of an infection or abscess present at the time of surgery These cases will be analyzed separately and excluded from the SIRs beginning with the 2016 data 52

54 SSI Surveillance Changes Revision hip and knee procedures: will require review of specific ICD-9 diagnosis or procedure codes in the 90 days prior to and including the index revision If present, mark YES to was the revision associated with prior infection at index joint Data will be used in risk factor analysis 53

55 SSI Surveillance : Reminder Courtesy of Janet Brooks RN, BSN, CIC NHSN Nurse Consultant

56 BSI Secondary to an SSI 55

57 SSI Case Study 56

58 SSI Case Study: Polling Questions Which is the site-specific organ space definition that should be reviewed for this case? 1. PJI periprosthetic joint infection 2. JNT - joint What is the date of the event? 1. Jan Mar 8 3. Mar 9 Does the patient have a BSI secondary to the SSI-PJI? 1. Yes 2. No 57

59 SSI Case Study: Polling Question PJI In 2014, NHSN adopted the Musculoskeletal Infection Society s definition of Periprosthetic Joint Infection Mar 9 First element used to meet the SSI infection criterion occurs for the first time during the surveillance period Yes The secondary attribution period for SSI is a17-day period which includes the date of event, 3 days prior and 13 days after 58

60 SSI Case Study: Polling Question A patient presents with an acute abdomen. During the exploratory laparotomy, the appendix is noted to be purulent. Despite antibiotics and irrigation, the patient develops an SSI. Would this be considered an HAI since the patient had an existing infection at the time of the operation? 1. Yes 2. No 59

61 SSI Case Study: Polling Question YES For procedure-based surveillance, the POA definition does not apply. This case would have a wound class of IV which is a data element for SSI risk-adjustment. SSI form will include YES to the question Is infection present at time of procedure. 60

62 VAE Surveillance Change VAE Third tier consolidated into PVAP Probable Ventilator- Associated Pneumonia 61

63 Is it a VAC? 62

64 Is it a IVAC? 63

65 Is It a IVAC? 64

66 Is it a PVAP? 65

67 MDRO Reporting Changes LabID event reporting FacWideIN reporting: If the laboratory specimen is collected in the Emergency Department or a 24-hour observation area, the assignment of location will be for these areas and NOT the admitting location if admission is on the same day; allows the facility to capture CO cases 66

68 MDRO Reporting Changes Facilities reporting on HA-CDI New specific infection type: GI-CDI Gastrointestinal System Clostridium difficile infection Does not impact CDI-LabID event reporting 67

69 MDRO Reporting Changes CRE New CRE organism added: CRE-Enterobacter In-plan reporting must include all CRE organisms: E. coli, Klebsiella pneumoniae/oxytoca, Enterobacter 68

70 MDRO & CDI LabID Event Calculator 69

71 MDRO & CDI LabID Event Calculator 70

72 NHSN Support 71

73 Thank you Great Job! 72