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
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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.

Catheter-associated Urinary Tract Infection (CAUTI) with Case Studies (Part I).

Catheter-associated Urinary Tract Infection (CAUTI) with Case Studies (Part I).


[ Silence ]>>Good morning everyone and
welcome to our third and final day of the 2014 NHSN Training Course. We want to acknowledge again, all of you here who have given your undivided
attention and great participation. Everyone in the room as well as
everyone watching the live web-stream, we do appreciate your participation. I have multiple updates that I’ll give
throughout the day but I have a couple of important things that you’ll
need to know first thing. We wanted to remind you that the
evaluation forms are in the back on the back table outside of this room. I was told that if you are getting CE’s,
well, when you apply for that you’ll be able to do the evaluation on the computer so you
don’t necessarily have to complete it today. But if you aren’t going to be
applying for CE’s then we ask that you do complete the evaluation form today,
and leave it on the table before you have to go. We really appreciate your feedback and
your input and it is important to us, so we do ask that you complete that
if you are able to give your input. With regards to feedback and input we wanted
to let you know, we know some of the people in the front have a hard
time with the bright lights. We can’t unfortunately dim the lights any more than we already have because
of the live web-streams. So we apologize if they’re a little
bright or hot on the tops of your heads. We also know that the round tables
haven’t been ideal for you in the room. Again, hoping that you’ve been able
to see the presentations with all of the drop-down slide viewing but I know
it’s difficult if you have to have your back or have to turn around to face the front. Just so you know, the reason we chose to
do it this way was because we really wanted to maximize the amount of people we could get in
a room and get here to this in-person training so that you’d be able to actually
be in the room if you wanted to. So many people enroll and register to try to get
on the random list that we felt that we should, you know, try to do this so that we
could maximize to the 300 or over, but we will evaluate for next year to see if there’s any way we can fix
that or get a bigger room. Let’s see, I wanted to remind you that the team
outside the door is in the back to help you with your transport to the airport. So, they can help you with all of that but they
need you to sign up on a sheet and let them know when your flight is so that
they can group people together and make sure everybody gets
to the airport on time. And if you are leaving early, which we
want you to stay today as late as possible to hear all the important information being
presented today, but if you do need to leave and you know that it’s going to be ahead of
schedule, please let them know now or as early as possible so that they can make sure
to set you up front aside to get you out early for the transportation. We ask that — oh, yes this is very important. So, you have met many of the individuals
who answer the NHSN mailbox for you. There is a group of user support
team that you were not able to meet because they were not presenters and they’ve
actually been working behind the scenes to continue to answer the mailbox of questions
that come in over the course of this training and are always the front line
individuals that help you. So there’s a group of those. The individuals, the infection preventionists,
a lot of the data analysts, data analyst methods and analytics team, you’ve met here, so
now you know that there’s not hundreds of people behind the scenes
available to answer your questions and when we give the training we always know
that there’s going to be a hike in the mailbox because of all the important
information that was presented. So over the next few weeks the
mailbox is going to double. Over the next two weeks we’re actually down
one IP because she’ll be away for two weeks, so we ask that you give us a little
bit of leeway and understanding if it takes a little bit longer to
answer questions in the next few weeks and give us your support with that, just
to make sure that we catch everybody back up with all the information
that’s been presented. So we just wanted to bring that
to your attention because I know when you ask questions it’s very important and you need those answers
because you need to do your job. We do recognize that too, so we will do the
best that we can to keep up with the questions that already have begun to
come in in these past two days from viewers watching the live web-streaming. And a reminder for these
presentations, they’ve all been taped. They will be archived and posted. We expect them to be up by mid to late April
and this way for your reviewing pleasure, and anyone that you want to pass the information
on to — individuals who couldn’t come, people who weren’t able to get
onto the live web-streaming. They will be broken up into
sections and sessions by topic so that individuals can watch them when
it fits into schedules and do it even in a little more piecemeal
than three days in a row. Because I know it’s a lot
of information to take in. There’s something you might want to watch
again, it’ll be available for you to watch. So I think with those, I will have
Kathy come up and talk about CAUTI, and we’ll give some more
announcements right before lunch. Thank you. [ Applause ]>>Good morning. Well, today we’re going to talk
about catheter-associated UTI’s, and we’re going to try to have a little bit of
fun today so, since you’ve had two long days. Hopefully you’ll enjoy this
morning’s presentation. So, I’m am going to have to cover a little
bit of information that I’ve already covered, such as HAI definitions, POA’s, because we
have people tuning in for the web-streams that may have not listened to
the [inaudible] definition. So if you want to tune out in those situations
you can, and hopefully you’ll tune back in when it’s something new for you,
but just a little bit of a warning. So, today we’re going to go over
the CAUTI, definitions and key terms that are utilized in CAUTI surveillance. We’re going to talk about how to collect
the urinary catheter and patient data. We’re going to again identify the data
collection forms and then we’re going to apply the definitions to
some patient case studies. So, same general overview
that we’ve done in the past. And we’re going to cover the epidemiology,
the definitions, and the changes for 2014. Talk about denominator collection
and I’ll provide you some resources, we’ll do case studies, and then lastly I
do want to give you an update on, you know, what’s going on with the CAUTI definitions. You probably have heard that we
are reviewing those definitions. We’ve actually been reviewing them since the end
of 2012 and hope to have some changes for 2015. I might not be able to give you a
lot of specifics because I’ve learned that don’t give specifics until it’s
actually totally done because as sure as you know what it’s going to change. So — but I can tell you what, you know,
what is being done and then for those of you that are coming to APIC I’ll also be going
a presentation there and maybe I’ll be able to give a little bit more
details at that time, so. So again, we’re not going to go over in-depth
today requirements for the Centers for Medicare and Medicaid Services Inpatient Quality
Reporting Program or the Oncology, the Cancer Exempt Hospitals Reporting. All that information’s available
on our website or through the QIO’s and I’ve provided you those resources here. Also, we will not be going through step by
step data entry and Maggie’s been covering all of the data analysis for us very
well, so we don’t have to do that. So, CAUTI’s, who cares about CAUTI’s? Right? Who cares? Urinary tract infection is tied, believe
it or not, you probably know this, with pneumonia as the second most common
type of health care associated infection, and it’s really only second
to SSI’s in overall incidents. And we know that the majority of them
are associated with indwelling catheters. I don’t know if you’re aware but a
little over 5% of ICU CAUTI’s result in bloodstream infections and in
non-ICU CAUTI’s that is up to about 7.4. So, interestingly enough, higher
secondary BSI rate outside of the ICU. 13,000 people die every year for UTI’s,
so you know, it does cause some morbidity and mortality, and interestingly, up to
1/3 of asymptomatic bacteriuria is treated with antimicrobials even though this is, you
know, in conflict with published guidelines and results in a lot of unnecessary
antibiotic usage, C. difficile infections, adverse reactions. And so, that’s one of the main reasons that
ASB was removed back in 2009 from our criteria. So, it’s important for us to shine a light, sort
of, on CAUTI and what we can do to prevent that and how we can treat it and
identify it correctly. And a lot of people are saying now that, you
know, CAUTI’s may be a proxy measure for the overall general quality
of care for patients. So, you know, that’s another reason that we might be concerned
about what happens in this area. So again, we just want to make sure that
all of our data that we enter is good data. And so, things to consider
for CAUTI surveillance. So, nice thing is that unlike SSI
surveillance, all CAUTI’s are going to require a positive urine culture. So you can start with your laboratory
as your basis for case finding. So hopefully you’re all able to
get a routinely generated report of your positive urine cultures
and that’s your starting point. But I do want to point out that
it’s really important for you to know your laboratory’s urine
culture reporting policies. Specifically, what are the ranges of
colony-forming units that they’re reporting? Some facilities don’t report down to
10 to the third, which is, you know, part of the definition for UTI’s. Some of them don’t quantify yeasts, and so your
facility’s not able to meet all the criterias that are currently written since we include
yeast as a pathogen for CAUTI’s at this time. Sometimes positive urine cultures are reported
for the unit on which they were collected and not necessarily on the
unit that the patient is on. So you may need to check to make
sure that you’re attributing that CAUTI to the right location. It seems to happen a lot with
patients that are discharged. Sometimes the discharge location — or
location for the culture is not accurate. So just — you need to consider
the transfer rules and how the laboratory report
might be affecting that. And finally, you know, just to take into account
that you need to account for positive cultures from the Emergency Department because those
could really represent CAUTI’s from patients that had recently been discharged
and might be — should be attributed to that
discharging location. So again, what are you going to look at first
and where is it going to be on the record? Those are, you know, things
that you need to think about. You’re going to be looking for your urine
culture results and your laboratory results. And then probably what you want to look
for — unless you’re in Pennsylvania, most facilities — not a lot of
facilities are doing surveillance for non-catheter associated UTI’s,
so you know, you’re going to look — maybe the next thing you look at is whether or not they had a urinary catheter
in place in the time period. You know, and you’re going to be
looking for nursing documentation and graphic sheets for those
types of information. This is a sample worksheet that, you know, that
we put out for your use for data collection. You guys — some facilities create their
own data collection sheet, which is fine, just as long as it collects all of
the information you need for NHSN, but this one is available
on the website for your use. And then, you know, the old spiel about making
sure that we’re all doing things the same way. I went over this pretty well with CLABSI. You know, we need to all be
consistently applying the definitions. Standardizing your chart review will
help you to be consistent over time. So if you get into a routine
of how you collect data and how you identify cases,
that will really help. Maintain the focus on the criteria
and don’t deviate from that. CAUTI is one of those areas sometimes where
people feel that maybe they’re not capturing all of the patients that they
clinically believe have a UTI. We hear this a lot with patients that are on
ventilators or spinal cord injury patients, maybe because, you know, they’re not
able to communicate, for whatever reason, suprapubic tenderness or CVA pain. Surprisingly, though, honestly only —
well, 80% of our patients that are reported as CAUTI’s have fever as their only symptom. That may be surprising to you or it may not be. So, if you think about it that way,
the spinal cord injury patients or the ventilated patients
are maybe not that different. I mean, most patients when we identify
it it’s through the use of a fever. You know, the other thing to think about
with that, I always tell people is that just because a patient is ventilated doesn’t
mean they can’t communicate pain. Especially with these sedation vacations
and depending on the level of sedation, patients can exhibit signs of pain if
their physical assessments are done. So, I don’t — I always hate for people to
just say, “Well they’re on a ventilator, we can’t tell whether or not
they have an suprapublic pain. So that’s not always the case. So again, think about surveillance definitions
versus clinical definitions and the fact that sometimes the two are not going to meet. You know, we’re looking — we’re using
the definitions for surveillance different than clinicians are using to make
determinations about what’s going on with a patient and what they should do. And our data elements are going to be limited. They’re going to be finite
and the clinicians are able to use everything that’s available to them. So, it’s okay if they don’t always match. We obviously try to make our criteria so that
they are as close to clinical definitions as possible, but we have a long way
to go, especially in CAUTI, I know. But we are definitely working on that now. Was that a laugh [laughter]. So, sometimes, you know, sometimes it’s
helpful to remind your staff about surveillance or to educate staff about
surveillance in clinical definitions. How many people here have had to have
this conversation in their — yeah. Yeah, yeah. Yep. And surprisingly, sometimes it’s infectious
disease physicians that you have to have that conversation with, which
is always surprising to me because I would have thought
they understood that. But we always want to make sure obviously
that we’re using the surveillance definitions as a determinant of what we report. And we’re always here at
[email protected], as Dawn told you, to receive your questions
and try to help you out. Oh! So, I want to make a disclaimer. I thought it would be fun if I
shared some of the funny emails that we get from users, because we get some. I didn’t include any identifiers
on these, so if it’s from you and you recognize it don’t
tell anybody [laughter]. And they will not know. So I’m going to share — as we go
along today I’m going to share a couple of funny emails that we have gotten. So, here’s one that I got from a user. She said, “I am looking at a patient that
presented to our facility on 2/15/13. A Foley was placed in the
ER on the admission date. During her stay she was afebrile
and symptom-free with one exception. A temp of 102 was documented at midnight. The nurse manager feels that this is possibly a
misdocumentation and would like some guidance. Do we still call this a CAUTI?” No, you can just discount that [inaudible]. Don’t worry about it. It’s probably a mistake. Yes, you have to still call this a CAUTI. All right, so we’re going to get into
the nuts and bolts of the definitions and we’re not really going to be talking about
non-catheter associated UTI’s here today. As you may or may not know, they
have their own criteria designated as the B criteria’s for SUTI. The A criterias are all catheter-associated, the
B criteria’s are all non catheter-associated. And I want to identify that ABUTI
can also be non-catheter associated or they can be catheter-associated. And if you are determining
whether or not an LCBI, BSI is secondary to a non-catheter
associated UTI, you have to make sure that you use non-catheter associated
definitions and you’ll see as we go along, if you don’t already know, why that’s important. So, there are basically two
specific types of UTI. Symptomatic UTI, or SUTI, or
an asymptomatic bacteremic UTI, or ABUTI, as we like to refer to it. I do want to point out sometimes people are
confused between asymptomatic bacteremic UTI and asymptomatic bacteriuria or
ASB, which we used to have in 2009. Asymptomatic bacteriuria just means
