Surgical, Site, Infections (SSI) Surveillance

Surgical, Site, Infections (SSI) Surveillance


>>All right. So we’re here to talk about surgical site
infection surveillance. And just as the others have
mentioned, what we want to discuss today is what’s
going to be new for 2013. So a lot of the stuff
will be the same, but where there are new
things, I have them highlighted for you in the slide set. So just, again, where does this
fit into the NHSN structure? It is one of four of
the patient safety — or it fits the patient safety
component, which is one of four NHSN components, the long-term care component
having just been activated in the last week or so. And –>>[Inaudible]>>Okay. Can you make it louder so they can hear me
in the back, please? Thank you. Okay. Is that better?>>Yes.>>Good. I felt like
I was yelling. So now I won’t have to yell. The procedure-associated
module is in the patient safety
component part of NHSN, and it current only includes
surgical site infection surveillance — or sorry — it includes surgical site
infection surveillance. In 2013 we’ll be getting rid of post-procedure
pneumonia altogether. So at the end of this year the
post-procedure pneumonia part of the module or that
event will be retired, so there will only be SSI left. So some of the resources
that you’ll need to do SSI surveillance, as others have shown you
are the forms of course. And for January 2013 we’ll be
updating the forms accordingly to what’s required. So you’ll need the
monthly reporting plan, as you usually do; the
surgical site infection form; and denominator for
procedure form. In addition, you’ll need the
patient safety component manual. And in the January 2013
addition you’ll want to look at chapter one, which
has an overview of NHSN, and in that will be included
some surveillance techniques. Chapter three has the reporting
plan information in it, and there will be a
table of instructions for completing the
reporting plan, which has not been
available in the past. And then chapter nine, which is
where the protocol is currently and we will be adding
the forms and the tables of instructions to that chapter. So sort of a new format for the
patient safety manual will be to have the protocol, the forms,
and the tables all together in the one place for you. Chapter 16 still includes some
key terms that you’ll want to make reference
to, and obviously, you also need the
infection site definitions, which will be in Chapter 17. Now, as has been mentioned
by previous speakers, the surveillance plan or the reporting plan is
our roadmap to your data. So when you put something
in your plan, those are the only data that
we look at and analyze at CDC. And they are the only ones
that are usually shared with entities like CMS. And typically they’re
the only ones used by state health departments,
although that’s not always true. So we refer to those kinds of
information as “in-plan data.” You might hear us talk
about in-plan data; it’s anything that’s you’ve
indicated in your plan. And the plans are
also really important because they drive a lot of the business logic
of the application. So a lot of times when
you go to enter an event or a denominator record, behind the scenes the
application is checking your plan to see if you’ve
got this particular thing that you’re trying to enter
in your plan for that month. And if you do, then
certain things happen, and are displayed,
and made required or optional on your forms. So it’s really, really important that you keep your
plans up-to-date and that they’re correct. And you have to have one for
every month of the year in order for your data to be useful. So most of you don’t
have the option of saying no surveillance,
you know, component followed anymore, but so you’ll have some
kind of plan in place. So one of the changes that
we’re making to the plan in 2013 for the procedure-associated
module — as I said, we’re going to be taking away the
post-procedure pneumonia, so that part is going
to be missing in 2013. And the other thing is that
currently now when you indicate that you have an SSI or that
you’re going to monitoring SSIs for a certain procedure, you
can circle in, out, or both. But in the future beginning of
2013 you’ll just be checking box for in or out or both. You can check both in and out, and that will mean
both behind the scenes. So you can still
do both of them, we just don’t have you
circle both anymore. Okay? So just a minor
change there to the plan. So let’s talk about some of
the surveillance methods. It is an active surveillance
method, just like everything else
at NHSN for surveillance. So you’ll determine which
surgical patients you want to monitor, either
those that you have to for certain regulations
or laws, or because you have an
interest in your facility for following these
particular operations and looking for infections. You’ll need to be reviewing
admission, readmission, and operating room logs
to follow your patients, to see where they are; and
review patient charts for signs and symptoms of surgical
site infection for any risk factor data that
might be required for reporting; and review laboratory, X-ray,
other diagnostic test reports to be sure that if you have
an organ space infection, you can meet the criteria of
that specific organ space site as well as the SSI site. And so that means you do have to review nurse’s
and physician notes. Now, how many of you can do
all of this kind of thing from your desk using
some combination of electronic or other reports? So a number of you. Well, I would encourage you
not to let it stop there. In fact, you really need to go
out and visit the units to get that additional information. And also to do — you
know, that’s an opportunity to do teaching, prevention
teaching, you know, look at the environment of care, make sure that things are going
the way they should be going in your units. Because remember, as
Denise Cardo said, “It’s all about prevention,”
right? And so even though we’re
doing our surveillance, we want to be actively
preventing infections as we go along. So if you’re just sitting
in your office trying to do surveillance that
really doesn’t count as active surveillance, you must
get out there and talk to people and go and visit your wards. Now, you may not have time to
do it every day, but they need to know who you are and that
you’re an ally and that, you know, this is a team sport. It’s not all your
responsibility. So let’s talk a little bit about post-discharge
surveillance methods. I think there’s a misconception
that for some reason for CMS you don’t have to do
post-discharge surveillance to meet that reporting
requirement, but that’s definitely
not the case. As you know, as Maggie
said already, the follow-up period
is thirty days. You know, that’s what’s
being pulled together, and we’ll talk more
about that in a minute. So patients don’t usually stay
in the hospital thirty days if the hospital has
anything to say about it. So we’re going to
have to have some kind of post-discharge
surveillance method in place so that we can monitor for infections once a
patient leaves the hospital. So how many of you use
some combination of surgeon or patient surveys using
mail, email, phone, Twitter? Whatever, Facebook. [Laughter] Could I
see those hands again? [Laughter] So that means a lot
of you are doing something else. So I would ask, “What
are you doing?” How many of you are
doing nothing? It’s okay. We’re not going to
remember your hand. [Laughter] Right. You’re going to have
to go to the mic.>>[Inaudible] users
in the room. So what we had –>>Please step to the
mic so we can hear you.>>One of our surgeons, he
with another quality analyst, developed what’s called
a “best practice alert.” We’re a children’s hospital,
so most of our surgeries, the return follow-up visit does
occur in our outpatient clinics.>>Okay.>>So in order for that
surgeon to get out of the chart, they have to address if they
have a surgical site infection. And that is for all of
our surgeries except for EMTs and fractures.>>Okay. So you’ve got
something incorporated into your overall system
that requires the surgeons to make a determination,
which is great. The thing that you need to be
sure is — for any method — is that the surgeons and
potentially their office staff, if you’re sending
something to the office, understand the definitions that
you’re using and the criteria. That they have to use the
same thing that you’re using, otherwise you’re going to
have, you know, discrepancies. So you know, you should
develop some kind of tool that includes the
surgical site infection and maybe the most common
specific infection site criteria for those procedures
that are being monitored that they can use. And we’ve been trying to develop
some tools for you to use, and we hope we’ll
have those ready for you sometime next year. They’ll be optional for your
use, but just something that, you know, we can share. And if you have something
that is really good that you think works
well, you know, please feel free to
share it with us. We’d love to see what kind
of tools you’ve created. I mean, I’m sure many
of you are very creative or you wouldn’t be
in infection control. And we’d love to see what you
have and maybe put it out there for others to look at. So be sure that you
have some kind of tool and that your surgeons and
their office staff are trained and understand what
they’re supposed to do when they’re supposed to do it, and that they’re using the same
definitions that you’re using. And again, the criteria
have to be met regardless of where the infection
is detected. And clinic records is something
that this lady shared with us. Okay. So you’ve seen
this slide before. This just focuses
on what’s required for CMS reporting through NHSN. And in January of this
year, as you know, the acute care hospitals had to begin reporting surgical site
infections and denominator data for inpatient colon and abdominal hysterectomy
procedures. Now, someone asked me
earlier to let you know if we knew what’s coming next, which procedures are
coming next for CMS. And honestly we don’t know. We haven’t heard of any,
which is probably a good thing because that means there won’t
be anything new for 2013. And we just don’t know yet
what the next ones will be. But as soon as we
know, you will know. Okay. So let’s talk
a little bit more about the reporting
requirements for CMS. So COLO and HYST
have to be included in your monthly reporting
plans every month in order for the data to be reported
on your behalf to CMS. So if it’s not in the plan, even if you’ve entered the
data, they won’t get it. So you’ve got make sure
you’ve got those in your plan. And you have to follow the
NHSN SSI protocol exactly, and report complete and accurate
data in a timely manner. That means that you need to report each surgical site
infection that’s detected or indicate that
there was no SSI for that particular
procedure for that month. And that for every COLO and HYST
procedure that are performed on inpatients in your
facility you need to have a record
entered into NHSN. And the link there is the
guidance that’s posted on our website that tells
you exactly what’s required and how SIRs will be calculated, as Maggie’s already
gone through with you. So just to remind you,
it’s a subset of SSIs that following in-plan inpatient
COLO and HYST procedures that will be used for fulfilling
the reporting requirements. And these are patients that
are eighteen years or older at the time of surgery that have
either deep incisional primary or organ space SSIs
— so no secondary, no deep incisional secondary because these don’t usually have
secondary infections anyway — and they’re detected by all
of the surveillance methods that during admission;
post-discharge; readmission to your facility; or
readmission to another facility. So any of the infections that
are detected within thirty days of the date of the procedure in those patient groups are
the ones that are shared. And as Maggie already mentioned, the risk models will be
based on age and ASA. So as a woman asked before
the break, “Why do we have to collect all this
other stuff?” Well, think of this 2012
risk model as being sort of a provisional model. It was the only one that we
could come to agreement with, or to agreement on with the
American College of Surgeons at the time that we needed to
make that agreement for CMS. That doesn’t mean that that’s
going to always be that way. So what we’re hoping
to do is, you know, continue to work collaboratively
with the American College of Surgeons and come up with
better risk models using more of the data that we’re
collecting so that, you know, it will be a fairer comparison
when these SIRs are calculated. So in the NHSN protocol
there’s a big table that includes a listing of all of the NHSN operative procedure
categories and a listing of their ICD-9-CM, and also for
certain of them their CPT codes. And this is just for COLO
and abdominal HYST just so that you have it accessible. If you haven’t already made
best friends with someone in medical records,
you probably need to — that and the IT people are
going to be really important for surgical site
infection surveillance. So you don’t need to be an
expert coder, but you do need to have some understanding
of how they’re coding things because if you’re
reading the op note and you think it’s one thing and
it gets coded as something else, the records coders are
following standard rules that they have to follow. And so you need to be sure that
you understand those nuances in order to get things into
the database correctly. Now, there’s one
little reporting detail about hysterectomies or
abdominal hysterectomies that caused some
confusion earlier this year, so I just wanted to have a
slide so that it’s easy for you to see how this was resolved. So which structures and how
they’re detached, that is, the surgical technique or
the approach that’s used, not the location of where the
structures were physically removed determines how the
ICD-9 code is assigned. So what does that mean? It means that if there’s
an assignment of a 68.41 as the ICD-9 code for a laparoscopic total
abdominal hysterectomy, then that is one of
our HYST categories. And it doesn’t matter if the uterus was removed
through the vagina. So it doesn’t have to be
removed through the abdomen; it can be removed through
the vagina and still be coded as a 68.41 and be considered
an abdominal hysterectomy. If it gets coded as a 68.51, then it’s considered a
laparoscopically-assisted vaginal hysterectomy, and usually that does
include a vaginal incision. So this is a coding sort
of issue that was vetted at the highest levels. There was discrepancy early in the calendar year among
medical records coders, and they went to the American
College of OBGYN and came to an agreement about how
these should be coded. And then we’ve adopted
that in our system. So we just wanted to make sure
that you understood it’s not — and we had given
conflicting guidance. So we’ve all got our
guidance aligned together, and this is what it is now. Okay. So I mentioned if, just
like with CLABSIs and CAUTIs, if you don’t have any to report,
you’ve done the surveillance and nobody got infected — hopefully that’s
most of the time– then you still need to indicate
in NHSN, in the application that you have no SSIs to report. So to do that, you click on
“event incomplete,” which is where the pointer is,
and then you click on the “missing PA events tab,” and
then you just simply go down and click the box for “report
no events” for those procedures in which you had
no SSIs that month. Okay? And then be sure
to hit the save button. Okay? And that will
indicate that there are none. What happens if you
have a late infection? Well, go ahead and
enter that infection, and what will happen
is automatically that report no events box
will be unchecked for you. So you don’t have to remember
to go back and do that; it will do it automatically. Okay? But do look at this and do
be aware that if, again, as Maggie was saying, if
there are discrepancies when you run some of those
reports to see how you’re doing and you think, “I
know, you know, there should be something
here,” you know, be sure to look at these incompletes and
missing event things to be sure that you haven’t forgotten
to check the no event box. Okay. Let’s talk a little bit
about the data collection forms. I’m going to go through the
denominator for procedure form with you and how to collect the
data on the denominator side. And then after lunch we’ll come
back together — is that right? Yeah. After lunch we’ll come
back together and Gloria will go through the infection side and
define the infection and go through the infection side. And then at the end of
the day we’ll do all of our case studies. So one of the key terms that is
critical that you understand is: What is an NHSN operative
procedure? This is not changing in 2013. So that’s the good news. But just to remind you, an
NHSN operative procedure is a procedure that is performed on a
patient who is an NHSN inpatient or outpatient, which
I’ll define next. It takes place during
an operation where a surgeon makes a skin
or mucous membrane incision — including a laparoscopic
or robotic approach — and primarily closes the
incision before the patient leaves the operating room,
and is represented by one of the NHSN operative procedure
codes that we have in our list. Now, “primary closure” still
means skin-to-skin closure, okay? What’s new for 2013 is how
we define primary closure. Excuse me. So primary closure in 2013 —
not this year, but in 2013 — will be defined as closure of
all tissue levels regardless of the presence of wires,
wicks, drains, or other devices or objects extruding
through the incision. Okay. So that’s clearly
different that what we say now. Now we say nothing can be
coming out of the incision. But in 2013 we will allow
the presence of wires, wicks, drains, or other devices or
objects that are in the incision and sticking out of it. However, regardless of
whether anything is extruding from the incision, if the skin
edges are not fully approximated for the entire length of
the incision, for example, they’re loosely closed with
gaps between the sutures or the staple points, then
the incision is not considered primarily closed, and therefore
the procedure would not be considered an NHSN operation. And in such cases any subsequent
infection would not be considered an SSI, although
it might be considered an HAI if it meets criteria for
another specific infection site, like a skin or soft
tissue infection. So that part is similar
to what we have now. It’s just because
we now have things that in 2013 will have
maybe some devices sticking out of an incision,
you need to be clear that there’s certain
surgical techniques where there’s this loose closure
or whatnot and — excuse me — we are looking for that
approximation around whatever that devices is, a drain
or a wire or something. So I hear rumbling. Not surprised. It still means that you
have to read the op note. And again, NHSN surveillance or
this, you know, public reporting of these data now
really requires you to have a relationship with
your OR and figure out ways that you can get this
information onto some kind of data system out of your OR
that you can have access to. And that may mean
changing the OR sheets and having some information
like primary closure, that they can check a box
that meets this definition so that it’s easy
for you to find. So be sure to be discussing
this with the surgeons. Now, we have a HICPAC
surveillance working group. And we have members of, you
know, surgeon members as well as members from the
AORN, the Association for Perioperative Nursing. And we are trying to work
hard with them to standardize or to incorporate some
of these new changes into the actual records
that ORs use. But that’s going
to take some time. And I would encourage you
to begin that discussion and dialogue with your operating
room staff as soon as you can to make the surveillance
easier for you. All right. One of the other key
terms in that definition of an operation is
an “NHSN inpatient.” Again, this is not
changing in 2013. These are patients
whose date of admission to the healthcare
facility and date of discharge are
different calendar days; and an outpatient would be a
patient whose date of admission to the healthcare
facility and date of discharge are the
same calendar day. Now, we know that
sometimes somebody comes in and they’re intended
to be an outpatient, but something happens for
whatever reason, and they end up not going home
until the next day. For NHSN that’s an inpatient, even if your billing department
calls it something else. So these, again, depending on
the procedures that you do, you’ll need to understand how
that works in your facility so that you can get
your patients into the right categories. Okay. What does an
operating room mean in NHSN? An operating room is
a patient care area that met the facilities
guidelines, institute, or American Institute
of Architects criteria for an operating room
when it was constructed or the last time
it was renovated. So it needs to meet
those guidelines for an operating room. So that might — you know,
obviously that’s going to include your traditional
operating rooms. But it will also probably
include your C-section rooms and possibly interventional
radiology — although that’s something
you’re going to have to check — and perhaps your cardiac cath
lab, and maybe other places where interventions
are done that are sort of like surgery or are surgery. So make sure that
you understand that. Again, this is a list
from a table in the manual that just shows that each NHSN
operative procedure category is defined by a group of
ICD-9 procedure codes. And for some of those we
do also have CPT codes, but it’s important to understand that CPT codes do not take
precedence over ICD-9 codes when you’re making the
categorization and you’re trying to figure out “Is this one part
of a HYST or part of a COLO?” They’re not — CPT and
ICD-9 codes are not a one-to-one match. So there’s no easy
way to make a complete and accurate list
of CPTs to ICD-9s. How many of your
inpatient ORs use CPT codes? So a few of you. How many of you think
you could get CPT codes if we switched just
to CPT codes? Not too many. CPT codes are primarily
used for billing purposes, and they’re a lot more
granular than ICD-9 codes. And they’re a lot more
up-to-date, frankly. And as you know, ICD-9 codes are
going to be going away anyway and will be replaced by
ICD-10 codes which, you know, is going to mean that
in 2014 things are going to change again. So you know, this SSI
surveillance is going to be changing in 2013
and again in 2014. So when Maggie was
talking about the models — the SSI models that underpin
the SIR calculations — you can see that it’s going
to be a while before we get to another period of
stability in the data, in the way the data
are collected and reported before we can
come up with new baseline data. I mean, we could do it now,
but it’s not going to be good for more than one year because
things are changing in 2013, they’ll change again in 2014. So this is a dilemma that
we just all have to live with until we can
come to a place where things are a
little bit more stable and then we’ve collected
enough data that we can rebaseline the
SSI data for calculating of both rates and SIRs. So it’s a work in progress. And it’s going to be a
little frustrating, I think, for all of us for
a number of years. Okay. So when you choose a procedure
that you’re going to monitor, then all of the procedures within that category
