Achieving Together Original Video (English)

Achieving Together Original Video (English)


I imagine I imagine I imagine I imagine a Texas Where HIV is rare And every person will have access To high quality prevention Care and treatment No matter their age Race Ethnicity Sexual orientation Gender identity Or socio-economic status We will end the HIV epidemic in Texas. We have a unique window of opportunity right now. We have the tools. We have the people. We have strong community partnerships. And we have game-changing advances in medical science. Now, we’re at a point in the movement where we can actually talk about someone’s HIV status and how their education level, their socio-economic status, their income level, how all of those play a role in someone’s HIV status. We have a plan that is by community and for community. We started with a hundred big ideas and these brought us all together and allowed us to move beyond those historical restrictions to really tackle the big issues. Sitting at the table, we emulate community. It allows us to be able to use this plan for active movement because it is a diverse plan to hit every vulnerable population. Creating Achieving Together was very inclusive. It gave us the opportunity of black and brown voices actually being heard. Most profound is knowing that this plan will impact lives for years to come lives of people who will be moving to Texas, of babies who are not yet born. This plan will ensure that they will live in a world that is free from new HIV diagnoses. We forget that the first word in HIV is “human” and this is a human issue. Everyone has a part to play in this movement. We can do this if we work together and keep our minds on the goal. Join us In ending the epidemic of HIV.

Insect Extinction – Behind the News

Insect Extinction – Behind the News


They are sometimes seen
as creepy… ..and they’re often crawly… ..or jumpy… ..or wriggly… ..or fly…y? Actually, there are lots of
different ways to describe insects because there are 30 million
different insect species in the world and they’re just the ones
we know about. In fact, if you put
all the insects together into one big, creepy, crawly,
wriggling mass, they’d outweigh all of humanity at least 17 times over. Now, hearing all that, who could blame you for thinking,
“Hey, insects are doing just fine.” But scientists say
that’s not the case. They are actually disappearing
at a worrying rate. A new study has found
that over the past decade the world’s insect populations
have reduced by 41%. That includes around 46%
of bee populations, 49% of beetles, 50% of crickets and grasshoppers and 53% of butterflies and moths. So, why are some insects dying out? Well, the finger is pointing
mostly towards us humans. Scientists say
habitat loss from deforestation, pollution and pesticides
and climate change are some of the biggest factors. The study predicted
a pretty sad future too where more than 40% of all
insect species could go extinct over the next few decades. Hey, Dan. How are you doing, Amelia?
Great to see you. Great to see you. This is amazing.
Yeah, it’s a fantastic place. Well, I think we should get cracking
and go and catch some bugs. I brought you along a net. Awesome! Let’s do it!
Yeah. Ben is a entomologist. That’s a scientist
that studies insects. So, I’ve always loved bugs. Ever since I was a pup, all I ever
wanted to be is a bug scientist. So, check this out, Amelia. I’ve caught a nice little fly
in the grass here. Oh, wow! He says even the tiniest,
most irritating insects are more important than they appear. They pollinate plants, they help to recycle material
in the environment, like plant material
but also animal material. They also play important roles
in food webs because, not only do they consume
things like plants, they are actually food sources for animals further up
the food chain. Ben, what would the world be
like without insects? I think we wouldn’t have
a world without insects. Once we remove that chain
from this kind of food web, everything collapses around it. We would pretty much have waste
piling up everywhere, and this is animal waste
and plant waste. We wouldn’t have any food to eat.
Whoa! So, it’s a pretty scary idea to think about
a world without insects. Ben says that’s why
it’s so important to take care of our environment and to keep a close eye
on how insects are going. Hey, I’ve got something! Let’s have a look. Oh, so this is a male velvet ant. Oh, look at that! This is a really good catch. So, what can I do and what can the kids of Australia
do to help insects? Some easy things you can do
around the home is reduce your reliance
on insecticides, spraying them
in and around the house. And as far as habitat loss,
to actually provide… By planting native plants
in your backyard which provide food sources
but also kind of habitat. While we go work on that, scientists like Ben
will keep spreading the word that without insects both pretty… Aww! ..and creepy… Ew! ..our world just
wouldn’t be the same.

This Stick Insect Came Back from Extinction

This Stick Insect Came Back from Extinction


(upbeat music) – [Narrator] This is the Lord
Howe Island stick insect, and this species did the impossible, they came back from extinction. The Lord Howe Island stick insect is the largest flightless stick insect, and can grow up to four inches in length. That’s almost the length
of an adult human’s hand. It is affectionately
nicknamed the tree lobster, the land lobster, and
even the walking sausage. Lord Howe Island stick insects were once so common on Lord Howe Island that they were used as bait by fishermen. Then a British supply ship
crashed on the island in 1918, accidentally introducing
rats who ate the insects. By 1960, they were declared extinct. Then in 2001, Australian
scientists discovered a tiny population hidden on a
small volcanic island nearby. Thanks to a breeding
program at Melbourne Zoo, they have been able to save
and repopulate this species. This is the Lord Howe Island stick insect. (upbeat music) (tone sounds)

Dallas Home Inspector Finds Termites Active Even In Cold Weather | (214) 960-1005 | CALL US!

Dallas Home Inspector Finds Termites Active Even In Cold Weather | (214) 960-1005 | CALL US!


Hi everyone this is Cliff with Home
Inspection Solutions It is a Valentine’s Day February 14, 2012 I’m inspecting a house here in the Plano area and this is, looks like a termite tube up in one of the corners here and this gonna take up a slow screwdriver here and break it open and see you can see those termites run up and
down there see that we’re moving across the screen here. Okay this is just an illustration of the fact that termites are active all year long yes they are
more active during April and May where coming out about warmer weather in to cool that you have to be on the lookout for
on all year long here they are in January or excuse me in February traditionally when we call months of the year around here although it has been warmer than usual
but you have to be on guard for termites every month of the
year here in Texas. This is Cliff with Home Inspection Solutions

Video: Texas human trafficking epidemic among worst in nation

Video: Texas human trafficking epidemic among worst in nation


 >>Mark: WELCOME BACK.  JUST ABOUT 9:23 MONDAY MORNING.  JANUARY IS NATIONAL SLAVERY AND  HUMAN TRAFFICKING PREVENTION  MONTH AND FEDERAL LAW  ENFORCEMENT ARE USING DIFFERENT  CAMPAIGNS TO RAISE AWARENESS.  >>Leslie: ACCORDING TO THE  HOTLINE.  IN 2016 THERE WERE MORE THAN  7600 REPORTED CASES OF HUMAN  TRAFFICKING AND 650 OF THOME  WERE IN TEXAS ALONE.  >>Mark: LAST YEAR THOUSANDS OF  PEOPLE CONTINUED TO BE VICTIMS.  TIFFANY WARE HAS LOOKS AT HOW  TWO AGENCIES ARE NOW  APPROACHING THAT ISSUE.  >>I DRINK, I DO WHATEVER DRUGS  HE HAD JUST TO LIKE CLEAR MY  MIND SO I WOULDN’T THINK ABOUT  IT.  BECAUSE AT THE TIME, I FELT  LIKE HE WAS PERFECT TO ME.  >>Reporter: THIS WOMA RECALLS  HOW SHE BECAME A VICTIM OF  HUMAN TRAFFICKING.  >>HE WOULD TELL ME HEY, YOUR  MOM DOESN’T LOVE YOU, NO ONE  LOVES YOU BECAUSE THEY ARE NOT  LOOKING FOR YOU.  >>Reporter: SHE SAID SHE SPENT  NIGHT AFTER NIGHT IN DIFFERENT  HOTEL ROOMS WITH DIFFERENT MEN  HELD AGAINST HER WILL AND  BEATEN.  THIS IS JUST ONE EXAMPLE OF HOW  THOUSANDS OF PEOPLE HAVE FALLEN  VICTIM TO HUMAN TRAFFICKING.  >>HSI LOOKS AT THIS  INVESTIGATIVE DISCIPLINE MORE  FROM A VICTIM CENTRIC  PERSPECTIVE.  WE HAVE DOZENS UPON DOZENS OF  VICTIM ASSISTANCE SPECIALISTS.  >>Reporter: SPECIAL AGENT IN  CHARGE SHANE FOLDEN SAID THEIR  BLUE CAMPAIGN IS A DRIVING  FORCE IN FIGHTING HUMAN  TRAFFICKING.  EDUCATING THE PUBLIC IS PART OF  THAT CAMPAIGN, INCLUDING WHAT  TO LOOK OUT FOR AS WARNING  SIGNS.  >>A RESTRICTION OF MOVEMENT OF  INDIVIDUALS OR INDIVIDUAL  DEFERS TO SPEAK OR AN  INDIVIDUAL HAS VERY, VERY FEW  POSSESSIONS.  >>Reporter: OVER AT THE FBI,  THERE ARE CRIMES AGAINST  CHILDREN FOCUSES UPON CASES  INVOLVING MINOR, PARTICULARLY  RUN AWAYS.  >>ONE OUT OF EVERY FOUR RUN  AWAYS WILL ACTUALLY BE  APPROACHED BY SOMEONE TO  TRAFFIC THEM WITHIN THE FIRST  48 HOURS.  >>Reporter: EACH YEAR, THE  FBI’S CROSS COUNTRY OPERATION  FOCUSES ON RECOVERING UNDERAGE  VICTIMS OF PROSTITUTION AND  GETTING THE PUBLIC’S ATTENTION  TO THE EPIDEMIC OF SEX  TRAFFICKING.  WHILE TECHNOLOGY AND SOCIAL  MEDIA CONTINUE TO PLAY A BIG  ROLE IN THIS ISSUE.  AGENCIES HOME THEIR MESSAGE AND  ACTION CONTINUE TO REACH AS  MANY PEOPLE AS POSSIBLE IN  ORDER TO SAVE LIVES.  >>VERY TROUBLING STATISTICS  THAT STATE THAT WITHIN FIVE  YEARS OF BEING TRAFFICKED, A  MINOR WILL START EXPERIENCING

Surgical Site Infections (SSI) Surveillance with Case Studies (Part I)

Surgical Site Infections (SSI) Surveillance with Case Studies (Part I)