that there are organisms in the urine, but an asymptomatic bacteremic UTI is one
where there’s not only organisms in the urine but there’s also a matching
organism in the blood stream. So the patient has a blood stream infection
as a result or concurrently with the UTI. So that is the difference,
they’re not the same animal, and it’s important that you understand that. Both types of infections, both SUTI’s and
ABUTI’s, if they’re catheter-associated, need to be reported as part of any CMS,
CAUTI surveillance that you’re doing. That’s another thing that’s sometimes
people don’t quite understand. You can’t just report the SUTI’s,
you also have to report the ABUTI’s. So, you know, over the years as
I’ve presented this information, I’ve presented it in different ways
and sometimes it’s hard for people to understand the logic of why
the definitions are as they are. Sometimes they seem like they’re really
complicated, so I’ve tried to present it in different ways and this
time I thought I’d tell you — just present the logic behind
the SUTI definitions. And one of the important points is that the
symptoms of a true UTI are going to vary whether or not the patient has a Foley in place. If the patient has a catheter in place they’re
going to have urgency sometimes, you know. I mean, how many people have had a patient and
they said, “I’ve got to go to the bathroom.” And you say, “You’ve got a
catheter in, just relax.” You know, “You can go.” So, that foreign body causes urgency, it can
cause burning, a burning sensation sometimes. You shouldn’t be having frequency,
so we took those out of patients — you know, they used to be in the
criteria for patients that had Foleys and they didn’t make any sense to be in there. So that’s why we’ve taken
them out of the criteria for patients that are currently catheterized. Infants, we know exhibit different
symptomatology as well for infections and that’s why we provide some infant-specific
criteria, and those additional ones are apnea, bradycardia, lethargy, vomiting, or hypothermia. Because, you know, patients can have instability
in temps when they have an infection. So, these are sort of the two big concepts of
why we have some complexity to our UTI criteria. So this is sort of an overview
of the UTI definitions. So, we can see that I’ve
divided these by age groups. SUTI one and SUTI two are
for patients of any age. SUTI three and SUTI four are for infants. And then we have our ABUTI’s, which
again, are for patients of any age. Now, I told you yesterday that infants not only
can meet these but they can meet any of these. It’s just the patients that are over one
year of age that cannot meet three or four. Okay. Within each of these different
types of UTI’s we have catheter-associated or non-catheter associated UTI’s. Make sense? All right. So now we’re going to look at how the
colony-forming units are applied to these. So, for SUTI one and SUTI three
we’re dealing with patients that have at least 100,000 colony-forming units. And I have an asterisk here, you’ll
notice that it goes down to — they have to have no more than two
organisms in that urine culture. And that’s because we want to make sure that
this is not a contaminated urine culture. If there’s three or more organisms
the chances are pretty high that that’s been just a poorly
collected culture, we don’t want to use it to
say that somebody has a UTI. We don’t want to over-call these UTI’s. ABUTI also requires greater than 100,000. You’ll never have an ABUTI that has less
than 100,000, and that’s for a reason. You know, we — this patient is asymptomatic,
so we want to have a high degree of — as high a degree as we can of
confidence that this is truly a UTI and so that’s why we’re going to require
a high colony-forming unit count. You’ll notice, though, there’s two
stars there and that means that not — we don’t use organisms, we use uropathogens. So there cannot be more than two uropathogens and we provide you a list of
what those uropathogens are. It’s a pretty broad list, but there are a
few organisms that are not on that list. That list is included in
the NHSN CAUTI protocol. I’m trying to remember. I think we have it on our organism
list, too, that’s on the website where we have MBI and we have common commensals. People are nodding, so. So that leaves SUTI two and SUTI four. So you’ll notice that one of the infants,
the SUTI three, has 100,000 or more. One of the infants has greater
than 1,000 or less than 100,000. So we have adult and child, adult and child. Or, I say adult — any age
and child, any age and child. So this group here, SUTI two and four
have a lower colony-forming count, 1,000 or more, but less than 100,000. Again, no more than two organisms
in the culture. Because this is a smaller colony-forming
count, we are going to require some symptoms — I’m sorry, some supportive positive
UA to give more credence to the fact that this is truly a good culture
and indicative of an infection. So that’s why this criteria requires this lower
level colony count and a supportive positive UA, again, within a time period of no more than
a single gap day between adjacent elements. Okay. Is this a good way to present this? Does this make sense? Okay. Good. Thank you for the feedback. Okay, so when we’re looking at a symptoms really
the main question that you have to ask yourself, and I went over this a little bit, was the
catheter in place at the date of the event? If the answer is yes, then you’re going to have
a limited number of symptoms that you can use. You can only use suprapubic tenderness,
costovertebral angle pain or tenderness, or fever greater than 38 degrees Celsius. If it’s a baby you can additionally
use hypothermia, less than 36, apnea, bradycardia, lethargy, or vomiting. Okay? You’ll notice what we’ve taken
out of there when you look at the no. So there was no catheter in
place on the date of the event. You’ll see here I bolded. You now have dysuria, frequency,
or urgency that you can utilize. And then you have all that
you had for the yes answer. You have your suprapubic tenderness, CVA pain or
tenderness, fever, and then the infant criteria. So we simply remove these
three, dysuria, frequency, or urgency if the catheter is in place. As I said, when there’s more than two species
of microorganisms that’s routinely regarded as a contaminated culture and we
don’t want to use it for NHSN. We do get questions about culture
reports that come back as mixed flora, and generally mixed flora represents
more than two organisms, two species, so if you have mixed flora and you
have any additional organism recovered from the same culture that’s going
to have more than two organisms. So, for example, if you have to
report that maybe there’s a greater than 100,000 Pseudomonas
aeruginosa, and there’s mixed flora, clinically we probably would
believe that greater than 100,000, but unfortunately we have mixed flora
in there so we can’t utilize that. This is one of the issues that we’re kind of
talking about with the new definitions also. You know, can we say if there’s
a preponderant organism, can we say that that should be utilized? As it stands right now, in that situation
you would not use that culture report. If the organisms are the same
genus but two different species, they’re considered two different organisms. So if you had a Pseudomonas and aeruginosa — aeruginosa and a Pseudomonas stutzeri
[assumed spelling], that’s two organisms. If you add anything onto that you’re
not going to be able to use the culture. And kind of the flip side of
that, if you have an organism that has just simply the same organism but has
different susceptibility pattern such as MRSA or MSSA, those are considered just
one organism because, you know, we know that how the laboratory works those
up they may just pick different colonies from, you know, that — cultures or colonies
that represent the same organisms and there is some variation
and resistance within those. So, we don’t want to say that those
are different organisms all together. So those will be considered just one organism. Okay. Sometimes, obviously patients will
have a positive urine culture — excuse me — shortly after their catheter is removed. So, for those patients if
the event date, the UTI date, is on the day of device discontinuation or the
following calendar day, just like for CLABSI, these are going to be considered
device-associated. As long as the device had already
been in for greater than two days. And, for this criteria you are
able to utilize urgency, frequency, and dysuria because the catheter
has been taken out. So I’ve given you two examples. First one, the Foley is placed and
it’s there, it’s placed on day one. Day two it’s still there. Day three it’s in place for part
of the day and then only for part of the day and then it’s removed. The next day the patient meets UTI criteria,
this is going to be considered a CAUTI. Unlike here, where the Foley’s placed
on day one, it’s taken out on day two. It was there for part of the day, taken out. The next day they have no Foley
and they meet criteria on day four. That is going to be a health care
associated UTI, but it’s not going to be considered a catheter-associated UTI. Whether or not you clinically agree with that
or not, that’s the definitional interpretation. Okay. So let’s just go over
the criteria as a whole here. So these are the A criteria
for SUTI’s, symptomatic UTI’s. A, meaning that these are going
to be catheter-associated. On the first you’ll see its split,
the first half of this is for patients that have the catheter in
place on the day of event. The second half are for those that
had it in for greater than two days but had it removed the day of
or the day before the event. Okay? So for the first ones, it’s in
place, it’s been in place for greater than two days on the day of event. They can have fever, suprapubic
tenderness, CVA angle pain or tenderness, and they have to have a positive urine
culture of greater than 10 to the fifth, and no more than two species of microorganisms. And again, the gap day for
— single gap day does apply. If the catheter had been in place for greater
than two days and it was removed the day of or the day before the event, then we add in
dysuria, urgency, frequency, and then, again, fever, CVA, suprapubic/SP tenderness, and the
same requirements for the positive urine culture of greater than or equal to 10 to the
5th and no more than two microorganisms. Now, you’ll notice that there is an asterisk
here for with no other recognized cause and for those astute clinicians, you’ll
notice that it’s not there for fever. And this is one of the questions that
we get the most and one that, you know, we are discussing how best to approach this. The reason it’s not there is because, to allow
— and this happens more with CAUTI than it does with CLABSI because, you know, with CLABSI
one you don’t have to have any symptoms. But you know, if the patient has a pneumonia
and they have a positive urine culture because they’ve pan cultured the patient,
if the fever is there the fever has to be utilized to meet the UTI criteria. If you’re doing pneumonia surveillance, you’ll
also have to use it for the pneumonia criteria, and that’s because at this point
we haven’t figured out a good way to operationalize clinical
judgment about where that UTI go — or where that fever is responsible for. And it may be responsible — it
may be due to both infections. If the patient has both infections they
may be running a fever because of both. I mean the body doesn’t —
does the body differentiate? I don’t know. So, the only way I think that we could
get around this would be if we were to identify a hierarchy of infections. Okay, if they have this and they have
this infection and this infection, you apply the fever to this infection. But you see that quickly becomes very complex. And so, that’s what we’re wrestling with. So for now the fever is a non-specific
symptom and you have to apply it to all potential infection types. Criteria in two, again this is in A so these
are catheter-associated infections you’ll see. Two, again, is for those patients that have
less than 100,000 but greater than 1,000. If the catheter is in place the symptoms
are exactly the same as they were for A. You’re going to have those symptoms
minus dysuria, frequency, and urgency. Additionally, however, you’re
going to have to have a positive UA and by positive we mean a dipstick that’s
positive for leukocyte esterase or nitrite. Or pyuria, that means greater than
or equal to 10 WBC’s of unspun urine. How many of you know whether or
not your lab spins your urine? Okay, how many of you don’t know? Yeah, so you need to see if it’s being reported
out to you or if not you need to clarify that with your laboratory because if it’s
spun urine, it’s greater than or equal to 10, if it’s unspun urine they’re going to be
looking at it under a high-powered field and it’s greater than five WBC’s to be positive. Okay? And, you could also
meet this using a gram stain if there’s microorganisms seen on unspun urine. Not many laboratories do this anymore. Questions that we do get
sometimes is what is trace? Is trace positive? Yeah, trace is positive. So if you have a trace leukocyte
esterase, it’s positive. Just like with one A; you know, we have
this top portion that was in place. We have the bottom portion that the catheter
was taken out the day of or the day before, that means that we’ve added back
in urgency, frequency, or dysuria. Just as above, this is the ones that have equal
to or greater than 1,000 but less than 100,000. And they have to have one
of the same positive UA’s. So the only difference between the top and the
bottom is the additional criteria of urgency, frequency, and dysuria, if the
catheter had just been removed. Clear? Yeah? Looks like everybody’s with me. Yay. So I’m not going to go over this diagram, I just want to point out
that it is in the protocol. Some people are very, you
know, they do much better with a flow chart than they do all of the text. So we do have it there. One is for — this one it happens
to be if the Foley is in place. We have one if the Foley is removed. There are similar flow charts
for three and four and for ABUTI. Now the criteria for the infants, one
year of age or less, is very similar. You’ll notice that three is very similar to one in that the colony-forming units is
greater than or equal to 100,000. The only difference between the adults — or
the all-age criteria and one and the three is that we’ve added, again, hypothermia,
apnea, bradycardia, lethargy, and vomiting. Other than that it’s exactly the same. The one difference that I’m going
to say is that you’ll notice that we have two asterisks down here. Rather than splitting this up, we have
simply said between those patients that have the catheter or those that had
it removed, we’ve just asterisked down here that if they had the catheter in place for
greater than two calendar days with the day of device placement being done and the
catheter was placed on the date of event, that they can utilize these symptoms here. Four is very similar to two, it’s the analogy of
two in that the colony-forming count is lower, it’s greater than 1,000 less than 100,000. Because of that you need a positive UA. The positive UA results are no different
for children than they are for adults. And, again, those additional
symptoms that I mentioned above. So, this, just to point out that this
double asterisks is how you’re going to determine whether or not this is a
catheter-associated device — or UTI or not. Asymptomatic bacteremic UTI — I’ll give you
a little bit of background for those of you that don’t know how this definition came about. Back in 2009 when we removed ASB, asymptomatic
bacteriuria, we didn’t anticipate a problem that would occur from that, and that was that
if a patient had a positive urine culture, but they didn’t have any symptoms,
it could no longer be called an ASB. It used to be that that could
be reported as an ASB. If it was recorded as an ASB, then it could be
said that an LCBI that occurred at the same time with a matching organism was secondary to that. Well, when we took away ASB, we now
had these positive blood cultures that matched a urine culture but
they couldn’t be called secondary and so if the central-line was
in place they became CLABSI’s. And that didn’t sit well with
people, it didn’t sit well with us. So, we developed asymptomatic bacteremic UTI. So this is for a patient that has a urinary
catheter in place or doesn’t have one, it could be catheter-associated
or not, and any age patient. So, we don’t have an infant one. They can have none of the symptoms that we’ve
mentioned for any of the other criteria. Okay? So, I’m not going to go through all those. They simply can’t have any
of the earlier UTI symptoms. Additionally, they have to have a positive
urine culture or greater than 10 to the fifth. Again, no more than two species, and a list of
specific uropathogens that have to be involved. And we’ll go over those in just a second. There has to be an accompanying,
