APIC Questions with Answers

Transcription

1 NHSN Webinar Monday, April 27 th 1:00-2:00pm EDT Miscellaneous Questions 1. How do I determine if an infection is present on admission or healthcareassociated? A: There is a logical sequence of considerations to distinguish between an infection that is present on admission according to NHSN protocols, and a healthcareassociated infection. To make a proper determination in 2015, proceed in this order: 1. Determine the date of the diagnostic test that is an element of the NHSN sitespecific infection criterion, for example, when considering a possible UTI, the urine culture. 2. Determine the infection window period (3 days before the diagnostic test, the day of the test and 3 days after for a total of 7 days). 3. Determine if all of the elements of the criterion are met during the infection window period. If they are, there is an infection event. If they are not, there is no event. 4. Determine the date of event, i.e., the date that the first element used to meet the infection criterion occurs for the first time within the infection window period. 5. Determine if the date of event is in the POA time period (i.e. during the 2 days before admission, the day of admission or the next day)? If it is, the infection is POA, if not, it is an HAI. Please note, when assigning a Repeat Infection Timeframe for a POA event, if the date of event is determined to be either of the two days prior to inpatient admission, then the date of event will be hospital day 1. In the rare case that a diagnostic test is not used to meet the criterion, use the first sign or symptom that is an element of the infection criterion in place of the diagnostic test. Page 1 of 14

2 2. What is the meaning of evidence of infection on gross anatomical exam found in several of the NHSN infection criteria? Page 2 of 14 A: This phrase refers to documentation of infection that is made following physical examination of the patient with or without invasive procedure. Gross anatomical exams include physical examination of a patient during admission or subsequent assessments of the patient, including those that occur during a medical procedure. The location of the infection as well as the NHSN infection criterion will determine if the exam must involve an invasive procedure. For example, gross anatomical exam of an intraabdominal abscess will require an invasive procedure to actually visualize the abscess. However, criteria for a Urinary System Infection (USI) include Patient has an abscess or other evidence of infection on gross anatomical exam, during invasive procedure, or on histopathologic exam. Since urethra is one of the specific locations included in USI, identification of pus from the urethra would be an example of evidence of infection made on gross anatomic exam without an invasive procedure. 3. My patient had a Foley catheter placed on admission and in place until day 4. On the 4 th day, the Foley was removed and then reinserted the next day. The patient subsequently developed an NHSN UTI with date of event on day 6. Is this UTI catheter-associated, or since the second catheter had not been in place for greater than 2 days, is this a non-catheter associated UTI for NHSN purposes? A: If a device is present for any part of a calendar day, then that day contributes to the minimum day requirement for the device-associated infection. In this example, because a Foley was present for some part of day 4 (i.e., before it was removed), and

3 Page 3 of 14 also some part of day 5 (i.e., after it was inserted) the indwelling catheter day count will continue for this patient. Since the UTI occurred after more than 2 days of catheter use and the catheter was in on the date of infection, in this case, this is a CAUTI for NHSN purposes. Another way to think of it is that if a full calendar day passes without device presence, then the day count begins anew for device days. An example would be the removal of a device on Monday, without reinsertion until Wednesday or later. The catheter day count for that patient would start anew on the date of insertion. Remember, NHSN is assessing the risk of catheter use in general and not the risk of an individual catheter. The same guidance applies to central line use in central line-associated bloodstream infection surveillance. 4. The CAUTI modifications shared in the March 2015 NHSN Newsletter go into effect April 1 st, and the SSI modifications on January 1 st. When do the other changes take effect? A: The other modifications to the definitions in chapter 17, CDC/NHSN Surveillance Definitions for Specific Types of Infections, should be applied to surveillance for events occurring on or after April 1, CAUTI Questions 5. If a patient is identified with an NHSN UTI at Facility A and during the Repeat Infection Timeframe (RIT) of that UTI is transferred to Facility B, how are positive urine cultures collected at the new facility handled? Can positive urine cultures at Facility B that occur in what would have been the UTI RIT at Facility A be considered a part of the previously identified UTI and therefore not considered in Facility B s UTI surveillance? A: RITs do not extend across admissions but the Transfer Rule does. (Transfer Rule: If the date of event is on the date of transfer or discharge, or the next day, the infection is attributed to the transferring/discharging location). This means that in the example provided, if a UTI is identified at Facility B on the day of transfer or the next day, the infection would be attributed to Facility A. Facility B should inform Facility A, who will consider the transfer rule and record any additional organisms as needed according to the NHSN protocol. For Facility B, a new RIT is established on day 1 of the admission to account for an infection present on admission.albeit attributed to the previous admission. If the date of event for a UTI is identified on