>>First of all, I just want
to introduce myself. I’m Janet Brooks and my subject matter
expertise right now is SSI and I probably feel like I know everyone of you in the room
from different questions that I’ve answered.
NSH
4
00:00:12,726 –>00:00:15,806
My mailbox, now people just say,
“Send it to Janet,” you know. So I feel like I know all of
you quite well at this point. I know where you are and how you feel. I had over 20 years experience in the trenches
as an infection preventionist at large and small hospitals so I know the
trials and tribulations with — especially as we change our definitions. I want to welcome everybody here
in the room and those of you that are listening via web
streaming today, all of those, probably thousands that are on there right now. I haven’t heard a number yet from
Courtney of how many are logging in but I’m sure there’s a lot of people listening. Let’s go ahead and get started. So our objectives today is to look at
our methodology for collecting our data and identify — we’re going to
focus on our SSI changes for 2014. I do go over filling in denominator data,
that’s your procedures; and your numerator data which is your surgical site infections. So especially for the newer IPs
this can be helpful for everybody. And then how to apply these
definitions to some case studies. And I’ve sort of thrown case studies throughout
the whole presentation this year rather than having a giant chunk at the end. I’m trying to present a piece of information
and then see how you can apply that. So I know that Kathy Bridson asked early on,
but I’m just curious again, how many of you — is it really maybe less than a year that
you’ve been as a younger IP or a new, as an infection preventionist, are
less than a year working with SSIs? Okay, good. I just want to kind of get a
feel for that because I do go over the basics and then some advanced issues. Well, this is my, you know, the go-to spot. This is the — we’re on the NHSN website and
this is your surgical site infection section. And over here on the right you can quick-link
rather than dragging down to the bottom of the page get to your trainings, your
protocols, your data collection forms, a whole section on CMS reporting materials. The bottom are supporting materials and I’m
going to be going over that in a minute. You can quick-link to your analysis resources. And I have to thank Maggie for her presentation. I mean, perfect timing in terms of really
hitting a lot of the SSI questions that I get as well that she gets around what’s
going on with risk adjustment and what we’re collecting right
now, some of this new data. And then we have our Frequently Asked Questions. And I think it was mentioned
early-on, I’m not sure by whom, but we’ve just finished updating all our FAQs to reflect the new definitions
and the new protocols. And there were quite a bit
of changes for SSI in ’14. And I think probably within the next
week the FAQs that I get, you know, for SSI Protocol will be up there. And we’ve actually moved this time
up into this protocol section here where you go grab the most or actual protocol. So you’re going to find your FAQs up there. Before you had scroll all
the way down to the bottom and we weren’t sure it was
jumping out enough for everybody. So this is the data collection forms
and again I’m highlighting things that I get asked questions about. What I want to show you is for
every data collection form — these are all the up-to-date forms. This is from the SSI section of the website. There is a Table of Instructions
that goes piece by piece for every element you’re
supposed to be entering on a form. There is a Table of Instruction that tells
you what that piece of information wants. So it’s got some good details in it. Those details are often found in the protocol
but it’s just good to know there are IPs that aren’t — don’t realize we have a
Table of Instruction for every single form. So here’s your actual Numerator SSI
Form and here’s your Denominator Form and here’s your Table of Instructions. Now for CMS supporting materials, I don’t
personally have to go to that a lot but I want to let you know that these are the ones that
are all geared specifically for SSI information. And the one that I like is this one
right here because I feel like, wow, am I sure I know when they
did their last update? Am I sure I know what’s coming in the future
and what we’re supposed to be reporting? And as you look at this, this was
just updated in December of 2013. So this has all your most
up-to-date reporting of requirements. And this is just not SSI. It’s that really nice page that they put out
that has all your deadlines, when it started, you know, when your due dates
are for reporting as well. So that’s the one that I find helpful,
and I always keep track of the date to make sure I have the most recent one. I’m not putting in a lot of details about
CMS reporting because we’ve been doing it for a while with COLOs and HYSTs. But for the IQRP Program it
is still COLOs and HYSTs. Nothing was added in 2014. But we do now have these new
PPS exempt cancer hospitals. It’s a handful of them. I think it might be more. Last time I heard 11/13. And they did start in January of ’14
reporting COLO and HYSTs as well. This is the section — if you
could see how many times I hit this in a day it would probably be shocking. This is the Supporting Material
Section down towards the bottom of the SSI section of the NHSN website. So what I use constantly — let’s see
if I have my little arrows in here. No, I didn’t. Yes. This is basically what those
of us that have been around a while, and you can tell I’ve been around a
while, called the famous Chapter 17. All of your HAI definitions, okay? We know that even though
it’s called the [inaudible], surveillance definitions for different types. Even though it’s not — it is a chapter
if you printed it out hard copy. I look at that constantly and because of
SSI organ spaces you have to get really, really familiar with this chapter. And you’ll know why in case
this has eluded you once we get into talking about organ space infections. My other favorite is, whoops, go back,
is this ICD-9 CM procedure code mapping to NHSN operative procedure categories. Again, I get daily emails from
the users, and I love you all. I’m not trying to sound negative at all. Don’t take this wrong. But I get emails where they’ll send me saying
my patient had blumty-blump procedure done. Is this an NHSN operative procedure? Is this an OTH Other procedure for
you poor folks in Pennsylvania? And you know who you are. You know that OTH Other category. And I basically have to turn it back around
because I never want to give an answer if I’m worried it’s not the correct one. And I say, because a lot of our procedure
codes are based on ICD-9 codes, I’m saying, will you do me a favor and send me
back the ICD-9 code for that case? And then I also tell them, but,
remember, we have this amazing resource where we have mapped all of the ICD-9
codes that could possibly be a procedure or operative codes into this guide. And here’s what it looks like. Now I just am curious, and I’ll
— how many of you use this? No judgment. Okay. Well, I’m glad I’m pointing it out. See, because what you’ll see here, and
I’ll try to highlight it, it comes out and you’ll see there’s white
columns and gray columns. So look over here. I’m going to put — this one right
here is a 4571 and it tells you. So if all you had was this list that said this
was a 4571, I’m like, was that a small bowel? Is that a COLO? What does that fit into? It tells you. That is in our NHSN COLO category. Then you go over here and
you see, oh, I had a 4281. Is that an NHSN operative procedure? And that’s a big old no. It’s nothing. It is not — you cannot report an
SSI to something that was a 4281. And then you go over here and you see a 45.8. And that means it’s an invalid code. And if you look in an ICD-9 — how many of
your guys — I’m asking too many questions. I’ll [inaudible]. How many of you guys have ICD-9
CM Code Books in your office? Well, we’re talking about
ICD-10s in a little bit. I highly recommend you put
that into your budget. As an IP, and this has nothing
to do with what I’m doing now, I couldn’t live without my ICD-9 Code Book
to able to look up and see what is this code? What is this procedure? I mean, it’s used daily. So I highly recommend you have that
because otherwise you have no ability to look that up on your own. So, anyways, if you look up this code,
45.8, that is showing it’s an invalid code and when I look that up in my ICD-9 code
it usually means it’s one they retired, just not used anymore. So you shouldn’t even be finding it. And then — oh, I’m sorry. Invalid means — sorry. I’ve got — the NU is No Longer in Use. It was an ICD-9 valid operative
procedure code and it’s out of use. And this 45.8 is just an invalid code. It would not be any kind of NHSN operative
procedure, so that’s really, really helpful. And it’s all separated out by pages in an Excel
document for you all to use as a resource. We also have at the top, have the
Training Section of the website. And right now there isn’t as much on it,
and we’re going to be updating the LECTORIS for new IPs, or those of you who haven’t
done it, to train to the new definitions and that’s actively being worked on now. And then once this webinar is ready — it takes,
you know, a few weeks, but you’ll then be able to find this webinar on the
training website as well. Now your monthly reporting plan is
really the roadmap of what you are — data you are sending to NHSN every month,
your in-plan procedures that you’re following. So for most of you, if you’re
an inpatient acute-care setting, you’re all going to have your COLOs and your
HYSTs in there, and then some of you are in states that have very specific other
procedures they want you to follow. It might be a handful more, and those will be
in your monthly surveillance reporting plan. And then those of you, I’m sorry, in California
— how many Californians do we have here? Oh, quite a few. Hi. I moved here from Napa,
California so I feel your pain. Have a very large selection
as well as Pennsylvania. You know, almost every operative procedure
in Pennsylvania and in California with 29 or something — a lot, so
they’ve got a lot in their plan. But the plan, by something being
in-plan and checked off, that drives and activates all the business rules
that live behind an application. So that’s what makes it a
active in-plan surveillance. And you must have one, you know. It’s a month-to-month. So you have to have COLOs in every
month that you’re following those. So this is what your monthly reporting plan, if
you had a look at this, this would be ICU-West and it’s telling — you can tell that
they’re following CLABSYs, COUTIES, and they’re just following
for inpatient hysterectomies. Now active surveillance, you know, you’ve got
your procedures being done but how are you going to find the surgical site infections? So you have to have a surveillance
method that’s very active and on-going. So you want to, first of all, determine which
patients need to be monitored so you know, you need to know who’s having — I’m going to
focus on COLO-HYST because we’re all kind of, most of us, in the same boat for those two — which patients are having those procedures
every month, and that’s important. And there’s lots of methods and these
are all pulled out from our beginning of our SSI protocol where we touch
on post-discharge surveillance. You can review your admission logs. Those are very important. And your re-admission logs. Some people actually can have a code in the logs
they run that say this is a re-admit of a person who was here in the last 30 days. So that can be a flag for you to let me check
this patient and see if they had a procedure. Everybody has different reporting
systems that have flags to give them a warning this may
be a patient that is suspicious. You’re going to look at your — if you — the last facility I was in my admission
logs always had their diagnosis. So, I mean, if I saw the word
like abscess, if I saw the word — any kind of infection, I was going to look
up that patient just to make sure I was — if they’d had a procedure the
month before, did I need to follow that to look for a surgical site infection. Your ED Logs are really helpful
if you can get that even if the patient isn’t readmitted
to your facility. If you can get your ED Logs with their
diagnosis or some sort of summaries, you can maybe find some of your superficial
SSIs where they come in and are treated but then are not readmitted to your facility. Also you can be reviewing, obviously,
all your lab reports for any sort of wound cultures that are being sent. And then you can — other diagnostic tests that
you find helpful, and reviewing nurses’ notes and physicians’ notes on key, on the patients. And then, also, what can be good, if you have
— and I know it can be really difficult, but if you have certain targeted high-risk
surgical wards you can try to get involved on maybe the weekly multi-disciplinary
rounds so you can then, in actual real time, be hearing about which patients
are struggling with wound healing or might be catching early some
possible surgical site infections. That being said, at this point we don’t
have, because we do get asked this, we do not have an actual set, mandatory, validated method that we say how
you are doing your surveillance or your post-discharge surveillance. That is still fairly — it’s customized
and is done, especially the post-discharge, differently in different facilities and we’re
going to be talking, you know, about that. But it is, again, something that you want to