must be followed. So this is just a picture of
those for a limb amputation, and you can see that
there are several codes — some of them have more, some
procedures have fewer — but you cannot pick and
choose among the ICD-9 codes. If any of those are done, then you must report a
record for that procedure. Okay? All right. So let’s go through
the form and talk about each of the data elements. So the form is just shown here. And this is the one that
we’ll be using for 2013. So it looks slightly
different than the current one. Again, the surveillance period
is one month, as it is for any of the other NHSN —
well, not any of them — but for most of the
other patient safety components events. And we complete a denominator
for procedure record for every operation
that you’re monitoring that meets the definition of
an NHSN operative procedure. And you need to submit
the data within a month of the end of this period. So for example, if your plan
indicates that you’re going to monitor COLO procedures
in January and you — 43 COLO procedures were
performed that month — then you should enter or import
43 separate COLO procedure records into NHSN by
the end of February. Now, we all know that
there’s a much longer lag time for CMS reporting, right? You’ve got four and
a half months. But I would definitely not wait because unlike CLABSI
surveillance where you just have one
record, one summary record for the month, for SSI
surveillance you’re going to have possibly hundreds
or thousands of records in a given month that
you need to enter. And you can’t leave
that to the last minute. So make sure that you keep up
with this on a monthly basis and get those data
entered or imported. And we’ll talk about how
to import records as well so that you’re not left
in a panic come, you know, August 15th or whatever
the next deadline is. Excuse me. Okay. So the patient
information that we collect — the gender and the
date of birth — are all the same as
for any other event. So they’re all required. And for the denominator for procedure we collect the
NHSN procedure code as well as the data procedures. So those are required fields
that you’ll need to enter. And then next comes
outpatient and duration. So outpatient is
a required field. And if the admission and discharge dates are
the same calendar date, then you say “Yes,”
otherwise you say “No.” So for most of you
it’s going to be “No” because you’re doing
inpatient surveillance. All right? In terms of duration, duration
is defined as the number of hours and minutes between
skin incision and skin closure. Again, that’s what we
call “primary closure.” We don’t want any of the other
times that are listed in the OR record — there’s anesthesia
time, there’s pump time, there’s lots of other times, but the only time we want is
the incision and closure time. Okay? Now, I’ve moved
some slides around. You may have noticed. Okay? I just moved this one
up, that last one up a couple. So the note here is
really, really important. In Chapter 9, in the new Chapter
9, which is the SSI chapter in 2013, be sure that
you pay attention to the reporting instructions
in the denominator data section of the chapter and the table of
instructions that will also be in that chapter because
they really are going to provide some important
guidance on many of the nuances of how to report the number
of operative procedure records and how you report duration,
and lots of other things. I’m going to show you some
of those this morning, but I’m not going to go through
every one of them because, you know, your eyes will
be glazed over as it is. And you know, the
reason we have so many of these reporting instructions
is because, you know, you’ve emailed us and you’ve
said, “Gosh, you know, I have this situation and I
can’t find guidance on how to do this in the manual.” And so what we’ve
done is we’ve tried to put those into the manual. Sometimes we put them in the
newsletters, but anything that goes in the newsletter
is important for us to get into the manual. So we’re really trying to
get them all into the manual, either in a reporting
instruction, a key term, or the table of instructions. So you cannot do SSI
surveillance properly without using all those sources. And we’re trying to put them
together a little bit more carefully in one
chapter for you. Okay. So I want to
talk about a few of those reporting instructions. And some of these deal with
“How do you handle duration of operation in various
situations?” So sometimes you have procedures that have more than
one incision. Right? So CBGB — coronary
artery bypass graft with both a chest and some
kind of donor site incision. That would be at least
two incisions, right? And operations like
carotid endarterectomy, CEA; spinal fusion; spinal refusion; and peripheral vascular
bypass grafts often have more than one incision to do
that particular procedure. Example, again, with
cabbage — CBGB — you’ve got the incision to
harvest the donor vessel. It could be in the arm,
it could be in the leg, and you’ve got a
separate chest incision. So they harvest the vessel,
and then they open the chest and put it in the chest. So you’re going to have at least
two incisions in that case. Another example is
for spinal fusion where there is both
an anterior approach, and then they flip
the patient over and then they do the
posterior approach. So you’re going to have
both an abdominal incision and a posterior incision
in the back. What we want you to
do in these cases for these procedures is
only report one denominator for procedure record and
record the duration as the time from the first skin incision to primary closure
of the last incision. All right? So if you do any of those
kinds of procedures, you may have this
situation come up and this is how you handle it. What do you do in the case where
you have one incision but more than one procedure type is done
through that single incision? How do you handle that? Well, if procedures in more than one NHSN operative
procedure category are done through the same incision during
the same trip the operating room, then you’ll want to create
a record for each procedure that you’re monitoring in
your monthly reporting plan and use the total
time for the duration for each of the records. So let’s do an example. Let’s say the patient had a
coronary artery bypass graft with a chest incision only. That’s a CBGC. And also at the same time they
did a mitral valve replacement. That happens to be a
“card,” a cardiac procedure. So those are two different
NHSN procedure categories, but one incision on
the patient, right? Everybody got that? Okay. So you’re only going
to have one skin incision to skin closure, right? So you’ll use that time — in this case, in this
example it’s five hours — you’ll report on your
CBGC record the duration of five hours and zero minutes and on the cardiac record
five hours and zero minutes. Does that make sense? What other things do you think
would be the same as well? Wound class? ASA? Those kind of things
will also be the same on those records. Okay? Why do we do that? Well, stay tuned
and I’ll tell you. There is a reason. Okay. Now, as with any
instruction there’s usually an exception, and there is an
exception for CBGCs and CBGBs that are done during
the same trip to the OR. In that case we want you to
only report one procedure, and that would be a CBGB. Okay? So remember what the difference
between those two are. A CBGC only has a
chest incision. You know, maybe they’re
just going to use the internal
mammary artery. So they just need to crack
the chest; find that artery; do the replacement; close it up. One incision just in the chest. Right? CBGB we’re harvesting
a vein from elsewhere and then putting
it into the chest. So you know, do we really
need two separate records? No. We’ve decided that we just
want you to report it as a CBGB. So here’s an example:
Patient was scheduled to have a coronary
artery bypass graft with a chest incision
only — a CBGC — however, during the
procedure it became necessary to harvest a vessel
from the leg. So basically that gets
converted, if you will, for NHSN to a CBGB because
now we have two incisions that we’re dealing with
in a different NHSN code. However, you’re going
to see probably that the ICD-9 coders
will give a code for both a CBGC record
and a CBGB record. And so you’re going
to see both of those, but in this particular
case we only want you to report one CBG record
and use the incision to closure time for, again, the
first incision from the chest to the closure of the chest. Okay? So if you’re doing CBGB
surveillance, that is something that you will probably run
into and have to deal with. And if you’ve ever tried
to enter a CBGB and a CBGC for the patient on the same day, you know that there’s
an error message and the app won’t
allow you to do it. Okay. Here’s another
reporting instruction. This one is the situation where
the patient returns to the OR within 24 hours of
their initial surgery and they go right back
through the same incision. Okay? So if the patient
goes to the OR more than once during the same
admission and another procedure of the same or a different NHSN
operative procedure category is performed through that incision
within 24 hours of the end of the original incision or
the end the original procedure, report only one denominator
for procedure form for the original procedure
combining the durations for both procedures. Okay? Let’s do an example. Patient had colon surgery
performed on Tuesday morning with a duration of three
hours and ten minutes. On Tuesday evening
— so the same day — he was returned to the OR where
the COLO incision was opened to repair a bleeding vessel. That happens to have
an OTH code in NHSN. So it’s not the same procedure. The duration of the second
procedure was one hour and ten minutes. In 2013, what we want you to
do is report only one COLO with a combined duration of
four hours and twenty minutes. So it’s the time of the first
procedure — the three ten — plus the time of the
repair procedure, one hours and ten minutes. So that’s a total of four
hours and twenty minutes. And then we don’t want you to
report a record for the OTH. Now, most of you would never
report an OTH record anyway, unless you’re in
Pennsylvania where you have to. So those of you in Pennsylvania
will have a little bit of a break in 2013 in terms
of what you have to report. Does that make sense? Yeah, kind of. [Laughter] Okay. All right. One more of these reporting
instructions, and that has to do with bilateral procedures. As you know, some procedures,
you got two of some things. Right? And sometimes they
want to work on both of them at the same time during
the same trip to the OR. So for example, a
patient could go in and have both knees
done at the same time. In this case, we want
separate records for each of these procedures because each of them can be independently
infected, right? I mean, you could go and have
both knees done and only one of them gets infected
and the other one’s fine. So you don’t want to be
combining them all into one. So when it’s a bilateral
type of operation, then we want two separate
records for each procedure. And what may become
a problem, though, is sometimes there’s
only one place on the op note to
indicate duration. So in that case, indicate
the incision time to closure for each procedure separately. If you can get the time
separate, that’s great. And if you can’t, then
use the total time and just split it evenly
between the two procedures. Okay? So that hasn’t changed. All right. Let’s talk about wound class. So wound class is a required
field, and you can see that in 2013 it’s not changing. We still have the
unknown category, but that will be going away,
I can tell you, in 2014. So please, if you
have ever reported or you have unknowns sometimes,
you need to start working on it now to be sure that you
have a way of categorizing those because you won’t be
able to save the record if it’s unknown in the future. Wound class, as you know, is
an assessment of the likelihood and degree of contamination
of the surgical wound at the time of the operation. And it should be assigned
by someone directly involved in the procedure in
performing the operation, and it should not be your
responsibility to assign it. Now, obviously when you’re
reviewing records you’re going to see things that make
your hair stand on end so, you know — with
respect to wound class — so this is another area of
conversation that you need to be having if you
haven’t already had it with your ORs this
year, just to make sure that they’re assigning
these things properly. Again, the HICPAC surveillance
working group is addressing wound class, and we will be
making some clarifications and probably some
changes for 2014; maybe not anything for 2013. Just to remind you,
and these currently are in the key terms section
of the NHSN manual, but these are the
definitions of wound class. And I’ve just starred
something that isn’t currently in the chapter or in the
definitions just to — it’s because it’s a
question we get asked a lot. So I’ve starred here
“genital tract” for both clean and clean-contaminated
because we include the female and male reproductive tracts in that catchall
phrase of “genital.” And I know that’s caused
confusion around hysterectomies. People are not always
understood that we — you really can’t have
a clean hysterectomy. So we would consider those
at least clean-contaminated, if not dirtier than that. Okay? So that’s for
clarification there. And for class three
and class four, these are the current
definitions. They’re not changing for 2013. So let’s do a couple of
examples of wound class. So Suzanne had a —
this is different. I’ve modified this from what’s
in your handout so you may want to change this, this first one. Suzanne had an appendectomy
following one day of acute abdominal pain
with rebound tenderness. At the end of the case
the surgeon indicates that the appendix was inflamed and the surgical
area was irrigated and cefoxitin was ordered for
three days postoperatively. We would expect that to
be a class three, right? Because the — let’s go back
and look at class three. We had incision into an acute
nonpurulent inflamed tissue. We didn’t have a
frank infection there. All right? So we would expect that would
be coded as a class three. Okay. The second one: Fred
had a cholecystectomy using a laparoscopic technique. The gallbladder was
removed successfully with no breaks in
operative asepsis. So we would expect that
should be coded as a two. And again, let’s look at that. We entered the elementary tract
under controlled conditions without unusual contamination. All right? And it specifically also says
that biliary tract is included in this if there are
no infection evidence or break in technique. Number four: George
had a — or sorry — George had a knee
prosthesis revision. When the surgeon makes the
incision into the surgical site, she notes that the knee joint
demonstrates purulent material and inflammation. A specimen is obtained and
sent to the laboratory, which grows
methicillin-sensitive Staph aureus. Because this is infected
already at the time of the surgery, we
would count that. We would expect a wound class
of four to be assigned this one. And then finally, this was one
we’ve had a number of questions on that we’ve added
for this class: Mary had a scheduled uneventful
abdominal hysterectomy. Again, we would expect that
to be a wound class of two. All right? All right. Let’s move onto the
next data field, which is general anesthesia. Again, no changes for 2013. We define general anesthesia
as the administration of drugs or gases that enter
the general circulation and affect the central
nervous system to render the patient pain
free; amnesic; unconscious; and often paralyzed
with relaxed muscled. All right? Sounds good. You ready for that? I think that starts over at
the Emory Conference Center at about 5:00 o’clock. All right. ASA class. The ASA class or ASA score is
a five-level system of scoring that is developed by
anesthesiology, and it looks at the preoperative physical
condition of the patient. And so the anesthesiologist or nurse anesthetist
should be coming in, and assessing the patient, and
giving the score that is put on the op note for you. Is there anybody that doesn’t
have this information available to them on an inpatient
type of procedure? Okay. Good. Okay. ASA class is only required
for inpatient procedures. So on the form it doesn’t
have an asterisk next to it because it’s a
conditionally-required field. So if, again, in your
plan or on the record if you’ve indicated this
is an outpatient procedure, then you won’t have
to do ASA score because they don’t often assign
it in outpatient procedures. If it’s there, that’s great. You can use it. But it’s not required unless
a patient’s an inpatient. And these are the definitions. Again, none of this has changed for the five different
wound classes. And we use it as a proxy
measure for, again, the underlying severity of
illness as one of the factors that it’s associated for risk
of surgical site infection. And that’s why it’s included
in many of our risk models that we’ve published and
Maggie mentioned earlier. Okay, emergency. Emergency is simply
defined as a nonelective and unscheduled operation. If it’s that, then you — if it’s unscheduled and
nonelective, then you would say “Yes” to this question. All right. For trauma, again, we
have a simple definition: If an operation was done because
of blunt or penetrating trauma, then you select “Yes.” If that’s the reason
they’re doing the surgery, then you select “Yes.” Now, sometimes the trauma
occurs, you know, days out and it may not be
the reason anymore that they’re doing the surgery,
so that may be something that you’ll have to determine. We’ve changed the name
of endoscope to “scope.” And the only reason
that we did that is because it’s a little more
generic and it’s a little easier for the surgeons to
get their arms around. So it hasn’t changed in
terms of its meaning. But you’ll see that it’s
called scope now instead of endoscope in 2013. And we’re still that if the
entire procedure was performed using a laparascope
or a robotic assist — because we kind of see those
as equivalent to each other — then you would select “Yes.” Now, there are some
caveats here. If it started out as a
laparoscopic approach but they had to extend
the incision so that they could assist
using their hand to pull out whatever it is
they’re trying to pull out and visualize better or
operate on, then that — you would have to
say “No” there. And then also if they just fully
end up having to fully convert to an open approach, so
it’s not just a hand assist, but they start with the
lap and then end up — things are more complicated
than they expected and they do a full
incision, then that needs to be considered an
open approach rather than laparoscopic. And usually you’ll be able
to tell that by the op note, and also you might be able to
tell it by the nursing notes in terms of the, you
know, the incision care, the wound care afterwards
whether or not that that involves just
the little trocar incisions for the laparascope or if there’s really an
incision there now that has to be dressed and taken care of. So those are a couple of sources
of data you can use there. So again, if for scope
regarding HYST or VHYST, make sure that you
say “Yes” regardless of how the uterus was
removed, whether it was through the abdomen
or through the vagina. And again, those ICD-9 codes
will help you after the fact to know whether you’ve
picked the right category. And finally, there is — again,
with cabbages — the CBGBs — if they used a scope to
harvest the donor vessel, then we ask you to — this is
a little bit of an exception — we do ask you to indicate “Yes” even though the
entire procedure wasn’t done with a scope. Okay? So this is an exception. And the reason for that is, as
you may recall or you’ll learn about later this afternoon, is
we have a way of distinguishing between primary incisions
and secondary incisions. So if for the CBGB scope equals
“Yes,” then we assume it’s for the harvest,
not for the chest. All right? If you say “CBGC with a scope,” then we know there’s
only a chest incision. And it was a minicab or
something like that was done and they didn’t crack
the sternum. Okay? So it’s just a
way for us to keep track of which incisions are
likely to get infected. So this is one exception
when it comes to the entire operative
procedure rule for CBGB. All right? Everybody clear on that? I know that some people
have been confused about that in the past. Okay. All right. Surgeon code is optional;
however, for prevention purposes
I think all of you should be collecting it,
but we will never use it at CDC because we don’t know
who your surgeons are and we can’t decipher
your codes. So there is a way for
you to indicate a code or the surgeon name if you
choose, and you can set up those code lists for your
surgeons and then enter that. And that way you can calculate
risk-adjusted metrics by surgeon or surgeon group if you want to. And if you do have more than
one surgeon performing the operation, then you’ll want to
enter the code for the surgeon who was primarily
responsible for the case. And if you have teams
of surgeons that typically work together,
you may want to make a team code and use that rather than
an individual surgeon code. So those are some ways you can
organize your surgeon data. All right. So here’s the big news that
hopefully you’ll be happy about, is that for 2013 you are
no longer going to have to tell us about implants. So you don’t have to
follow implants anymore. You don’t have to figure out
whether something’s an implant. Yay. [Applause] And what
goes along with that as of course you know
is with implants you had to follow certain
infections for up to a year. But instead, we’re going to have
certain operative procedures that would require monitoring
for either thirty days or ninety days, depending
on the procedure type — and I’ll show you that
list in a minute — when you’re identifying
deep incisional or organ space infections. And why did we do this? Well, we finally just said, “You
know, there’s too many implants and it’s not really
helping us that much with the stratification of the
surgical site infection data.” And also, we heard you loud and
clear that it’s really difficult to collect the data, it’s
difficult to be consistent across data collectors,
and a lot of things that are really implants
are not even documented in a chart or an OR record. So we’ve just decided that we
will not use implant anymore in 2013, and instead we’ll
just have a follow-up period that is required for
certain procedures. And that list, actually, I think
Gloria is going to show you when she does her presentation. Okay. So let’s talk
about a few other things. And there are certain
additional fields for some procedures
that are required. So I want to run
through those with you in case you’re monitoring those. So for five procedures we
collect additional risk factors: Caesarean section; spinal
fusion; spinal refusion; hip and knee arthroplasties. And when any of these
procedures are included in your monthly plan, then
you must collect these additional data. So for C-section we
collect height and weight — height in feet, or in
inches, or in meters; and weight in pounds
or kilograms. And that’s so we can
calculate obesity or body mass index
to determine obesity. And then the number of hours
in labor in the hospital. Okay. And we used to