matching blood culture with at least one organism to the urine culture. If all that occurs within a time-frame that
doesn’t exceed a gap of one calendar day between two adjacent elements, then this is an
ABUTI, and you would not call it primary BSI. Okay? That list of uropathogens are listed
here, as I told you it’s pretty broad — gram negative bacilli, staph
species, yeast, beta hemolytic strep, enterococcus, gardnerella vaginalis. We took these lists from —
I can’t remember the source, but we didn’t make this list up [laughter]. I can get you the list at
the source if you want it. Aerococcus urinae and choroni bacterium. You know, it’s very seldom that I hear
of an organism that doesn’t fit in here. So, and that complete list is,
you know, listing up the species as well as the genus, is on our website. Okay. So, just to say again, only the events for
ABUTI that had catheters in place for greater than two calendar days prior to the date of onset are catheter-associated
otherwise they are none. And then UTI’s is one of them that we get
a lot of questions about the recurrence. Is it new or is it a recurrence? Do we have to report a whole separate UTI? And the guidance here is no
different than it was for LCBI. We say look to see what evidence
of infection is still occurring, does it appear that the infection
has resolved clinically or are they still being treated
for the first UTI? If either of those is yes, then we would not
assign a UTI, we would say it’s a continuation. And that is irrespective of whether
or not it’s the same organism. So, I always use yeast as an
example because it happens so often. Somebody’s being treated for E. coli UTI and four days later they have a
positive urine culture for yeast. They’re probably still being treated at
four days and in that case, if they are, then you’re just going to add that yeast onto —
if you’ve reported the UTI, you’re going to add that yeast on as a pathogen to that, rather
than calling it a separate infection. Okay, you ready for another email? They get funnier as we go along. So, this is one we got. “Good afternoon. I have a patient who met all the criteria for
CAUTI on 1/21 when she spiked a fever, however, she was declared brain-dead on
1/18 and was only being kept around so her organs could be harvested. Would she be considered a CAUTI.” I thought, that’s a really
strange way to phrase that. She was only being kept around
so her organs could be harvested. The answer is yes, we do include
patients that are in hospital, you know, they’re organ-donation patients, because we
shouldn’t be giving them UTI’s even though, you know, they’re here for organ-donation. So, and we actually have reviewed
that decision with our patient — our organ transplant team and they
were in agreement with it, so yes. That got people talking. Okay, now we’re going to go on to key terms. So, obviously all CAUTI’s have to HAI. So we’re going to talk about POA versus HAI. Here’s where you might want to tune out if
you’ve heard this all more than you want to. A POA infection is one that
all criteria, all criteria, are present during the two calendar
days before the day of admission, the first day of admission,
and/or the day after admission, and are documented in the medical record. If it’s POA, you shouldn’t be reporting
it to NHSN, we are only interested in health care associated infections,
and acceptable documentation, again, does not include that reported by the patient. If the patient says I was
febrile, you can’t utilize that. You can if a report comes from the other
hospital that the patient’s febrile. And something I didn’t mention
is that we really, you know, we’re trying to balance what we
require for you to know and whatnot. We didn’t want you to have to go back
and ask the facility what the fever was. So, as long as it’s documented
that the patient was febrile, you can use that to meet
that part of the criteria. Physician diagnoses is not a
part of the CAUTI definition. So, a patient coming in and a physician says
he has a UTI, that is not sufficient to say that the patient had a UTI on admission. Okay? Patient is going to have to meet
the criteria during that time period. So here’s the unlucky family again. Grandpa Unlucky has been in an inpatient rehab
facility following multiple fractures sustained in a multi-car pileup when Atlanta sustained
the Snowmageddon of 2014 [laughter], otherwise known as a half
an inch of snow [laughter]. Yep. He’s now transferred by the way, to your
hospital with a Foley catheter which has been in place for two weeks and
reported by health care worker of fever the day before transfer
and a change in mental status. He’s afebrile on admission and his urine
cultures collected on admission are positive for greater than 100,000 CFU’s of E. coli. So, we’re going to vote again this morning. Which of the following is most accurate? He does not have a UTI. Has a UTI attributed to the new hospital. Or he has a UTI attributable to the rehab
facility and is POA to the hospital. Okay. Let’s see how you’ve done. Couple more seconds. So, 96% of you think that the patient has
a UTI attributable to the rehab facility and POA to the hospital, and
that is the correct answer. And let’s see why. So, he — on the date that he’s admitted
to your hospital there was a report of fever the day before transfer, which
was reported by a health care professional. And he had a urine culture collected,
which was greater than 100,000 of E. coli. So he meets SUTI one A, present on admission. Actually, attributable to the other hospital
and we do encourage you to communicate with other facilities to let them know when
you identify an infection that is attributable to them and if I was you I certainly would,
because I don’t want to be compared to somebody that was not collecting all of their data. Definition of a health care associated
infection, again, it’s considered HAI if all of the infection’s specific criteria were not
present during the POA definition time period. So, not POA, but they were all present on or
after the third calendar day of admission. Again, they have to occur within a
time period that does not exceed a gap of a single calendar day between
any two adjacent elements. And, did we define a gap day
as a calendar day in which none of the infection criteria are present. The transfer rule, as you all know, is if
the patient meets the criteria on the day of transfer or the next day,
we’re going to attribute that back to the transferring location. If it occurs after that time period,
after the day of transfer, the next day, it’s going to be attributable
to the receiving facility. And, you know, this applies also
to patients that are discharged. If they go home and then you find out
the next day, they come back and you find out that they have — even if they
don’t come back, if you find out, maybe you have communications
with your medical offices. But if you’re aware of it you’re going
to attribute that back to your facility if it occurs on the day of
transfer, the next day. I’m sorry, I said transfer, I meant discharge. Okay, warning. The next slide is very important. Does this work? [Ambulance sound] All right, here’s an example. And I say it’s really important because we
actually get this question all the time. I know that people don’t understand
this as well as they should. So this is an example that is not
present on admission, it is an HAI. Day one, the patient’s admitted. They’re asymptomatic. They have, however, a urine culture that’s
collected for 10,000 CFU’s of E. coli in the urine, but they’re asymptomatic,
as I said, and there’s no documentation in the two days prior that
they were symptomatic either. Second day they’re asymptomatic. The third day they run a fever. And the fourth day they have a culture, again, and they’re now 100,000 colony-forming
units of E. coli in the urine. This meets the symptomatic UTI criteria. They didn’t meet it in the POA. They had a positive culture but
they didn’t have any symptoms. You left that catheter in,
you know, for four days. It doesn’t say they had one
here, but you’re only going to report it if they did, probably, so. So, this is a UTI that’s got to
be reported for your facility. Okay? This is one of those examples
where it’s neither POA nor HAI and you’re not going to report anything. Patient came in and they were asymptomatic. They had a fever on the second day. The third day they’re asymptomatic again. The next day, I don’t know why, but
they do a culture on the patient. It happens. And it’s positive for 100,000 of E. coli. Asymptomatic five and six. So, we didn’t meet the criteria in the first
two days, and we didn’t meet them after that and we only had a positive
culture on day three or later. Day seven would be too long because there
would be a gap day here — two gap days here. So, this is one of those cases where
they don’t meet either criteria and it’s not going to be reported. Although, you and I believe they
have — may believe they have a UTI. Okay. Good news is we probably also would
think that they probably came in with it. Okay, I’ve covered this, the gap
day rule or the gap day definition. So, I’ll give you an example
of the gap day again. Patient is admitted on April 1st to the ICU. They put in the Foley Six
days later they had a temp. On 4/8 they’re asymptomatic, they’re afebrile. This is a gap day. They don’t have any suprapubic tenderness,
they have no CVA pain, they have no fever. It’s a gap day. The next day they have a positive urine culture. So, because there’s a single gap day here
and the Foley’s been in longer than two days, this is going to be a catheter-associated UTI. Again, if 4/9 had been asymptomatic, and 4/10 the urine culture had been
collected it would not be considered a UTI. Because there would have been two gap days. Okay. Our definition of an
indwelling catheter has not changed. That’s good to hear, hey? So it’s simply a tube that’s inserted into
the urinary bladder through the urethra, that’s left in place and is
connected to a collection system. It includes those patients
that are getting irrigations. Those patients are probably at higher risk of
UTI’s, so we include those patients as well. It doesn’t include straight, in and out
catheters, nor suprapubic catheters, no nephrostomy tubes, but if a patient has
suprapubic catheter or nephrostomy tubes, which happens sometimes, and a Foley, they are included in your
catheter-associated UTI surveillance. If the Foley’s there, they’re included. I got a question this week from
somebody that they had a patient, I think it was a spinal cord injury
patient, that they were doing — he was doing intermittent self-caths and
then at night the nursing staff was putting in a Foley catheter, and they
were taking it out every day. Is this something that you guys see? No? Okay, so she wanted to know if they were
eligible for CAUTI and my answer is yes, because the catheter was
in place each day for — an indwelling catheter was in
place some point of each day. So on the third night, they now
become eligible for a CAUTI. We get all sorts of crazy questions. Okay. And I think we’ve pretty much covered what
is the definition of a catheter-associated UTI. So, the only thing I want to highlight is it
is the date of the event that you’re looking at to determine whether or not
the catheter had been in two days. The date of the event, the date of the
last element used to meet the criteria. Discontinuation and reinsertion. We get this all the time, and as I said, we’re coming out within the
newsletter with guidance for this. But if the Foley catheter is discontinued and a full catheter day passes before a
Foley is reinserted then the day count for determining catheter-associated
UTI begins anew. Otherwise, it continues from
the previous catheter. So, I have two examples. Patient has a Foley, day three, day four. They took it out on day five. They put it back in on day six. And — I’m sorry, they took it out
on April 2nd, and they put it back in on April 3rd, this becomes day six. Continues from day five for Foley because there
was not a full calendar day without a Foley As opposed to this example down here where
they took the Foley out on April 2nd. There was no Foley for the whole day on
April 3rd and they replaced it on April 4th, this becomes new Foley day one, Foley day
two, and Foley day three on April 6th. On this date they’re eligible for another CAUTI. Okay? Again, somewhat arbitrary
but just trying to make a rule so that we all do it all the same. We just pretty much covered this; the date
of the event is the date of the last symptom. So if you have a temp on one day and a
urine culture the next day, this is — you’ve now met criteria,
this is your date of event. So, quick examples of a device-associated. Patient has a Foley inserted on
day one, they’re asymptomatic. The Foley remains in place and
they spike a fever on day two. They still have a fever on day three and they
have a positive urine culture on day four. That meets criteria, E. coli. Because they didn’t meet the
criteria in the first two days, even though they had a fever here, this
is a device-associated, this is a CAUTI. Okay? They would have had to have their culture
in the first two days for this to be a UTI but not a catheter-associated UTI. You’re just going to ignore this fever
then and utilize day three or day four. I’m sorry, I want to correct that. You can count the fever in here because what we
tell you to do is to look at the date of event. So scratch what I just said
because I don’t want to confuse you. It’s easy to do. It’s easy for me to get confused,
so just look at your date of event. Your date of event is day four here. It’s the date of the last element, because
that day is not in the first two days of the catheter, this is considered
a catheter-associated UTI. That’s really the easiest way to do it, and
it’ll get you into the least amount of trouble. And I can get in trouble sometimes,
in case you hadn’t guessed that. All right. This is not a CAUTI. Foley is inserted on day four. They have a temp of 100.6 the next day. They send the urine culture and it’s positive
for 100,000, they meet the SUTI criteria on this date, day five, but the Foley
hadn’t been in place for greater than two calendar days on
the date of event here. It had only been in, it was on its second day. So this is not catheter-associated UTI. This is also not a catheter-associated UTI. Foley inserted on day four, removed. They’re asymptomatic four days later, day eight. On day nine there’s still
no Foley, they have a fever. And on day 10 they have a
fever and they have candida. The date of event in this case
is day 10 and it was not the day of removal nor the next day, it was after that. So, it’s not considered CAUTI. Last example, I think. Patient comes into the ICU,
has a Foley put in on day four, removed on day eight, reinserted on day nine. And on day 10 they meet criteria. This is one of those reinsertion ones. This is going to be considered
a catheter-associated — oh wait, this patient has a Foley in place
for some part of each calendar day for greater than two days, and there was not a full
calendar day without a Foley in place. So this is a CAUTI. Is that clear? Location of attribution for CAUTI
is the same as it was for LCBI, it’s the location where the patient was
assigned on the day of the UTI event. And, again, the date of the
last element for the criteria, with the only exception being the transfer
rule which, I think, we’ve pretty much covered. If it occurs on the day of transfer
or discharge and the next day, it goes back to the attributing location. I’m just going to go over one example
here that we get a lot of questions about and that’s the small tie transfer rule. So in this case, patient is
in the ICU on day one of admit and on day two they’re also in the ICU. On day three they start in the ICU, then
they go to five west, then they go to CCU. And the next day they have
an HAI, in this case a UTI. This HAI is going to be attributable to the ICU since that was the first
location the day before the event. So this is, you know, your transfer rule time
period here, the day of transfer, the next day. And so this is the ICU here. Trying to expand that incubation
period, you know, to the longest time we can in those two days. Okay. Oh, this came through [inaudible]. I wanted — this was supposed to
come through in two different pieces. So we send out an email to people that said,
“It appears a user from your organization with user name XXX is in the process of
updating their SDN digital certificate. CDC is in the process of reviewing their status and will notify the user via email
when the process is complete. At that time the user will be able to log in.” So we get an email back from this person
that says, “I’ve already installed it on two computers a couple of weeks ago. You better make sure it works right
because it is a hassle to get this done and I did it all myself and it worked fine. Please do not screw it up.” [ Laughter ] Apparently, she’s worked
with us before [laughter]. Aren’t you glad those digital