be doing and have a part of your surveillance. There was a misconception in the beginning that
CMS would never get any SSIs that are found by post-discharge surveillance,
and that’s not true. That’s the AR Model. But the 30-day surveillance where
they use the age in the ASA Code, they’re finding the ones no matter how
they’re found, whether it’s admission, re-admission to your facility, post-discharge. So you want to develop some sort of tools
to have a consistent way that you feel like you’re capturing your
post-discharge surveillance. Now if you find a patient whose
found via post-discharge — you know, they come into the ER and then that’s
how they maybe first culture the wound is in the ER, but then they readmit the patient. That would be a readmit to your facility. You kind of go to the deepest level,
the most complicated that had occurred, like this became bad enough
this patient was readmitted for care of this surgical site infection. And also, again, you can get a connection to
reviewing all of your post-op clinic records. And there are also — I mean, the ultimate, and
there are facilities that have the person power to do this, is, if you think about it, especially if you’re not a hospital that’s
doing every single one, it could be difficult. But if you’re only doing COLOs and HYSTs you
really have to think about the fact if I need — these are both 30-day procedures. You don’t have to go out 90 days. And have some sort of method that you can review
that chart, fully review each chart, at 30 days. So this is just a little glance at our — on
the left you’ll see this is the denominator for collection form that’s
used for every procedure. Now remember, when you sign up to do COLOs
and HYSTs, you’re saying, I’m doing every COLO and HYST, every procedure
that meets that criteria. And then on the right is your actual
infection, your SSI Surveillance Form. So we’re going to go over some key terms. And this is a new slide this next one. It’s not in your packet. This was my little bit of armor that I put on. My friends were joking, saying, “You
should come on with a bulletproof vest and say don’t kill the messenger.” But I know that we have thrown a lot of changes for SSI surveillance at you
all in 2013 and in 2014. There’s only two more coming
in ’15 which you have to wait to the very end of the presentation to get that. But then we’re done. Then it’s level. Don’t quote me on that. But, anyway, these changes that have occurred
in 2013 and 2014, definition of primary closure and all the things that we’ve done this year,
did not happen in a little group of people at NHSN saying, “Let’s, you know,
let’s change up our definitions.” There was a year and a half — you know HICPAC
Guidelines, you know HICPAC Working Groups. There was a year and a half, HICPAC/SSI Working
Group, that was very multi-disciplinary — surgeons, IPs, A or N Representatives,
CDC, NHSN, infection preventionists — and it went on for over a year and a half
to really look at trying to harmonize, and you’re hearing that word a lot, but to try
harmonize our definitions with the definitions that are really being out there and applied
by other surgical professional organizations like the Society of Thoracic
Surgeons and the definitions they use for their complex cardiac cases; like
the Society of Orthopedic Surgeons and how do they really look at joint infections;
like the Musculoskeletal Infection Society where we got our new PJI definitions. These are the people that asked for this. This came at a surgeon level of can we harmonize
so that when we look at NHSN data we really feel like this makes more sense and is more valid. And, historically, when you looked at NHSN
data in the past, before these changes, and compared it to any of
these other surgical societies, we were reporting much lower
numbers than they were. So that’s why some of this came — this why all,
really, all the changes came about were driven by a really, really well-thought
group of very sharp people that were trying to get this harmonization. So, present on admission. This was gone over a lot last year because we
have a new present-on-admission definition, and Kathy reviewed it again today. POA does not apply to HAIs. If you look at the POA definition,
it’s like it does — has to occur in the first two
days; it has to do this and that. It doesn’t work with SSIs
because they’re procedure-based. Everything’s procedure-based. Think of Maggie saying you got to be
driven by the date of the procedure. And they all have these long
30-day surveillance periods. So the whole POA definition just doesn’t
even work for surgical site infections. And it says that in black and white now. I mean, it’s kind of what we knew was
true but we didn’t have it in writing. And then when we had the POA definition we
realized it doesn’t apply to like lab ID, to VAE, and it doesn’t apply
to surgical site infections. They’re procedure-based. So once a procedure starts, the clock sort of starts ticking again is
the way I like to think of it. And the HAI definition doesn’t work because
that’s the one that bounces off of the POA and says oh, if everything happens on
day three it’s an HAI after admission. Well, again, these are procedure-based
with long surveillance periods. And the HAI definition is what
introduces the whole gap-day rule, and we don’t apply this tight little gap-day to
a person who has a 30-day surveillance period. Things can brew, and they can start
as superficial and move to deep, so we don’t have that gap-day
rule which shows up in HAIs. And that’s why we, again, very clearly, if
you go into Chapter Two, our HAI Chapter, you’ll see it says this doesn’t
apply to surgical site infections. So this was a big change this year. Last year the big change was the
definition of a primary closure. If you think about before 2013, man, that
incision had to be just closed up tight as could be and not a wick
or a drain coming out. And then we had a new definition
which was very much based on the American College of
Surgeons’ definitions. It’s very, very tightly based on
Misquip’s [assumed spelling] definition of operative procedures, primary
procedure versus an open procedure. But what we did in 2014 is,
again, it’s all those procedures in Table I, which we’re familiar with. It, you know, tells you what they are or,
and all the OTH categories for Pennsylvania, and it takes place in an OR where at least one
incision is made into a skin or mucous membrane, and also that’s your laparoscopic procedures, or
an incision left open during a prior procedure. This is to cover for — now that you remove
the incision method from your definition, it means you may have a patient who goes
to the OR and they leave the incision open and then they return two days later to close it. Well, that still is a procedure but
they’re cutting through the fascia or something to start that procedure. So you still want to include them. And then it takes place — this is the same
as it has been for the last couple of years — in an operating room which is
defined as a patient care area that meets the FGI or the AIA criteria. And that’s the same; that did
not change from last year. So, again, just to be clear, as of 2014
the incisional closure is no longer a part of a definition of an NHSN operative procedure. So all otherwise eligible, meaning an
incision was made and it took place in an OR, will be entered into your denominator data. And if you think about that it’s the
same as thinking of here’s my denominator and you base your surveillance
and you’re writing up a surgical site infections
on your denominator. So if it’s in your denominator and
they have developed an infection in that surveillance period
you will attribute it. We’ll get into that more. So, these are some of the FAQs that I went
ahead and just put them in right at the get-go. So why are both primary closures as well as
non-primary closures now being collected as part of the denominator data that’s being
sent to NHSN for surgical site procedures that are followed in our
facilities’ surveillance plan? Well, both non-primary closures are common now and the previous definition did not have any
representation of this surgical practice. Therefore, it’s important to collect data on
these procedures and the related infections to really gain a comprehensive
picture of the surgical risk factors in order to guide prevention needs. So now you’re going to have an ability —
now what Maggie said was really important. Right now none of these open procedures,
other than primaries they call it, field the check box, are going to
be impacting your SIRS that you run. They’re not being sent to CMS. We don’t have any baseline
data to look at these. They’re there for you to look at. And it can be very helpful for a surgeons
to be able to see, especially those that — the COLOs and where, you know, not a majority
by any means, but some are left open — that you’ll be able to actually
give them information. Okay, here’s how many SSIs you
had that met this criteria. But you had this many based on this procedure. You have that internally now. But we’re not sharing that data with CMS and
it’s not affecting your SIR at this point because we’re not going to re-baseline. We haven’t re-baselined. So everything, as Maggie said, is
based on 2006 through 2008 data. Our primary closure definition did
not change from last year, same. And you’ll remember, last year in
the manual we actually gave you — because sometimes you don’t know what
something is unless you know what it isn’t. So we also last year in the NA, and this is
just, you know, cut and pasted from your manual, we also gave you the non-primary
closure definition of incision. And that is right here. Wordy just because I’m just — it’s a placeholder to remind
you this is your definition from the SSI protocol, okay,
for a non-primary closure. It was also in there last year. Didn’t change at all. We just weren’t applying it. So what we — non-primary closure
basically means your open procedures. So when you — and we’ll get to that
in terms of when you fill this is. So if a patient — this is my next most
frequently asked question lately — if a patient underwent an NHSN operative
procedure with a non-primary closure — so it was left completely open — and subsequently this patient
develops a surgical site infection from that operative procedure, must we
include this in the SSI in the numerator? And, yes, that procedure is in your denominator
data and if the patient develops an SSI that meets criteria within the
surveillance period, which is — it will be entered into your — oh, I
said denominator again — numerator. Correction, that should say numerator data — and it will be linked to that
procedure that is already sitting there in your denominator data
marked as an open procedure. Every procedure, when it goes
over, is going to have a field that says was this a primary
closure or an other than primary? So it is linked to a known open procedure. And this was just a reminder note that that — the SIRS are not going to be
impacted by this collection. We’re just getting this baseline
data and then we’ll be able to actually look at it and see if it matters. Does it matter? Is there a huge difference between the
procedures that are left open and closed? But we won’t know that until we get
that at least years two’s data from you. All right. Mea culpa. A lot of changes. So, this has been corrected. If you go back to you facilities
and print out key terms and tables of instructions for your denominator. What happened? The SSI protocol itself has the
correct non-primary closure definition, but that same definition also lived in key terms
and it lived in the little Table of Instructions to fill out your denominator form and we did not
— remember that there was this little sentence in here about oh, if it’s a
non-primary closure it is not an SSI. So that is incorrect. That is not true. That’s 2013’s statement. It’s been corrected. But if you by any chance — how
many of you work off of a hard copy of a manual versus really going to the site? Probably, yeah, at least half. So if you printed off a hard copy of your
Table of Instructions and your key terms, just go and print those off again so that you
have the correct non-primary closure definition. The one in the — most people use the protocol. The protocol is correct, but
I just want to point this out. Now this is a list — and actually, it’s like I can tell you this is sort
of — I have to thank our users. I tell you that sometimes you all show us
things or have put together little things that are very helpful that we like to share. This was a list that someone put together. I tweaked it with the IP a little bit. But she put this together for a training
for her OR staff of trying to think of all the examples she could have. What would be a non-primary closure? What it may include, what
it may be described as. And then what a primary closure may include. And so I thought this was just a
really helpful listing of things. And I highlighted the one,
and it’s very unusual, but you’ll see on the left
side here I highlighted this. It doesn’t happen very often but we get enough. I’ve gotten a couple of questions so we decided
we want to make sure we are clear on this and also is stated in the protocol. There are some cases where
they actually do the procedure. They know they’re going to go
right back in in a day or two. So if you look at the patient from the outside
it looks like they closed up the patient. But, actually, in fact, it’s just a
very temporary closure at the skin. The fascia is completely open, the muscle
is open, because they’re going to just kind of unzip that patient in a day
or two and finish the procedure. So, in fact, this — because,
when you read the definition, it says they must be closed