collect estimated blood loss, but that went away at the
beginning of this year. Okay? So we’re not
collecting that anymore. So height, weight,
and duration of labor if you’re monitoring C-sections
would be additional data that you have to report. And just a note on labor for
those of you who do follow this: We’ve added a little
bit more detail, or we will be adding it in 2013. So labor is defined as the
length of time from beginning of active labor as an inpatient
to delivery of the infant, and it’s expressed in hours. So if it’s less than or
equal to thirty minutes, you round down to the nearest
whole hour, which would be zero; if it’s greater than thirty
minutes, you round up. And if there’s no
labor, then it’s zero. Okay? You need to look for that
documentation in the chart. And labor can be defined
by your hospital’s policies and procedures, but it
should reflect the onset of regular contractions
or induction that leads to delivery during
this admission. Okay? So we’re looking
at just the information that should be available to you
within the hospital admission. Okay? For spinal fusions and
refusions, we collect data on spinal level, on diabetes,
and the approach or technique. So you indicate which
procedure you’re monitoring, and then check the appropriate
spinal level, and then whether or not the patient is diabetic,
and the approach that was used. And all of that should
be documented because they’re all
indicated by ICD-9 code. For hips, we have you tell
us the type of hip procedure, whether it was total
primary; partial primary; total revision; or
partial revision. This will change in 2014. All right? It will be a lot different
in 2014 than it is in 2013. We wanted to make the change
in 2013 but we couldn’t do it. So you can expect that if you’re
monitoring these procedures, that they will look
different in 2014. And we’ll let you know
what it’s going to be as the time gets closer. Same thing with knee prosthesis
— this is no different for 2013 than it is in 2012, but
it will change in 2014. Okay? So to sum up this part,
I just will say that you need to complete and enter
or import a denominator for procedure record for
every NHSN operative procedure performed that is
selected for surveillance. So anyone — it’s
not only the ones that have infections;
it’s all of them. And you need to be sure
to use the protocol, the table of instructions, and
the key terms that I mentioned as resources in order to
help guide you to report and collect the data
appropriately. All right. So let’s move on and talk
a little bit about linking and importing records. So in order for the
NHSN tool to — in order to keep the data
entry simple or simpler in the NHSN application, we
have this linking procedure so that we can pull
together the information in the denominator record with
that in the infection record without you having
to reproduce it so that we can get a
match on the two records. Okay? So one of the most
important things to remember is that you must enter
your denominator for procedure record before
you try to enter an SSI record. You cannot link an SSI
record to something that isn’t there, right? So that doesn’t mean
you have to import or enter all your
procedures, you know? Let’s say you find
your infection but you haven’t gotten your
denominators entered yet. You could enter that
one denominator record and then enter your SSI
and get that linkage done and then later enter the
rest of your procedures. Okay? So enter the record,
the denominator record first, and then enter or
import your SSI record, and then link the two. So in the app when
you’re in the event type, you select event type field
on your add event screen. And you’ve indicated that you’ve
got a surgical site infection. And then the screen repaints
and you see this button come up that says “link
unlink to procedure.” And if you simply go down once
the screen repaints and click on this button, it will bring
up a list for that patient of all the operative
procedures that patient has had. So it may only be one
procedure as it is in this case, and if that’s the procedure
you want to link to, then all you do is go
over and click the box and then click link
unlink here or down here. It doesn’t matter. All right? [ Pause ] And then when it
will take you — the app will take you
back to your event record, and you’ll see the
information pulled over automatically for you. So you don’t have to
retype it in there, just indicate it’s an SSI, click
the link button, click “Yes, I want to link this
procedure,” and it will fill in the details for you. Now, that doesn’t mean
that you’re done, right? It just means that the
next thing you need to do is finish entering
the other information so that you can save the record. So you’ll have to enter
your date of event and the location — although
that’s optional now — and the facility,
date, etc. Okay? So once you finish
entering your SSI record and click the save button, then that means the
data are linked together and you’re good to go. And then when you go
to analysis, then, that infection’s always going
to be tied to that procedure for the rate calculations, for
the SIR calculations, etc. Okay? All right. Let’s talk about import. How many of you use
the CSV type of import? Great. How many of you are
trying to get that together in your hospital but
have had trouble? A few. All right. So that’s why we say you
need your IT person to be one of your best friends because
it does take a little action on their part to
get you started. And if you haven’t done
this yet, we really, really encourage
you to try to do it because it will save
you a ton of time. How many of you use
the CDA method of import from another vendor? So some of you. So that’s good, too. That also saves you
a lot of time. So to get information
about importing, you can go out to the NHSN
website on the public website, go to the resource library. And then on that page just click on “patient safety component
resources” and it will bring you down to these options
that are listed here, where you see a document for how
to import the procedure data, and then another one with
the file specifications for the import, and then a
sample of an import of a CSV or a spreadsheet type of file that you can practice importing
— or you can look at it, not practice importing — but
you can look at it and see if yours is formed the
same way as that one. And this is just a screenshot of that file specification
document. And you’ll probably want to
print it out and give it and go over it with your IT folks. What it shows you on the top
here, for example, is it will go through and list all of the
fields that we’ve just reviewed, so from patient ID through
the optional custom fields. And it tells you whether
that field is required or not required, what values
that particular field has, and then how long and what
format those fields are in. So for example, in
gender the values are M F, and actually there’s
another one, an “other” now. And it’s a character type field
of one — a length of one — whereas the date of
birth is also required, and it’s in the MMDDYYYY format. So it gives the specification. And you can see, then, that a
column in the spreadsheet is where the information for
each of these fields goes. So this first column would
be the patient ID data, the second column would be where
the gender information goes, and then the third column would
be, you know, the date of birth, etc. So it’s just each column,
then, in your spreadsheet is where this information goes. And it is called a
“comma-separated file” because it actually is
laid out as a long string of data separated
by an actual comma. So even if you don’t
have information — you’re not required to
capture information — you still need to have
that column accounted for or the file will
not import properly. In addition, there are
some fields that are marked “optional for import.” So we’ve seen required,
we saw optional, but there’s another category
called optional for import. And for example, for C-section
patients the height, the weight, and the duration of labor
are optional for import, meaning if you can’t get that
information out of your OR — which is unlikely,
right, they’re not going to usually have that
information there — then you will have
to enter those data. After you get your import
you’ll need to go into that file and put those values in there. Or you can actually import the
file and enter them in NHSN. A screen will be available
for you to do that. Okay. So that’s that. And then finally, if you — when you’re creating
the spreadsheet — if you include what’s called a
“header row” where you’ve got, you know, a label for what’s
in each of the columns, which is a really good thing to
have when you first create it so you know you’re putting
things in the right order, be sure you delete that
header row before you try to import the data. Otherwise it will
not import properly. Okay? And once you
have this set up, you know, it works pretty well. So the hard part is
getting it set up. And we’re definitely here on — you can email us if you’re
having problems and we’ll try to work with you to
get this set up so that you can import your data. You may — again, you’re going
to need some IT help probably to get the information from your
OR, but we can work with you and your IT person to
make this happen for you. I just waned to show
you that if you’re in the NHSN application,
there is also a help. You can use the NHSN help system to get this same
kind of information. And to do that you would go
to the import and export link and then indicate procedures. And then if you click on
help here, it will take you to the help system
and it will guide you through what we just saw. So you can find that
information in the help system. If you lose your notes,
you can always go there, plus it’s out on website. So we’ve got it for you
in a variety of places to help you get that done. It’s really, really a time
saver, and it’s worth the effort that you put into
it to get it done. So just a couple of other
resources before we wrap it up and take questions. There’s a huge document that
hopefully you’re familiar with. It’s a big spreadsheet,
and it is a mapping of all the ICD-9 CM
procedure codes — all of them from
00.01 through 99.99. And in that spreadsheet
we have whether or not a particular
code is mapped to an NHSN operative
procedure code or OTH; whether or not it’s considered a
nonoperation or an NO in NHSN; or whether it actually
doesn’t really exist yet. So we put in placeholders even
for codes that don’t yet exist. So if you’re ever, you
know, have an ICD-9 code and you’re not sure whether
it’s an NHSN procedure or not, you can go to this spreadsheet
and find it very quickly and figure out whether or
not it should be something that is included
in your reporting. And then, as others
have mentioned, we do have our interactive
training courses online that you can do anytime. We will be updating these
with the new information. So, you know, if you need a
refresher, you know, January and you want to try the
interactive training courses, they should be posted. If they’re not posted,
the webstreaming, again, will be posted and we will be
setting up Q&A times for those, for each topic in
the coming months. Okay. So with that, I’ll stop. And we’ve got time
for questions. In fact, we have lots
of time for questions. And if we finish our questions
early, we’ll be able to go to lunch early as well. Yes? Go ahead.>>One of our medical
coders has pointed out to us that under the COLO ICD-9
codes there’s a separate code for colostomies, and
they’re wondering why that is since it’s not a primary
closure, I would assume. So.>>So that’s going to be
discussed this afternoon. We do consider that
primary closure, though. Colostomies we do consider as — in a way, in my mind the way
I sort of justify that — it’s like a drain, right,
that you put in adjacent to the actual incision. So we do include colostomy
procedures as those that are primarily closed.>>Thank you.>>Yep.>>When is the 2013
going to be out? The manual?>>We hope it will be out towards the middle
to end of December. That’s our goal.>>Okay, thanks.>>We didn’t want to
put it out too soon because we don’t want
people using it now, so. Yes?>>I work for a large hospital
system that performs lots of the three type of procedures
that we’re currently reporting. And because of the volume, our
goal is to automate as much as possible because
otherwise it’s unmanageable. But as we’re looking at the
rules for combining procedures and the various exceptions of
pulling the data over from our OR system, those
exceptions make it impossible to fully automate the process. Is there a possibility
moving forward for you guys to consider simplifying those
in such a way that we’re able to simply take the fields from
what the nurse enters in the OR and make it more intuitive so that there’s not
that manual element?>>We’ve certainly discussed
this, and we’ll continue to discuss it with
the working group. You know, we also have
IPs on the working group and the state health
department representatives, etc. So you know, we understand
that it’s problematic. It comes down to “How
useful are the data going to be if we don’t?” Well, let me put it this
way: You know, the struggle that we’re in right
now is a struggle between clinical
credibility of a data and consistency of the data. And so we could make things
very simple and very easy to be consistent, and that
will pull us further away from clinical credibility. And since we’re trying to
influence the clinicians with the data so that they
can work on better prevention, that becomes the big dilemma. So it’s this balance
that we’re trying to find between keeping — you know, making the data clinically
credible, yet making the collection
reporting consistent and easy to do. That is the real
challenge these days. So we’ll continue
to talk about it. We know that it’s difficult
and, you know, we’re trying to simplify as much as we can. Yes?>>I have a question
for the group. I’d like to know if
anyone else is dealing with the McKesson HSM OR system? And if you are, can you come
and talk to me and tell me — give me some good news? [Laughter]>>So did everybody
hear that cry for help?>>So I’m right here
at the front, so.>>Okay. She’s at
the front table. Anybody that has
a McKesson system that would like to talk to her.>>I’m only familiar with
reporting the COLO and HYSTs in NHSN, so all of mine
are in-plan reporting. I just would like
to hear from you. As I’m hearing more and more
about the statistical analysis and listening to you
today, I see that value of doing additional SSI
reporting into NHSN. Why would you not, or would
you, include that in-plan? I’m not sure what in-plan — what the importance of
in-plan means except for including in-plan
for CMS reporting.>>Yeah. So, yeah. In general your question
is “Why would you want to put something
in-plan versus not?”>>Yeah.>>So one of the main drivers
of putting something in-plan is that you’re committed to
following the protocol. For me that’s number one. All right? So if you want to deviate in any
way, don’t put it in your plan. But if you’re willing to
follow the protocol exactly, then I would encourage
you to put it in your plan because then all the
business rules will be in play and it will keep you as
you’re entering your data from making mistakes. If something is entered
off-plan, there are no business rules
— there are virtually none. There are a few, but
there are virtually none. So that means you could put in
a value that makes no sense just because you’re quickly typing
and it wouldn’t be caught. And so you could end
up with some nonsense. So putting it in-plan helps
you to get better data because you’re not — you know, it’s going to edit
check as you go. So that’s one thing. And on the analysis side, you
can analyze your data in or out of plan so, you know, you
have that flexibility. But that’s what I would say.>>And if it’s –>>And — excuse me — the other
thing is that we would be able to use it in the aggregate. And so that’s very
helpful to everyone. If you’ve actually followed
the rules and it’s in-plan, then it will go in
the national database. Otherwise it doesn’t.>>And CMS is only allowed
to pull COLO and HYST at this time regardless
of what you have in-plan?>>That’s right. And CMS does not ever
access the database. We give them the
data on your behalf. That was part of the
agreement that you signed when you joined NHSN, allowing
us to do that on your behalf. So they don’t have
access to the data; they only get what is specified
as we’ve described in a dataset.>>And so at the
beginning of my year, if I decide to include
six procedures in-plan and six months into the year
we have other unforeseen issues happening and have
to make the decision that we can no longer
follow two procedures, can we change midyear
what’s in-plan?>>Yes. You can always
modify your plan at any time. You can’t delete a plan, but
you can modify it any time. I think that’s the other
thing about that — I don’t know what
state you’re in — but a lot of the state health
department reporting only uses in-plan data as well. So they may only have access
to your in-plan stuff. So if you want them
to have access to it for whatever reason, maybe
there’s a collaborative. Or you know, there’s a lot
of researchers now are using or accessing NHSN data and they
will only typically use in-plan data as well. So it makes your data
available to, you know, good causes if you will, if
you’re willing to do that and you’ve agreed as part of
being in a group or something.>>Okay. Thank you.>>In the back first, thank you.>>Thank you for a very
informative presentation. I think with all this data
it will give us a richer and more robust database,
but is there any thought about increasing the mandate
for ICPs in facilities to assist us with this process? [Applause]>>You know, I only wish
we had that kind of power.>>But you do.>>Well, we really don’t. I think that question has
been asked for at least 20 of the 28 years I’ve
worked here. And we’ve had, you know,
working groups with APIC and others trying to
figure out, you know, “What is the magic number
of IPs needed in that?” and it’s not an easy
thing to do. But I think that it’s being
recognized how difficult this is and how much IPs do. I mean, this is just
one part of your job. And here you are spending
three days focused on it. You know? That’s a big deal. You’ve got all the
prevention work to do. A lot of you have employee
health stuff that you have to do, and on and on, teaching,
etc. You know what you do. So I think, you know,
one thing — you know, I’ll get on my
soapbox a little bit — one thing I think IPs need
to realize and to embrace is that this is not their
total responsibility; this is a hospital commitment. Once CMS entered the
picture, they upped the ante. And you know, you’ve been trying to get administrative
support all along, I’m sure. Well, now you’ve got it. They may not have given you
additional resources yet, but if they don’t get paid
because you haven’t had the help that you need, you know,
that gets their attention. So I think we need to sort
of be creative and work with the administrators to let
them understand that, you know, “I cannot do this by myself. I need this information
from the OR. It has to become a priority. I need, you know, this,
that, and the other if we’re going to
get this done.” So you know, we keep trying
to give that message as much as we can to these
other entities, and hopefully it’s helping. But I don’t think we’re ever
going to be able to say, “You need one IP per
X number of whatever.” It wouldn’t be beds
anymore anyway; it would be something else. And so we’ll try to
do it in other ways. In the front here, please?>>I just wanted to add –>>Oh, sorry. I can’t hear you.>>I just want to add to
that real quick if I could for all those IPs that are
now struggling in front of the computer and all of the
data reporting and not getting on the floor as much
as they wish. With public reporting of the
core measures at all hospitals, start back in the early 2000s,
saw the same thing really that, you know, someone in the QI
department was given, you know, their ORX or cart tool and
told to start abstracting. And today, if you look
at that same program now and the processes in place
to ensure they get their APU, there’s quite a few
more FTEs involved in the process these days. And it’s the growing
pains you’re sitting through right now, but
it is a positive move to get much more HAI
prevention for you.>>Thanks, Charlie.>>I’ve got a couple
of questions. A couple of my hospitals feel like they haven’t
gotten clear direction on one question that
they’ve asked. They said they’ve got two —
especially trauma patients — that they have surgical
procedures like a triple A and then have pelvic fractures and get hardware
in a second spot. And then there’s
infection which — kind of all of over the
patient and which — do they do two separate
denominator forms for the two separate NHSN codes, and do then you report surgical
site infections for both, or how do you determine
which was the primary?>>Right. Well, so a
lot of that depends on how many incisions you have. Right? So if you have an
incision for the triple A and say an incision
for the fracture, then you have two different
operative procedures, right? So two different records. You have a record for each
if they’re in your plan. Right? That’s the other
caveat: They got to be in-plan, then you have to have
a record for each. And each of those has their
own one class duration, etc., etc. And then depending
on where the infection is, it’s either going to be in one
or the other incision site. I think in the scenario you’re
describing you’d never have sort of a common organ space, one
that you’d have to sort out. But that’s another issue that
we’ll talk about this afternoon. So I think in your case it
would be pretty straightforward: Two records. And if infection occurred
at either of those sites, then those infections
would be reported as well.>>Okay. And we had heard
that height, weight, and diabetes were going to be
added to the denominator form in 2013; is that
not going to happen?>>We wish. But no, you’re saved
another year. That got pushed back to 2014.>>Okay. And then something I
just might want to mention just in helping a lot of
hospitals get clicked up: The import instructions are
excellent online, but if you use that different help —
rather than NHSN at CDC.gov, you use NHSN CDA different help
— that gets it to Paul’s group and he answers right away. That’s really been helpful to
have a separate help email.>>Good. Well, I’m sorry that
Paul isn’t here right now to hear that, but we’ll make
sure to pass that along to him. In the back?>>Yes, ma’am. My question is in regards
to primary closure. It states here — I understand that many times a
surgeon may close the skin but the patient is
technically left open for operative, you
know, purposes. They may go back in, the
fascia is not closed. How can you have
primary closure — if the skin edges are
not fully approximated for the entire length of the
incision, you can’t have a wick or a drain and the incision
be fully approximated. Can you explain that
to me, please?>>Yeah. What we’ve heard is
that usually if there’s a wick or a drain, then the
incision’s closed all the way up to that point, right?>>Not necessarily.>>Well, so that’s the
issue that you’re going to have to figure out. And sometimes there’s this — for whatever reasons
they don’t really — they might close like this. You know, it’s a big [inaudible]
some may be not that big. But there will be big