certificates are going away? Has anyone here been Sammified
[assumed spelling]? Okay. Do you like it?>>Yes.>>All right, cool. All right. Sammified is a new system that you
guys will all be moving over to. Instead of digital certificates they
give you these cool little Bingo cards that they’ll have you put in codes
for and they’re good forever. So, I like this. Okay, now we’re just going to
very, very quickly, like I said, I’m not going to spend a
lot of time on data entry. I do just want to highlight three
fields here on this section. Urinary catheter — we’re going
to ask you to identify whether or not there is a urinary catheter in place
greater than two calendar days on date of event or if it had been removed but was in
place for greater than two calendar days. Or neither. There was not urinary catheter in place on
the day of event or not in place greater than two days on the date of event. Okay? This is going to drive
the system to identify this as either catheter-associated
or non-catheter associated. The location for device insertion
is optional, if you want it. Sometimes we get questions from facilities that
say, “Well, they put one in and they took it out then they put another one in. And there are different units
what do we put in?” We say, “You can make your own determination,
your own policy about what you want to do with that because we don’t
utilize that field right now. So, you know, you get to make your decision. And the date of device-insertion
is also optional at this point. I did get a question this week from somebody. It looks like on the form — I don’t see
it on here, maybe it’s on the screen. It actually says urinary catheter at time
of specimen collection and that’s an error. We missed pulling that off when we
changed the definition, so this is correct and it’s been there for a year
and a half and nobody noticed it until a user emailed me yesterday. So, just know that it’s at the date of event, is what we’re concerned about
with a catheter presence. Not the date of specimen collection. Okay, your summary data is collected pretty much
the same way it’s on the same forms as for LCBI. Again, you’re going to collect the number
of patients that are present at the time of the count, each day on the unit,
and enter that in this field here. And then the number of patients that have a
urinary catheter that are there at that time on that unit and enter it here for each
day, and then you’ll sum the numbers at the bottom at the end of the month. For NICU, I do want to point out that there
is no in-plan CAUTI surveillance for NICU’s. We no longer allow that because
they’re just used so infrequently in that patient population the
data’s not really that meaningful. But some facilities are opting
to continue to do this off-plan. So if you’re doing that,
those will be entered here. URC days and you’ll be stratifying
it by the different birth weights. And again, birth weight, not weight at that
time, but the weight of the baby at birth. Special care areas, there’s no difference
in how the data is collected here between a special care area
and an ICU or a ward. Unlike, you know, CLABSI’s you have permanent
or temporary central lines for LCBI’s, here it’s just a urinary catheter and it’s
enter — I do again, for all of these events or all of these location types you are going
to have to tell us if you’ve had no events for this month and that’s where you’re
going to check it here — CAUTI. If you don’t check that and you don’t enter any
CAUTI events you’ll get an alert and it’ll say, you know, we don’t know, do
you really not have any UTI’s or have you just forgotten to enter them? You’ll also get an alert if you
don’t enter your patient days or your urinary catheter days for that month. And so, this is the example of the alert. In-plan denominators are reported for
these locations with no associated events. So in this case the ICU, you entered summary
data, you told us how many patient days you had and how many urinary tract days you
had but you didn’t enter any CAUTI’s and you didn’t tell us that
there were no events. So you can — handy-dandy little thing here. You can just go down here
and check these if that’s so. A smart person might wait and do that. Probably not a good idea,
but you could do that, so. Again, if you want to collect your data
electronically, we’re happy to have you do that. We just ask that you concurrently
collect your data manually. You go on the unit or have whoever does
it on the unit collect it manually, do the patient count and the catheter day count at the same time each day and
collect it electronically. Also, compare those two for three months. As long as there’s no difference more than 5%
in either direction, you can then do that for that location, just use your electronic methods. If there is a deviation of greater than
5% than you got to start all over again and try to figure out where the problem
is, get it right, until you, you know — make changes until you are able to
get an accurate count electronically and then you can move ahead with that. So, you need to do it in location
for three months, minimum. Just another sign. I do want to say that oncology hospitals have to
report separately for all locations and units. Anybody from an oncology hospital here? Nobody. Okay. And to remind you that you’re
CMS reportable data has to be included in your monthly reporting plans. If you don’t put it in your monthly
reporting plan it will not be sent to CMS and you won’t be happy, they won’t be happy. Here’s your resources. This is the training site for
urinary tract infection information. We have Lectora, which is a self-paced
software program and does have self-testing, and there’s questions in there and
you have to score greater than 80%. We do expect that people will do the training
at least once before they utilize the system. And then we have — these webinars will be
on there as people have told you in April. I believe, I hope this one is down,
I think it is because it’s outdated. These are just the forms that you’ll use to
report your data, and more resources for you. This is a summary online listing of
all the training that’s available that would be pertinent to
you doing CAUTI training. Okay, so another funny email. So we sent this out, you know, we sent
— this is what we call blast email, to everybody that’s a participant, you know. We said, “We will be restarting NHS application
in a few minutes, please plan accordingly.” You know, because if people have
got data on there we want them to save it so it doesn’t get lost. And somebody reported back, “I haven’t started
baking yet, I don’t know if I’ll get to it.” [ Laughter ] I’m not sure what that meant, but [laughter]. I don’t know what she was referring
to, like baking the data, you know, like she didn’t get it in or if she was thought
she was talking to somebody else or what, but we weren’t really sure how to respond, so. Okay, so we have finished about 15 minutes
early and I’m going to look to Courtney to see before we get into the case studies. Do you want to take a break now or do
you want me to start for 15 minutes. [ Inaudible Speaker ] What’s that? [ Inaudible Speaker ] I’m sorry? Keep going? [ Inaudible Speaker ] For 15 minutes? Okay. We’ll keep going for 15 minutes.>>[Inaudible] questions.>>I can, but I would rather wait because
we might cover the question in the — you’re going to be extra special, you’re the only person that’s
going to get to ask a question. How do you like that? Go ahead. Go ahead [laughter]. [ Inaudible Speaker ] Page 23. Okay. Gap day. Page 23, oh my page is different
— my page is different than your page.>>I’m trying to resolve your three-day Foley
rule plus the gap day example of symptomatology. So you said that you have to
have the Foley in for three days by the last day of symptomatology. So in your gap day example you have a
temperature on 4/7, like Monday, whatever, and then you have a gap day, day two. And then you have a culture
on day three, Wednesday. You’re saying that if the
Foley was inserted on Monday?>>This one?>>This would count?>>No I didn’t [laughter].>>On the same day that they
had the first element or some –>>Thank you, is it this one?>>Yes.>>Okay, so –>>So, if instead of the
Foley being placed on 4/1 –>>Yes.>>The Foley was placed on 4/7.>>Okay.>>Because I’m trying to determine if the
Foley has to be in place for three days on the first day of symptoms, or on the
last day, and you just said the last day. Okay. So that means in this example,
this Foley can be placed on 4/7, the day of the temperature,
and then there’s a gap day, and then the day of the urine is the
third day, that’s three or more days.>>That is correct.>>So this would be counted as a CAUTI. Foley placed on the day of the
first symptom, that makes no sense.>>Well, hopefully, if the patient has
the fever they’re going to be looking to find out why the patient has a fever. Okay?>>Correct, but they placed the Foley on the
same day so it shouldn’t be related to that.>>And, clinically, I’m going to agree with you. And the hope is that most of the time if they
have a fever they’re probably going to try to figure out why they have
the fever and they’re going to collect that culture sometime sooner. There will be rare instances — we can sit
here and try to come up with situations that don’t work and those
situations do happen rarely. Okay?>>This is not an uncommon
situation, where they place a Foley because a patient is having problems. Not having problems due to
having the presence of a device.>>It’s a surveillance definition
and we made these rules because people asked for
them, users asked for them. Because before we had no minimum time period. Right? So, in that case it
still would’ve been a CAUTI.>>Without the ability to have some clinical
correlation, we can’t use these numbers to be able to drive performance improvement. I’ll just –>>I understand.>>Okay.>>I understand. Okay, so let’s — we’ll keep going. No, I don’t think so. Well — [ Applause ] [ Silence ] Okay, let’s start with our case study. Oh. So actually we’ll — so before we start
the case studies I wanted to share something that on the web that highlights the
importance of making good methodology when performing HAI surveillance. So, here we go. Escape — oops, that’s right. That’s not right, here. Here. Okay.>>Hi, I’m [inaudible] and my
CEO says I should talk to you because you’re hospital has zero health
care associated infections for three years.>>Yes, as the infection
preventionist I can say that’s true.>>Wow, that’s amazing. I mean, I have my organization [inaudible]
zero infections and we have had some ruts but we had a month here or there where we
have had none, but zero for three years. That’s incredible.>>Yes. We did it. I have zero infections, for three years.>>How? I mean, don’t you ever
have bacterial trans-location where the patient has no infection but the pathogen escapes the GI
tract and appears in a blood culture?>>We have those cases but my ID
doctor throws those out [laughter].>>Your ID doctor? What is he doing surveillance for?>>He always does surveillance after I
find the cases that meet the definition.>>Has he done any online training
on how to use the definitions or done any [inaudible] trainings on the NHSN
definition or gone to a [inaudible] training?>>No he is an ID doctor.>>So, despite the fact that you have
cases that meet the NHSN CLABSI definition, you don’t count them because your ID physician,
who has no training on epidemiologic definitions or NHSN training doesn’t
think they are NHSN cases?>>Yes. He is an ID doctor [laughter].>>Does he say they don’t meet
the NHSN CLABSI definition?>>He is an ID doctor [laughter].>>You already said they met the
definition why even have them look at them?>>He is an ID doctor [laughter].>>We established that. Have you been to training
on the NHSN definition?>>Yes, I have done many classes and do the
[inaudible] training on the definitions.>>So, you are having someone who is incompetent at using the definition override your
judgment as a trained epidemiologist.>>He is an ID doctor [laughter].>>Yes, and if I had a central
line infection I would want him to give advice on how to manage that infection. Why does he even want to
look at the CLABSI cases?>>He is very interested in CLABSI. As Chair of the Infection
Control Committee he gets a bonus for lowering the hospital’s
infections [laughter].>>Don’t you see that is a conflict of interest. Why would you allow that surveillance
to potentially be compromised like that?>>He is an ID doctor.>>Let’s talk about CAUTI. No CAUTI?>>We have zero HAIs. My ID doctor reviews them.>>Is your ID doctor’s name Dr. No? Let’s talk about SSIs. No small bowel infections? No colon surgery infections?>>I have had no HAIs for three years.>>How do you do surveillance for SSIs?>>I look at the microbiology results
and if there are none they are cleared.>>What about radiology results?>>I look at the microbiology results
and if there are none they are cleared.>>Why would a surgeon culture a gut leak, they
use the x-rays to find abscesses and then treat. How about MD notes, do you
read them on the cases?>>Doctors at my hospital write a lot.>>Yes, how do you assure yourself they
aren’t diagnosing a surgical site infection in their notes or describing a wound
infection if you don’t read the notes?>>Doctors at my hospital write a lot.>>Do you do a search for antibiotic therapy
post- surgery or returns to the O.R.?>>I have no HAIs for three years.>>I will take that as a no. So you never had a failed anastomosis
that resulted in an infection?>>We have those cases but my ID
doctor throws those out [laughter].>>Doesn’t he know that the definition
does not exclude them from being cases?>>Yes, but he disagrees with the definition.>>I can disagree with gravity but it
doesn’t mean that it no longer applies to me.>>He is an ID doctor. I have had no HAIs for three years.>>Liar. Oh, I feel an HAI coming on.>>I also have 100% hand hygiene compliance,
do you want to know how [laughter]? [ Applause ] [ Inaudible Speaker ] All right [laughter]. So, I don’t think I want to take
comments after that [laughter]. [ Inaudible Speaker ] Oh, the author’s here? Oh! [ Applause ] Oh, Bravo! Bravo. Who is the author? [ Inaudible Speaker ] Greg Meyers [assumed spelling]. Okay. Nice job. So that was just a little light-hearted. I thought you guys would enjoy that. I enjoyed it. Somebody sent it to me and, you know, I think
it’s really — it does drive home, you know, that we all need to do what we’re supposed
to do and I understand that there are — that the definitions are not perfect. Believe me, we get emails all the time
and we understand it and we are — I hope that you heard in the last two days
that we do listen to you and that we are trying to improve them, you know, where we can. So, we can go ahead and start one case
study and we’re going to just look at these, we’re not going to get into
surveillance versus clinical. We’re just going to learn, make sure that
we’re accurately reporting the definitions or applying the definitions and
we’ll try to optimize the consistency and that application and improve data quality. So, as I said yesterday, when you’re looking
through these case studies you might want to consider looking at them in this order. Is it a POA? If it’s a POA and they haven’t been
discharged in the last two days you can stop, we don’t need to have it reported at
NHSN, we’re only interested in HAI’s. Is it an HAI if it’s not POA? If it’s not an HAI — remember
we talked about there’s some that are not POA, that are not HAI — then stop. Finally — next you’re going to ask
yourself is it catheter-associated UTI. And then you’re going to need to look at where
to attribute it if it is a CAUTI So case one. Mama Unlucky is admitted unconscious
after she fell when three deer ran out in front of her while skiing. She has a broken femur. A Foley and a peripheral IV are inserted. On day three her Foley is removed, she’s
awake and making good recovery progress. On the fourth day she’s up with assistance
but she complains of pain on voiding, has a UA collected and it has
slight leukocyte esterase, negative nitrites, and 15 WBC’s on spun urine. The next day they collect a urine
culture which has 10 the fourth, or 10,000 CFU’s per ml of E. coli. So, questions for you is does this
patient have a CAUTI and if so what type? Choose yes, a SUTI one A. Yes,
a SUTI two A. Yes, an ABUTI. Or, no CAUTI at all. You can vote. A couple more seconds. Okay, so let’s see what you all say. Oh, we have some difference of opinions here. We have 50% say it’s a CAUTI two A,
and some people, 38% say no CAUTI. This is no CAUTI. Okay, so criteria were not met in the POA time
period and the patient does not meet criteria for UTI with dysuria and positive urine culture
and a UA — I’m sorry that do meet that, but the date of event was later
than the day after removal. Right? So, the Foley was removed on day three. The patient didn’t meet criteria
the date of event, until day five. Okay? So, it’s a UTI but it’s
not a catheter-associated UTI. Okay?