at all tissue levels. And people sometimes wonder, what
does that mean, all tissue levels? This would encompass where, yes,
the skin looks closed but, in fact, the fascia and muscle layers are open. And they really do this when
they’re going to take them right, usually back to surgery in
a pretty immediate manner. But I just wanted to, you know, show you that. Let me see if there’s anything else different. Of course, you know, and I’ve got some slides that will show you some more
examples that may be helpful. You may not like them but they may be helpful. So, my son is a graphic designer so I
have to thank him for doing this for me.>>Aw.>>Aw, I know. So — because, you know, it’s hard for
us to grab things from the internet. Sometimes there’s not — we’re not
supposed to get them from there. And so I said to him, “I
want one nice and tight, one that has some little
closures, one that’s wide open.” Then he calls me up. He goes, “Mom, would you
like staples or sutures?”>>[Laughter] So I said, “I
think I’ll go with staples. I think they’re stronger.” So, of course, this is a primary closure. This is now a primary closure. Now you probably have packing in
here and everything, you know, and you might even have a
little wound vac placed in here. But this would be open. Or you have a wound vac here and a
wound vac here but they’ve closed this. And this is a other than primary. This is an open. And this again could be completely
filled with — let me go in here. He did not draw these. I said, “Hey, [inaudible],
could you do a moon vac?” He’s like [inaudible]. So these are representative of —
you can see this was never closed in any skin edges and is just completely packed. That’s going to be — because some folks have
asked, “Well, if they pack the whole thing or if they put a wound vac
in, does that mean it’s now like what you consider closed
because look at — .” And I said, “No, no, no. That they never brought any of these skin edges
together and they’ve put that whole wound vac in there, so both of these would be considered
fully open, not closed at the level.” So when you go into — now this is cut from
your actual application when you enter, okay? So when you get here to wound closure technique
it’s a dropdown and it’s going to say primary. And then it doesn’t say open. I’m just warning you. Then it says other than primary. So that’s your selection right there, okay? So in the past what procedures
were you sending to us? Only procedures. Until this year the only thing
that should have been going into your denominator data was
your primarily closed incisions. That is what, when you sent us
your COLOs, you sent us your HYSTs, we were taking that all of
those were closed primarily. Now we put out a guidance in a newsletter
and if you guys didn’t, you know, look back in November, after we sent in the
NHSN Newsletter a summary of what was coming. We’ve been telling you this for what every
[inaudible] we told you what was coming. But we told you it was coming and there was a, and we’ll call it an uproar,
there was an outcry, an outcry. They’re like yikes, there’s no way
that we can have something in place to capture wound culture and
be ready for this in 2014. What can we do? Help. So we put our heads together. We really do care. We try to listen. And we said, what can we do? What’s a workaround? So we went to our actual people up there with
the brains that build these applications. Well, we have rules around when
fields have to get entered, and fields get entered way ahead
to prepare for what’s coming. And this field had been built
into the application. We couldn’t remove the field
of incisional closure. We couldn’t remove the diabetes field. They were built into the 2014 application. Because I’ve been getting emails that said that
newsletter said this isn’t coming until 2015. And it said, we said, “No.” We said, “In 2015 you really
have to have the answer right and we’re giving you the workaround for 2014.” And what it said up here in the intro paragraph
of this, it said, “All SSI fields are built into the NHSN application for release.” That was us and maybe we should
have wordsmithed it to let you know. I mean, we couldn’t take these fields out. So the workaround that we said was, “Report these denominators the same
way you were determining in ’13.” Because in ’13 what you sent us was only
supposed to be your closed procedures. So how were you determining what
your primary closures were in 2013? So I’ll give you three sort of examples. A facility I work pretty closely
with, because I used to work there for a long time, a big university. Well, as soon as this definition changed of what
was a primary closure and it was much more open, they built a field into their OR record. They educated the OR, the
whole team, and actually — because they didn’t know how are we going
to know what’s open and closed to send NHSN? So they, a way long time ago, had built
in a field that said, in the OR record, that said this is an incision
that has a primary closure. And they educated them. When the definition changed they said okay, new definition of primary closure,
and they educated the staff. I’ve also spoken to hospitals that
said we can’t open up every record. We don’t have the person power to do that. So we have started looking at the ones we — we have a flag of like — we
look at every Class 3 and 4. I mean, one Class 3 and 4. Because they’re the ones
that were probably left open. And we try to pull out the
ones that left open that way. And then, honestly, there were other
people that said well, here’s what we do. We send all our COLOs over. We send all our HYSTs over to you. And then, if during the surveillance
period we find an SSI and it was — we were like, oh, wait. They didn’t close this one. We pull that out then and
we don’t attribute that SSI. Was that meeting the definition? Not really but it was the method they were
using because you had to have something in place to decide what you were sending us in 2013. So that’s what we mean by the workaround. What were you doing in ’13? And use that same method to
fill in those two fields. So if, in fact, in 2013, you don’t think
there were a lot of people doing this. But if you were sending all your COLOs and
only pulling them out, the denominator, when you found an SSI attributive of one and
not sending us the SSI and not sending us that procedure, what you would be doing in 2014, if you’re doing that same
thing, that’s all you can do. You’re not going to pull that denominator
out when you find that open procedure. You’re going to pull that record
out and change that record, because you’ve now discovered that’s a
record where that was an open procedure. Okay? So what we’d like you doing in 2014,
the fields are there, is working on a method that you will be able to more easily capture
the closure method for your operative procedures because people have been — they’re surprised. I’m like I tried to send my January procedures
and they’re saying they’re incomplete because I don’t have incisional
closure method on there, okay? So. All right. Let’s do a case. Get your little clickers ready. So a patient is admitted
with a ruptured diverticulum and a COLO procedure is performed
in the In-patient OR. The case is entered as a Wound Class III. They obtained a specimen in the OR
which returns positive for E. coli. The surgeon staples closed the incision at
four locations with packing placed in-between. Is this procedure primarily closed for 2014? Let’s get your voting started. Well, you guys are fast on this. And I’m going to give you 10 more seconds. You’ll all get this right after
that lovely graphic of my son’s. Yes, 90% of you said yes. It was closed to the skin at four
locations and packed in-between. The rationale, the skin was
closed at some point. Okay, what I should have said or I’m just
going to say something as I’m saying that. We’re going to assume in my
presentations that they closed the fascia. I didn’t — and every single case something — did I remember to say closed
at all tissue levels? But, anyway. So fascia was closed in that case and
the skin was closed at four points. Thus, and this is straight
out of the definition, “If any portion of incision is closed
at the level of the skin by any manner, a designation of a primary closure
should apply to that surgery.” If you are reporting COLOs in
your monthly reporting plan, should this case be entered
into your denominator data? So start your voting. Get your little clickers out. I can give you 10 seconds. Very good. Yes, because this was a [inaudible]. Excellent. You guys are sharp. The real — oh, I thought I
had a rationale in that case. Well, I guess I didn’t. So the rationale in that is that, remember, in your denominator data you are
putting in open and closed procedures. So this is the next one. A patient is admitted with an acute abdomen. They’re taken to the OR for an appendectomy
for a suspected ruptured appendix. Wound Class is III. The surgeon does not close the incision, leaves it open with a wound vac
to heal by secondary intention. Is this procedure primarily closed for 2014? Set your clickers. Yes, no? All right, 10 seconds. Correct. It was left completely
open with a wound vac. Kind of like that picture I showed. It wouldn’t have been quite that
big an incision for an appy. It would have been a bad
appy if it looked like that. This incision was left completely open. A non-primary closure is defined as
a closure that is other than primary and includes surgeries where the superficial
layers are left completely open during the original surgery so they can’t be
classified as a primary closure. So if you’re filing appy in your monthly
reporting plan should this procedure be in your denominator data? Yes. No, it was a contaminated case. Let’s see if everyone’s got this. All right, 10 seconds. Oh, good. This one I was a little nervous. Yes. And this was in some ways — it drove
a little bit our decision to like we want to just — you tell us all your COLOs
that are happening in your inpatient OR because I cannot — there were a
lot, a lot of times that I heard, “Well, we don’t send in NHSN our COLOs
where it was like contaminated. We don’t send — I think we’re not supposed to
send any just in Wound Class III’s and IV’s.” And I’m like where is that in the definition? There’s no — it never said you have
to have such and such wound class to be an NHSN operative procedure. It was never driven by wound class. And neither was the reporting of an SSI
ever driven by, oh, don’t send us your SSIs if it was a Wound Class III or IV, because
that’s what the SIRS are taking in. Not so much the one that goes to CMS but ours. If you look at that for COLO and HYST your wound
class is definitely taken into account on both of those so that is — I
just want to clear up that — it’s really cleared up this year
because we’re saying send them all. But, you know, in the past we’ve
really heard people were holding back. And then how can you say we have a
level playing field when we’re looking at our data in terms of comparative data? So, good job on that. Wound class — I keep telling you
my rationale before I go to it — is not a part of the NHSN
Operative Procedure definition, and a high wound class is not an exclusion
for reporting in your denominator data. All procedures that meet the NHSN definition
of an operative procedure should be reported if they’re part of your facility’s
reporting plan. So let’s take the same case,
so if you have to look back, and that patient was now
readmitted two weeks later. That person who had the ruptured appendix and
had the open, the other than primary closure and a wound vac place, are
readmitted two weeks later. They were in for a week. So it’s now it’s about post-op day 21. They have a fever, acute abdominal pain, and
CT evidence of two intra-abdominal abscesses. And they do a CT-guided drainage
of 100 cc’s of purulent drainage. The drainage is culture positive
for E coli and B frage and the patient meets criteria
for a GI IAB organ/space SSI. Because this was a contaminated case this
infection should not be reported to NHSN as attributable to the appy procedure. Is that true or false? All right. The voting is open. You guys are nice and fast. That break must have given you caffeine. I heard that you all drank 60
gallons of coffee yesterday. Had anybody told you that [laughter]? You didn’t hear that. I was just — I was somewhat of
a contributor to that, but, wow. I sort of did the math. I’m like, is that half a gallon a
person if there’s 300 people here? It just shows how much coffee we have to drink
to do our jobs and get through this much. All right, so. Very good. False. I had sort of told you that. But this really, I think, I don’t know if
how many of you — I saw some head nodding. I think this has been happening
in the past, you know. People just thought, yeah, I
don’t have to tell them that. It was a contaminated procedure
and they got an SSI but, you know, NHSN doesn’t want to know that. And that, that was sort of some
urban myth that occurred we think. So as of 2014 incisional
closure is no longer a part — am I beating you over the head with this? — is no longer a part of the NHSN
Operative Procedure definition. So all otherwise eligible procedures
are included, and this is a biggy, any subsequent infections that
meet criteria should be reported and linked to that open procedure. Again, it won’t be used in certain analysis
and it show up in your analysis for a while because this is our baseline year and then, as
I think, Maggie has said, we’re going to be able to — we’re looking at stuff that’s
based on 2006 through 2008 procedures. So they’re a little bit apple and
oranges at this point with the changes. But what’s beautiful is once we’ve all