gaps and open areas. So that we would consider
not primarily closed. So sometimes you might
have a wick in one of them and then another nothing. So in that case we would
say “Not primarily closed.” Why do we care about
that, right? Because the wound
can be contaminated after surgery, right?>>Absolutely.>>And we don’t want to
include those in our ones that are primarily closed because they really have
different risk factors. So I know that makes it
difficult for surveillance. No question. You know, I’m not
trying to minimize that. And that’s why you have to
begin to understand and work with your surgeons and
find out what they do, what are their techniques? And you know, we found — we’ve
had feedback from hospitals. New York, for example, has been
requiring colon surveillance for a number of years now. And so they were the first ones to start asking all these
questions about primary closure because they were finding these
techniques that were, you know, pretty much unknown to us. And so we had to
make some decisions about how to handle them. So it does make it more
difficult, but again, if you work with the surgeons
and you know, you know, who’s doing what, then you
can be on the lookout for them and how they’re managing
those particular patients. And so it may not be
everybody you have to look at; it may just be a few
surgeons and their patients.>>Thank you.>>Yes?>>I just want to say fantastic
sessions, and it’s so exciting to be here at the CDC. Just data entry ease —
is there any thinking about the consideration of
when we enter the antibiotics susceptibility with
the organisms, to have it in alphabetical order to make it a little
easier to go through? [Applause]>>Yeah. There’s actually — you know, it’s so funny because
when we first developed NHSN, we never intended —
I mean we struggled. That was the one thing we
struggled with a lot is, you know, how do we make the
antibiograms easier to enter? Because believe it or not, in the old NIS DOS
system it was easier. And you know, to think
that when you move to the Internet it’s going to
be harder was really a hard pill for us to swallow,
let alone, you know, to put out there for you to do. And so, you know, it’s
been modified once not so satisfactorily. And it’s still something that
we are continuing to work on. We do have a change request in, to spend some more time
during our usability study that we’ve conducted last
year that came through loud and clear — not that we
didn’t know it already — but you know, we will be trying
to find a way to make it easier for you to get those
susceptibility data in.>>Great. And on another
addition, if you could put on your change form perhaps if
we have, like, multiple units that we’re entering information
on, it would be so awesome to see all of our different
units and then you put in all admission days,
all patient days. All –>>It’s actually built already.>>Yeah?>>But it’s not quite final. So I’m not sure. I don’t know if anybody
knows off the top of their head whether that
will be January or not. It was supposed to be
released in October. So we have it. So I don’t know if you
understand what she’s saying. Basically as you know now for entering your summary
denominator-type records it’s one record per month. And so you have to keep,
you know, adding records. And so what we’re doing is we’re
basically making it into, like, a line list so — and it
will be driven by the plan. So when you go to enter
denominator records, say for ICU or whatever, actually for an
event type, all of the locations in your plan will
automatically show up. And what’s required will be
there, and you’ll just be able to just go across and check
boxes or enter numbers and handle it that way. So it will be a lot easier,
but it’s been a real challenge to actually make that happen. You know, we all thought this
is a great idea, but the nuances of making the application work
properly has been a bit more of a challenge than we thought. So hopefully that will be in
our January release as well.>>And finally, why did you add
that we have to check no events? Because that’s kind of
a little bit of pain.>>Yes. We added that
actually at the request of the state health departments.>>Oh.>>Because — well, and I
think it’s a good thing. You know, it keeps them from
calling you to find out whether or not you forgot to
report or whatever. So you know, it really
is a way of verifying that you didn’t just forget to
enter something because a lot of times you do forget. So that’s really all it’s for.>>Thank you. And NHSN Team, thank
you for listening to us.>>You’re welcome.>>Hey. Thanks for all the
work that obviously has gone into all these revisions
and changes. And I can’t even imagine the
logistics of all of this. With that being said,
I knew that VAA –>>Could you speak in
the mic a little bit more so we can hear you? Thanks.>>That being said I knew that the VAE definitions were
certainly changing in January but I did not —
and I knew all the of the definitions
were being worked on — but I didn’t realize all of
the changes that were going to be implemented
starting January 2013 and it being October 2013. So particularly like things
like primary wound closure, I guess my question
is not so much to you but to the other
folks in the room: Am I the only one that’s
going to be challenged with making sure all of the clinicians understand
these changes and get all of this done in the
next eight weeks?>>Well, to a little
bit to our defense, we actually have had
information on this since June — since APIC? We presented at APIC
in the NHSN meeting, and that information’s
been out there since then. Now, some of it’s changed a
little bit, and it hasn’t been in as much detail as
you’ve heard today, but we’ve been trying
to warn you for a while that things would be changing. Everybody’s going to struggle. There’s no question about that. And that’s why we
wanted this course as soon as we could get it.>>And I really appreciate that.>>But it will be a
challenge, there’s no question.>>And do you have — as
coming from a health system that bases everything on the
top ten percentile of NHSN for our HAIs, they
want everything within the top ten percentile. Do you have any suggestions
as to how I relate or as senior leaders the change in the baseline given the
changes in the definitions? Because, like, SSIs is
certainly going to change, as you’ve already said for 2013
and then change again in 2014. So collecting that baseline
data’s going to be — take time.>>Oh, yeah.>>So.>>Yeah.>>Any pearly words of
wisdom and how I relay that?>>Well, I think, you know,
the best thing you can say to them is that, you
know, all of these — some of these changes
will impact the data: The way I collect data, the
way the data are analyzed. And therefore, you know,
while you may want this kind of information for your
dashboard or whatever, just recognize that it
is going to be changing and that we’re not going
to have a good baseline. “We” meaning your hospital and “we” meaning the
nation for a while. And that’s just — that
happens in surveillance. I mean, when they changed
the HIV definition, you know, you have to wait before you can
really understand the impact of, you know, how that reporting
change has made on the data. So I don’t really have
any other words of wisdom. I think that’s just something
that we all have to work on with our administrators
to let them know the nature of the changes and that
they will change the data.>>Okay.>>All right.>>Thank you.>>Thanks.>>Great job, Teresa. I have always been baffled by location being
present on the SSI form.>>It’s optional.>>I understand. But the way I’m reading it is
that it’s conditionally required to be filled in if you’re
doing MDRL and the organism — let’s say MRSA was detected and the geographic location
would have been one, a surgical post op unit for
that patient that was in-plan. And with 2013 coming and
a lot more participation or mandatory participation
in the MDRL, I’m wondering about the build-in
of the locations, the other geographic
locations for the facility? In other words, if you
put a location in there, it has to be a location that’s
in your location table, correct?>>Absolutely.>>So the build-in of all of those geographic
locations going forward because we’re going
to be checking “yes” for MDRL in-plan
I would imagine, which means location would no
longer be conditionally required on the SSI form, right?>>Well, remember
for CMS reporting — and we’ll do this tomorrow — it’s lab ID event,
not infection. So you’re not even going to
be looking at the SSI form for that reporting requirement. Now, you will still have
to put location in, though. So that is something that
I’m sure Angela will talk about tomorrow. But if you haven’t already
entered all your locations into the location manager
of the NHSN application, you need to start on that, too. That’s one more thing. [Multiple speakers] That’s
really where you’re going. Yeah. Yeah. And Angela will talk
more about that tomorrow. Yes?>>I had a follow up on
my previous questions. I had time to sit
and think about it. And let me preface with
I have great respect for what you guys do and
am constantly in awe, I think, of what you guys do. But you talked about validity
of the data and, you know, the issue with being able to
really automate the data was to ensure that it was valid. And I guess I wanted to ensure
that you guys knew the concern from the other end is if we’re
not able to automate the data as we send it to you, I think
the validity of the data on our side and the quality
of the data may be compromised because of the burden. And I’m — you know, I’m
picturing as we’re going through these reports,
if we don’t have the time or the resources to be able to send you 300 denominator
sheets completely filled out every month, we
send what we can. And we make the decisions
for what the best data is. But we don’t have the time
and the resources to — you know, to focus on
improving that data. So I thought I would throw
that out there, too, is that — I mean, there’s certainly
a quality validity issue on that side supporting the
reduction of the burden.>>Absolutely. I mean, I think that
goes without saying. There is, as I think
Charlie mentioned, we’re in a situation now
where you’re being asked to do way more than you
have the resources to do. You know, when NHSN
was transitioned — when we transitioned
the NIS system to NHSN, remember it was a totally
voluntary system and only people that wanted to do it and had
the resources to do it, did it. So the system was
built on the principle that it would be a
voluntary reporting system. And it has been — because
we had some useful features for data sharing
— it has been easy for state health
departments, CMS, and others to use
the system rather than create a new one,
and that makes sense. We don’t want to spend money
we don’t have to spend. But we’re trying to put
a bit of a square peg into a round hole at this point. And so what we’re working on
is trying to get those two to be more of the same shape. And we’re just in a
growing pains period. And unfortunately you’re
in, you know, at ground zero of that and, you know,
paying the price. So the resource issue
is one that, you know, we continue to work on at,
you know, our levels to try to make the big associations
of, like, AHA and get them on our side and help them
to understand that you need to do what you can do to help
these IPs get the resources they need and work on the
IT resources in terms of meaningful use that
Dr. Pollack talked about. As you can imagine, just
like everything else in healthcare, it’s
multifactorial. So trying to get the ball moving in forward motion
is what we’re doing. And, you know, we can do what we
can do, but you’re going to have to do what you can
do on your level. And, you know, we recognize if you’re doing the best you
can do, that’s all we can ask. I can’t tell you that
a validator isn’t going to come behind you and
say you didn’t do well. That will happen at some point, hopefully not in
the near future. Hopefully you’ll have time to get your processes
in order as well. But that’s just where
we are at the movement.>>Let me clarify: My hospital
system’s data system is perfect. [Laughter] Just so we’re clear. Ours is fine. I was talking about
everybody else.>>Well, good. They may all want to
come work for you.>>To build a little
bit on what she said, I think it would be really
helpful if CDC wrote a letter to either hospital associations
in the different states or people that run
hospitals — CEOs — because these folks
have no clue what we do. None. I’ve tried in
vain to, you know, delineate how all
the hours are spent and they just don’t get it. And they’re in the
mode for saving money and arbitrarily they’re
cutting resources to the point where we’re going to
have to end up putting in work that’s not good and not up to the level we
want it to be. And I don’t know about
anybody else here, but I’m not real
comfortable with that. If you don’t talk to COOs,
I think CDC always thinks to back off of making a
statement that you really need to help your ITs and think
about those resources because we need this data. And I don’t see what the CDC
would be risking by doing that. I really don’t. [Applause]>>Let me just mention that
we do have regular meetings, monthly meetings with
AHA, their top leadership. They are the ones that want
to make the communications to the executives
in the hospital. You know, I know — we have
written letters to CEOs before, and I can tell you
they’ve gone nowhere. So we can try again. I’m not saying we can’t,
but I wouldn’t be — I’m not as optimistic as you are that it will actually have
the effect that you want. But I will carry
that message forward.>>Just very quickly, Teresa,
I do appreciate on the bottom of each form that
we use to figure out if we have an
infection or not that it says that it takes 22 minutes of time
or something to that effect. Well, that’s for every
noninfection as well. It’s not just for
every infection. We [inaudible] investigate
thinking that there may or may not be an infection in
all that time and it wasn’t. Which is a good thing, but I
like that the number is on there so you multiply that times
every patient you look at.>>Yeah. That’s an
excellent point. And you know, it’s funny. The reason that those numbers
are on there is because in order for us to collect data
at the federal level, we have to have what’s
called “OMB clearance.” Office of Management and Budget
is supposed to be looking out for all of its citizens and keeping the big brother
government from, you know, asking you a million questions. And so in order to
do a data collection like a surveillance
system, we have to indicate “How much time does it
take to collect the data?” They don’t ask us how much
time it takes, as you said, to rule out that it
isn’t one of these. And if we put that burden in,
it would increase significantly. So it’s a really good point. And I’m not sure if
we can add it or not, just so they understand
that it’s not — I mean it looks huge as it is. I don’t know if you’ve ever
gone to the Federal Register and seen the number of hours. It’s, you know, it’s ridiculous. But we certainly know as
IPs ourselves what it takes to get the data and, you
know, again we’re really, really appreciative that you’re
here, both in person and on — attending by webstreaming — because we know that you’re
interested and committed and want to do the
best you can do. So give yourselves a pat
on the back for being here and making the effort daily. One last question and then
I’ll let you go to lunch.>>I had a question about the
upcoming changes for the hips and the knees that are
going to be in 2014. And are those the kind
of changes that are going to be addressed in ICD-9 coding that we can extract
via that resource?>>I think the changes
will better align with the way the coding is. Now, it will better
align with ICD-9 codings, but bear in mind we’ll
have to relook at all of that for the ICD-10s. So I don’t know that part yet. But essentially what
those changes will be, will be about really putting
together the revisions in a better way or keeping
track of those revisions in a better way than
we can do it now. The primaries are not a
problem; it’s those patients that have multiple revisions
where we’re not actually able in the way we do it now to
characterize the risk of SSI as well as we would like. So it’s — the changes
are to really better, to get us better data on
the hips and the knees, especially those
that are revised. Okay?

2016 NHSN – Secondary Bloodstream Infections

2016 NHSN – Secondary Bloodstream Infections


Welcome to the 2016 National Healthcare Safety Network Quick Learn series. These CDC presentations are an educational resource for healthcare facilities working to prevent Healthcare Associated Infections, or H-A-Is. In this series, we’ll review secondary bloodstream infections. NHSN frequently receives questions about the correct application of the Repeat Infection Timeframe, or RIT, concept as it relates to secondary bloodstream infections. We are often asked, “If a bloodstream infection, or BSI, is determined to be secondary to a primary site of infection, does this create a BSI RIT that will account for all subsequent positive blood cultures from this patient for the next 13 days?” The answer is no. The Repeat Infection Timeframe and Secondary Bloodstream Infection attribution period are two distinct periods. Let’s review. For purposes of NHSN surveillance, a bloodstream infection if the organism identified from the blood is related to an NHSN-defined primary site-specific infection. For a bloodstream infection to be identified as secondary BSI, all of the following must be true. First, the patient must meet one of the NHSN site-specific infection criteria. Second, the blood culture collection date must occur in the site-specific infection’s Secondary BSI Attribution Period. And third, one of the scenarios outlined in the Secondary BSI Guide found in Appendix 1 of the BSI protocol, must be satisfied. That is: EITHER an organism identified from the site specific infection that is used as an element to meet the site-specific infection criterion must have at least one matching organism found in the blood specimen OR the positive blood specimen must be used as an element to meet the site-specific infection criterion. Let’s look at examples of each of the two scenarios. In the first scenario, the organism identified from an infection site must be used as an element to meet the site-specific infection criterion AND the blood specimen must contain at least one matching organism to the site specimen. In this example, E.coli is found in the urine. The symptomatic urinary tract infection, or SUTI-1, infection criterion is met. Within the SUTI secondary BSI attribution period, the same organism found in the urine culture is also found in the blood culture. Therefore, the BSI is secondary to the SUTI. In the second scenario, the positive blood specimen must be used as an element to meet the site-specific infection criterion. In this example we have a non-surgical intra-abdominal, or IAB infection. This patient meets IAB criterion 3b, which requires 2 signs or symptoms, in this case, the nausea and abdominal pain, an imaging test evidence of infection AND identification of an organism in a blood specimen. Because the pathogen in the blood specimen is used to meet the IAB infection criterion, the BSI is secondary to the IAB infection. Note the blood culture collection date on 2/16 occurs within the IAB infection window period and likewise in the IAB secondary BSI attribution period. These examples are the only two ways that a BSI may be considered secondary. Now, given those two examples, let’s review the concept of the repeat infection timeframe, or RIT. The RIT is a 14-day timeframe during which no new infections of the same type are reported. The date of event is Day 1 of the 14-day RIT. Additional pathogens identified during the RIT from the same type of infection are simply added to the event. A new event is not reported. Now, let’s review the concept of the secondary bloodstream infection, or BSI, attribution period. The secondary BSI attribution period is the period in which a positive blood specimen must be collected to be considered as a secondary bloodstream infection to a primary site infection. This period includes the Infection Window Period plus the RIT. It is 14-17 days in length, depending upon the date of event. It’s important to point out the RIT and the secondary BSI attribution period are both associated with the site-specific infection. In this example, the site specific infection is the SUTI. Any additional qualifying urine culture pathogens identified within that SUTI RIT are added to the originally reported event. No new UTI infections are reported during the repeat infection timeframe. In this example, the pathogen, Staphylococcus aureus, is added to the originally reported SUTI event. Continuing with the same example, note the secondary BSI Attribution period for the SUTI does NOT apply to all subsequent bloodstream infections. The Secondary BSI attribution period is associated with the SUTI only. The blood culture with a collection date during the secondary BSI attribution period of the SUTI that does not have a matching organism to the site specific culture of urine cannot be attributed as secondary to the SUTI event. The secondary BSI attribution period does not automatically account for all positive blood cultures that occur during that period. The blood culture collected on 2/20 that is growing Klebsiella pneumoniae does not have a matching organism to the urine culture Therefore, it cannot be attributed as a secondary BSI to the SUTI. This BSI must be evaluated to determine if it’s secondary to another site of infection or if it’s a primary BSI. It could possibly be a central line-associated bloodstream infection, or CLABSI. Do not confuse a primary BSI Repeat Infection Timeframe with a secondary BSI attribution period. In this example, the infection criterion for a laboratory confirmed bloodstream infection, LCBI is met. A primary bloodstream infection is identified. Just like all other identified site-specific infections, identification of a primary BSI produces a 14 day repeat infection timeframe, or RIT, in this case a BSI RIT. Note that a primary BSI never has a secondary BSI attribution period. No new primary BSIs will be reported during this BSI-RIT. In this case the organisms do not have to match. The BSI is a primary site of infection and any additional organisms recovered during the RIT of the same type of infection, a BSI in this case, are added to the originally reported event. Returning to our original question… If a BSI is determined to be secondary to another primary site of infection, does this create a BSI RIT, which means I can exclude all positive blood cultures from the same patient from BSI surveillance during the next 13 days? The answer is NO. A secondary BSI does not create a BSI RIT for all subsequent positive blood cultures. The concepts covered in this quick learn apply to HAI and POA determinations. Based on that determination, the assignment of pathogens recovered from subsequent blood cultures are assigned accordingly. This concludes the NHSN Quick Learn focusing on BSIs and RITs. For additional questions, please contact NHSN user support at [email protected]

Surgical Site Infections (SSI) Surveillance with Case Studies (Part II).

Surgical Site Infections (SSI) Surveillance with Case Studies (Part II).