2016 NHSN – Infection Prevention and Surveillance in LTC

2016 NHSN – Infection Prevention and Surveillance in LTC


>>Welcome to Atlanta
and the start of the 2016 NHSN
Annual Training. We tried to order
some pretty weather for those of you who have come from the north, and I hope we did alright. My name for those of
who I haven’t had the privilege to meet yet
is Nimalie Stone. And I’m the medical
epidemiologist for long-term care here
in the Division of Healthcare Quality
Promotion at the CDC. And I am thrilled
that we are beginning our annual training this year with long-term care content. This is our first
year where long-term care has had an
opportunity to present, so I appreciate all of
you being a part of this and we hope that
with your feedback, we can continue
to make this part of the agenda in the future. Some of you will be
here with us for the entire week of the training, but others will
just be here today focused on the long-term
care content, and we really appreciate
and thank you for your travel and spending
some time with us and welcome you again —
just a few housekeeping items to cover before we start
with the presentations. If there is an emergency, please
note the nearest exit sign and the locations around the room. Safety first, right? CDC and our planners,
presenters, as well as spouses and partners
wish to disclose that we have no
financial interests or other relationships
with the manufacturers of commercial products,
suppliers of commercial services or
commercial supporters. Our planners have reviewed
content to ensure there’s no bias. And presentations
will not include any discussion of the unlabeled
use of a product or a product under investigational use. CDC did not accept
commercial support for this continuing
education activity. And no specific
case studies will be addressed during
the training. Continuing Education
credits are available and instruction on how to apply for CE credits are in your folders. Please be sure to
scan in and scan out daily with Avaris so we can note your
attendance for the training. Also, note in the
resource manual a few handouts for long-term
care are in the back. Please feel free to
bring coffee, water and snacks into the
conference room. If you have any travel, parking, registration or
logistics questions, check with our colleagues
from Avaris at the front desk. Also, team members
from the NHSN Help Desk will be out front to answer or address other questions you may have. No photography inside the CDC is allowed. Please put your phones on
silent or vibrate mode. Also, we ask that all
of you hold your questions until the end
of each presentation. And with all that said,
why don’t we get started with our
preconference session? And in the next — So,
here in the next 30 minutes or so, I wanted
to have the opportunity to share with you
a perspective on some of the Infection
Surveillance and Prevention activities
have happening in long-term care
and I think many of you have heard me
talk before, so I was trying to think
of what I could say that would be novel
or interesting, and I thought, well since
this is our first time up here talking with you
as part of this NHSN training, let’s just do
a little retrospective and go back to 2009,
when in August, CDC hosted the Healthcare-Associated
Infections, HAI Surveillance in
Long-term Care Conference. And this was a group of academic partners, health
department partners, colleagues that represented
most of the nursing home professional
organizations like AMDA, the Society for Post-acute
and Long-term Care Medicine, the American
Healthcare Association, and the goal of the
discussion was to help guide CDC’s planning
around implementation of surveillance,
HAI surveillance infrastructure for
long-term care. This was before NHSN
had a component for long-term care facility
providers to report. And here were some of the takeaway, highlight summary statements
that came from that conference. CDC in partnership with national
collaborators is committed to developing a national HAI
Surveillance program tailored for an accessible to
long-term care facilities. In addition, the top
priority of this HAI Surveillance Program will be to provide information
and support for quality improvement
efforts among participating facilities. So it’s just a major
rationale for creating this surveillance
infrastructure. And we walked out with a proposed plan that there would be a
long-term care component designed within the
framework of NHSN based on the existing modules
we had available for hospitals and other
healthcare settings, but with adaptation
for the long-term care population and
for providers. So this was August 2009. That’s five and a half years ago. And then a few years
after that, about three years in fact, in 2012,
we saw the release of the long-term care
facility infection reporting component within NHSN. And right on the heels
of that came the updated infection
surveillance definitions for long-term care
facilities that was a joint effort published by
CDC and the Society for Healthcare Epidemiologist
of America/SHEA, and what was convenient
and not by accident was that these efforts informed
one another so as the criteria for surveillance were
being developed by our academic partners
and researchers and nursing home partners in the field as the McGeer definitions for long-term care
were being revised, we were integrating
those criteria into the infection
reporting events within NHSN, so there would be
congruence if you will and alignment between those efforts. And a few months
later, we looked at how many facilities had come in to the long-term
care facility component and this is three years ago
in February of 2013. So that’s about five,
roughly months after the component
had been released, and there 61 nursing homes
represented among 14 states. And you can see most of
the states had just one or two nursing homes that
had gotten enrolled, a couple which had
tried to maybe actively engage nursing
home providers in the conversation had gotten a few more. And Vermont was planning
this for a couple of years — for several years in fact
before NHSN came live. So they had quite a bit of
traction already in their state. So this is what the
map looked like three years ago when component
was pretty new. And here it is today. Three years later, we can
see we’ve got quite a few more states and quite
a few more facilities, 280 nursing homes that
have enrolled and are now actively
eligible to report. They may not all
be reporting and I think that’s important
to recognize, but one of the big hurdles,
right, is enrollment. So these have — these
280 facilities have actually made it through
the enrollment process with help and successfully,
and they represent 38 states, plus the
District of Columbia. And here you can see
more than a handful of states that have
worked intentionally with providers to engage nursing homes in this, supported them, and much of this
effort has been led by our state health department. How many of you are
here representing your state health
department today? Fantastic. Well, I applaud you
and thank you for all the work that you have
done in this effort. And then many of you
probably are representing quality improvement
organization or QINs. How many of you are representing QINs? Welcome. So it’s about half and half. That’s fantastic. Well hopefully you all
know each other already. If not, this is a
fabulous opportunity to meet and talk about
how your activities and efforts align with one another’s, especially in long-term care especially in the
next few years. So what were some
of the drivers for NHSN use in these
first three years of our experience with a component? I think as I mentioned
already, the state HAI programs engaging nursing
homes and promoting it as a tool for
supporting prevention efforts around C.
difficile infection and multidrug-resistant organisms. In addition, we
found that hospital systems or hospital
partners were working with their affiliated
nursing homes and long-term care facilities to help them start to
get involved in NHSN. There have been some policy
statements, probably written by folks who
are here in the room about the importance and
the opportunity that NHSN reporting offers
for long-term care when it comes to HAI Surveillance. One of the biggest statements
that came out from the Department of Health
and Human Services in the spring of 2013
was the HAI Prevention Roadmap and the Action
Plan to eliminate HAIs. And there was a chapter
specifically focused on long-term care that
made NHSN enrollment and reporting one of the top
priorities for this setting. And then not that long
ago, just nine months ago, I guess last summer,
the counsel for State and Territorial
Epidemiologists put a position statement
that also endorsed and encouraged the use of
NHSN as the standard setting for Infection Surveillance
in long-term care. So we’ve also seen in
this timeline a lot of awareness of the
role of NHSN reporting from state and federal incentive programs. For example, all of
you are intimately connected to the CMS
reporting programs and other post-acute
care settings like long-term acute
care hospitals and inpatient rehabilitation
facilities not — in addition to dialysis clinics
and acute care hospitals. About a year ago,
Nevada became the first state to require
NHSN reporting from skilled nursing
facilities, and they’re still in the midst of
implementing that. And then interestingly, you
know, the survey process and the regulatory process
is a very powerful driver of change in
the nursing homes. And if you are not
connected to and working with your state survey
agency and the folks that do oversight
of nursing homes, I would encourage you
to get to know them and make them aware of
the work you’re doing, because I think again,
there’s a lot alignment between everybody’s
goals to raise the quality and safety
in these facilities, but in Wisconsin,
there were surveyors starting to ask when the
visit nursing homes, they just ask about
NHSN — Do you know it? Have you heard of it? Do you use it? Just part of your
surveillance program, and although it was
not a requirement and there was not
citation or deficiency if you said, no, I’ve
never heard of it, the fact that people
were talking about it and being asked about
it really started to get facilities interested
in paying attention. So we have kind of had a
facelift, not that long ago. And our website has got
a lot of new training resources and Angela
and others will kind of walk you through those
resources later in this session. But one the strengths
and one of the reasons why we wanted to see
NHSN become an — you know, become a
resource for long-term care was the power of
standardization — the power of standardizing our
approach to identifying events and tracking our data
and reporting our data. And as you hopefully are
aware, the component current affords reporting
options for facilities in urinary tract
infection surveillance, as well as
multidrug-resistant organism and C. difficile
surveillance through laboratory identified
events surveillance, as well as some prevention
process measures such as adherence to hand hygiene and gown and glove use. And there’s a lot of
interconnectedness between use of antibiotics. For example in urinary
tract infections and how that has
impact on our rates of resistant C. diff that are
activities at the bedside. So there was some
strategy to how these initial early events
were rolled out. I wanted to share
briefly a little bit of information from analysis
that we did to look at some of our very,
very early adapters of the long-term care
facility component, and these were the facilities
that enrolled and reported data with the first two full
calendar years that the system was up and available,
and that’s January of 2013 through December of 2014. There are about 200
facilities that had enrolled in that time frame, and you can see the median
bed size was about a hundred. The daily census was comparable, 99. The median staff hours
per week that were given to Infection
Control was 14 — 14 hours a week for Infection
Control in these facilities. You can see the inner
core trial range there from as low as eight hours
a week to the high, well, you know — This
75 percent was 24 hours, so that’s still not a lot
of time if you think about how much work there is
to do in infection prevention and incorporate not
just surveillance, but all the teaching
and prevention work to make a change
if you’re looking at event outcomes that you want to see go down, so not a lot of time. And in that cohort,
three-quarters of them have submitted at least one
monthly reporting plan so the question is, okay, you’re enrolled, how many of them are actually
trying to use the system? And in this two-year
window, we saw 155 put at least one month of
reporting intention. Now submitting a
plan doesn’t mean that you completed the month, right, so there is more to see there. Let’s see, when we looked
at the month intended versus the month of
completed, you see a range, but actually it’s not that bad, right? Our sort of most
successful event reporting is actually urinary
tract infection, which kind of surprised
me a little because that’s one of the more
complex events to report. There’s more signs and
symptoms surveillance, in addition to looking at
laboratory data, right? So you have to do a
little more on the chart, but 81 percent of the
facilities that intended to report a month with the data completed that, and C.