stabilized and we re-baseline, it will be all, it will be, I think, some
really good comparable data. So, this is new duration of operative procedure. You can probably guess why we had to have
a new duration of an operative procedure because what was our old duration
was incision start, incision stop. Well, we’ve just removed incision as necessary. These procedures are not necessarily closed. So we had to have a new definition
for your duration time. You don’t have to put in the procedure
start time in the application. You never have. You have to figure it out in your head. And how many times have I counted
on my fingers 1, 10, doing — you have to figure out how many
hours long the procedure was. But the procedure start time is
when the procedure has begun. Now for a patient that’s going in
and having an incision it’s beginning when they make the incision. They’ve begun that procedure. But if it’s someone who arrives with an open
wound, and maybe it was just closed to the level of the fascia, it’s when they
start and cut into the fascia or start the closure of that procedure. So, again, it’s the procedure start time. And the procedure finish
time is — this was all taken from the American Association
of Clinical Anesthesia. Clinical directives is right out of
their guidelines, all these times. And they’re ones that AORN,
when we were looking at this, very much assured us is a
— so you can blame AORN. They assured us that this is a very common
time that is captured in most OR records. Sometimes it might be called Procedure Stop
Time; it might be called Procedure Finish Time. You might have a different word
for it but if you work with your — which you’ve probably already
started doing that — your OR liaisons to capture the time
that most closely reflects this. The most common question I’ve been getting
is, does this match anesthesia stop time? And the answer is no, because anesthesia stop
time, when we did some investigating and looked at the definition — if you have a really
complicated case, some of your cardiac cases and others, they don’t have
an anesthesia stop time. You see them in the elevators. They’re bagging the patient
all the way up to the ICU. That anesthesia stop time doesn’t finish
until they sign off on that patient who goes from the OR to the ICU directly. You’d have these extreme extended stop times. So it isn’t the same as your
anesthesia stop time. Now we did not give a work-around
for height and weight. I’ve never seen — I mean every OR — I
mean every hospital I’ve ever worked for, they wanted to know the patient’s
height and weight. It’s also often needed to
use for dosing of patients. You have to know their BMI;
you have to know their weight for dosing of different medications. The height has to be entered
in feet and inches or meters. Either one that you enter it will transpose
and fill in the other one automatically. We have a little glitch that
they’re fixing right now. What we wanted to do is to automatically
— if you put in 68 inches it will be happy and it will convert it to five
feet eight inches for example. But sometimes that doesn’t work. So if you get an error message
just try in your head to switch it. We’re working on fixing it. It’s been reported. But just put it in as feet and inches. And there was a little problem
with meters for a bit. I mean this was a new field that if you
put in an odd number for a meter like 1.63 which would be the equivalent
— I’m making this up. I don’t know. It’s a half an inch of something, you
know, like that’s five foot 10-1/2. Those odd numbers for some reason
were giving you an error report. Again, if you enter your meters and you get a
little error, try bumping it up an even number. But we’re working on fixing that as we speak. So, hopefully, we’ll step getting
these error messages with the height. The weight is the most recent record — weight
recorded in the medical record in pounds or kilograms and it then converts
and does the other one for you or otherwise closest to the procedure. We, you know, if they didn’t — the last
one they got was at the pre-op check. That used that. We didn’t mean you had to like absolutely
put the patient on the scale before or after. We’re not being ridiculously
picky about the weight so that’s what we’re saying the most
recent or closest to the procedure that you can find in the medical record. So, and I don’t know if Dawn will be upset
that I’m saying this because we really, really don’t think this should be happening. But there have been a couple of cases where
a patient arrives, has never been seen at that facility ever, ever, ever, has a
procedure done and then maybe, I don’t know, they sign out AMA or something and
there is literally is not a height and weight on that patient. There’s no other medical record to look at. They didn’t capture anything in the OR. And you can’t send that record over. You’ll keep getting an error message
because something has to be in that field. You guys have to promise me you won’t abuse
this because it should be extremely rare that this would occur because you have
access to the entire medical record. And if they didn’t capture it at
that sting I want you to look back when they were there before for something
and try to find the height and weight. I want you to look in the OR. I want you to look at all available records to
find this because this is an important field. This is what’s going to give us
when we readjust, think about this. this is what’s going to give us our obesity. Think of the risk factor
for obesity with our SSIs. But it will give you an error message and if you absolutely can’t find it
you have to put in like one pound. And if you have to put, or you have
to put that they are one foot tall, and that will tell the Maggie folks that
this was not available and the problem for you all it’s just not going to
show up in your risk adjusted data. So work hard with your IT Departments. Work hard with your nursing staff. This we never expected we’d need any
kind of workaround and we didn’t give it to get these fields available for you all. And just let people know what good data
it’s going to give us in the future for risk of SSIs based on obesity. Diabetes — so this is also a new field. It isn’t new because those of you — how
many of you have been reporting C-sections? Yeah, probably the Pennsylvania
folks [laughter]. Those Pennsylvania folks, yeah. So, okay, so again, don’t
shoot the messenger here. This — remember the HICPAC Working
Group I was telling you about. This was the very, very last
field that everyone argued over. I mean, really, it was — this was a
toughie for the HICPAC Working Group. And this is the definition that they
came up with and it is based on treatment that a patient is actually receiving
treatment for their diabetes, not just they’re controlling
it by diet alone, okay? So the definition. It would exclude a person,
though, who receives just a — especially cardiac procedures and
a lot of different skip measures. You have to control their glucose
right around the time of the OR. So you might see a patient who got a dose
or two to control some hyper or hypoglycemia around the time of their OR procedure. We’re not talking about that. These are people that are
being treated with this. So we’ve had some issues with people saying,
you know, I don’t have a way to find this and we don’t — many people
have found ways to find it but at this point we did develop a
diabetes workaround for you for 2014. Again, the field is there. It already had been built in the application. If at this time you don’t have an
ability to capture this field just send over all your procedures
that will default to No. That they’re not diabetic, okay? So we did offer a workaround. It’s a very easy workaround. Now in yellow you’ll see what
I put here at the bottom. We have gotten a lot of feedback from our
users that they would like this to be based on an ICD-9 or what will be
ICD-10 diagnosis code of diabetes. And I think probably, I would
guess a lot of you may be doing that already even though we didn’t — because then everyone was asking
me, “Where’s my code list? Tell me my list.” I said, “We didn’t make a list because
we didn’t make this code based. But we’ve heard your concerns and we
are actively in discussion about this.” And it’s the time to do it because right now — well ICD-9s go away in October 1st
so we’re going to be needing to look at what the ICD-10 codes look like. And they may be very well suited to this but
at this point it is not a code-based system. Now the rationale isn’t — you
know, I’ve been trying for all these to give you the rationale behind why we ask for
this which does have an added burden, you know. I know that as years of being an IP. But, obviously, the diabetes and obesity which
will be determined, and I’ll show you this. What’s really neat because someone said to
me, “Well, you know, BMI’s what’s important. You should be determining the BMI.” Well, the person hadn’t gone into
the application yet because as soon as you do you see — and it was
new; they didn’t know it yet. As soon as you put it the height and the
weight, boom, the BMI automatically fills in. So I can pretend I’m a patient and check my
BMI, you know, as I’m trying to lose weight. Oh, let me see if I’ve lost. Is my BMI any better? I can just go into our application
and figure it out myself. So, anyway, so that was to capture our obesity. And it automatically calculates the BMI for you and it will give us much better
risk-adjusted data in the future. And probably, you know, again, we’re
re-baselining everything in 2015 when things have stabilized and
so urinalysis, you know, at the — the analysis that you do for risk
factors should be available after that. Now that’s all. That covered all the big changes. Our definition of an NHSN inpatient
did not change, or an outpatient. If they are a inpatient it means
that their day of admission, their day of discharge, are
two different calendar days. If they are an outpatient it
means their day of admission and their day of discharge is the same day. And so what I will say, and
that’s the same day, you know. So the way I’m going to — what I do want
to address for this is that I get a lot of questions, and again, it’s that definition — NHSN definitions don’t go by people’s
billing code definitions, okay? It’s just a whole different definition. And CMS bases their definition
of like you are supposed to be sending your inpatient procedures
to us based on our definition. So if you have an acute care OR, it’s your main OR where you have inpatients
having their hysterectomies and you have outpatients having their
hysterectomies if it isn’t being happening in an outpatient surgery center,
and you have hysterectomy cases that they send home the exact same day. They come in at 8:00, they have their
hysterectomy in your OR at 10:00, and they’re home at 7:00 that night, that
should not go into your denominator data. It was done in your OR but it does not meet
our definition of an inpatient HYST procedure. But if they come into your inpatient acute
care OR and they come in one day and spend and leave the next calendar day, that is
considered an inpatient HYST procedure. Whether for some billing purposes that was
called a outpatient or a observation patient, you know, whatever, it still meets
our definition of an inpatient. Operating room hasn’t changed one bit. I’m not going to linger. This is a long presentation but these are
— most of your C-section rooms, hopefully, are coded as meet the standards
for an operating room. Many, many cardiac cath labs will meet and
that’s where you’ll see maybe an inpatient that gets sent to cardiac cath
lab to have a pacer insertion and pacemakers are an NHSN operative procedure. A little reminder that when
you do make a decision to follow a procedure category
you’re following all of the NHSN procedure ICD-9
Codes that fall in that category. You can’t say, “Well, I’m just
going to follow 6831s and 6839s.” You need to follow that whole grouping
that meets our definition based on ICD-9 CM Codes of abdominal hysterectomy. So this would be a — shows for [inaudible]. Okay, I’m going to show you,
even though I have a little, what I call my errata slide
at the end with our errors. And this will also be in the NHSN application. There’s a reporting instruction
which we’re going to get to. But I want to show it to you here. There’s a reporting instruction
that we now are reporting all APPYs. We don’t want you to look up every appy in
Delvin [assumed spelling] and see did they do — was it incidental or did they just do this? Was it a rupture? It’s just an added burden. If comes across coded as an appy, send it to us in your denominator data as
an appy if you follow those. There is a parentheses in
this Table I currently, if you look at it, that says, “Not incidental.” We didn’t realize it was in there. You know, we put the reporting instruction
in but it says, and that that is not — should be — just cross that off. It should just say that we — it shouldn’t say, “Not incidental APPYs,” because
we changed that in 2014. We’ll get to that. That’s table one. So, we’re going to move on now to how to
complete a denominator for procedure form. Now for many of you, this is,
you know, this is old hat. You — collection period is a month. You complete a denominator for procedure form for every operative procedure meeting
the NHSN operative procedure definition that was done during that period
in your monthly reporting plan. And you try to get that data submitted within
a month of the end of the reporting period. For example, if your monthly
reporting plan indicates that you monitor COLO [phonic] procedures in