>>I had a few good questions during the break. Even though we still have
another hour — two hours. I’m going to present for another hour and
a half and then Maggie’s going to come back and present on how to export data. But, I did want to give you two points —
because one which I might not come back to. If a patient has a — you get their ICD-9 codes
back and what you see is two colo codes — different codes, but they’re
both in the colo group. That’s one colo procedure. Do not put in two colos. That’s true for anytime you see multiple
ICD-9 codes that fit into these same NHSN and operative procedure codes,
that’s one procedure. They just happened to do two
things that both met colo criteria. And again, I am a broken record, I know. That is in your denominator
reporting instructions. Okay, so let’s go ahead and get started. So there are a few procedures that have
some additional fields that you get to have to put some denominator data into. And there’s five procedures,
that if you’re following these in your reporting plan, there’s extra fields. That’s C-sections, which have
been true for quite a while, your fusions/re-fusions, H-pros and K-pros. All of these have a little bit additional. So for C-section you’re going
to need to put in the number of hours they were in labor in the hospital. The length of time from beginning of
active labor as an inpatient to delivery of the infant, expressed in hours. And if it’s less than 30 round
down, greater than 30 round up. If there’s no hours of labor, like a
planned, elective C-section, it’s zero hours. And you just need to check for
documentation in the chart. And this can be defined as active labor, but
however your hospital policy is doing it. We don’t micromanage this data field,
but it is something you’ll need to know. Fusion/re-fusions have, again, two areas. The first one is you’re going to tell us at what level the procedure
was done and then the approach. And some people have said, “Oh, what
if it’s anterior and posterior?” Remember we have a field
for anterior and posterior. When they’re both done, you’ll put that in. And if they do it at a multiple procedure
level, if it somehow ends up actually crossing into atlas axis and atlas axis cervical. You do the area — choose the area that
had the most number of vertebrae fused. And in our — because I just
answered this recently. People say, “Well how do I know which this is?” In our table of instructions,
again, broken record. We have the exact different
spinal-level cervical vertebrae named. We say, you know, with atlas axis goes these. This through this, this through this. So we really tell you exactly
which vertebrae are included in these groups in the table of instructions. We don’t have unknown anymore. If it’s unknown or not listed, you’re going to
need to obtain information for that procedure, you know, and usually you’ll have to
just read the op note and they’ll say it. If they didn’t, I would just really
base it on what the ICD-9 code is. Some of the ICD-9 codes will actually
say this is a cervical fusion, if they didn’t note it you can use that as well. We used to have a lateral transverse
code, and that got replaced by trans-oral. Because it’s more the terminology. If you actually go into the
current ICD-9 Code Book, you won’t find that lateral transverse listed,
it’s now — you’ll find trans-oral approach. All right. Forgot I had all these popups,
but I’ve told you all that. All right, now hip arthroplasties and K-pros. H-pros and K-pros have some additional fields. They’ve always had additional fields,
and they have a few more this year. I do want to get a show of hands, how many of you are reporting H-pros
and/or K-pros right now? Huge number, wow, okay that
— 90% it looks like. So, I mean that’s a very high number. I did not expect that. Okay, so I may spend a little more
time on these next couple slides. And I will tell you this is a little confusing
right now with ICD-9 codes and so I am going to just open myself to saying please,
if it doesn’t make sense here, you can send me questions in the NHSN mailbox. So, what we did. We provided this for you. One of the sort of experts here
at CDC is a orthopedic surgeon. And she was really, really sweet, because
I said, you know what, “We’re IPs, we’re not surgical nurse, we’re not orthopods,
sometimes when someone says it’s a total — total primary, like what does that mean?” So this is her best at — can
you put them in little, tiny, short sentences of when we’re saying something’s
a hemi-partial revision, what does that sort of mean in just easy lingo to understand. So I think — I’ve shared this with
a couple people via the mailbox and they’ve found this to be very helpful. So I’m just providing this sort of real life
language of what these mean for you, okay? And there’s also some really good resources
that she included that she thinks if you want to know more about what hip resurfacing means,
she put in a link for that — hemis and totals. So she was very sweet to
provide this information. Now for K-pros she did the same thing. Gave some good resources for us to use and
kind of gave a description of what this means when you see someone’s had one of these. And again, you all could have probably gone
to your orthopedic advanced practice nurse, you know, that you have and gotten something
similar, but I wanted to provide something. So, because we had these fields and
people were like well, what ICD-9, you know, how do I know what this is? So if you’re manually reviewing, you can
read it and try to put it together yourself, but if you’re using ICD-9 codes, we
provided for this because it was confusing. And this came out in a newsletter. It’s in your Alls Newsletter Box. We provided a mapping tool,
if you were using ICD-9 codes to help you just select these
boxes you’re going to see based on what the ICD-9 code that came across. So unfortunately, manual chart review,
or direct entry into the OR database, would be required to correctly specify these for
the H-pro and K-pro can be difficult due to — and this is the keyword, the lack
of specificity of ICD-9 codes — CM codes they just don’t map
one to one — they don’t. And if you could really tease out and read in
detail every op note, maybe you could figure out what they’re doing, but everybody
doesn’t have the ability to do this. And the good news, from everything
we’ve heard is that ICD-10 PCS coding is much
more granular and more specific. And hopefully we won’t have a thing where — yeah, every .00.81 to 00.84 is a K-pro hemi
partial revision, so we’re going to see. So what we did, is we’ve told you these
are your K-pro fields and if you find, and you want to use ICD-9
codes, if you find an 81.54, you will call that a total, total primary. Okay because you have to first
click total, then total primary. And, you know you can see all these. And if you find anything
that’s a 00.81 to 00.84, that’s a hemi partial revision,
anything in that code. So we’re hoping that these will help you, and
this is in an NHSN newsletter that was sent to everybody just for this mapping. And you should be able to
find it in your mailboxes, when — if you forgot to open that one. I know we get busy. We did the same thing for the H-pro mapping. These are the different possible
fields that you could use for ICD-9 code mapping for
these new required fields. And you’ll see them all listed here for
the resurfacing, the hemis, the totals. Now this is where this orange
note, I want to give you a note and this will make a little more sense, I think when Maggie then talks,
if you’re using CSV files. Due to a defect that we’re going to be
correcting when NHSN goes from ICD-9 to ICD 10s. That 00.71 and 00.73 — see they’re
in this hemi partial revision? They really are hemi partial
revisions, those codes. If you are putting — uploading this via like
a CSV file, or you’re entering ICD-9 codes, when you go to import that, you’re going to get
an error message that that code doesn’t match for a hemi partial revision,
but it is how we want it coded. So 0071s and 0073s we prefer you don’t use
an ICD-9 code for those and just name it as a hemi partial revision, okay? Then you will not get that error message. And it’s all here, you know, it just says
leave that code field blank and just select that it’s a hemi partial revision. Just for those two codes. And this will all go away and be
fixed when we go to ICD-10 codes. So in summary, complete and enter — or
import a denominator for procedure record for every NHSN operative procedure that’s
performed and selected for surveillance. Use the SSI protocols, your
table of instructions, key terms, and chapters from the Patient Safety Manual. Now, we’re going to go briefly
to linking a procedure. So you’ve gotten all your denominator
data in there for the month. And now you’re doing spectacular surveillance
and you’re out there finding your SSIs. And you want to link these two together. It’s basically telling you, this
denominator, this procedure done on this day, I now have an SSI on this day. And as Maggie said, it’s procedure-based. That SSI may have occurred in March,
the procedure was in February. It’s going to show up as a February infection. If it’s linked to that in
terms of your SIR and analysis. Even though — because that’s the
denominator, is the day you do the procedure. Linking is really important because
it gives you the correct risk factors that were matched very specifically
for that SSI. So all those risk factors are in there. So first you enter the denominator. You don’t want to put in an SSI if you
haven’t gotten your denominator data in yet. If you found the SSI for some reason
and you haven’t done any of your — just hold it back for a little bit and
make sure you’ve got your denominators. And then you’re going to enter the SSI
record and you’re going to link the two. Now this is something I really want
to emphasis how important this is and it will make your life easier
and you will get less error messages, because I made this mistake
many times as an IP myself. If I forget and I start going, “Oh I got
my SSI, let me start entering all my data,” I enter it all and then I say
I’m going to link this procedure and I get this big error,
“That procedure is not found.” And I’m like, wait, I know I put
that procedure in, try again, still. You don’t want to enter any of
your SSI data into this, okay? Just get the patient’s name, link an event. You’re going to put in that you have this SSI. See all I have filled in here [inaudible] is
that there’s an SSI, and I’m going to link it to the patient’s — you do
have the patient’s ID up above. And then when you link it you’re
going to click that button, okay? And then it’s going to send you to
the procedures that patient’s had. Don’t put any more in than that. You’re going to select this
procedure next to the colo and you’re going to hit that link button. And then when you go back, it’s going
to send you right back to that record. And it’s going to have filled in
the stuff that you put in before. Because if you have the tiniest little
mismatch from what you put in there in that denominator data from something
you go forward and put your numerator. You’ll get that error message that we can’t find
that procedure because they don’t match exactly. That will help you a lot. See there you go. And then it auto-filled this. And now all the data are linked
together and they’re exactly right. They’re not mismatched at all. And then you click — don’t
forget the save button. Now we’re getting into the meat of it. People will come up and will
ask me like, when are you? I said no, we’re going to cover the SSIs next. So now. Superficial SSI this — because
you are — very few of you are brand new, I am not going to read every definition. I’m going to highlight the issues, the concerns
that happen and point out what’s different. So remember colo and hyst procedures
are both 30-day procedures. So for those — they never go beyond that. And I want to tell you something,
because I was giving a training for some of our state health departments
a couple months ago. And they are finding facilities that think
because CMS just get our deep, incisional, and are organ-based infections that they
can completely blow off superficial SSIs and not look for them, not report them. Well when you look at when you do when you agree that you are an NHSN facility,
and you have your certificates. You agree — when you sign up to do
something that you’re following the protocol. So you are supposed to be doing
superficial, deep, and organ spaces, just that we only send the
deep and organ space to CMS. But there was never anything that
said don’t look at superficials, at least not at this point, we
haven’t gotten rid of that definition. And we did not really change
anything with superficial SSI, except it is the only definition that still
has diagnosis of a superficial incisional SSI by the surgeon, and you’ll see that that
was removed for deep and organ space. Now this is a new — let me,
I want to go back one more, I want to get to that — I get to that layer. So this is the newest reporting instructions. Someone asked me about this
before the lunch break. This has really been simplified. So in the past we had a lot
of little funny rules. If something is a deep, if it meets
superficial deep and organ space, you should split the difference
and call it a deep. If something is a superficial and organ space, and you actually find the
organ space is draining through the incision, then you call it deep. And there were a lot of little
funny rules about splitting. We got rid of all of those. You simply call the infection at the deepest
level that it actually went to within — this is the keyword, within the
appropriate surveillance period. So if you write a superficial SSI up on day 20,
after a hyst and then the patient comes back in on day 40, and it’s progressed
to a deep, you do not upgrade that. You did not meet the definition
of a deep in surgical — a deep incision in the 30
day surveillance period okay? That really drives everything. If you try to enter a superficial
SSI beyond the 30-day period. This is where we talk about the
application, the business rules behind things. We try to make the application — some
people have been asking about validating, how do you know it’s the right data? You’re going to get an error
message that says this. Because you’ve already said
you’re sending us a superficial. And if it’s beyond the 30-day period,
you’re going to get an error message and it won’t specifically say — tell you why, but it’s going to say it
doesn’t meet definition. So stop and look. Because sometimes it just falls off our plate. You know, you’re busy. It’s like oh I didn’t even notice this was day
35, that’s why I’m getting that error message. All right? Now, I do want to point out — look next —
here next to the 90-day surveillance period. This is just cut from the protocol. Over here, you’ll see the note
at the bottom of this page. This is table three from our manual. Superficial incisional SSIs are only
followed for 30 days for all procedures. This is another question we get. Someone will be reporting. They’ll say, oh, here’s my 90-day
surveillance categories, okay? So we have — We got rid of implants. Remember back in 2012, if a patient had a — yeah [applause], you guys are still
happy — you’re still happy about that. Remember back in 2012 you had to look for every little internal staple
and implant followed for a year. That went away in January of 2013. So it doesn’t matter if they used
an implant in that procedure or not. You can breasts are in the 90-day
surveillance period and the breast with an implant, the breast without an implant. They’re all followed for 90 days. But this note down here is
telling you, no matter what. For all of these categories, superficial
is only ever followed for 30 days. So I’ve had people really get confused,
because they’re ending a superficial SSI on like a breast procedure and they
know that’s a 90-day procedure. And they don’t understand why. You’re going to get that same error message
because you can only report the superficials. It’s the deep over here and the
organ space that you can follow for the beyond 30-day and up to 90-day period. So a couple little reporting
instructions for superficial SSIs. Do not report a stitch abscess. Now I’m going to define stitch abscess because
I have had some surgeon notes copied to me, where you’ve got a person with
their huge abscess in their muscle, and they say, well that’s where a stitch was. I’m like nah, nah, nah. That’s not what we mean by a stitch abscess. We mean. And I’ve, you know, I’ve had some
personally myself, it’s where the suture, the staple enters the skin and
you get a localized little abscess at that external lateral position. That’s what we define as a stitch abscess. Those should not be reported as SSIs. They don’t meet our criteria. Also, don’t report a localized stab wound. Now someone asked me, they thought
this meant like from a street fight. I’m like no [laughter]. Those might get infected,
but they’re also done as — no we mean when they make a stab wound
to put in a JP or something like that. That’s what we mean by a stab wound. So if you have a — they have done
a stab wound to insert a drain and you get a localized infection
of the skin around the stab wound. That is not an SSI. Now if you’re Pennsylvania, they must
feel like we’re picking on them by now, that could become a skin soft tissue, you know, just non-SSI skin soft tissue
infection, it may meet. But it shouldn’t be reported as an SSI. And that’s what I say there. And the last one is a little
messy, but it’s cellulitis. So here’s where we go with physician diagnosis. I’m going to give you two
examples of physician diagnosis. You have a patient that literally — let’s flip back to our definition
of a superficial SSI for you here. You have a patient who comes in, and
the only symptoms they have are redness, and a little redness and some warmth. That’s it. It’s looking a little angry. But that’s all you’ve got. That’s a cellulitis. There isn’t drainage coming out of it. The surgeon isn’t opening it and doing
anything fancy, you’ve just got that. The physician calls this SSI and treats them. That does not — what supersedes is the fact
we don’t want you reporting cellulitis alone. So if a physician treats a cellulitis, that doesn’t mean you now do criterion
D. We don’t want you doing that, that’s a reporting instruction. What we would have to report, and they
say, “Well what would we have to report that the physician would call an SSI?” You could have a patient who has a lot of serous
drainage coming from their superficial incision. Look at this, A. It’s not purulent,
but it’s really a ton and it’s serous. And the physician calls that
an SSI and treats it. This is where a physician
diagnosis would come in. You would call that, and you’d use criterion
D. We don’t see it having to be used a lot because usually they’ll meet
with some other reason, okay? The other one I want to talk about. Oh man, I hope I can finish this, I’m
going to have to start talking fast, is I get a lot of questions of what do you
mean by an aseptically obtained culture? Basically, if that culture arrives to your lab,
or the lab that you use and that lab accepts that culture, and that culture comes back with
a known — with an actual organism identified. It isn’t mixed skin flora, it isn’t mixed
flora, it isn’t mixed cutaneous flora. It has an organism in it. You assume that your facility obtained that
properly following proper policy and procedure for how your lab and your
facility wants wounds collected. If you think your facility is not following
proper technique for collecting wound cultures. That’s an educational opportunity. But you can’t just look at things and
say, “Ah, I don’t like how that looks, I don’t think that was aseptically obtained.” That’s not your call. This is the — you have to trust
that your lab runs proper specimens, the ones that weren’t properly
obtained should be coming out as mixed cultures and just a bunch of junk. And those don’t meet our criteria, okay? So I won’t address that. And then the last one I want to address — and a lot of people really get this is the
criterion C. So you could have a patient who comes in with a really
red, hot, angry looking wound. The surgeon wants to know what’s going
on underneath it, or the surgeon wants to know what’s going on underneath
it, or the ER physician. And they actually open the wound. It is deliberately opened. This is no spontaneous dehiscence in here. And they deliberately open
it, remove a couple staples. And a bunch of stuff drains
out, they poke around, they look, and they do not get a culture. They say, “I’m not culturing it, I’m just going to open this thing up, and
drain it, and do whatever.” If that patient came in with these wounds,
pain, tenderness, swelling, a hot — there’s some reason that physician
decided to open up that incision, and they choose to not culture, this will
meet criterion C. If they do that same thing and they get under there and they’re like
“Oh, I think this might be a seroma,” and they culture it, and it’s
culture-negative, you don’t meet this criteria. A culture-negative finding
does not meet this criteria. If they get in there and there’s this icky,
thick black-ish looking stuff and it looks like it may be an infected hematoma,
and they open it, and they drain it, and they send a culture, and it’s
positive, that’s an infected hematoma. I get that a lot. Is every seroma infected? No. Is every hematoma infected? No. But this is how they’re
often found, is right like this. So I just want you to be
clear on that no culture done versus a negative culture, versus a positive. And spontaneous dehiscence, which will show up
in our deep incisional, doesn’t show up here. And I think it’s actually because
there’s a lot superficial incisions that will spontaneously dehis a little
bit, you know, they’ll have some issues, but we do have spontaneous dehiscence in deep. Because you really don’t — if a deep wound,
for it to spontaneously dehis to the deep level, that’s a major thing, versus a little
superficial dehiscence, which is what we’ll — so, but for the superficial, it has to be deliberately opened to
meet that specific criteria. All right. So you can have both, a superficial
incisional primary. I’ll use the CBGB’s as an example for that. The CBGBs, that if your chest
incision gets infected, that would be a superficial incisional primary. If your leg incision gets infected,
that’s a superficial incisional secondary. We only have a handful of procedures
that have two separate sites setup, but you’ll find that in your dropdown menu. You’ll be telling them, am I
writing up the SIP or the SIS? Okay? And so that’s what
you would do with those. And if a patient has both and they develop
an infection of their chest site, way up here and they have an infection of their
leg site, you’re putting in two SSIs. They’ve got a SIS and a SIP. So here’s an example I’ll get you. This is not in your clickers,
it’s just follow along. Patient delivers a baby by C-section on
August 23rd and on her first postpartum visit to her surgeon on the 20th, she noticed yellow,
purulent drainage in the superficial incision. Does Gretchen have a surgical site infection? I’m hearing lots of yeses. Yes. That’s purulent drainage
that’s criterion A. Okay. Is it a superficial SSI? At this point, from the knowledge
we have in front of us, yes. It’s from — it’s just purulent drainage
coming out of that superficial incision. Is this a SIP primary, or is it a SIS secondary?>>SIP.>>SIP. You guys are good. It’s a SIP. She didn’t even have — a C-section
doesn’t have a secondary site. So here’s another example. If a patient underwent a coronary artery bypass
graft CBGB, the surgeon got the donor vessel from a site in the leg, five days postop, the
patient has pain and edema in the leg incision. They open the superficial incision,
drain the pus, irrigate the wound. Does this person have a superficial
incisional SSI? Yes. Is it a SIS or a SIP?>>A SIS.>>Right, the secondary site, SIS. Let’s do another little case. You’ll need your clickers for
this, so share if there’s someone who hasn’t had the chance to use it. So, 2/18 you have a 45-year-old male admitted and he had a laparoscopic left
hemicolectomy, that’s 1735 and that’s a colo. Three trocar cites were closed and the
fourth site they used to place a JP drain. Then on 2/24, that’s about a week later, you have purulent drainage noted
at one of the trocar sites. The culture is obtained and it’s positive
for Enterobacter species and E. coli and the patient is started on antibiotics. Is this procedure considered
a primary closure for 2014? Got some voting going. Ten seconds, you guys are
so fast with those now. Yes. It is. Remember you’ve closed all
those trocar sites were closed. And if you have someone, I’m
going to just tell you this. I’m not sure it’s as clearly expressed
in our current manual as it was in ’13. If you have someone who has four trocar sites