4 day 3 or later of admission to Facility B, that UTI will be considered a healthcareassociated UTI for Facility B, regardless of events reported at Facility A. 6. Please clarify the following scenario. A patient presents with an E. coli UTI with date of event on the day of admission and is treated with antibiotics. On day 8 a urine culture that is collected is negative for growth. On day 21 (beyond the 14 day repeat infection timeframe [or RIT]) another positive urine culture that is collected is positive for E coli > 100K colony forming units/ml. Would this be considered an extension of the UTI from day 1 despite the negative urine on day 8 if an infectious disease doctor says it could be an extension of the existing UTI from admission? A: No. For NHSN surveillance, the urine culture collected outside of the RIT should be evaluated for another UTI and should not be considered an extension of the UTI from day 1. It is acknowledged that these surveillance criteria will not always match the clinical opinion of whether an infection was present; however, the need for objective and reliable surveillance definitions and criteria is paramount when data are being used for public reporting purposes. The RIT states that an infection with a date of event identified outside of the RIT must be reported as an infection in any inplan reporting that is occurring. 7. Please clarify the role of fever and age in the UTI definitions. How does fever and age > 65 years affect the CAUTI criteria? A: The exclusion of fever as a symptom of symptomatic UTI in patients greater than 65 years of age applies only to SUTI criterion 1b, for non-catheter-associated UTI. Because fever is a non-specific symptom for UTI in the elderly, non-catheterized patient, it is not used for non-catheterized SUTI identification in NHSN. Therefore one of the other localizing signs or symptoms of UTI must be present to meet the NHSN SUTI 1b criteria in this patient population to avoid over-reporting UTIs. BSI Event Questions 8. How do I determine if a bloodstream infection (BSI) is primary in nature or secondary to another site and therefore not reported as a central lineassociated BSI (CLABSI)? A: If you believe that there is a non-blood source of infection to which a BSI may be secondary, you must first fully meet one of the NHSN site specific infection definitions. These are outlined in Chapter 17 [CDC/NHSN Surveillance Definitions for Specific Types of Infections], as well as the PNEU, UTI, SSI and VAE protocols. If Page 4 of 14

5 Page 5 of 14 the patient does not meet any of the infection criteria in Chapter 17, PNEU, UTI, SSI or VAE then the LCBI must be reported as a primary LCBI and as a CLABSI if central line-association requirements are met. IF you have identified that a site specific definition has been met to which you believe the BSI may be secondary, apply guidelines located in Appendix 1, Secondary BSI Guide, found at the end of Chapter 4 (Bloodstream Infection Event [Central Line-Associated Bloodstream Infection and Non-central line-associated Bloodstream Infection]) in the NHSN manual. In order for the BSI to be secondary to the other site of infection, the blood culture must either be an element used to meet the site-specific criterion OR blood and site-specific specimen cultures (used to meet the infection criterion) must match for at least one organism. You may find it helpful to use the Secondary BSI flow diagrams located on page 4-26 and 4-27 of the BSI chapter. The rules for infection window period and secondary BSI attribution period must be followed as well. More guidance about these rules may be found in Chapter 2 (Identifying HAIs in NHSN). Note however, that in the case of VAE, the guidance for assigning a secondary BSI to VAE, as outlined in the VAE protocol, must be adhered to. In an effort to assist users, a table of criteria that has blood as an element to meet criteria was published in the March NHSN newsletter. This table may also be found on the FAQ document posted on the BSI webpage. 9. When will mucosal-barrier injury- laboratory-confirmed bloodstream infection (or MBI-LCBI) data be removed from the CLABSI data that is submitted to CMS? A: NHSN does not plan to remove the requirement for hospitals to include MBI- LCBIs as a part of in-plan CLABSI reporting. Facilities will still be required to report these events to NHSN if the location's monthly reporting plan includes CLABSI surveillance. Instead, NHSN will be removing the MBI-LCBI counts from the main LCBI tracking metrics and will create a separate report for MBI-LCBI tracking. This means that the MBI-LCBIs will not be included in any of the CLABSI metrics used for national reporting or for files that are shared with CMS. They will only be used in specific MBI-LCBI reports. CDC intends to use the 2015 NHSN data as the new baseline for all of the HAI standardized infection ratios (SIR) calculated for subsequent years. Therefore, it is in the 2016 SIR data, which will use 2015 as the baseline, that users will see the MBI-LCBIs removed from their CLABSI counts reported to CMS. We believe that the continued collection and tracking of MBI-LCBI