January and 43 COLOs were done that month, then you should enter 43 separate COLO
procedures into NHSN by the end of February. You don’t want to — do not want to wait. We get panic calls to the end — or the day
before like, CMS submission deadline for this because you’re going to have, you know,
a real problem on your hands if you — it takes a while to enter that many. And so, you want to make sure you
get them in, in a timely manner. And Maggie is going to take the last
half hour, like after lunch of the — the two hours we have and
she’s going to be addressing — because you’re going to see what — when’s
she going to talk about how to import data for using like, CSV files or CDA — so
Maggie’s handling that portion of it, which — so that’ll — we’ll end with giving
you details on importing procedures. So the first part, as it is for all of ours, is
that you have your basic patient information. Anything with an asterisk is a required field, your patient ID, your gender,
your date of birth. Now remember with patient ID,
you want to use the ID that lives with the patient admission to admission. Many facilities you get the — the patient
ID number and then you might have a — what you call an encounter number or a — it
really links it to that particular admission, but use the one that lives admission
to admission or you’ll have problems with being able to have your information like. You know, because the procedure — you — you just have to use that
permanent number as your patient ID. And then again, your NHSN procedure — your date of your procedure and your NHSN
operative procedure code and that complete list of the — of the NHSN operative
procedure codes is, you know, obviously found in the SSI
section of the manual. And when we say, “with code”
that means not the ICD9 code, this is like — this is a COLO, this is a hiss. That’s the code number that has to go in there. The ICD9 is — see that next to it — we
don’t require the ICD9 code to be entered. Some of you may be choosing that,
but it’s not a required field. So if you do enter an ICD9 CM code first, the
NHSN will automatically auto fill and know that that code, like for instance, is
an abdominal aortic aneurism repair, and so it auto fills it for
you if you’re doing that. Then you get into the next
section on a denominator form, which is your actual procedure details. So first of all, you know what the definition of
an inpatient or outpatient is, we just did it. You’ll note that on every form, that’s required. So for most of you [inaudible] —
some of you may be following some of your outpatient surgery centers. Most of the time, you all will be
entering that this was not an outpatient. You’re going to use your new
duration, it’s — this didn’t change. The field is still just a duration field, but you’re going to use your new procedure
start time, procedure finish time definitions. Now in Chapter Nine, which is the SSI
protocol, still sometimes say chapters, but it is Chapter Nine if you print it out. It is — there are a lot of
reporting instructions and I — we’ve reformatted and I hope
people found it helpful. We reformatted the SSI section and kind of,
it flows I think a little more easily read and we have, you know, a whole section
that is a little extra helpful. You can almost think of them as FAQ’s
reporting instructions for your denominator data for this — when you’re entering in
procedures and you have like a question, if you’re not sure what you’re supposed to do. Look there because a lot of times
when I’m answering questions, I’m — I say to people, “Oh, that’s in your
denominator reporting instruction. Here it is.” And I’ll cut and paste it, that’s reporting
instruction number four or something. So get familiar with those. And every year, we sometimes add a new
one that we realize might be helpful that people have been asking
a lot of questions about. It’s just kind of like the extra
stuff around denominator reporting. And then, we also have the same
thing for when you’re thinking about your numerator, your
surgical site infection. We have a lot of details on
reporting instructions for that too. So here’s the only two real– the big denominator reporting instructions
was again, the incidental APPYs. We use to say we only want an — we don’t
want any incidentals, we just want your like, APPYs that had to do with like a real —
like maybe appendicitis case and we just — the burden was just — especially with
so many people running off of line list, of here’s these operative procedures
that happened, here’s the APPYs. For them to open up every one and determine,
you know, should it, shouldn’t it — it just didn’t really make sense. And then for XLAPs it was the same thing. We had a reporting instruction that
if a person had an XLAP that — then led to any other NHSN operative
procedure being done in that area — like we open you up, what’s going on in there. That’s what XLAP is for, you know? And then they did something
else, you weren’t supposed to know, so you tell us they had an XLAP. Even though your coders may have definitely
coded an XLAP, again it would make you have to almost look up every XLAP and
see if something else happened. Now that being said, someone did point
out and I confirmed it, there is — there are coding rules — I am
absolutely not a coding expert. And your coders you hope are the subject matter
experts for your — for — as your coders. There is when you — when you all go out and
get your ICD10 books, don’t waste money on ICD9 at this point — there is — well, there was at
least in ICD9 a reporting instruction that said, “If they do an XLAP and it leaves to them
going in and doing surgery on the colon area, don’t report — don’t put an XLAP in.” Well, that was a coding rule, you know? It wasn’t, you know, an NHSN rule or anything. So hopefully your coders — those aren’t
coming across anyway, but in that — so I just want to let you know
that at this point if you’re coders and if you’re basing your coding off of
line lists that either come from your OR and they said they did an XLAP
or that comes from your coders — go ahead and just report it as an XLAP. Some operative procedures
have more than one incision. For example CABG, some CEA’s,
fusions, refusions, PVBY — they can have more than one incision. So an example would be a CABG, they might
have an incision on the donor vessels made for the leg and then they
also have the chest incision. And like a fusion with an
anterior and a posterior report. You complete one denominator for procedure. You’re not putting in two denominators — one for the leg part of the
CABG and one for the CABG. That’s one operative procedure with
a duration time being from the start to the procedure to the procedure finish time. But if procedures and more than one
NHSN operative procedure category done through the same incision and I
get asked — asked this a lot — during the same trip to the OR, you want
to then create a record for each procedure that you are monitoring in
your monthly reporting plan and use the total duration for the whole thing. Okay? So, I’m going to give you two examples. You could have a person that
had an — absolutely had — they were planning to do a CABG and
they were planning to do a card. They knew they were going to do a CABG and they
were going to replace a valve at the same time. Okay? It’s going to make that
a little longer procedure, yes. If you are from a hospital that’s following
cards and following CABG’s, you are going to put down the entire time that
that took on each of those. So your card is going to say that this was
a five-hour procedure and your CABG is going to say that this was a five-hour procedure. All right, so you’re going
to have both of those. The other question that I got — I’m giving you
all my little thinking of these things I get — is I had someone the other
day asked and said a person — they went in and they were
planning to do a HYST, but when they got in there they realized
they had to do a COLO procedure as well. You know, so it was like, surprise. So, am I supposed to put that COLO in because
they didn’t think they were going to do a COLO? I’m like, “Yeah, you absolutely
— if that COLO is coded and [inaudible] came across,
you want to put that COLO in.” It was a surprise, but you do put in the COLO. Because the thing is, they weren’t —
you know — it was something like, “Well, what if I wasn’t following HYST in my
plan, do I — but I am following COLO?” I was like, “Yup, the COLO
goes in your denominator data.” This is an exception here and we have had
this happen, where they send a patient down and for some reason, they don’t — the coding
— they were sending them down to have a CBGC, remember that’s when just a chest. Usually it’s when they’re doing
internal mammary, so you were going to — they thought the patient was just
going to come out with a chest incision and that got coded somehow, probably based
on how it was entered into the OR data. During the procedure they realized they
were going to need to use a leg vein and so, they actually did a CBGB on the patient
because they harvested a leg vein. So a CBGC — it really became, you
know, also a CBGB and when that happens, you don’t send it over, obviously
as two procedures. You just send it over as the CBGB
because that tells you there’s the chest and the leg incision. Okay? So basically, and that happens sometimes. So this is our 24-hour rule I sometimes call it. So if a patient goes to the OR more than once
during the same admission and another procedure of the same or different NHSN
operative procedure categories perform through the same incision within 24 hours
of the end of the original procedure, you only report one denominator for
procedure form, for the original procedure. Okay, so we have an example for you here
and then you’re going to combine the — at the time from the second onto the first. So a patient has a COLO and it
was performed on Tuesday morning, and it had duration of three
hours and 10 minutes. Tuesday evening the patient returns to
the OR where the COLO incision was opened to repair a bleeding vessel — that’s an
OTH other — I just happened to know that. The duration of the second procedure
was one hour and 10 minutes. You only report the COLO with a combined
now of four hours and 20 minutes. That OTH other procedure is not
going to be in your denominator data. And the concept here is that that second
procedure is really only being done because that original procedure
usually has some sort of complication that needed immediate attention and
so it’s almost treated as an extension of the original one where they’re
so close together in time like that. If that same thing happened
and it’s beyond 24-hour period, you’re going to still have a COLO
procedure in your denominator data and if you follow the OTH category you’d
have an OTH in your denominator data that — that represented that repair
of a bleeding vessel. Now this — we’re going to clean up the
language around this because I kind — I haven’t had a lot, but a couple questions. If you look in the NH — the SSI
protocol, under our definition of a primary and nonprimary closure, there
is this little note here. Where’d my mouse go, come on
[inaudible], where’d it go? Anyway, and it — this note
reflects what to do when you — this note completely reflects what — how
you’re supposed to sign the incisional closure when someone goes right back
to the OR within 24 hours. What — like if they went to the OR and
they left the incision open due to swelling, and then they return to the OR eight —
18 hours later to close that incision, so that second procedures not even
going to be in your denominator data. We want assigning the incisional
closure type for the one that is in our denominator data, that first procedure. Okay? So that’s what this
instruction was applying to. Okay? Let’s try a case now and
see if we can apply some of these. So a patient has a COLO and a HYST through a
single incision during a single trip to the OR and both of these procedures are in your
monthly reporting plan, which would be true for a lot of us here who do COLO and HYST. The incision is at — starts at 8:23
and the procedure finish time is 11:33. They did note in the OR record that
the HYST part of the procedure — because they’ll sometimes, you’ll see
that of when they transfer the team and you now have a different
team doing the HYST part of it. You may have a different team, depending
on the expertise — began at 10:00. Which statement is true? Only the COLO should be reported because it’s
really higher on our priority list of risk of infection, which we’re going to be getting
to, but it’s something you are very familiar with — that list, which on has the
highest risk of developing an SSI. COLO is higher than HYST. Number two — two separate procedures should of
reported a COLO with a duration time of one hour and 37 minutes and a HYST with a duration
time of one hour and 33, or two separate — also two separate procedures should be
reported — one for COLO and one for HYST, but each should have a duration
time of three hours and 10 minutes. Which — which do you think is true? One, two or three? Votes are coming in. All right, 10 more seconds. Very good. It’s two. Remember, you don’t split the time
when you have two procedures like that doing between this — number three
is a correct answer. It’s going to be two separate procedures,
but each will have the entire duration. We’ll be getting to a couple examples of when do you ever split the
duration of an operative procedure. We’ll be getting to that. And I’m not going to — that’s just
basically the — this is your actual — I cut this from our denominator
for reporting instructions. This is in there as a very specific
example telling you what to do. Because of bleeding during surgery, a