and they close three of them and leave one open and they just don’t close it — you still
have a — if any of multiple incisions, when you have a procedure that has multiple
incisions, like a laparoscopic procedure, if one of those is closed primarily, it’s
considered a closed — operative procedure. Primary closed. Very good. Case five, the rationale they’re using
for this one, the surgeon was just using that existing trocar site to place the JP
drain, rather than creating another stab wound. And if there’s multiple incisions
and one of them is closed primary, the whole procedure does meet criteria for
a closed — primarily closed procedure. What should be reported to NHSN? Well nothing in terms of — that, you know, the surgeon did not open the
wound, so the criteria not met. Nothing is an SSI, but not an HAI. It should be a superficial incisional
primary, or a deep incisional primary. You can look back at the case. Give you about 10 seconds. Lots of votes coming in. All right. You guys are good. Superficial incisional primary. And I’ll show you. We’ll go through this so you can see why. It happened within 30 days. It was only the skin and
the subcutaneous tissue. And you had purulent drainage
at that trocar site. It was superficial. And there was an organism that was
cultured, obtained, and was positive. So a lot of times you’ll meet more than one
criteria in an SSI definition and that’s fine. It’s not like when you go to enter
it, it’s asking was this A, B, or C. It just — it will meet criteria. Let’s try another one. Let’s go on to something
that isn’t a colo or a hyst. So this patient has a hip arthroplasty,
especially because all of you — so many — almost all of you are following hips or knees. And it’s performed on 3/17 at hospital
A. They get discharged on 3/19. That’s pretty darn fast, but
they get them out quickly now. They’re readmitted to hospital B on 3/25 with
purulent drainage from the superficial incision and further investigation
at that hospital concludes that this is a superficial incisional SSI. What should hospital B do? This is not clickers — this
is just [Background noise]? Exactly. They need to notify
hospital A about the SSI and give as much information as they can. And what should hospital A do? Exactly. They need to report that SSI to NHSN
if it’s in their hospital reporting plan. Hospital B doesn’t know if hospital
A is following H pros or not. Give them the chance to know this happened. And they’re going to report it because they’re
the ones you have to think it’s procedure-based. They’re the ones that have
it on their denominator data. I get questions from rehab facilities and
stuff saying, well they were fine when the left and then they went to rehab
and now they have an SSI. That doesn’t seem fair that I have to count it. I’m like, well the rehab can’t count it, they
don’t have the denominator data and it wasn’t — again you have to kind of get your brain
around that this is very procedure based. What if the same infection, this
H-pro met criteria on day 35? Postop day 35? What would you do? Right. It’s not an SSI. They have an infection, but it doesn’t
meet SSI criteria and it’s not reported. They’ve been gone forever, you know, they’ve
been gone for over 10 days from your facility. You don’t — it isn’t anything at that point. SSIs are always associated with that
particular procedure through linking. And if you don’t have that procedure in your
database you can’t link that infection to it. And you only follow your
superficials for 30 days. Let’s try case seven. So this is a 70-year-old male who was admitted
on 3/10 and underwent a hemi-colectomy and a repair of an abdominal wall hernia, via
the same incision on the day of admission. The incision was closed, and a JP was placed
via a stab wound in the left lower quadrant. And the patient went home about
four days later on the 14th. Then three days later that patient arrives
to the ED, has a red, painful incision. The incision is draining yellow, foul smelling
discharge from the superficial incision. The physician removes two staples,
we see these cases all the time. Probes the wound. The fascia is intact and there’s
only subcutaneous tissue involved, and no cultures were obtained. Antibiotics are ordered, the wound is packed
and the patient is discharged home from the ED. Great, you’ve seen these cases. This is — definitively we see these out there. So what should be reported to NHSN? Nothing, the wound culture was
negative, so it doesn’t meet criteria. Nothing. He had two procedures, so you
don’t know which one caused the infection. Valid point. It should be an SSI SIP attributed to the colo. It should be an SSI DIP attributed
to the hernia. All right, start those buttons going. A little tougher one this time. I’m sort of testing you on
something I haven’t taught you yet. But you guys are very experienced
so I’m sure you’ll get this. All right 10 seconds. I’ve got almost most of the responses. Finish it up. All right. Let’s see how you did. Oh, my gosh. Look at you guys. All right. Okay. There was only maybe
one person that said one. And one said two. Okay. It is correct. This is a superficial incisional primary
attributed to colo and here’s why. Because we’re going to go over that now. If more than one operative procedure
is done through a single incision, first attempt to determine the procedure that
is thought to be associated with the infection. So for example, here’s where one you could. The patient has a CBGC so just, you know,
and had a CARD done at the same time. And they come back with a valve infection. You know, it’s an organ space valve, then
the SSI should be attributed to what? The CARD. I mean you can tell sometimes
when you’re dealing with organ space which is the culprit so-to-speak. If it’s not clear, which is really
the case, almost really is the case with any incisional SSI superficial or deep,
you’re going to use the NHSNs principle after procedure selection list to determine
which of those procedures is higher risk for getting — because we’ve looked at this. We’ve said which procedures? And we re-baselined that list last year. And it changed things around
quite a bit when we did that. So there’s five lists that are in
table five, this is table five. You have your abdominal operations
linked all together, your thoracic. We combined neurosurgical
operations of the sprain and bine — spine and brain together this year,
because the risk worked either way. So it didn’t make sense to
keep it a separate list. It won’t change your data. They lined up exactly. It just was kind of confusing
to have them separated. And the neck. And the categories with the highest risks
are listed above those with the lowest. So we use this a lot. So if you look at this, that person
that had a colo and a hernia. Well hernias are way down here and the
colo is way up here and it was incisional. So this would be attributed to the colon. Man, I think I had something with lunch. Okay, let’s do deep incisional SSI. And for this one I put a little posted note to
remind you of the only thing we tweaked on this, the same thing you’ve been looking
at for the past couple years. Is that we did remove MD
diagnosis from deep incisional SSI. Okay? So, you’re going to
need to meet this criteria. So, and again the thing — this is pretty clear. Purulent drainage, but again
remember, we want them to be saying that this drainage is coming from the deep area. That means, they somehow have enough knowledge. And often it’s because they’ve had
to open it, that this infection is down in the fascia muscle layer, or that —
now for here you can spontaneously dehis, but what they’re saying again, the
key word here is a deep incision. So when it opens up, they’re
like seeing the fascia muscle. It really opened up. It was a bad dehiscence. Or it was deliberately opened. And this is the same again. And it is culture positive. Or they chose — now this we see more rarely. If it’s to the level that a person’s literally
— they’ve opened up to the deep level. A lot of times they’re back in the OR. But they’re usually — they
culture to see what’s going on. And you do have to have some kind of symptoms
here, but fever, and it’s just localized pain or tenderness, and a negative culture,
again, will not meet this criteria. So it’s very, very similar to superficial. But here, you can have a spontaneous
dehiscence or deliberately open. And the last one is that they
just really observe in that area, the deep incision on direct exam. Means the physician looks at it and sees what
looks like an abscess purulent fluid, whatever, in the deep area during an invasive
procedure, or by histopath or imaging. So the invasion procedure here could be that
they actually take the person down to CT, doesn’t mean they have to go to the OR, and
they drain an abscess that appears when it — based on the imaging they did
of it and when they go down, that this is still localized
to that muscle fascia level. Okay? Very similar, you have
the primary and the deep. Primary infections or secondary
sites, exactly what we just talked about for superficial, pertains to deep. Let’s try another case. So you have a patient is admitted to the
hospital on 3/12 for an elective surgery and you do have an active MRSA
screening protocol at your facility. And so you screen everyone, do a
little nares swab on admission. And they are MRSA positive patient. On the same day, the patient undergoes
a total abdominal hysterectomy. The postop course is unremarkable,
and the patient is discharged on 3/15. On 3/18, the patient’s readmitted
with complaints of acute incisional pain since the day before. The surgeon opens the wound and
notices the fascia is not intact. Now that thing that I’m saying,
you’re saying oh, they don’t do that. They — surgeons very often will really
note what’s going on with the fascia. That’s a big thing for them, has this gone deep
enough that it’s into the fascia layer or not. When they say it’s intact, they’re telling
you it didn’t cause anything there. It looks good. So that’s the key when you say its intact,
that’s a key that you’re probably dealing with something that’s gone to the level of
the fascia, but it’s intact and not affected. Once you get into the fascia muscle, then
you’ve got the deep infection going on. And they send a specimen from the deep wound and on 3/20 the culture results
are positive for MRSA. Is this an SSI, yes it meets criteria — or no that patient was colonized
with MRSA, so this is a POA? Yeah, so surgeons might want to pull
that one, but it doesn’t fool us right? I figured you guys were too smart for that. All right. Still I see the votes coming
in, but let’s go ahead. Yeah. You guys, you nailed that one [laughter]. All right. We’ve all heard it though, right? Yeah, so you know, that’s why it hits home. What infection should be reported? Look back on that case, is this a
SIP, a superficial incisional primary, superficial incisional secondary — man these
are tongue twisters, deep incisional primary, deep incisional secondary, or is this maybe
an organ space SSI, intra-abdominal infection? So go ahead and start your clickers. All right I’ll give you about 10 more seconds. I think everyone’s voting quickly on this. Exactly. It’s a deep incisional primary. The fascia was involved. They were in the deep area when
they got the cultural result. And here you are. Which one did you hit? You hit that one we talked about. They opened the incision,
they deliberately opened it. It was culture positive, and she had increased, acute localized pain from
the day before, all right? And very good. All right. Different scenario. Let’s take this and change it up a little bit. It’s still the same patient. She still came in for that elective
surgery, still MRSA positive. Has the hyst on the same day. The postop course, she’s
still discharged on the 15th. She comes in on the 18th with complaints
again of that acute incisional pain. The surgeon opens the wound,
clear serous drainage is found and notes the fascia is not intact. Sends a specimen from the deep wound. And on 3/20, the culture results
come back as final and no growth. What infection should reported? Superficial incisional primary,
a deep incisional primary, an organ space, or nothing, it’s not an SSI? Go ahead and pass your clicker to someone
who hasn’t gotten a chance to vote, or vote. Give you 10 more seconds. All righty, let’s see if you got this one. Very good that’s correct. Nothing, it’s not an SSI. And I’m going to show you why. Here we go. They did deliberately open this. She had some pain. What came out was a lot of serous fluid. Maybe think of what sometimes
causes serous fluid, seromas. And it was culture negative. They cultured it, but it didn’t grow anything. So this is probably someone who had a
non-infected seroma that they drained, okay? So those are often found in that area. Okay? Make sense? All right, now we’ll get into organ space. Again, now what we did is we removed MD
diagnosis has been removed from organ space. And what I want to try to map out for you on
my hands here is so you have your SSI chapter, you’ve got your superficial, your deep,
and now we’re moving onto your organ space. And then you have — that
has to pair with organ space, your Chapter 17 definitions
of site-specific infections. You have to meet the one to
start looking at the other, okay? And because we removed — I
just want to clarify this, diagnosis from this, it’s
thrown some people off. And I’m going to give you an exact example,
is that you have to meet one of these. Okay? Purulent drainage from a drain
that’s placed into the organ space, okay. Organisms isolated from an aseptically
obtained culture of tissue or fluid in the organ space area, or an abscess of —
and this is this huge general statement here. Or other evidence of infection that’s detected
on direct exam, or during an invasive procedure, or by histopath, or imaging test. This other evidence of infection
is a real catchall. I have had concerns expressed to me of
oh my goodness, we will never be call — or call another post C-section endometritis
because you removed physician diagnosis. And I said no, no, no. And we’re rephrasing this in 15. It’s going to be a much better phrase,
we’re going to say, “No other evidence of infection on gross an anatomical exam.” Okay? So what happens when you have a patient
who comes in, they’ve had a C-section, they come in febrile, tender, the
physician is usually palpating the fundus and it’s very, very tender. The physician at that point it like oh my
gosh, I think we’ve got an endometritis. That is that other evidence of infection. And then you then go and see if that patient
actually meets your endometritis definition. So that’s — I want to kind of explain that that
C is a huge category, that is basically saying, this has started a surgeon on the path of
looking at what is going on with this patient and now — when you don’t have like
frank purulence, or a drain put in, or an abscess that’s obviously seen on CT,
you know, that lets you go down the path to see if it ultimately will meet. We do have — so the specific sites of infection
that you can use after SSIs are listed here. And we do have a new definition added. It didn’t replace one. We still have joint infection down here. I’ll get this little, please —
where’d my mouse wake up again — ah. Well, it moved over here. I’m like that’s where it went. Okay. Joint infections still exist, but it isn’t if a person has a prosthetic
joint in place, okay. If they’ve done H-pro or a K-pro. And you have — you’ve had
an H-pro, K-pro procedure. For H-pros and K-pros you use this new
PJI definition and if you are a place that follows everything and you just had sort
of like a wrist surgery that got infected, or an ankle or something like
that, joint still exists for that. But you won’t actually — under H-pro and
K-pro, when you look at your dropdown now, you won’t find joint listed
anymore, you’ll just find PJI. Okay? We’re going to cover that briefly. We can’t do it in detail, but. Because a lot of you all are
following hips and knees, I want to, you know, give some time to this. So number one, I will tell you right up front, you will be calling less
PJIs then you call joints. Your numbers are going to go down. It’s the kind of thing to note in your
infection control committee minutes. I don’t know if you keep little magic arrows
of timeline of this is when something changed. Because think about our old PJI definition. You could have a single coag negative
staph that grows in broth from an aspirate of actual joint fluid, and
that met our joint infection. Okay? And this new definition was done after
much, much, much work and a huge conference of the MSIS, which is the
Musculoskeletal Infection Society. And then we worked in collaboration with them. That’s new harmony we’re talking
about, to really get a definition that I think our orthopedic surgeons are
really going to respect, but I think — and hopefully you all are all going to your OR committee meetings when
they happen once a month. This is something you need to take to your OR
committee meetings and you need to educate them that we have a new definition
for our joint infections. It’s based on your societies,
you know, the Orthopedic Surgeon, the Musculoskeletal Infection
Society’s definition. This is almost identical
to their new definition. So it should make your orthopedic
surgeons very happy. But they need to be informed,
because if they have a little less than maybe — I want to say this correctly. If they’re possibly not following best
practice for what you should do to rule out that you have a true joint infection, them
knowing what’s in here may change that practice. And a big one be the fact that you’re
going to need two positive periprosthetic, that’s your tissue or fluid down at the level
of the joint, cultures with identical organisms. Not the antibiograms don’t have to match,
just you’re going to have Staph aureus in two cultures, or you’re going
to have Staph epidermidis in two. They have to be matching and identical. And before a single culture
could buy you a joint infection. The other and any of us who’ve worked a lot with
hips and knees, know that sinus tract and in — I don’t — the slide would have been insane. But there is a definition of what a
sinus track is in the new PJI definition. But what it comes out as the patient presents
it looks like they have a little defect in the incision and pus is like coming
out and then when they take them back, they actually find that this is this
tract of pus is coming like right from the knee joint and exiting
out of the incision. That’s called a sinus tract. So if they just see that sinus tract and they
didn’t even get any cultures, and they take them to the OR and they’re like
you see that keyword — oh my gosh, they have a sinus tract,
that will meet PJI definition. Or, so here’s where you get
where there’s less evidence. Here’s where you have a single
tissue or fluid here. If you have a single, you’re going to
need some other blood work to be done. And on the form you’re just going
to click off when you enter it. Other positive lab tests. Because these all fit that criteria. You’re going to need to see an elevated
C-reactive protein, or an elevated ESR. Both of these are indications
of inflammation in the joint. So that’s a key one. And there is — this is my last correction. It was a typo, it was not there originally, but
sometimes our manuals do a little magic thing. This was a C-reactive protein
which came over as 100. That would be like saying a
patient has a fever of 370 degrees. You will never see a C-reactive
protein of — it was 10 is what it is. So it’s corrected here. It is not corrected in the manual yet. So it should be 10 not 100 there. Then, you’re going to also have WBCs, C-elevated
— WBCs in your synovial fluid would be B — or this is a new practice they’re doing more. There literally doing like
what we kind of do on urine. They’re doing a leukocyte esterase test strip. And if it’s a leukocyte esterase positive,
if you have a practice that’s doing that, that will also meet B. And then
the last one is you have greater than 90% PMNs showing in the fluid. So you’re looking for infected fluid and
a single positive, but any of these — three of these five will also
buy you a PJI definition. Okay? If a patient has an infection in the
organ space that was being operated on, I think we’ve covered this
enough, and subsequent continuation of this infection type during the
remainder of the surveillance period, it is considered an organ space SSI, if the
organ space SSIs site-specific criteria are met. Again, you can have a patient — it’s not
like you open somebody up and say, “Oh, they ruptured their colon,
let’s just leave it open.” They do everything, everything in
their power to clean out that patient. They do colectomies. They might form a colostomy. They throw antibiotic washings
numerous, numerous times. And they give them usually extended antibiotics. They are doing everything they can to prevent
that patient, but we know those patients that are wound class three and four are at very
high-risk of getting SSIs and that is calculated in your SIRs in the data that’s sent over to us. And it’s even going to be doubly calculated — we’ll be able to see what’s happening
with those that were left open? How often are they getting infected? Or did it work, all the washouts that they
did and everything they did to prevent it. So here’s an example, on 8/1 a patient presents
to the ED with an acute abdomen and is admitted to the OR on the same day for a colo-resection. They found peritoneal abscess was
noted at the time of the surgery. The abscesses were drained
and thorough abdominal washout of the incision was loosely closed
with some packing between the staples. And the JP was place in an adjacent stab wound. The patient was discharged, wounds
were healing well on the fourth. On the eighth they came back to
the ED with fever, abdominal pain, and purulent drainage via the
JP drain that was still in. This is reported as an SSI IAB, because
it meets criterion three A. And I’m sad to say I have them all memorized. That’s the one where you basically
have a drain that was placed in the OR, is draining purulent drainage,
we’re talking about coming from the outside, not a localized infection. And they came in they were symptomatic. That’s criterion three A of GI IAB. And I believe — I think
Courtney can correct me here. You all were given in your
resource manual the IAB definition from Chapter 17, I think you have that. If you want to look at that. It’s like everybody’s favorite
definition now that we do colos. All right? So let’s — in Chapter nine again, this
is repetitive, I have to take this out. We have a lot of organ space
reporting instructions as well. And these are just some of
them that we’re going over. So please, you know, read over, after the organ
space we have reporting instructions specific to them. So when a patient has an SSI
and has more than one operation. So if a patient had several NHSN operations
prior to an SSI, report the operation that was performed most closely
in time to the infection date. And this does not apply to
that, though, 24-hour rule. I’m not talking about two done within
24 hours, because then you only have that first denominator in your data. So here’s an example, if you have a patient
who underwent a colo on 2/14, one week later, when they’re still in the
hospital, they go back to the OR and they have an appe, via the same incision. They develop an incisional SSI on 2/28. This SSI is attributed to the
second procedure not the colo. Even if you’re not following that in
your plan, you don’t want to jump back to the colo procedure, they’ve had a
major other NHSN operative procedure, so you attribute to the most recent. Let’s do case nine. So, on 3/10 your patient is admitted and
underwent a hemi-colectomy due to colon cancer. The wound class was listed
as clean-contaminated. Four days later, their temp is
38.7, they have abdominal pain, ultrasonography shows an
intra-abdominal abscess. They take them back to the OR
for an I and D of the abscess. The specimen collected for
culture, and antibiotics were begun. The abscess grew, you know, E. coli. They were discharged home on
oral antibiotics on the 18th. Does this patient meet criteria
for an organ space SSI? Go ahead and use your clickers for this. It’s a voting one. Give you 10 seconds. Almost everyone has voted, I can
see from my magic window here. Yep. Very good. Yes. And here’s the reason. You’ve got occurred within
the proper time period. Abscess was within the intra-abdominal
organ space. There was actually an aseptically
obtained specimen as well at that time. And they saw — there was an abscess seen
during, they took them back to the OR. So this can meet on more than one level. So this is — and meets the
definition for an organ space. And it has to then meet the IAB criteria. So, okay? So two different criteria
must be met for an organ space. Your site-specific organ space,