6 data is important because these infections cause significant morbidity and mortality for patients, and through their identification and measurement exists the potential to identify new prevention efforts. 10. A patient has a blood culture collected on hospital day 4 that meets LCBI criteria. No central line is in place and a BSI event is identified. On hospital day 5 a central line is inserted. Another blood culture is collected on hospital day 8, that is positive for a pathogen, and the patient meets CLABSI criteria. Should the primary non-central-line-associated event be changed to a CLABSI within NHSN? A: No. Do not change the device-association determination during the RIT. If a primary BSI is identified that begins the RIT, do not "upgrade" the event if a patient later meets CLABSI criteria during the RIT of the BSI. The second positive culture is considered an extension of the first non-central-line associated BSI. LabID Event Questions for APIC 11. If I have an inpatient psychiatric facility (IPF) located within my acute care hospital and it has a different CCN, do I have to map and report separately for this IPF location for LabID Event reporting? A: Since there are no Centers for Medicare and Medicaid reporting mandates for the IPFs at this time, facilities are not required to report to NHSN separately for these locations. Instead, for FacWideIN, facilities can continue to include and report LabID events from the IPF location just like they ve been doing, and NHSN will remove the counts prior to sending FacWideIN data to CMS. Remember, if the IPF does have a different CCN number than the ACH, the patient day and admission counts for the IPF location must be removed from those denominator counts for MDRO and CDI reporting. Additional information is available in the March 2015 NHSN newsletter found here: March_2015.pdf 12. Question. Should patients in swing beds be included with inpatient counts for LabID Event reporting? A: The answer to this question depends on the location of the beds. If these beds reside in an inpatient location, then, yes, patients staying in the swing beds must be included in all NHSN surveillance being performed in that location. This includes all event data and all denominator data for the inpatient location. Page 6 of 14

7 13. Am I required to add FacWideOUT to my NHSN Monthly Reporting Plan since acute care hospitals (ACH) are required to include 24-hour observation and emergency department locations when reporting in-plan FacWideIN LabID Events? A: No. FacWideOUT is not required for participating in facility-wide inpatient reporting for LabID Events. However, if facilities are reporting FacWideIN LabID event data for participation in the CMS Inpatient Quality Reporting Program, they must add each outpatient emergency department location and each 24-hour observation location to their monthly reporting plan. If these locations are already set-up in the NHSN application, the monthly reporting plan will auto-populate these additional outpatient locations when FacWideIN is selected. 14. LabID reporting is so time consuming because it requires everything to be entered manually. Is there a way to upload all of the required denominators and events? A: Currently the application will not accept downloads of this information. However, the good news is that NHSN is working on a process to make downloads possible. More information will be shared with users as it becomes available. SSI Q&As 15. Can a patient develop a surgical site infection per NHSN definitions following a dirty/infected surgical procedure or would such an infection be considered present or incubating on admission or at the time of surgery? If yes, does this SSI need to be reported to NHSN? A: Patients who have an NHSN operative procedure coded as dirty/infected can develop a subsequent SSI, including an organ space SSI. If the patient subsequently meets SSI definition during the surveillance time period. This SSI should be reported if this procedure is in your monthly reporting plan. The present on admission definition does not apply to SSIs. SSIs that occur after surgeries where an infection was present at the time of surgery may meet the new PATOS - Infection Present at Time of Surgery criteria. When entering an SSI that meets criteria for PATOS the PATOS field on the SSI event form should be marked as YES. When investigating an SSI look back at the operative procedure notes to determine if the patient had an infection at the same level as the SSI being investigated. SSIs that meet PATOS criteria are NOT excluded from SSI reporting. The SSI should still be entered into NHSN if it has occurred following a Page 7 of 14