drain was placed in that abdominal incision and the incision was in loosely closed. Does this incision meet criteria
for a primary closure in 2014? One yes, or two no. Just to give me a little more information
about that incision where they did two things, they had to leave in a drain
and loosely close it. All right? 10 seconds, people are voting very fast. I make this too easy. All right. Yes, that is a primary closed wound
because it closed at any tissue level and wick strains coming out are allowed. You can have wicks and drains and some packing, as long as it’s closed at
some level at the skin. Now we’re going to get into a little
bit about bilateral procedure. So procedures that are for bilaterally
— we’re not talking about two procedures and one incision, but where you have
kind of a left and a right side. For example, your kpros is
a perfect example of that. Some hips I’m even even seeing being
done at the same time as bilaterals. In those cases, you actually
do do two separate denominator for procedure forms are completed
for a bilateral hip. So, to document the duration of the procedure, you’re going to indicate the procedure
start time to the procedure finish time for each distinct procedure
separately if they told you that or ultimately take the total time and divide it. Now some people, they really very
clearly note in the opnote — we finish this and now we’re
moving onto the next knee. And then you could really know in
case one knee was more complicated, but a lot of times what you really have — and
in terms of burden as well, you have one time. Like we did a bilateral knees
and it took us four hours. So then you’re going to just split it in
half and give each knee a two-hour procedure. So let’s do a case [inaudible]. So case four, a patient has a
bilateral knee prosthesis — a kpro — implanted during a single trip to the OR. The left kpro procedure start time
was at 8:30 a.m. and there was no note of a procedure finish time for this knee. Then they did a right kpro and the
procedure finish time for that was at 11:30 a.m. Which statement is correct? One kpro procedure should be reported
with a combined duration of three hours. Two separate kpro procedures should be reported,
each with a duration of one hour and 30 minutes or two separate kpros should be entered and each should have a duration
of three hours and zero minutes. Which one is true, is correct? And — you guys are voting really fast. You’re ready to go to lunch, aren’t you? Watching that clock there. All right, 10 seconds because
you’re — so many — And that is correct. This was a bilateral. Number two — you’re going to take that and
split the time since they didn’t note it. Bilateral procedures you split the time
if they didn’t note it between the two. Another common one if you think about that, if they do a bilateral breast procedures
is the other one that jumps to mind — the hips, knees and breasts are the
most common where you would apply this. So I want to let you know that there’s new
and updated reporting instructions for use — again, in page 915 is where you’re
going to find your actual SSI. Nine means it’s Chapter Nine — 9-15 is where you’ll find your actual event
reporting instructions for when you — if you have a question about
how to report infections, there’s additional reporting instructions. And your denominator reporting instructions
start on page 19 of your SSI protocol. Now let’s go next to your
denominator for reporting, see if we can get through
denominator before the lunch break. This is just again, your wound class is
going to go in next, it’s a required field. We removed unknown as a choice, so if it comes
across as unknown, you’re going to want to talk to the team, educate them, hopefully
get them to enter one because if — it’s going to come across as an incomplete
record, so you’re going to have to get that data and educate your — I — it
should be extremely rare, wound class is very important
part of an operative procedure. And we get a lot of questions
and — about wound class. Can you please tell me what
this wound class should be? Tell me if I should call
this the IP [inaudible]. What should I call this wound class? What should I call that? We have really stopped giving wound class
recommendations, that’s not our role in NHSN. It should be applied by someone who is the
field and involved in that specific case. So there — we’re going to
talk a little bit about — more about this, but you’ll note here at
the bottom of this one, clean wound class. There are a set of procedures and they’re right
there — APPYs, billys, procedures [inaudible], COLOs, rectal, small bowel and vaginal HYST. You will never be able to enter those when you’re entering your
denominator data as a clean procedure. That’s really the only time at this
point that we really want an IP, we’ll have to maybe put in something different. If you’re still having problems with your
OR, calling any of these clean procedures — you’re not going to be able to
because clean is not an option on your dropdown menu in the application. It just starts as a clean contaminate it,
so that’s where you’ll work again with your OR liaisons, your OR education
team to make sure that they know — this group based on really
outside expertise and experts in this said these should
never, ever be called clean. Aside from that, they’re —
we really have removed any — the sense of saying that we’re going to tell
you this has to be clean contaminated, whatever. So, that’s, you know, why we don’t
like to assign wound classes. In last year under wound class, we had
had an asterisk next to the work “genital” and that asterisk had said that that actually —
the word genital should — this was last year — should — and you’ll see if you look back — what also means the male and
female reproduction tracts, which are quite different
than your genital tract. And that was something NHSN had put in —
that was our own thing we put in last year and we realized we aren’t happy with it. We took it out, it is in part — we really have
the wound class exactly how it’s written now by the — the group that developed these. We didn’t develop wound classes, so we removed
that because that would imply that an ovary is, you know, is always a contaminated
class and that’s just not true or a procedure on the testes is contaminated. Well, that is not true and we
got a lot of pushback about that. And then you’ve got your contaminated,
dirty infected — these did not change. They’re cut exactly from the guidelines. I went over this, but these are the procedures
that can never be coded as a clean wound class. So based on this, you really could have a
clean c-section, it’s not your genital tract. It connects to, but we got
a lot of questions like, “We have a lot of really planned
elective non-ruptured c-section patients.” I mean, they’re kind of clean as a
whistle when they go in, they — you know. Do I have to call that clean contaminated?” And we have historic — there has
been historically that we have — that’s been said yes, but we now have a
saying, “You know, you can have c-sections that are elective, plan, no ruptured, no
connection to the — to the genital tract there, you know, that would — could meet criteria.” So again, what we’re really putting
it to is it really needs to based on the findings of that particular case. We’re not involved there. We don’t know what happened in that OR
and let them assign the wound class. And if you feel like there’s some really
gross errors going on, then you need to work with your liaisons and your OR to correct those. General anesthesia hasn’t — hasn’t
changed at all — our definition there. I’m going to breeze by the things that have
been the same for years, so for timing, but it’s all here if you need it. ASA score, again, they’re — I think
a while ago, but we took it out. There was an unknown, we have no more unknown
— you’re going to need to know the ASA score and this is set by the American Society of Anesthesiologist classifications
and we updated ours a little. There had been one update, so I mean,
it’s very subtle, but the ASA scores that are written in the manual are up to date. This was the new wording, it was a little
different — tweaked nothing substantive, but there is an ASA score of six that
you guys might find in your records. How many of you have ever
seen a six come across? Go have a seat. Yeah, I’ve got about 10 hands up. What six is, is the ASA score
that’s usually assigned on a brain dead patient when
they’re harvesting organs. And so, we do not want those —
you don’t want a — you’re — those procedures are not going
to go into your denominator data. A procedure done on a brain dead ASA six
patient shouldn’t go in your denominator data because if you think about it — there’s absolutely zero risk that
patient’s going to get an SSI. I mean, that — bluntly put
that’s true, you know, so. Okay, emergency procedure — select if
the emergency — and these again, all — a lot of these things you’re seeing pasted
here, I’ve — from the table of instructions. So if you forget this, look at your table of
instructions for your denominator procedure. So an emergency means that
they really did not allow for your standard immediate pre-op
preparation that you do on those cases. What’s your normal pre-op prep
that should be done for a patient with that procedure that’s being done? They couldn’t get their vital signs stable or they couldn’t do the correct antiseptic
skin prep or for colon procedures, they were not able to even do a colon prep. That’s an emergency procedure. If they were there long enough that
they got everything done perfectly, well that probably won’t get
coded as an emergency procedure because you know how long a
bowel prep takes, you now? It takes while. So, now trauma it seems like it shouldn’t
be a difficult field to fill out, but I do get questions about this. Trauma — yes, no. They said, “Well, what kind of trauma? How long ago?” And like, someone had trauma in their knee a
year ago and now they’re back and we’re fixing that trauma, you know, we’re tweaking it a bit. I’m like, “No, no, no. We mean the patient who is on the table right
then has sustained a trauma that you are in an immediate nature needing to repair.” So a patient who has a fall and
breaks her hip, blunt trauma — that’s blunt, I get that one a lot — has a broken hip, now needs
an Hpro procedure to be done. That is considered that was due to a trauma. Now they might not have gotten that patient
to the OR the day the trauma happened, but that is being done due to
a fractured hip that occurred. It — you know, but not one that occurred
a year ago, and now has to have a revision, so hopefully that’ll help with that. Scope — this is if the entire NHSN
procedure was performed using a laparoscopic or robotic assist. And so, that’s when you say scope
yes as one of the risk factors. No if the extended — if it
was extended for hands assist, there are some huge extensions they do now
and they take lab [inaudible] and they open it up like to three inches long and put in
these wound protectors and hand assist — so you have the surgeon actually
putting their hand completely into the colon and pulling things out. Well, that’s — now that would
be a scope no because you have like a three inch — you
actually have an incision. It’s not — no longer just
a laparoscopic procedure. If a scope was used for an entire HYST or
VAG HYST, but they then just remove the — the uterus through the vagina,
that’s still a scope procedure. You know, the fact that they
had to actually remove it — it’s not — make it not a scope procedure. The diabetes field — we
went over that definition and you were given the workaround for that. So that’s the diabetes — it’s now new,
it’s just that before it was only there for c-section patients and now
it’s for all procedures that are in your denominator reporting plan. Height, weight we covered — just to remind you, these are all these new wonderful
risk factors we’ll be able to have risk adjustment for very soon. And this is a picture of what it looks like or
if you haven’t actually visually seen it yet, you can see how the height is in. It automatically figured out the meters. The weight is in, it automatically
fills in kilograms or pounds, depending what you put in it. And there’s that wonderful little
BMI that it calculates for you. Closure technique — I’d already
shown you a picture of that. It’s going to either say primary or
other than primary on your dropdown. And if you’re — if you tend to fill out
a form and then hand it off for someone, this is what it’s going to look like. We already discussed that definition. Surgeon code — this is not a mandatory field. It’s certainly helpful and I highly recommend it so you can give surgeon specific
information back. So that’s where you can use that,
still not asterisk, not required, but a question I get a lot
particularly for reconstructive cases or breast procedures if you follow those. They’ll have a team, a primary physician
who does the, like bilateral mastectomies and then a plastic surgeon who
comes in and does the implants. So you have a team and they said,
“Who should we attribute this SSI to?” Well, this is not a required field of ours and
we don’t really dictate how you want to do that, but we say, “It’s usually the person who’s
primary in the case or who has the most — the longest part or more complex part
of the procedure, but if you have a team that works a lot together, you can
just set up a surgeon code team.” So your code that says 300,
well that’s Dr. X and Dr. Y who always do these two cases together. And then you’re not pointing your
finger at any particular surgeon. Now, I’m going to stop. This is a perfect place to stop.