where they saw the abscess on CT and then took them back and found it. And those of the site-specific. And all those site-specific organisms
are in Chapter 17, the HAI chapter. What type of SSI does this patient have? Is it a superficial primary, a deep incisional
primary, an SSI organ space intra-abdominal, my GI IAB as this is called, or SSI —
there’s another one which is called GI GIT, which is gastrointestinal; one’s intra-abdominal
and one’s — the GIT is our gastrointestinal? Which one do you think this
patient met based on the findings? Okay, 10 more seconds. Almost all the votes are in. Very good. I was afraid, now there’s a — that maybe that
would trick you up a little more than it did. Not that I’m trying to trick you. But this is a GI IAB intra-abdominal
which means — and this is — at the top of each of these
definitions in Chapter 17, it tells you where to apply this definition. So a GI IAB infection means it’s not
specified elsewhere under gallbladder — it’s an infection that’s
not specified elsewhere. Such as, these are our gallbladder,
your bile ducts, liver, excluding a viral hepatitis,
your spleen, your pancreas. All these infections are
the intro-abdominal space. Your peritoneum, subphrenic,
subdiaphrenic space, or other intra-abdominal
tissue not specified elsewhere. So the intra-abdominal infection has
to meet one of the following criteria. The patient has to have an
organism or an abscess. Now we did add this last year
this said organisms cultured from purulent material from
the intra-abdominal space. But a lot of times they wouldn’t say — use the word purulent, even though they were
saying it was an abscess they were culturing. So we added — we did very
little changes to Chapter 17, but we felt this was importance enough
with how heavily this criteria is used to make sure we know that if they
go in, they’ve seen an abscess and they’re culturing the abscess and there’s
organisms found, that will meet criterion one. And then the next one is they have
abscess or just other evidence of intra-abdominal infection
during an invasive procedure. So they can go in and see a really bad
abscess or really inflamed peritoneal cavity. And they cannot culture. Because I have this question’s
in my mailbox right now. Can you have an SSI and not
have a positive culture? And hopefully by you seeing this,
you absolutely can meet SSI criteria where a culture is not sent. And the last one is the one that they have to
have two of the following signs and symptoms; fever, nausea, vomiting,
abdominal pain, or jaundice. And one of the following, and these are
— I’m not going to labor over these. You all know these. We didn’t change these definitions at all
and we’ll be touching on a couple of these in some cases coming up all right? So what you think about is the really most
specific ones are up top and when you get into maybe a little less certainty. Is this really going to meet GI IAB? We want to see some symptoms in here
as well as this, you know, so these, as you see there’s no symptoms
associated the patient has to have. This asterisk here means with
no other recognized cause. So that is very much of a clinical thing
you have to look at based on the case. Now, why was this not a GI GIT? The person had a colo procedure, we operated
on their colon, so why wasn’t this a GI GIT, well because this was not an infection. The GIT tract if you look at
it, it’s really for things like the stomach, the actual colon itself. Things that are a part of the actual tract. They did surgery on that, but
it actually expanded and went in to cause an infection in
the intra-abdominal area. So therefore, the IAB was the
appropriate choice for this kind of general intra-abdominal infection. Let’s change the scenario one more time
and let’s say at the time of the I and D, it was discovered when they took him back in that the patient had suffered
an anastomotic leak from which all these abscesses had developed. Does this change your determination
of this being an SSI IAB? No. This was not a voting. Although an anastomotic leak can be
— is a complication of the surgery, the fact remains that this patient
meets the criterion for an SSI. If the surgery hadn’t been performed, there’d
be no anastomoses that could have leaked. It’s the complication that caused an infection. That being said, does every single
anastomotic leak cause an infection? No. You can get that patient there super early. It can be a tiny leak, but they’re still
becoming symptomatic and they get them to the OR and they’re just — they
don’t meet that criteria. They still have to meet the criteria. They often will, but it isn’t an automatic
that you say, oh anastomotic leak equals SSI. All right let’s try this one, case 10. We have a patient has an
abdominal hysterectomy on the 22nd. They come in on the first with
pelvic pain and a temp of 38.4. And an MRI is done and reveals there’s some sort
of fluid collection in the deep pelvic tissue. The surgeon opens the patient — goes
back to surgery, they open the wound in the OR, and drain purulent fluid. Specimen is sent to the lab
for culture and it’s noted that by what the lab says
as an infected hematoma. So maybe that fluid when they got in
there was that dark chocolaty brown, antibiotics were begun and the
incision was closed back up again. And that culture was positive
for Pseudomonas aeruginosa. So what should be reported? Should we report an intra-abdominal
organ space infection, and other reproductive organ space infection,
or an other organ space endometritis infection? What do you think? This is a voting question, go
ahead and use your clickers. A lot of discussion on this one, that’s good. All right 10 seconds, you’ve almost all voted. Okay. Now, I knew this was going
to cause a problem because — not a problem, it’s a teaching opportunity. Because I think that I, when I was in IP, true
confession, I think I was calling these this. And I was calling them IABs. Here’s the reason, and this is again getting
back to where I read you the IAB definition and especially with hyst being reportable. IAB or other intra-abdominal tissue
or area not specified elsewhere. That’s the IAB. Now let’s go to the OREP. Here’s our OREP. I’ve got it cut and pasted in front of you. An OREP is other reproductive. What was done for this patient? She had a hysterectomy, and where
did they find that fluid collection? Deep pelvic tissues. So when you find those deep
pelvic infections showing up, hopefully not very often,
after your hysterectomies. Go look at your OREP definitions. That’s where they should be attributed to. It doesn’t mean every hyst
produces a deep pelvic, it can have caused a general intra-abdominal
if it progressed, but if that’s what this is, and I see a lot, you need to go here. And honestly when you look at the
OREP definition, it is much — it’s easier to hit than and IAB honestly. It’s just when you look at it,
you’re going to hit this more easily. And you may have been missing some of your true,
other reproductive after hysterectomy cases, if you haven’t been remembering this
deep pelvic tissue falls under that. Let’s do case 11. You have a 5/15, 45-year-old female
undergoes an abdominal hysterectomy and a colectomy is performed
through the same incision. And both of these procedures are in
your monthly reporting plan in May. Which one should you enter
into NHSN since they did both? You got it both are entered. And we’ve covered this so much. I’m just telling you. I’m really trying to help you really become
best friends with reporting instructions. So this is reporting instruction number three. I just cut and pasted it from the
denominator reporting instructions. Now, let’s continue this case. This 45-year-old female, who she underwent
the abdominal hysterectomy and the colectomy. It was performed through the same incision. And on 5/19 she spikes a temp to
38, has abdominal pain, and emesis. Ultrasound shows fluid collection
in the abdominal cavity. Fluid specimen for culture is obtained
by needle aspiration and on 5/20 that culture grows E. faecium
many neutrophils are seen, okay? Is this an HAI? Yes. Is this a deep incisional
primary, a deep incisional secondary, an SSI organ space site-specific IAB, this
is an IAB, but there is no SSI infection? Okay, 10 seconds. Very good. This one was not, you know, you got it. And which procedure is this SSI
attributed to, hyst, colo or both of these? Do you have to attribute one to each? Get your voting. All right five seconds, because I
can see almost everyone’s voted. You guys are so quick on the draw here. And you’re right, it’s attributed to the colo. And what’s our rationale? Remember table five here. Okay, we’re going to go on to table
five, where you had two procedures, just a general intra-abdominal infection,
you cannot tell which one to attribute it to and again, this is from our
reporting instructions here. You need to go to table five and look where
the colo is, and look where the hyst is. Okay? So it needs to be attributed
to the colo procedure. Much higher risk in terms of what
may have caused an infection. All right case 12, I think we’re getting
close to the end of our cases here. So this is — on the 15th of January
a 60-year-old female was admitted with an acute abdomen. Sent to the OR and the finding was a ruptured
diverticulum with fecal contamination of the abdominal cavity,
wound class contaminated. Colectomy is performed with
a colostomy formation. The incision is loosely closed with staples to
allow for drainage and antibiotics are ordered. So on 1/19 the patient is progressing well
and is afebrile and is discharged home. She did pretty well, she got out in four
days, they must be a stellar facility. That’s usually a pretty complicated recovery. But anyways she did. She comes back though, it’s now 10
days postop and she presents to the ED with fever, 38.5, abdominal pain. The CT scan is suspicious for some possible
small abscesses in the intra-abdominal space. The MD starts some antibiotics,
the patient is discharged. No cultures were obtained. And the discharge notes states patient
returned with possible intra-abdominal abscess. We also see a lot of these
little squishy kind of notes. So — oops, I went the wrong direction. Okay, so should this patient’s
chart be reviewed to see if they meet criteria for an organ space SSI? Yes. You’re hopefully you found this
somehow that this patient came to an ED. Hopefully you’re reviewing ED notes. Your SSI surveillance should not just
be driven by a positive culture result. I hope after hearing this, you’re
getting that you have to do more. That’s not going to be enough because
for every single one of these criteria, you do not have to have a positive culture
result and you can still meet your SSI criteria. So you will be found when the
validating starts to be underreporting. And some of you are already being validated
— I shouldn’t say starts, if you get picked. Be underreporting — if you
don’t have methods beyond — hopefully you have methods beyond looking
at just your lab’s positive wound results. So yes you all agree. You voted yes, 100% of you. We need to have found this
chart hopefully somehow. Now, does this — yes — okay, this is the
rationale why you want to look at that chart. In organ space, it doesn’t say you
have to have absolutely found it. There’s enough suspicion with saying
this person might have an abscess that it warrants you looking beyond just
the general organ space definition to see, does this patient meet criteria for an inter-abdominal infection
based on Chapter 17 HAI criteria. So let’s go progress here. Does this patient meet site-specific criteria,
a specific type of infection to be reported? And start looking at the case and see
if you think this will meet criteria. I’ll give you about 10 more seconds. This one’s a little trickier I will say. All right, I’m going to close the voting. And the answer is no. And we’re going to go through
why it’s no, you ready? And here’s how you should be doing this. Get your criterion in front of you okay. All right settle down, I’m going
to go through it you ready? Simmer down. Here we go. Does this patient meet criterion
one of an IAB infection? No. Read that. Does this patient meet criterion two;
seen during an invasive procedure? No. All they did was an imaging test
that said possible small abscesses. Let’s look at number three. Did this patient have fever and abdominal pain? Yes, I highlighted those. Did they culture anything on this patient? No. So you don’t meet one. Did they culture two? No. So what are you stuck with looking at now? Three. Three means you have an organism in
the blood and you have imaging test evidence. This patient would not meet criteria, unless
that patient would had had an organism in the blood that would have pointed to it. And this is where people, if they’re not
applying the definitions, just say, “Oh, they think it’s a possible
abscess let’s call it an IAB. It’s so little. I mean there were some possible
small abscesses.” They didn’t drill deep enough to
know if this actually meets criteria. So you also don’t want to be
over calling your infections. If all you have is an imaging
test, you’ve got to remember this for IABs and there’s nothing more. And they don’t do an invasive procedure, and
they do nothing but a positive imaging test. It’s not going to meet. And I want to allow enough time for questions. So I am going to skip case 13. It’s there. It’s nothing that exciting. Because I want. That was the last case, but I
want to get into the last section so I can leave a few minutes
at the end for questions. And I’ll be able to hang out after
Maggie’s section if you need to find me. I don’t want to answer questions
because mine leads right into Maggie’s and you don’t want miss that. So I will answer before Maggie’s
and then I’ll hang around after Maggie’s I’ll come back up front. So this is just completing the event form. You’ve done this. This is my — hang in there
guys, we’re almost done. And this is what you’re going
to complete for every SSI. This is your patient information. Nothing fancy here, but there’s
a new thing I want to point out. Did you notice on the form, Medicare number,
required as of July first of 2014, for events — that’s the keyword; events that are
reported to NHSN for acute care facilities that are participating in the CMS IQR program. This is a new CMS rule. We’ve been telling you about it, but
it didn’t go into effect in January. Now what this is going to mean is —
because I’ve been getting this question. They really wrote the rule that
it’s for events, and not just SSIs. These are your events you’re reporting. You’re doing colos, your hysts. But they didn’t write for procedures. So all those denominators you’re
sending over, because people are saying, “Do I have to have this Medicare
number on all my denominators?” No. Its events. So at this point, until they change the rule, CMS just wants it on your SSI well,
I mean for what I’m telling you. But this applies to all the people who have
been speaking today when you’re reporting for CMS an event, like a [inaudible]. You’re going to need to start
having this number July first. And this gives you the details about it. I’m really good at jumping
the gun on my slides aren’t I? So this is just telling you what I just said. Then you’re going to note if it’s
an outpatient procedure or not. And again, we have that same MDR
infection surveillance question. If you’re not following MDR like staph, MRSA
and the MDRs surveillance plan and you kind of forget and you think, well yeah this
is an MRSA SSI, I think I’ll check yes. You’ll get an error message, that’s
why it’s smart and it will say, sorry you are not following
this plan in your facility. So you can’t kind of mess it up
because the application knows that. And then this is just your basic, put in
your procedure, put in the type it is. The date of the event and the
date admitted to the facility. These highlighted fields are required. You ICD-9 CM does is optional. You do not have to put that in. Was the patient’s date of admission
and date of discharge the same day? If it is that’s going to be a yes there and
then this is are you following this plan? Now this one I want to talk about,
because you all get error messages and then you get a little confused. If you have a patient, you enter the date
the patient was admitted to the hospital when the operation was performed, not
the date when they were re-admitted. So when you’re looking at a patient
who had a procedure on the first, gets discharged on the seventh comes back
in on the 14th with an SSI, if you forget and put down their admission date as the
14th you get a big, fat error message, because you can’t have their
admission precede the actual procedure. So you just look back at the — where
they were and put the admission date for when they actually did
the operative procedure and that error message will magically go away. Location field has always been optional. It isn’t really work or that necessary. These are procedure-based,
they’re not location-based. There’s no transfer rules all that. So it’s just an optional field. So this is, again, reminding you because we
use the admission date of the primary procedure that you’re attributing to,
not your re-admission date. Because your date of admitted has to be less
than or equal to the date of the procedure, which has to be less than or
equal to the date of the event. Then, you have to fill in your specific events. This is where you say am I saying a
superficial, deep, organ space infection, you’re going to fill in which kind. You are going to need to put in which — if it’s
an organ space, you need to select which one. And the thing that’s good if
you haven’t played in this, is that basically we have
figured that out for you. You don’t have a choice of
everything in Chapter 17. If it was a cardiac procedure, you
only have a few choices; superficial, deep, endocarditis, mediastinitis. The organ spaces are filtered
in the dropdown to be specific to the kind of procedure that’s being done. So look at that and know what your choices are. I have a little cheat sheet that next to
colo in my manual which lives by my desk so I have looked through all these
when I somehow had a minute and wrote down what is every organ
spaces allowable for colo? What is allowable as an organ space for a hyst? So that I can remember what’s
on those dropdown menus. It’s really faster than me
thinking, wait can I call it a this? I just have it written down. Then you’re going to say your site-specific. How does this meet? Why do you think this met the criteria? And you’re going to fill that all in there. And this is a required box. You have to say how you found the procedure. Was it when the people was still
in-house and had never been there, post discharge surveillance, readmitted to your
facility, or readmitted to a facility other than where the operation was performed. And again, this is where we have to rely on IPs
to give us that information that we had someone that you did a HIP on and now
they’re back here with an infection. Again, this is required, did the
patient have a secondary BSI? Yes, no? That’s required. Did the patient die? Yes, no is required. Now again, I’m kind of the first one
who’s really going through actual entry of the form and I want to address this. This is a required field, back in the old days,
when it was NIS and I’ve been there since then. Been there done that. There used to be a yes, no, or unknown. But they got rid of that. So it’s yes no. And basically, what we like to say. If you see in that death note
summary that the patient died from a surgical site infection, you can say yes. But with litigation and risk and
everything else, I that’s all we’re asking. Did the physician who wrote the death
summary for a patient who expired say it was because of a surgical site infection? I think if they say that,
comfortably you can say yes. If you can’t find that that’s documented
in the chart, I would select no. And then lastly, you’d have your discharge
date is still an optional field here. If they identified a pathogen. And do you necessarily have a pathogen
when you have an SSI, no not necessarily. You’re then going to go in the back
and you’re going to have your dropdown of what infections — pathogens were found. Now I want to point out something here
because if you haven’t discovered this, when you’re actually in your application,
now I don’t know how many of you are actually in the application and entering
these themselves. Some big facilities, the IPs actually filling
something out that then goes to someone else who might be more of an administrative
assistance level, who’s really dealing with the application. But if you’re not and you’re doing
this yourself, what throw people off, when you’re in the application and you’re going
to enter your organisms, the organism list. You can imagine, you know
how many organisms we have. It opens up with the most frequently
hit organisms that we think people use. So what will happen is I’ll get emails that
will say, this person has enterococcus species or Enterobacteriaceae species and
I can’t find it in the dropdown, I guess it means I don’t have to put this in. No. When you enter that organism
list, go to the very bottom and there’s a thing that says all pathogens. Select all pathogens and you
really see the complete list, but we don’t want to make you
fight through every single one. So you’ll find your less frequent
odd ball organisms on that list. See, I’m going to be giving you so much,
I think my mailbox is going to be empty from now on, what do you think [laughter]? Yeah, yeah, no more emails? All right. Now again, and you’ve heard this in every
single one, so I’m not going to belabor it. You need to pay attention to your
alert page when you open it up. And you may be an alert that says look you’re
missing one procedure associated event here. It’s like, what does that mean? So what you’re going to do is go to your events
and it’s going to show that it’s incomplete and it tells you that that — you
did a hysterectomy on a patient. You have some hysterectomies you’ve entered. But there’s been no SSIs attributable. And that’s great. You did a couple, but nobody had SSI. You just need to say that
we had no SSIs attributable to this procedure that’s in our reporting plan. They just want to make sure
you didn’t forget to enter any. Especially, when states and
people are being validated. They really want to know that it wasn’t just —
oops, I forgot to put them in, it’s really no. I didn’t have any. And then you’re going to report the
no events and click the save button. So in summary you want to complete and
enter a surgical site infection record for every procedure that’s
in your surveillance plan, using all these wonderful instructions
that I’ve been pointing you to. Now here is the — so it’s in one spot. Here’s the errata I told you about. The three things; non-primary closure and
the key terms, and table of instructions. Please go reprint it, it’s
correct what’s in there now. So just — I want you to
have the correct definition. The not incidental to another procedure should
be crossed out from table one, next to appe. And that PJI definition, your
C-reactive protein should be greater than 10, not greater than 100, so. All right. Now, I want to give you a very quick heads up. And we’ll probably have more details
by the time APIC comes around. But what’s coming in 2015. So the big thing here. And probably a lot of you
have gotten this email. It’s all — this is all I know right now. And maybe Dawn knows more, but this
is the information I have right now about our transition to ICD-10,
CMPCS and CPT code based procedures. So CDC is actively working,
we’ve received some of these now. It’s a huge project. We had to bring on people that
were specialty coders to do this. We are mapping all of the ICD-10
CMPCS codes and the CPT codes. We’re offering dual mapping to all
of our procedures that are followed under SSI surveillance and we are anticipating
that these will be available by July of 2014, so you’ll be able to kind of get
a look at what they are and share with IT and do whatever you need. The ICD-10 CMPCS codes will replace
ICD-9 CM codes on October first. Unless something changes. We’re still only hearing these
go away on October first of 2014. But NHSN will not have the ability to
receive these codes in our application. Think about these application bills,
until the January 15th release. So we can’t take ICD-10 codes until January. So the guidance we’re giving you right now is
that the NHSN guidance for that last quarter of 2014, so it’s your October,
November, December, if ICD-10s role out when
they say they will roll out, is that you’re going to want to not use codes. And maybe many of you don’t. You won’t put in an ICD, you know,
10 code, because we can’t it, but you’ll say this is a hip, this is a
colo and you’ll have the cheat sheet by then that you’ll know what your ICD-10
hips, and colos, and hysts are, but you just can’t put the actual
code in, because we can’t take it. And then at the time of the January release,