difficile, I don’t think it
anyone was surprised as our most popular
event to report, and about 74 percent
of the time, people got it done
for that month. So pretty good, actually. So 83 percent of
facilities overall who had a reporting plan
or more submitted — completed at least one month of
data in this two-year period. But then we tried to
look at little bit more at the stability
of reporting. So is this a one and
done, or did I get it and start reporting
and stay reporting? So we defined consistent
reporters, people who had — or facilities I should say
that had completed at least six or more months of data in a calendar year. And there, you can
see in the red box that from calendar
year 2013 to ’14, we saw pretty substantial
drop in consistent reporting. In 2013, we had 70
facilities representing 75 or 76 percent of the
facilities intending to report one month
or more data actually consistently report,
so six months or more of reporting, but then
in 2014, we saw that fall off to less than 50 percent — 47 in 2014. So we wondered maybe
what could have accounted for that,
and we looked at — We don’t have a huge amount
of information about these facilities, right,
but we looked at, you know, well, how
did the consistent reporting cohort
change geographically? And what’s interesting,
you can see there are a couple of places in
particular where in 2013, we had a lot more folks consistently
reporting that they kind of fell off in calendar year 2014. And if those of you who work in the health
departments, you know, we have projects that pretty
much go from year to year. So, we are going to focus
on this effort for this calendar year and
then budgets change or priorities change
or we have finished this, and so we move
to our next effort. And what you’re
seeing is that when that external support goes away, then the internal
motivation to sustain engagement in the
system seems to fall. And I don’t if many of you are probably familiar
with long-term care. How many of you
work primarily with long-term care in
your positions? So not a huge number,
but for those of you who have worked with
nursing home providers, you know that there are reasons
why this could happen — that in fact, there
are quite a few barriers to sustaining
voluntary reporting. Now, remember there are no
incentives except in Nevada, there’s no other place
where this is a must-do. There’s not a penalty
or a financial driver to engage in NHSN
for nursing homes. And things like staff
turnover, limitations in Infection Prevention
staff and resources, and we looked at the current
landscape of these, and I consider these
facilities perhaps the higher end of
the curve in terms of their willingness
to dedicate time to infection prevention
because they actually went through the steps and hurdles
of getting enrolled. So here we are at
sort of the higher functional or more
committed group and yet there’s not a lot
of time being given to nursing home Infection
Prevention work. And there are a lot of
competing priorities. So as this project ends
and people move onto the next thing, it’s
very hard for them to maintain and sustain their engagement. In addition, I think this is an important message for all of us. Facilities, currently
nursing homes using NHSN may not be getting
the maximum value and benefit from their own data. And there are some reasons
for that we can explore. And I think some of you
who have experience already working
with nursing homes and NHSN reporting,
could probably teach us why some of those
challenges are there. But we have to make
NHSN more useful and valuable to the providers so that they want to stay involved. So external partners
like you and programs that drive NHSN use by nursing homes are
incredibly important right now to help
them become aware of the system but also to use it. And participation
and collaboratives really does help
maintain engagement and provide some scaffolding
if you will for accountability. It also really
creates a powerful forum for sharing experiences in seeing how individual
facilities experience may compare to peers, and
that’s again something that you all can bring to those providers that
you’re working with. So what’s going to
happen in the next few years, I just wanted
to highlight things, most of which you already are aware of. But just in case you
hadn’t heard, there are some great opportunities
in the next year or two coming to nursing
homes to help support these kinds of
activities and the work that you’ve already been doing,
lays the foundation for that. So, we’ve seen incredible
attention to reducing antibiotic-resistant organisms and C.
difficile in our communities, and
we have messaged quite a lot in the last year and
a half the importance of health departments
to be at the hub of coordinating work
and communities to reduce resistance and improve antibiotic use and stewardship and across the healthcare spectrum. And there are a lot of
different activities that colleagues in health
departments can engage within including looking
at the way transitions of care occur and
where do people move and how do they move,
and we know that there are certain dyads or
triads that share a lot of patients within a
community or region and if there’s a problem in one
of those facilities, it’s going to somehow
influence and impact those others that are
sharing that population. So understanding that continuum of care and how people
move is a critical piece to addressing prevention. Promoting NHSN Surveillance
as vehicle for mapping and tracking
facility-level data, we see the benefit of
this when we work at the hospital partners
who have a lot of data for a few years now,
and you can really see the way we can target
our prevention work with those facilities that
seem to have a bigger problem. And wouldn’t it be nice
to know where those pockets of needs might
be in other parts of the healthcare continuum
in particular nursing homes where we don’t have a lot of data yet. There are opportunities
for health department partners and quality
improvement organizations to help with implementation
of prevention and stewardship activities
to bring again community of care partners
together, to facilitate conversations, improve
quality of care and information flow
when people are moving, and there’s
an opportunity really to measure the impact, the
change of all of these activities and find those gaps and close those gaps. This is where we want to see our regional prevention
work take us. In addition and not by accident, our colleagues at
CMS are working to drive C. difficile
prevention in the same — using the similar,
very similar strategies around collaboration and
information sharing and identifying the strategic
communities that need support. So, the CMS C. difficile
reporting and reduction project which
has been announced and is in the early
stages of getting kicked off is happening
within the framework of the National
Nursing Home Quality Care Collaborative and
those of you work with the QIO
programs are already very much involved
in that effort. In fact, in its first
few years, the Nursing Home Quality Care
Collaborative has already brought a large
number of nursing homes into the group
— over 7,000. The CDI Project goal is
to recruit 15 percent of nursing homes
across the country. That’s roughly 2,000
— a little over 2,000 facilities to
enroll into NHSN and sustain CDI reporting over
the course of the project. And you can see it is a multiyear effort. And the participant
facilities working in this collaborative and this
CDI Project piece of it, which you could see is a subset,
right, at the larger group. They will receive
training and support on CDI reporting and then
everyone involved in the collaborative will
get education and resources around C. difficile prevention
and antibiotic stewardship. And you can see some
of the types of information and pieces
of that program that will be rolling out
over the next few years. So, why do it now? Because doing — getting involved now and doing this work
now will hopefully get these facilities prepared for whatever might come in the future. When we were at that
conference all those years ago in 2009
talking about well where else could we go with
HAI Surveillance data? Here were some of the things
that we could eventually get to. We could look at the scope,
the burden if you will of HAI’s in long-term care at national level. This is how we leverage the
powerful data of NHSN and all of the information
reported by hospitals. We can look at the HAI
incident rates in this setting and
inform our prevention and control policies and efforts. We can be strategic in
the places that we work. We can provide quality of care measures for regulatory
and licensing, which is how we’ve
seen NHSN evolve in hospitals and other
post-acute care settings over the last decade,
and eventually perhaps, there would
be the opportunity to use those same
measures to guide transparency in making
this data that is so powerful accessible to
all including our consumers and the patient’s themselves
who rely on these facilities. And there are step-stones
around — along that path. We’re not quite there yet, but
I do hope that you’re aware of large regulatory
update being made to the nursing home requirements
for participation at CMS released in
the summer, that incorporates quite a lot
of new expectations for Infection Prevention and Control programs
in nursing homes. This is just a quick
highlight of some of those new regulations, things
like a risk assessment of the population that
guides the resources and staffing planned for
care in that building, integrating Infection Prevention into the larger
Quality Assurance and Performance Improvement
program that every facility needs to have,
having an annual review and update of the
Infection Prevention Program including
policies and procedures, again that would keep up
with the changing population that you’re caring for in the building. Something very new is
the expectation of antibiotic use protocols
and monitoring as part of stewardship in every nursing home and designating
an individual to be the Infection Prevention control officer,
and in particular, making sure that individual has specific infection
prevention training, which is a huge
need and gap right now, which has to
be closed in order for any of this other stuff to work. And then having not
only that designated individual with infection
prevention training, but also making sure
that for the bedside frontline caregiving
staff, there is education and training as well
around infection prevention practice, so
very positive changes, but I do think this is a big,
big heavy lift as well — so to be aware that
your partners that you’re to, to bring
into a conversation about NHSN are also seeing this looming out there in the future. They have to see how
working with you and working within your
programs are going to help them achieve
these goals and actually service resources
to their programs and not as perhaps distractions,
right, that I’m not going to get this work done
that I must get done. So we have to do a lot
to align our efforts. I wanted to quickly
mention that there’s some legislation that came out
in the Fall of 2014, so it’s been out there for a little while. The Improving
Medicare Post-Acute Care Transformation
Act or IMPACT Act which was intended
to align measures of quality in
reporting among all of the providers delivering
post-acute care in this country and hopefully
this language — this terminology is
familiar to all of you that we have acute
care hospitals, right, and we used to just
focus so much of our work there because
people stayed there for a long time and generally by the time they were
ready to leave, they were safe enough to go home. But now as we’ve seen lengths of stay change and
shorten and shorten and we’ve seen different
payment incentives, we’ve got a whole new
crop of providers that help patients who
are leaving acute care hospitals but are
not ready to go back into their homes, be
safely transitioned, and this post-acute care arena
is probably the place where we need to be starting
to shift all of our focus because people are
still receiving high level acute care, right. So, these are
long-term acute care hospitals that are
all for intensive purposes like step-down ICUs. People are on ventilators. They’re receiving IVs. They’re — they have
wounds and we know that those are the
trifecta of risk factors for resistant organisms
and antibiotic exposure and the
complications from that. We have inpatient
rehab facilities that are trying to
strengthen somebody and get them independent
again before they can go back into their
environment and home and be strong enough and safe enough to recover
their function, and then skilled nursing
facilities which are the biggest
post-acute care provider, also providing more
and more not a destination for
care, but a bridge. So I’m only coming for
a few weeks to rehab or get my skilled
care needs met before I go back to my home
in the community. So right now, there’s a
lot of differences in the way payment is going
into post-acute care and also the way we track and measure quality in
these settings. The goal of this
legislation was frankly to better align and to
make it more equitable, because you may
be receiving very similar care in two
different places and getting very
different resources, and that’s kind of a problem. So, this was intended
to look at the whole post-acute care arena
and address some of those disparities in payment
and measures of quality. And so currently, we
know that CMS has quality reporting
incentive programs for long-term care
acute hospital and inpatient rehabilitation
facilities that include NHSN reporting, right? Everybody’s aware of that. And now we have kind
of a door open that if we want to see alignment
and standardization across post-acute
care, that NHSN reporting could be a
natural next step for skilled nursing
facilities, and that’s the reason I
raise this today. It’s not here yet
and we don’t know when, but I think
there’s precedent and there is potential now for
that to come in the future. So, just to summarize — I think all of you have seen yourself, that nursing homes are
really being expected more and more to take
action in tracking and preventing the spread of HAIs. And we hope that providers
will see NHSN as a resource to support their
prevention efforts by providing that data
for action and allowing them to track their
current opportunities for improvement and measure
the change in their efforts. Nursing homes are
starting to look at NHSN and thanks again to you, we’re starting to see reporting
and use of the system grow. We have evidence that consistent
reporting can be done. It’s feasible but it takes a lot of external support
and resources. And we need to continue
leveraging these opportunities coming
in the next year to grow the industry’s involvement. And the message — one
of the key messages I hope that you all agree
with and can take to frontline nursing
homes in your states is that this is an
exciting opportunity to get involved now,
take advantage of the help, take advantage
of the resources and the knowledge that
all of you are going to bring to them so
they will be prepared for whatever the future might look like. The facilities that
are now starting to get involved in surveillance and prevention programs will
be seen in their community as progressive forward
thinking leaders, and that they will
have in place a lot of the expectations the programs
to meet whatever regulatory or quality incentives
may come down the road. So I’m going to stop there, and thank you so much for your time. I think we have a
minute maybe or two for questions if
anyone has a question. [ Applause ] Yes, here in the front. [ Inaudible Question ] So the question for those of you in the back is in
long-term care, often times residents
may have a primary care physician that is not a
part of the facility, responsible for their
prescriptions, and if we’re talking about
antibiotic stewardship, how do we engage those
primary care providers in the discussion
and engage them? It’s a very good question. Long-term care is
a large spectrum, right and in nursing homes, generally there are physician leaders that can help corral
the provider’s practicing in their building. These are the medical
directors, the physician leaders in
those nursing homes. But, when you start
to move into some of the more community-based
facilities, residential care or assisted
living, then the model changes and you do have each
individual person has their own caregiver, their
own doc, and there may or may not be somebody
at the building itself, coordinating
those care decisions. There — Our division
does recognize that stewardship has to
come and the message around antibiotic use has to
be across all care settings, so hospitals, long-term
care and outpatient. And we do have actually
quite a lot already around improving antibiotic
use in primary care for pediatrics and
we’ve started to move that discussion
to look at adults who are receiving
antibiotics for respiratory tract infections. We know there’s a
large spectrum and a lot of overuse of antibiotics for things like bronchitis for example. So there are members of our team that are focused on outpatient and there are conversations
with some of those primary care
providers and even things like Minute Clinics, and
there’s a whole new world, right, of primary care evolving in Urgent Care. So we are talking to those
providers and figuring out how does stewardship
look in outpatient care. But you’re right,
we do have to make sure we continue to expand that. Anybody else brave
enough at the start to stand up — Yes in the back? [ Inaudible Question ] So — Help me see how that —
What could we do — I’d like — The question is how
do we help improve communication at Care
Transition actively sort of now, instead of trying
to look back at old data and say, oh,
there’s a problem here. We should go. There — We have put
some pieces of, I guess, tools out like there’s
an inner-facility communication transfer form, which actually I have to credit
our colleagues from Utah. They were the ones that
got us started and really very graciously
allowed us to share with the rest of everyone out
there that example form, right, that you can use to catch
key infection prevention and antibiotic use was there
and history of MDRO. Carriage or infection
was part of the tool. So we have health departments
who are trying to operationalize that
within in collaboratives that bring hospitals and
nursing homes together. It’s a little tricky to
have real-time data when we don’t have much data
yet from long-term care, but how many of you are familiar with the TAP analysis
within NHSN? I see several hands. Yes, good, that’s wonderful to hear. I’m sure it’ll come up
again probably this week. But that kind of — The
goal of that strategy is to target those
communities or facilities where there are — where they’re
having SIRs that are higher. That could become — be
— The more and more of you that have access to
that data in real time and have group-sharing
information with you, that can
be used perhaps to feedback more quickly
information to the community to get that conversation going,
but I — we can talk. I’d love to hear some thoughts, and I know many of you do work with cross collaborative settings, right? You bring groups
together already, so maybe there are forum
that exists to have that conversation and
to make that more of an active intervention
within your groups. So I want to be mindful
of the time and also I’m probably the least
important person up here this afternoon,
because my colleagues who are coming up next
are really the folks who make NHSN go and
provide the educational resources and tools and
content and slides that you hope — can
take advantage of as you got out and
engage nursing homes.