8 procedure for which SSI surveillance is performed and reflected in your facility s monthly reporting plan. Complete details for the new PATOS field are found in the SSI protocol on the NHSN Website. 16. If a patient is felt to have an organ/space SSI, but doesn t meet a site-specific infection criteria, can a deep incisional SSI be reported instead? A: No, SSIs should only be reported for levels at which they actually meet criterion. For example if a patient had a hip arthroplasty, an HPRO procedure, and they were readmitted with a possible SSI, if they did not meet the organ space PJI (Periprosthetic Joint Infection) criteria, do not simply downgrade and call the infection a deep incisional SSI. It should only be reported as a deep incisional SSI if it met the definition for deep incisional SSI. 17. When we the new mappings for the upcoming transition to ICD-10-CM codes be available from NHSN? A: NHSN is keeping NHSN users and vendors updated regarding the transition via NHSN Newsletters and s. The latest March NHSN Newsletter had an update in the SSI section of the newsletter regarding this transition. NHSN has received the ICD- 10-CM and CPT mappings and is working feverishly to validate this data for all of the NHSN operative procedure categories for SSI surveillance. These mappings are anticipated to be available sometime this Spring. At this point ICD-10-CM codes will replace ICD-9-CM codes on October 1, 2015 however NHSN will not have the ability to receive these codes until the January 2016 release. The NHSN guidance for entry of surgical denominator data for the last quarter of 2015 data is to enter the NHSN Procedure Code (e.g. COLO or HYST) but do not enter any ICD-10-CM codes associated with the procedure. Because the amount of work involved in mapping the new codes to the NHSN Operative Procedure Categories is substantial, NHSN had to consider the practicality of including the mapping work to the current NHSN operative procedure code category OTH-Other. OTH Other is a catch-all category for NHSN operative procedures for which NHSN does not perform any in-plan SSI surveillance nor provide any benchmarking data. The NHSN Category OTH will not be mapped to Page 8 of 14

9 Page 9 of 14 ICD-10-CM and CPT codes and the procedures in that group will not be considered an NHSN operative procedure. VAE & PNEU/VAP 18. What lower respiratory tract event surveillance can be done in-plan for NHSN reporting? 1) Ventilator-associated event (VAE) surveillance is the ONLY in-plan respiratory event surveillance for mechanically ventilated adult inpatients housed in adult locations (regardless of the age of the patient). Pediatric and neonatal units are excluded from VAE surveillance (even in circumstances where a pediatric unit may occasionally care for adult patients). 2) Pediatric ventilator-associated pneumonia (VAP) surveillance using pneumonia (PNEU) definitions is the ONLY in-plan respiratory event surveillance for mechanically ventilated inpatients in pediatric locations (regardless of the age of the patient). In-plan surveillance for ventilator-associated PNEU is no longer available for patients in neonatal locations. NOTE: The PNEU definition (PNU2 & PNU3) is available for use as a site specific infection to which a bloodstream infection can be assigned as a secondary BSI for all patients to include adults, children, neonates, ventilated or non-ventilated. 19. Why am I required to report an Infection-related ventilator associated complication (IVAC) when the qualifying antimicrobial day parameter is met based on antimicrobial agents that were not administered to treat a respiratory infection? A: The IVAC definition, is not intended to specifically identify infectious events arising from the respiratory tract it is meant to identify events that may be infectious in nature and associated with a period of respiratory deterioration (whether arising from the lungs or elsewhere). Therefore, the list of eligible antimicrobial agents that is included in the VAE protocol is quite broad, and some agents are drugs that are rarely used to treat respiratory infections. There is no requirement to determine the reason for the administration of the antimicrobial. It may be helpful to consider that having an IVAC is not necessarily worse than having a VAC. The VAE algorithm is progressive in terms of criteria to be met but this is not to imply that each subsequent tier is more clinically significant than the

