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Application of the NHSN 2015

Definitions

Joan N. Hebden RN, MS, CIC

Clinical Program Manager – Infection Prevention

Wolters Kluwer Health

The pessimist complains about the wind; the optimist

expects it to change; the realist adjusts the sails.“

William Arthur Ward

American writer

Surveillance – A fast moving trajectory

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Application of the NHSN Surveillance

Definitions

How well are we doing?

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AJIC Case Studies

Am J Infect Control 40 (2012) S32-S40

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)

• 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):678-686.

Variation in Application of NHSN Definitions

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Clinical Vignette – CLABSI

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#2 – Negative control- response of NO

#6 – Positive control – response of YES

Correct respond bolded

• Results:

Mean percentage of correct responses = 61.1% with low inter-

rater 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


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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”


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• 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

NHSN 2015 Definition Changes

General NHSN HAI Changes

Acknowledgement: Some slides are from the

Utah Department of Health

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• 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 site-

specific 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


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• 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


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• 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


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Adding an additional pathogen to event forms in

NHSN

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NHSN Supporting Materials

http://www.cdc.gov/nhsn/acute-care-hospital/CAUTI/index.html

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NHSN Supporting Materials: Worksheet

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Example Worksheet

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• 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 14-17 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


Utilizing NHSN 2015 Definitions

• Clinical scenarios

Acknowledgement: Some of the slides represent material

presented at the NHSN Training Conference: Feb 17-19,

2015

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Is it a CLABSI?

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• 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: 1st set grew

CNS and the 2nd set grew Staph epidermidis. No other source

of infection is identified

BSI Case Study

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BSI Case Study:

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• Does this patient have a LCBSI? If so, what criterion?

1. Yes

2. No

BSI Case Study: Polling Question

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• Does this patient have a LCBSI? YES

BSI Case Study: Polling Question

CLABSI Reporting in Dialysis Patients

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CLABSI Reporting in Dialysis Patients

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Is it a CAUTI?

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Is it a CAUTI?

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• UTI

Is it a CAUTI?

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• 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 38.40 C. Fever work-up performed -

urine and blood cultures sent

• 4/6: Temperature remains 38.40 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

UTI Case Study

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• 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

UTI Case Study: Polling Questions

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• 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


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4/6

4/5 –

T 384

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• Does this patient meet the criteria for secondary BSI

attribution?

1. Yes

2. No


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• 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


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• Is this a CAUTI?

1. Yes

2. No


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• Yes

• Rationale: Catheter was in place for > 2 calendar days and

the date of event – day 9 – was the day after catheter

removal


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Is it a CAUTI?

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• 4/4: Patient admitted for emergent colectomy. Urinary

catheter inserted in the OR.

UTI Case Study

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• Does this patient meet SUTI 1a. Criteria?

1. Yes

2. No

• If NO, why?

UTI Case Study: Polling Question

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• NO – Candida not an acceptable pathogen

UTI Case Study: Polling Question

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• 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

SSI Surveillance Changes

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• 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

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SSI Surveillance Changes

SSI Surveillance : Reminder

Courtesy of Janet Brooks RN, BSN, CIC – NHSN Nurse Consultant

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BSI Secondary to an SSI

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SSI Case Study

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• 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 15

2. Mar 8

3. Mar 9

Does the patient have a BSI secondary to the SSI-PJI?

1. Yes

2. No

SSI Case Study: Polling Questions

• 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

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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

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• 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”.

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• VAE

• Third tier consolidated into PVAP – Probable Ventilator-

Associated Pneumonia

VAE Surveillance Change

Is it a VAC?

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http://www.cdc.gov/nhsn/VAE-calculator/

Is it a IVAC?

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Is It a IVAC?

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Is it a PVAP?

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• 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

MDRO Reporting Changes

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• Facilities reporting on HA-CDI

• New specific infection type: GI-CDI Gastrointestinal System

Clostridium difficile infection

• Does not impact CDI-LabID event reporting


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• CRE

• New CRE organism added: CRE-Enterobacter

• In-plan reporting must include all CRE organisms: E. coli,

Klebsiella pneumoniae/oxytoca, Enterobacter


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• http://www.cdc.gov/nhsn/labid-calculator/index.html#

MDRO & CDI LabID Event Calculator

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MDRO & CDI LabID Event Calculator

NHSN Support

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Thank you

Great Job!

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