Surgical Site Infections (SSI) – Event Form for January 2016

Surgical Site Infections (SSI) – Event Form for January 2016


Welcome to the 2016 National Healthcare Safety Network, or N-S-H-N, Quick Learn series. These C-D-C presentations are an educational resource for healthcare facilities working to prevent Healthcare Associated Infections, or H-A-Is. This presentation reviews the Surgical Site Infection, or S-S-I, event form. PATOS, or Infection Present at the Time of Surgery, is a required field on the S-S-I event form. N-H-S-N frequently receives questions about how to fill out the PATOS field. In this session, we will answer some of the most frequently asked questions.The patient does not have to meet the N-H-S-N definition of an S-S-I at the time of the primary procedure, but there must be evidence of an infection or abscess present at the time of surgery. One question we are frequently asked is, “If I find an infection that meets criteria for a PATOS S-S-I, do I have to report this as an S-S-I event?” The answer is YES. S-S-I Events with the PATOS field marked as ‘YES’ are reported if they are attributable to an operative procedure that the facility is following in its reporting plan. Another question we get is, “If a patient has infection present at the time of surgery, does that mean that any subsequent S-S-I will automatically be PATOS equals YES?” The answer is NO. The PATOS field should only be marked ‘YES’ when it applies to an S-S-I event that is at the same level as the infection that was present at the time of surgery. For example, if a patient had an intra-abdominal infection at the time of surgery and then later returns in the surveillance period with an organ space S-S-I, the PATOS field would be YES. However, if the patient returns with a superficial or deep incisional S-S-I, the PATOS field would be NO. Here are two other questions we get: “Are S-S-I events with PATOS marked YES included in the Standardized Infection Ratio, or S-I-R? And for COLO and HYST procedures, are these S-S-I PATOS events reported to C-M-S? All S-S-Is reported as present at time of surgery are included in the S-I-R if the wound closure method is noted as a “primary closure.” Procedures with closure methods other than primary, are not included in S-I-R analysis. All COLO and HYST procedures which are primary closures and their associated SSIs events are reported to C-M-S. Recently we were asked, “How will the S-S-I, S-I-R be affected after the new baseline?” The S-S-I and procedure data reported for 2015 will be used as a new baseline for S-S-I S-I-Rs. During the re-baseline analysis, PATOS may be excluded from future S-S-I S-I-Rs calculated on the 2015 baseline. When the re-baseline and new risk adjustments are implemented later in 2016, this new data will be applied retrospectively to the 2015 data. This means there will be 2 S-I-Rs; one using the 2006-2008 baseline and the other using the new baseline. Both will be sent to C-M-S. We are frequently asked to give a few examples of what would and would not be a PATOS equals YES on an S-S-I event. First, what can be a PATOS? PATOS means that there is evidence of an infection or abscess at the start of, or during, the index surgical procedure. In other words, it’s present pre-operatively. For PATOS you do not need to meet S-S-I infection definitions. Some examples of PATOS include abscess, infection in the O-R note, purulence or pus, septic or feculent peritonitis, or a ruptured appendix. There are some exceptions to PATOS. PATOS is not diagnosis-driven. For example, diverticulitis, peritonitis, or appendicitis alone does not always mean there was a PATOS infection. There must also be evidence of infection in the organ space. Here’s some guidance to regarding what is not a PATOS. If the only finding is an organism from a culture obtained in the O-R or on a pathology report from a surgical specimen, this is not a PATOS. However, if the culture was taken from an abscess or pus, this is a PATOS equals yes for a subsequent SSI at that same level. If a rupture or perforation of the colon has occurred, but there is no evidence of infection, this would not be a PATOS. Fecal spillage or a nicked bowel during procedure would not be a PATOS. This is a complication, but there was no infection caused by this at the time of surgery. Inflammation, necrosis, or gangrene alone is not a PATOS. Fresh traumas that are contaminated cases do not necessarily meet PATOS. For example, a fresh gunshot wound to the abdomen is an emergency; it’s a trauma case with a high wound class but it would not have had time for infection to develop. You can find more details in the PATOS section of the 2016 S-S-I protocol. For more information, visit C-D-C-dot-gov-slash-N-H-S-N. You can e-mail questions to N-H-S-N at C-D-C-dot-gov.

Catheter-Associated Urinary Tract Infection (CAUTI) Case Studies

Catheter-Associated Urinary Tract Infection (CAUTI) Case Studies


>>Alright. Well let’s first
just real quick go over the purpose of
our case studies. First of all, it just gives
you good training on the use of the definitions, and these
are all based on the new, January 13 definitions. Try to learn to accurately
apply these definitions and to realize these are
surveillance definitions. And can be very consistent
in our application and improve our data quality. And I was just speaking with
someone during the break, and I think when we roll out
all these new definitions and we’ve been talking
a lot about validation of denominator data, I
think it’s really good when you move this many
kind of new definitions, it’s good to get
with someone when — with your numerator as well. And when you’re starting to
write up these [inaudible], you know, based on
new definitions, just have someone you can sit
with and validate, say, “Mike, have I got this right?” [Chuckles], you know. But hopefully going
through this will help you. Alright, let’s start
with case one. Day 1, we have a
50-year-old patient with end-stage pancreatic
cancer, with liver and bone meds admitted to the
hospital with advanced directive for comfort care and antibiotics
only, a Foley catheter, a peripheral IV and
nasal canula inserted. On day four now, the
Foley is still in place. The patient is febrile
to 38.0 centigrade. Has suprapubic tenderness. IV ampicillin was started after a urine was
obtained for culture. Day five the patient’s
having difficulty breathing. The chest x-ray shows
an infiltrate in the left lung base. On day six those urine culture
results are back that were taken on the fourth, and it shows
10 to the 5th of e coli. Day seven, you’ve got WBC’s
of 3,400, patchy infiltrates in both lung bases, continued
episodes of dyspnea [inaudible] in the left lower lobe. And on day 11 the
patient expired [pause]. Does this patient have a UTI? And if so, what type? Yes, a SUTI Criterion 1A. You can get your definitions
there, kind of in front of you. There was a — the SUTI page
was cut and pasted on there. Yes, SUTI, Criterion 2A. Yes, and ABUTI, or no UTI. Go ahead and use your clickers. This is to vote. [ Background conversations ]>>All of mine are voting
questions except the last two I think [pause]. Alright. [ Background conversations ]>>We’re getting there. I need a few more
responses we’re waiting for. [ Background conversations ]>>I can see there’s some group
consensus going on at tables; good discussion [pause]. Alright. I’m going to give
you about 10 more seconds. I don’t use the little
timer, but I’m going to close the poling
in about 10 seconds. So go ahead and get
those responses in. [ Background conversations ]>>See I can see how
many of you have voted. I have a little magic
screen here. [ Background conversations ]>>Alrighty. [ Background conversations ]>>And the answer is
yes, they have a SUTI 1a. Okay? And we’re going
to go through and show you the rationale. You all did great on that
[background conversations]. So I have that page right
in front of me there. The catheter had been in
place in place for greater than two calendar days. Suprapubic tenderness,
and greater than 10 to the 5th colony-forming units. See, that wasn’t so hard, right? But that fever that she had? That was only 38. It was not greater than 38. So you had to use that
suprapubic tenderness. [ Pause ]>>Alright. Case 2. On 8/2 a
66-year-old went to the OR for an exploratory lab and
Foley was inserted in the OR, and they were transferred
to ICU post-op. On 8/3 the patient was
stable; Foley’s still in place. On 8/4 the patient was
noted to be febrile to 38.9 and complained of
diffuse abdominal pain. The WBC’s were increased
to 19,000. He had cloudy, foul-smelling
urine, and the urinalysis showed
2+ protein, 1+ nitrites, 2+ leukocyte esterase, WBC’s
of 10,000 and 3+ bacteria. And the culture was 10 to the 4th colony-forming
units of e coli. The abdominal pain seemed to be
localized to the surgical area. Is this a UTI? And if so, what type? Was there no UTI? Yes, it was a SUTI criterion 1b. Yes, a SUTI criterion
2a, or yes, an ABUTI. [ Pause ]>>Place your votes. [ Background conversations ]>>Alright I’m going to give
you about 10 more seconds. Make a decision;
place your vote. [ Background conversations ]>>Okay. [ Background conversations ]>>Yes. Look how well
you all are doing; 90% of you got that one right. Yes. This is a SUTI,
criterion 2a. And we’ll go over that. So remember, 2a is where you
have the little bit lower colony-forming counts, but
the patient has had a Foley in for two days, had the fever
that was greater than 38. Had the leukocyte esterase
and the nitrite positive. Remember the leukocyte
esterase points to the fact that there may be some
WBC’s in the urine. And the nitrite points to the fact there may be
some bacteria in the urine. If you — that’s fallen off
your radar of what that means. Pyuria was present and also
we then had a urine culture that was 10 to the 4th,
so that’s why we went to the criterion 2a and why we
needed a little more evidence that was found there in
that urinalysis, okay? Alright. Case 3. Day 1 you have a 58-year-old
patient who’s admitted to the ED with GI bleed and a
Foley is inserted. Day two the patient
spikes a temp of 38.6, the indwelling catheter
remains in place and a urine specimen is sent. On day 3 the culture results
are back and it’s 10 to the 5th of pseudomonas aeruginosa
in that urine culture. Is this an HAI? And if so, what type? Yes it’s a UTI but not a CAUTI because the catheter had not
been in for two calendar days. No, it meets the definition
for present on admission. Or yes, it’s a SUTI,
criterion 1a. Go ahead and place your votes. [ Background conversations ]>>This first table’s
having lots of discussion. I’m enjoying this over here. Alright, I’m going to give
you about 10 more seconds. It looks like almost everybody
has voted except this one trouble-making table over here. [ Background conversations ]>>Okay, closing it off here. [ Background conversations ]>>No. This meets the definition
for POA or Present on Admission. Very good. Let’s go over that
[background conversations]. An infection is considered
present on admission if it occurs on the day of hospital admission
or the next day. The infection must fully
meet a CDC/NHSN criterion on the third hospital
day to be — prior to the third
hospital day to be POA. And this one definitely
occurred. They’d only been in house
just that second day and they had the symptoms. Okay? Alright. Case 4 — you guys
are doing great. Day 1, an 84-year-old
patient is admitted to an LTAC with a diabetic foot ulcer and
a indwelling catheter in place. On day 8 — so now
we’re 8 days later — indwelling catheter is still
in place and there are no signs and symptoms of infection. Day 9, the patient
becomes hypotensive. The CBC shows a WBC of
15,000, a temp of 38.0. The foot ulcer is
draining moderate amount of purulent drainage, and
the patient is pan cultured. The blood culture and the
urine culture both grow strep pyogenes, and the urine
is showing greater than 10 to the 5th colony-forming
units in that result. The foot culture is positive for
pseudomonas aeruginosa [pause]. Is this a UTI? And if so, what type? 1) No because the
blood’s C to the urine and therefore there is no UTI. Yes, it’s an ABUTI. Or yes, it’s SUTI criterion
1a with a secondary BSI. [ Background conversations ]>>Alright I’m going to
give you 10 more seconds. Maybe I should have had
the “unsure” question 4. Yeah [chuckles]. [Background conversations]
10 more seconds. Give it your best guess. [ Background conversations ]>>Alrighty [pause]. Very good. Yes, this is an Asymptomatic
Bacteremic UTI. Alright. And we’ll go over
the rationale for that. There were no signs
and symptoms. Remember that temperature
was not greater than 38. It was 38 on the nose. And the positive blood
culture has to have at least one uropathogen
matching to the urine culture, which the patient had. What if — this is part 2 —
the organism in both cultures — both the blood and urine
— had been micrococcus? Is this a UTI? Yes, this is an ABUTI? Or No, this is not an ABUTI. Go ahead and vote on that one. [ Background conversations ]>>Okay, listen we’re
almost there. I’m going to go ahead, give
you about 10 more seconds. Finish up your poling. [ Background conversations ]>>Very good. No, this is not an ABUTI. And your rationale here, micrococcus is not