10 one before. The fundamental definition within the algorithm is the VAC definition so even in those circumstances where an IVAC is detected that event still met the VAC definition. In the case of the IVAC, there is simply some additional evidence that the event may be infectious in nature, as opposed to non-infectious. This is what the IVAC definition is intended to detect. 20. Can you explain baseline period of stability or improvement and the period of worsening oxygenation that is required to meet the VAC definition? A: By definition the baseline period of stability or improvement on the ventilator is defined as the 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2, and must be characterized by 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values After a period of stability or improvement on the ventilator, there must be at least one of the following indicators of worsening oxygenation: 1. An increase in daily minimum FiO2 of 0.20 (20 points) over the daily minimum FiO2 in the baseline period, sustained for 2 calendar days. OR 2. An increase in daily minimum PEEP values of 3 cmh2o over the daily minimum PEEP in the baseline period, sustained for 2 calendar days. For a better understanding, let s look at a few examples. Page 10 of 14

11 Slide 1. Focusing on the FiO2 parameter you will note there is NO baseline period of stability or improvement as the daily minimum values immediately preceding the evidence of worsening oxygenation on MV days 4 & 5 are increasing in value. The daily minimum FiO2 values on MV days 2 & 3 are not stable or decreasing in value. SO the VAC definition is not met. Slide 2. Again focusing on the FiO2 parameter, in this example, there is a baseline period of STABILITY. The values on MV days 2 & 3 are stable. The period of stability is immediately followed by evidence of worsening oxygenation represented by an increase that is 20 points over both days of the period of stability and this increase is SUSTAINED for 2 days. Therefore the VAC definition is met. Page 11 of 14

12 Slide 3. In this example there is a baseline period of improvement. The values on MV days 2 & 3 are decreasing. The period of improvement is immediately followed by evidence of worsening oxygenation represented by an increase that is 20 points over both days of the period of stability and this increase is SUSTAINED for 2 days. Therefore the VAC definition is met. Slide 4. Now let s focus on the PEEP parameter. In this example there is a baseline period of improvement on MV days 2 & 3 and this period of improvement is immediately followed by an increase that is 3cm H2O over one day of the baseline period but not both days of the baseline period. To qualify as evidence of worsening Page 12 of 14

13 oxygenation, the increase must be relative to both days of the baseline period. Therefore, in this example the VAC definition is not met. Slide 5. Once again focusing on the PEEP parameter, let s look at one more example. In this example there is a baseline period of stability on MV days 2 & 3 and this period of stability is immediately followed by evidence of worsening oxygenation represented by an increase that is 3cm H2O over the baseline period. Note that despite the fact that the increase on day 4 actually decreases on day 5 the 3cm H2O increase over the baseline period is still SUSTAINED. Therefore the VAC definition is met. 21. Many times a period of stability or improvement is established and subsequently the VAC definition is met using this baseline period when in fact the patient is not at all clinically stable. Why must I report such an event? A: As you know to meet the VAC definition there must be 2 days that represents a baseline period of stability or improvement that is immediately followed by 2 days that represent evidence of worsening oxygenation. Both the baseline period and the period representing evidence of worsening oxygenation is determined based upon the daily minimum PEEP or FiO2 values. Selecting the daily minimum values is not to say the patient is clinically stable at that one value (of PEEP or FiO2) throughout the day but instead, has some respiratory stability across days. Tolerate of a minimum value (for at least one hour) for two or more days establishes a baseline period. To detect a VAC however, worsening of oxygenation would need to be detected immediately following that baseline period. That would require that an increase in oxygenation is needed such that the patient could not continue to Page 13 of 14

14 tolerate that minimum value (even for a short period). In addition not only could the patient not tolerate the minimum value established during the baseline but the minimum that they are able to tolerate is at least 3 cm H2O for PEEP or 20 points for FiO2 over the baseline period. Additionally not only is the daily minimum value increased, it remains increased for at least 2 consecutive days. The NHSN VAC criteria represents a reasonably cautious approach to event detection with relatively high, sustained thresholds of changes in PEEP and FiO2, so as to minimize capture of events that are of questionable clinical significance. Page 14 of 14