TB and HIV | Infectious diseases | NCLEX-RN | Khan Academy

TB and HIV | Infectious diseases | NCLEX-RN | Khan Academy


Charles: This is Charles Prober. Morgan: And this is Morgan Theis. Charles: And now we’re going
to talk about the interaction between tuberculosis and HIV,
human immunodeficiency virus. We’re going to talk about this because the two actually
commonly occur together in different parts of the world, and one infection makes the
other one typically worse. Together, they create what one
might refer to as a “perfect storm.” The stick figures which you’ve drawn
show nine individuals on a top line, one of whom is colored
in a different color. This is meant to depict the roughly
nine million people each year who are infected with tuberculosis, one of whom, or about 13%,
is co-infected with HIV. That’s a very large
portion of the population for which this is a problem. It represents over 1 million people. The stick figures beneath are meant to
depict death caused by tuberculosis. There are three individuals depicted here that represent the roughly
1.5 million individuals who die each year from tuberculosis. And about 1 in 3 of these
individuals is co-infected with HIV. So the combination of HIV and
tuberculosis is incredibly important. In very general terms, each
infection makes the other one worse. In other words, if you’re
infected with tuberculosis and you are or become
co-infected with HIV, the tuberculosis infection
becomes more severe. It is more likely to be disseminated. It is more likely to be associated
with severe necrosis of the lungs or miliary TB or TB meningitis. So HIV makes tuberculosis worse. Morgan: So almost in every way. Charles: Almost in every way. Morgan: Right, OK. Charles: And similarly, tuberculosis makes HIV worse. Through mechanisms that are
not clear to me at least, being infected with TB makes
the HIV virus proliferate more and makes the progression of
the HIV infection more severe, so they are mutually bad for each other. Morgan: So this why we call
it “the perfect storm.” Charles: Precisely. Now clearly, ultimately, you
have to treat both infections because they’re both bad infections. Morgan: Right. Charles: For tuberculosis, we will be talking about the
anti-tuberculose drugs to use in another video, but you do have
to use the anti-tuberculose drugs. With HIV, of course, you
have to use antiretrovirals in order to control the infection. Morgan: Right. Charles: So it’s a given that you
have to treat both infections. But another part of the perfect storm is that when you begin to treat,
you may have an adverse effect in something called the “immune
reconstitution inflammatory syndrome.” It’s abbreviated IRIS. Morgan: OK. I was going to say that’s a big word. Charles: It is a big phrase. IRIS stands for the immune
reconstitution inflammatory syndrome. In order to describe the effects of IRIS, I’m going to talk about two hypothetical
patients infected with tuberculosis. Morgan: OK. Immune reconstitution inflammatory … Charles: Syndrome. Let’s imagine one patient
infected with tuberculosis and it’s a latent infection. It’s a quiet infection. It’s a sub-clinical infection. In those patients, when you get infected, if you’re infected with HIV and
you recognize the HIV infection and you begin to treat the HIV
infection with antiretrovirals, the TB infection may
become clinically manifest. It is uncovered. That actually is referred
to as “unmasking IRIS.” In other words, the treatment
of the HIV with antiretrovirals, presumably because you
reconstitute the immune system, makes the TB infection become evident. That’s called unmasking IRIS. Morgan: OK. So before you had this
latent TB infection, you might not have even known
you were sick as a patient, you get HIV, you still
don’t know you have the TB, and then you start treating the HIV, and that’s when all of a
sudden you realize you have TB. You get this clinical tuberculosis – Charlie: Exactly. Morgan: OK. Charlie: So it’s unmasked. You recognize it at that point. You then treat the TB infection, and of course, you’re in the meantime
still treating the HIV infection. That’s one hypothetical patient. Another is a patient known to
be infected with tuberculosis. They have clinical disease. Perhaps they have the most common clinical
disease, which is pulmonary disease. Then you determine that they
also are infected with HIV, so you begin, again, treating the
HIV infection with antiretrovirals. Paradoxically, as you
treat the HIV infection, the TB infection gets worse. Again, it’s thought that that results
from when you treat the HIV infection, the immune system becomes more robust, because you’re controlling
the HIV infection, which was previously tamping
down the immune system, so the immune system becomes more robust, and as a result of that
robust immune system, temporarily, the TB infection gets worse. That’s called “paradoxical IRIS.” Morgan: Paradoxical IRIS, OK, so that makes me think maybe we
just shouldn’t treat the HIV. Charles: And of course, that
would be not good thinking, not because you said it, but because
you must treat the HIV infection because otherwise, it will progress,
and the patient will die of HIV. This is a temporary phenomena where you get transient
worsening of the TB infection. Then as you continue to
treat the HIV infection and you continue to
treat the TB infection, they both eventually settle down, ideally. Morgan: OK. This is more something that is
interesting and we watch out for because it can be acutely problematic, but that you wouldn’t actually
change a treatment for. You would just have to be
aware of it and eventually, as you treat the HIV, you treat the TB, hopefully, things will actually move
in the correct direction (laughs). Charles: Exactly. Then the final thing
that I’d like to mention with regards to this perfect storm, this badness between having both
TB and HIV at the same time, is that the drugs used to treat
each of those two infections may adversely interact with each other. One that is probably the most important
adverse interaction to know about is the effect of rifampin, a key
drug for treating tuberculosis, on the different antiretroviral agents. Specifically, rifampin is known to be an inducer of important
enzymes in the liver that are responsible for
metabolizing a lot of drugs. The enzyme system happens to be
called the “cytochrome P450 enzymes.” Rifampin induces that enzyme, in other words, makes
the enzyme more active. That enzyme is responsible for
enhancing the metabolism of many drugs, including antiretrovirals, so you end up, when you give the rifampin, causing the antiretrovirals
to be metabolized more quickly and lose their effectiveness more quickly. So you have to be aware of that
and other kinds of interactions, of drug interactions so that you can modify and modulate your
therapy of the infections accordingly. We’ll talk about that at another time.