a uropathogen, and therefore this
is not an ABUTI. Remember you need to have — the organisms have to be
on that uropathogen list, and here it is again. And remember, that list is
going to be able to be found in the NHSN manual in your
ABUTI criterion section. It will be right there listed. So that’s helpful for
you to remember, okay? Let’s go on to Case 5. On 8/5 we have a 76-year-old
woman’s admitted from the LTAC at 8:00 am for surgical
debridement of a sacral decub. The medical history’s notable
for severe rheumatoid arthritis and congestive heart failure. A routine admission
UA is performed. It’s positive for leukocyte
esterase and 3 WBC’s by high-powered field
of spun urine. The patient’s afebrile. Denies urinary urgency,
frequency, or pain. And there’s no suprapubic
or CVA pain. And a Foley and a peripheral
IV are inserted in the OR. The next day, 8/6, the wound
care specialist documents that the wound is clean. Temp of 37.4 and the Foley is
draining some cloudy urine. On 8/7 the temp is 38.2
degrees centigrade. The Foley is removed. Encouraged to push PO fluids
and a urine specimen is sent to the lab for culture
and sensitivity. On 8/8 the temp is still 38.6
and the patient’s complaining of dysuria and pain with
palpation to the suprapubic area and bactrim is started. On 8/9 that urine specimen
that was sent on 8/7, the results are back and
are positive for e coli, 100,000 colony-forming units
and the patient is afebrile and preparing for
discharge back to the LTAC. Does this patient have a UTI? And is a CAUTI? 1) No, the UTI was
present on admission. 2) Yes, the patient has a
SUTI 1a and it is a CAUTI. 3) The patient has a SUTI
1b, but it is not a CAUTI. [ Background conversations ]>>Okay I’m going to give
you about 10 more seconds. We’re looking close here, but about 10 more seconds
finish your voting. [ Background conversations ]>>Alrighty. [ Background conversations ]>>Yes. You guys
are doing great. This patient has a SUTI
1a and it is a CAUTI. And we’ll go over the rationale. This all occurred
on hospital Day 3. So it’s been — so greater
than 2 calendar days. And then she had fever
and suprapubic tenderness and the urine culture was
greater than 10 to the 5th of colony-forming units. Now the trick question
there may have been that positive UA on admission. But remember, UA’s
may be positive for non-infectious
reasons, and since symptoms of UTI were definitely
not present on admission and only developed
following Foley insertion, this would meet our
definition for a CAUTI [pause]. Alright? Let’s go on to Case 6. This is a 48-year-old
male who was involved in a motorcycle accident. Has a closed-head injury;
multiple fractures. Taken to the OR for ORIF’s and
evacuation of subdural hematoma. A Foley catheter and left
subclavian catheter placed in the ED and the patient
remains on the ventilator that was placed in the OR. The lungs are clear bilaterally. Now 6 days post-op — we’ve moved on here —
and the temp is 99.8. You have some rhonchi
in the left lung base. The chest x-ray shows a
possible infiltrate atelectasis in this area. The Foley remains in place
draining clear, yellow urine. The patient remains ventilated and has increased
sputum production. Post-op Day 7, you
have a temp of 100.3. The vent settings are
stable and there’s no change to the sputum production. Post-op Day 8 the temp
is now 101.9 Fahrenheit. The lung sounds are
clear; chest x-ray clear. Patient still remains on
the vent, and the Foley and central line
still remain in place. Pan cultures are sent. An empiric antibiotic
treatment was begun. Post-op Day 9, the urine
culture shows 100,000 CFU’s of pseudomonas aeruginosa. The sputum has — shows
pseudomonas aeruginosa. And the blood culture
was no growth. The physical assessment
is normal and the patient has no
response to suprapubic or costovertebral
angle palpation. Does this person have a UTI? And if so — patient rather,
have a UTI and if so, what type? Is there 1) No UTI. Yes, it’s an ABUTI. Yes, it’s a SUTI 2a. Or yes, a SUTI 1a? [ Silence ] [ Background conversations ]>>Okay, I’m going to give
you about 10 more seconds. [ Background conversations ]>>Couple more seconds and [ Background conversations ] . Okay. [ Background conversations ]>>Yes. This patient has
a SUTI 1a, 87% of you. That’s great. [ Background conversations ]>>The Foley was in place for
greater than 2 calendar days. You had that fever. Had a positive urine
culture with greater than 10 to the 5th colony-forming units with just the one,
single pathogen. Now let’s put a little
tweak to this. What if the patient
had been afebrile — you didn’t have that temp —
but you had an elevated WBC and the urine was really cloudy. But the culture results
were the same too. Would the patient have a UTI? No UTI. Yes, still a SUTI 1a. Or yes, an ABUTI. [ Background conversations ]>>Yeah. [Background
conversations] . This one? [Background
conversations]. Yes. [ Background conversations ]>>Someone asked if the elevated
WBC’s and the cloudy urine — the WBC’s were in the urine,
and the answer is yes. That was urine WBC’s
were elevated. [Background conversations] but
the patient doesn’t have a temp. [Background conversations] not that I’m giving you
a hint, but — [ Background conversations ]>>Alright 10 seconds. [ Background conversations ]>>Oh. Very good. No UTI. And the rationale
on that, remember this was a
patient without symptoms. At this point we
took the fever away. Remember they don’t have
a matching blood culture, so it can’t be an ABUTI. And the elevated BC and
cloudy urine are not part of our NHSN UTI surveillance
criteria. But I can tell you, I know —
I can’t tell you how many times when I’m investigating a urinary
tract infection and you try to figure out why they
spent this urine specimen, cloudy urine. Man, lots and lots of
times you see that — seems that that’s why they’re
sending the culture was because they saw cloudy urine. But that is not part of
the definition [pause]. Remember your surveillance
definition tends to work better in some patient populations
than others — which we’ve already talked
about a little bit in terms of how they can respond
to being able to express about different symptoms. And the patient should
be thoroughly assessed for UTI symptoms including that suprapubic tenderness
and the CVA pain. And this is where we can — it
can be really helpful in terms of educating your
nurses in terms of good physical assessments
or any of your clinicians. And again, that that
clinical diagnosis may differ from surveillance determination. You know, and you may
see often these 10 to the 5th being treated
by physicians and called, but it doesn’t meet our
surveillance definition, because that to us is a —
would have been when you take that fever away, that would
have been an asymptomatic UTI, which we don’t document
unless it’s ABUTI. Alright, let’s do Case 7. It’s 8/25 and a 73-year-old
patient in a neurosurgical ICU was
admitted following a cerebral vascular accident. Ventilated. Has a subclavian catheter and
a Foley in place on admit, and the patient reacts
only to painful stimuli. A 9 to the WBC is slightly
elevated at 12,000. Temp of 37.4. The urine is cloudy and the
lungs are clear to auscultation. On 9/3 the WBC’s are at
15,800 per cubic millimeter. Temperature of 37.6. Breath sounds slightly course. Minimal clear sputum. Urine unchanged. The blood and endotracheal and
urine specimens are collected and there’s no suprapubic
or CVA pain noted. On 9/4 blood and endotracheal
cultures are no growth and the urine is 10 to the
5th colony-forming units of enterococcus faecium. Does this patient have a UTI? And if so, what type? Yes they have an ABUTI. They have a SUTI criterion 1a. A SUTI criterion 1b. Or no UTI. [ Background conversations ]>>Okay. We just have 10 minutes
left for our case studies, so I want to give you —
get through all these, so let’s wrap this
voting up in 10 seconds. [ Background conversations ]>>Alright. Here we go. [Inaudible] [pause]. Really good. 88% of you correct answer. There is no UTI. Because there were
no urinary symptoms, and there wasn’t a
fever greater than 38 and no matching cultures, the urine surveillance
for UTI are not met. But let’s give it a
little tweak here. What if the patient’s
temp had been 38.1 and the patient also
met the criteria. You saw that pulmonary
stuff going on. Had met criteria
for probable VAP. Including a bronchioalveolar
lavage with — oop — I’ll have to change
the organism here. With our VAE criteria, we
wouldn’t have enterococcus — I just noticed that —
but we’ll just say we did. Enterococcus faecium. So you have the same
organism now from the BAL as you do in the urine. So here’s the new question. Does this patient have a UTI? No. The patient’s fever
is due to pneumonia. Therefore the patient
is symptomless. Yes, it’s a SUTI 1a. Fever is nonspecific
and may be due to more than one infection at a time. [ Background conversations ]>>What? I know. [ Background conversations ]>>Alright. 10 seconds because we’re getting
close to the end of the day. [ Background conversations ]>>Alright. Here we go. [ Background conversations ]>>Yes. Because fever’s
nonspecific and definitely may
be due to more than one infection at a time. They had — the patient
had a SUTI 1a. The indwelling catheter
was present. The fever and the urine culture,
and greater than 10 to the 5th of a colony-forming units. Alright. We have 4-year-old
admitted following an MVA. Taken to the OR for ORIF
and internal fixation of a left upper and right
lower extremity fractures. Admitted to the Pediatric
Surgical Care Unit with a Foley catheter
draining yellow urine and a right femur attraction. IV in the right antecubital
vein. 8/18 afebrile, taking
clear, liquid diet and beginning oral pain med
using incentive spirometer. The Foley’s draining
yellow urine. 8/19 next day tolerating
a solid diet. The IV is converted
to a saline lock. Foley draining yellow urine. 8/20 the Foley is
removed at 0800 and the patient is
voiding without problems. And the patient has a slight
cough of clear phlegm. 8:21 in the morning, the
patient is requesting a bedpan frequently. Crying with urination. Temp of 37.9. The cough is unchanged and a straight cath urine
specimen’s collected. The urine’s cloudy and the UA is
positive for leukocyte esterase. Nitrite’s negative. A WBC of 10 for high-powered
field. Later that evening
the gram stain of the urine shows
many gram negative rods and empiric Bactrim is started. On 8/23 that culture comes back and it’s 50,000 colony-forming
units of e coli. Does this patient have a UTI? No. Or yes, a SUTI 1b. Yes a SUTI 2a. Or yes, a SUTI 2b. [ Background conversations ]>>Alright. Place your votes. 10 more seconds. [ Background conversations ]>>Alright. [ Background conversations ]>>Yes, this is a SUTI 2a. If you look at that lower
part of the definition, the patient had an indwelling
catheter in place for two days. It had just been removed. And we had frequency and dysuria
that she was complaining of. Leukocyte esterase positive. You had that 10 WBC’s
for high-powered field, and they saw microorganisms. And the organism result was
between that greater than 10 to the 3rd but less than
10 to the 5th [pause]. Well, we only have — we — [ Background conversations ]>>Okay. We’re going to
go to the last couple that lets you practice counting
those denominators we were talking about. So let me get to those. [ Background conversations ]>>All these cases
are in your packet, and you’ll have the
answer sheets as well. Alright. Let’s talk
about counting Foley days for your denominators
we were discussing. So I want you to look
at this, alright? And tell me how many indwelling
catheter days you think you have. Look at the status. This — everything was
counted at 12 noon, okay? In this unit. And do you have 6, 5, 4,
3, 2 or 1 catheter days for that day on the unit? [ Silence ]>>And this one is not a —
this is not one you can vote on, so I’m just going to show you. But just, you know, make
your decision in your head, what you think your
answer is, okay? I’m going to give you
a couple more minutes, but count was done at noon. [ Background conversations ]>>Alright? [ Background conversations ]>>I see most people look
like they — there’s two. And I’m going to show
you where they are here. You have this one,
patient 101, Mr. Black. Had an indwelling
catheter that whole day. And at that — at noon, and 106
had an indwelling Foley at noon. Now you might have
thought there were three, but look at the patient
[inaudible]. They weren’t admitted until
2:00 in the afternoon. So at noon that — they
would not have been there with a Foley. So those are the
only two patients that at noon would
have had a Foley. Okay, let’s try one
more [pause]. Okay. Let’s — same thing. Now this is again, another unit. How many indwelling catheter
days do you see here? And this is a unit where they’re
doing their catheter counting at 11:00 pm. [ Silence ]>>Think you got it? Okay, here we go [pause]. See if you guessed
right on this one. One. [Background conversations]. It looks like people are happy. It’s this patient — Miss
Dallas — is the only one. We don’t count condom caths
and suprapubics don’t count. And that other indwelling,
they’d already been discharged. So we have one Foley
catheter day that day. Great. Well thank
you very much —