we’ll be able to accept the new ICD-10 codes. We don’t want you to go back retrospectively. You don’t go back to that
last quarter and put them in. It just doesn’t exist in our 2014 applications. You just get to move forward in ’15. So you’ll just be putting in procedure
names for the last quarter and no codes. And we’re also going to have CPT codes. And what else is coming in 2015, I want to
leave five minutes for questions or [inaudible]. PATOS. We’ve been talking
about this for a long time. In 2015, a new field’s going in. It’s on your numerator form. I love things on the numerator because
we’re all looking at those charts anyway. It means that this tells us, it captures a
condition or a diagnosis that the patient at the time they went to
surgery, they had an infection. This is telling us that when
that patient went to surgery, the physician documented that
that patient was infected. That would be your ruptured appendixes,
your ruptured colons and all that. And there’ll be a field when
you’re filling out an SSI that you’ll be say yes this was
present at the time of surgery. I think that will be very helpful
and something you can really trust that you’ve looked at it and you’ve noted that. The last one that’s going to come
for H-pro and K-pro procedures and this is going to be denominator data. This has been wanted for a really long time. If a total or partial hip revision
is being done, it’s being associated because of a prior infection at that joint,
you’re going to be able to have a field that says prior infection of this joint, for
those joints that just keep coming in infected and you can’t seem to get it cleared up. The end. And are you at the end of your rope? [ Applause ] All right so if you — the
mics have been turned live. So if you want to come to the mic.>>Yes.>>Hi. This is Lisa from Fairview in Minnesota. So if we have a patient that comes in say in
our colo, they’ve got a rupture or something like that, they come in, they have an abscess and say we do multiple procedures
over multiple days. So the surgeon goes in over
multiple days and is cleaning out, and cleaning out, and cleaning out. Do we have to call that a separate
surgical site infection for every? For every? You see what I’m saying, if they’re having
five operations, is that five different?>>Well, I should have addressed
that and I thought I had it in here. Once you have a procedure done and if they
go back and do like an I and D to that wound, which you wouldn’t be doing five
colos, you’re doing I and Ds, then infections that occur
after that are attributable. You have there — we have in our reporting,
if you do an invasive procedure at the site. Like if you have a patient who had a joint
replaced and developed a big hematoma and they go in and have that hematoma aspirated
and it’s not infected, it’s just they had to get rid of that hematoma, and the infection
occurs after that invasive manipulation, it’s not attributable to the H-pro, you could have easily introduced
something during that procedure. Same, if they had that colo
the clock stops ticking — starts ticking again when they take them back and have another operative
procedure whether it’s just an — you know if they find that
first SSI at the I and D. Yes, that’s yours because it’s the
first infection after the colo. But if they keep having them, they’re
not attributable back to that first colo, because you’ve had other invasive procedures.>>Okay, so would that go
for any surgical procedure, say someone comes in and they have a deep wound. And so maybe that’s not reportable,
but that’s something that we follow. So if they have a deep wound and we keep
debriding that wound or whatever over days?>>That I would want more detail. I’m very, very reluctant to answer
an actual case without the details. So what we said, the opening of a
wound and that is not healing properly, and it’s in the protocol, and it starts —
you have to start doing some wound packing and wound management, that
is not considered invasive. You’ve opened up this superficial incisional
wound and you’re dealing with trying to help it. That’s now what we call an
invasive manipulation. Invasive manipulation is going
down into deep organ spaces, going down into the deep
joint and that sort of thing. Not the management of a wound
— postop wound to help it heal.>>Okay, great thank you.>>Often they meet anyway, when they start
opening them up, you’re going to hit one of those, because they’re opening it
and culturing it, but if they haven’t and they eventually do, you
will need to attribute that if it’s in the surveillance period. Yes?>>I have a question on that same slide
that you made the change for PJI definition in the HAI Chapter has a typo and it’s
greater than 10 not greater than 100. On the one before that in A;
three A. It says elevated serum, C-reactive protein, and you said or electrolyte?>>Right.>>And is it and? It’s printed as and, so is it or or is it and?>>It’s or.>>Thank you. Yeah so, okay we’re going to start
Maggie’s and then she and I can both — we’ll have more time for questions at
the end, but we want to have Mag’s. Thank you. [ Applause ]>>I’m back [laughter]. But you guys won’t have to see me
tomorrow, well at least not up here so. Oh, I don’t feel so sad about that [laughter]. I get to relax tomorrow a little bit. Thank you Courtney. All right. So, I’m really. I just want to spend a few moments talking
about the procedure import process. I’m not going to go into great detail about it. But really, you know, in our past
training courses we had included this type of training in with the protocol training. And we thought, well let’s, you know,
lighten this a little bit and just focus on how the changes have impacted importing data. So, I’ll briefly review that
procedure import process. And we’re going to focus today on CSV files. We know that many folks are using
Clinical Document Architecture, or CDA. But we’re not going to be
focusing on that today. And of course I’ll discuss the 2014 changes. Okay, so on our website, actually it’s
on the SSI reporting protocol page at the bottom we have a section
called Supporting Materials. And in that section we have
specifications, file specifications, and resources for importing
procedure data using a CSV file. We are currently updating a training slides
set that will go into more in depth materials about the process than what I’m
going to be going through today. So those will be up on the website soon. In the room, can I get a show of hands,
how many people import using CSV? Wow, quite a bit of people. That’s great. Okay. So hopefully you’re aware
of some of these changes already. But, if not then that’s why we’re here. So this is a snapshot of the file
specifications for the CSV import. We do update these as there are
changes to data requirements. So I strongly recommend that if you have
not downloaded this document for 2014 that you go ahead and do so and communicate
this with your IT department or whomever it is that helps you produce this file. So of course you need the help
from your IT staff if you’re going to be importing procedure
level data using a CSV file. So I really just want to drive home
the point that the procedure data that are imported must follow
these specifications. Okay, they have to follow the order
of fields that we have specified here. And you have to actually read through carefully
all the notes that are on that first page. There are a lot of notes. But those notes are there
to help prevent any issues with importing your data while
you’re in the process of that. This is just a snapshot of what the, you know, first section of those file specifications
looks like, with the data fields. And what I want to point out here is these
are in a different order than how they appear on the actual data collection form. So that’s why you have to follow this
order and not the order on the paper form. In addition, we provide specifications
for the values that are allowed, the data format, and the requirements. And these must be followed. So you cannot use your own
format for wound class, or ASA. You have to follow the values that we have here. Because basically, this is
taking the place of data entry. And when you manually enter data, you
don’t just type in the wound class. You actually select from a list of values. So that’s why you must use what we have here. We do have some hospitals
that use custom fields. And you import custom fields
with your procedure data file. But you have to make sure
that those fields are set up in NHSN prior to importing any of these data. So that’s just a heads up. The data requirements that we provide in the specifications document
assume in plan reporting. Just like when you look at the paper
form, and we have all those asterisks next to certain fields, all those
field requirements assume that you are following that procedure in plan. And so the same goes for importing data. However, we do have some fields
labeled as optional for import. And optional for import is a field that is
essentially at the end of the day required to have a complete in plan record. However, these fields were marked as optional
for import, because they were thought of as not being available from OR systems. And so you may have had to use a
different system and it was too difficult to bring it into the import file. So we said, okay you can bring these data in
with these values missing, but at some point, you’ll have to complete it manually
through our data entry screens. And we’ll provide a list in our data
entry screens of your incomplete records. So I really want you all to think of our file
specification as a companion to and not in place of the full requirements for procedures as we’ve
described in our tables of instructions, okay? These do not replace anything. They’re really meant to just
be a companion to that. So in addition to reading through the protocols
for surveillance, the tables of instructions, the requirements on the form, our key terms. If you’re importing data, you
need this in there as well. It’s all one package. Okay? And I am reiterating that point here,
that it is a companion to our protocol. And so all of those requirements
must still be followed. Let’s talk a little bit about
the changes for 2014. I know I mentioned some of these this morning. I know Janet mentioned some of
these, but repetition is good. So wound class for procedures that
have a date of 2014 and forward. You can no longer report these with
a wound class value of U or unknown. For these spinal-level variable
for fusion and re-fusions, again, you can no longer report these with a value
of not specified for 2014 and forward. And the same goes for type of approach,
where you can no longer report not specified. For type of approach we made
a couple other modifications. The value of trans-oral is new for
2014 procedures only and going forward. And lateral transverse is an old
value that is basically retired. So you can only use that value for
procedures dated in 2013 and earlier. Of course, we have our new type
of H-pro and type of K-pro fields. So, previously we just had two variables,
type of hip, type of knee and that was it. Well, now we have additional
fields, looking at specific types of total, hemi, or resurfacing procedures. So once you import a value for your
hip and knee that tells us the type, you will also be required to
complete one of these bottom three; either total, hemi, or resurfacing. These are all separate variables
in your file specification. So if you are importing these
types of procedures, just know that you’ll need
to complete that as well. And we only need values in
one of them, not all three. Course height and weight as we discussed this
morning, or as Janet discussed this morning. This is required for all procedures
dated with 2014 and forward, however, we marked this as optional for import. So this means you can import a
file with these values missing, but you must complete these
manually through NHSN in order for the record to be complete, okay? So just keep that in mind if you have a large
file that you’re importing and you decide to keep these missing, you will have
to complete these at some point. And of course diabetes is required for all
procedures beginning this year as well. Closure technique, again, required only
for procedures dated 2014 and forward. This is also marked as optional for import. So again, you can import these data with
this value missing, but you must complete it at some point manually through NHSN. And the values that we allow are PRI for
primary or OTH for other than primary. In addition, we did change — slightly
change the order of the fields. We had to shift everything
down by one or two variables. So this applies to all procedures,
regardless of the procedure date. So if you’re still needing to import procedures
from 2013, you have to follow this order, and I believe it is just
the addition of a column. If you’re using an Excel type CSV file. So you again may want to
hand those specifications over to whomever’s helping you create this file
and just make sure that everything’s in order. With this, just know that
in our supporting materials on that SSI website, we do have a sample file. And in that sample file we do
include a header row as the first row that includes the variable name, so
that you know what data are supposed to be in each column. Now you cannot import a file with those
variable names in that header row. But if you’re looking to make sure everything’s
in order, you can kind of copy that in to your file, just to make
sure everything’s okay and then you can remove it
before importing your data. So if you’re not familiar, in order to
import a file, once you’ve created your file, you can import data by using
the import/export option in NHSN and selecting the import type
of import procedures, delimited. You’ll be asked to select your
file, which is a CSV file. And then you click submit. And you’ll notice when you submit, you’ll see a
progress bar appearing and depending on the size of the file, it may take a few moments
to get the entire thing into the system. So just be patient. But once the entire file has been submitted, and
actually, you know, now that I’m reading this, I kind of don’t like the word submitted,
because no data are saved at this point yet. It’s really just — I don’t even know what the
right word is, but they’re not yet submitted. So what we’re doing is we’re
trying to just transfer those data into this temporary holding space so that you
can review and make sure everything’s good. You can have up to five tabs
when you import your data. There are inserts, bad data, updates,
multiple records, and duplicate data. Today I’m just going to focus
on inserts and bad data. The other three will be described in the
slide set that will update on our website. So the inserts tab is the good tab. That means everything’s cool. You can import the data as they are
with no additional modification. And what we do is we try to provide you with
the information for all these procedures. But because you can import so many
different data fields, it’s very wide. So you have to scroll your window over if you
want to see some of the additional information. However, if you click edit. It will bring up a very short
screen that’s more vertical with all the data fields
completed for that record. But at that point, if you make any changes and
you click save, it’s still not saved in NHSN. It’s just in this holding place until
you’re ready to finish the import. The bad data tab is just
as it sounds, its bad data. So we are not going to let you import it,
any records that are labelled as bad data. We try to do data quality checks through
this and prevent any potential errors. So if you’re using the wrong value for a certain
data field, or if the procedure date is in, you know, 1909, we’re going to try
and prevent that from happening. But what I wanted to let you know is
that if you see this bad data tab, you cannot import anything. So it is all or nothing. You want to make sure that you are left
with just an inserts tab, or an updates tab. If you have a bad data tab, or anything else,
you’re not going to be able to do any importing. So we recommend that if you have a
lot of records in the bad data tab, stop what you’re doing, go back to
the original file that you have, or go back to the person who’s
going to help you with these data and get it fixed in the source file. Because it could take you a lot
of time to update these records. And again, nothing is saved at this point. So if you leave your desk and you’re
logged out of NHSN, it’s all gone. Okay, so this is just kind of repeating
what I had to say, just on the last slide. So you should only have the
inserts or updates tab. And once everything is good, you click
update at the bottom of that list. And then when all records have been imported, you’ll see a message confirming
that it has been successful. You’ll see that nice little green checkmark
that you often see when entering data in NHSN. So, just a few helpful tips. Facilities will be stopped if the
data are not in correct order, or if they do not leave empty
placeholders for optional fields, okay? So there are a lot of optional fields that we
allow you to bring in, such as custom fields. When you’re looking at the data in Excel,
you have to leave those empty columns for those optional fields, otherwise
everything’s going to be shifted. And hopefully this goes without saying, but — and I know all of you in the room and
those watching on the web streaming, who — this is your job, you know,
you’re IPs, you already know this, but the people who help you may not know this. So it’s extremely important that the same
definitions and protocols are followed, okay? So there are many times where your OR
staff or your IT staff are not aware of our standard CDC definitions
for these data fields. So it requires a lot of teamwork and
communication when you’re first getting started with these files, or if you need
to modify the data in these files for new protocols like we’re seeing this year. Your data managers, your IT staff, OR staff,
they can email NHSN directly with questions if they have any questions
about what something means. They’re free to do that if they’d like. It’s equally important for you, as the IP, to
understand the data elements that are captured from your OR or other systems as well. Making sure that the procedure duration
is in alignment with our definitions. And that other elements are also in alignment. Also make sure your patient IDs are correct. So, you know, we notice that some folks may
have trouble linking SSIs because the data that were imported may be missing
leading zeroes for your patient ID and when your entering the SSI,
you’re including the leading zeroes. So, even though all of these patient IDs here
look very similar to us, to the application, those are completely different patients. Those are different numbers. Any time you add leading zeroes
or dashes, or any sort of prefix, that’s considered a different patient. So, you know, make sure you’re
aware of how the format of those patient IDs are being
used in that import file. And of course, I know this isn’t import talk,
but I have to talk about checking the data. I’m a data girl. So I recommend that data are check to
ensure accurate data have been collected. That the data that you are importing do meet
our protocols and everything matches up. You don’t have to do this
constantly, constantly, but you should do some sporadic checks on this. You should especially check your data if any of
our definitions have changed, or if you’re aware of any changes that occurred in your OR system. Just to make sure everything matches up. And of course, you can utilize our analysis
output options to help accomplish this. Using line lists and frequency tables. We also have a variable called imported
and you can add this to the procedure list or frequency table to look at specifically
those records those were imported to us. Especially if you said, well, you know what? We’re brand new to this, we’re going to try this with one procedure category just this
month to see how everything works out. You can run analysis only
on those imported records. So these are links to our resources
related to importing the data. Again, we will be updating a full slide set that will include much more
detail than I went through today. So, I thank you for your attention. I’m happy to take questions. And Janet is coming up as well for questions. But, before I forget, I was asked to
make an announcement that folks here from Oregon can meet over in this corner
up here at the very beginning of the break which is coming up in about 10 minutes. So, if you’re from Oregon
please meet them over there. And all right, questions? So, I’m going to go ahead and give a shout out
to people that are listening web streaming. Because we have a couple questions
and we haven’t really had those. So I’m going to send a shout
out to Elaine Decker. She’s listening from San
Francisco General Hospital. And here’s her question. She had a little longer of a question, but
I’m going to give you the short answer. She wants to know is there a way that
we know the BMI, we can just enter a BMI and not enter a height and weight. And I’ve been asked this already. And the answer at this point is no. We really want to know that it is a correct BMI and that it has been calculated
using our internal calculator. So we do want to see the height and the weight
and then our application will enter the BMI. So I just wanted to give her that answer. And then I have one other quick questions. This is from Beverly Stergil [assumed spelling]
from Carilion Roanoke Memorial Hospital, are you still on the line, I hope. I don’t know if they can answer. But anyway this was around what I
said about the reporting instruction. That if they are using ICD-9
codes and they have — should any ex-lap be reported
regardless of whether results in a procedure from another category. Now that was the old one. You have to look into it, see
if another procedure was done, another procedure was done,
don’t report the ex-lap. Okay, but we took that rule
away to try to simplify. So if you’re just dealing with line list. So yes if you get a line list
from your OR, from your coders, however you’re getting your line lists. And you have an ex-lap and
a colo, put them both in. Now think of an ex-lap and a colo. If you develop an SSI, it’s
never going to be attributed to the ex-lap because the colo’s deeper. But you’ve got that in your
denominator data, all right? And sometimes they do just do an ex-lap. And those will be in there as well, all right. So I just wanted to clarify that. I’m going to — I think that was
the only thing I needed to clarify. Okay, in the back there? Hi.>>Hi Janet, Joan Hebton [assumed spelling]. I have a comment and then a question. I am a bit concerned about the optional field
for ICD-9 on the surgical procedural form. And the reason relates to some
of the auditing I’ve performed, state auditing that would suggest that there
may be procedures placed in the denominator, for colon, specifically,
that shouldn’t be there. And I wonder when you’re — you
don’t have really any way to know that if you’re only entering
the NHSN procedure code.>>Right. That’s a great question. And I can tell you that I was in a big
meeting room last week dealing with that. It’s that question of when and if we’re going
to go to a process where we are more code-based and we would require that the primary ICD,
at that point it will be 10 code be entered. And we’re not there yet, but we are very
aware of it as an issue and are working at it at a high leadership level right now.>>Yeah, because many times the OR databases that you’re creating your CSV files
do not have that piece of data.>>Right.>>That isn’t tagged on to the
end when it goes to billing.>>Right.>>So it really become a big
concern in light of the trajectory that we’re on about public reporting.>>Absolutely.>>Because I can see SSI reporting
increasing dramatically in the next few years.>>Yeah. I’m a proponent of
— that we are moving that way and I will take your feedback definitely.>>Thank you.>>Back to your group. Yes, on the left?>>Hi, Janet. Thank you. Shannon from San Diego. And I have a question I’ve
been emailing the surgeon and I know we don’t take what surgeon’s say. So I sent him the definition. He did a fusion procedure and
took a patient back and did an I and D of the deep sub-fascia thoracic
postoperative, posterior spinal [inaudible]. And then he found to have an opening in
the inferior part of the thoracic wound that appears to be deep and sub fascia. He cultured multiple layers of that
incision, superficial and deep, however, the deep culture negatives and the
superficial culture is positive for candida. And he claims that since the superficial culture
was positive, then it’s a superficial infection, yet the operative descriptor looks
like it’s a deeper infection.>>Yeah.>>So?>>Yeah. You’ve got it correctly. If it’s meeting the deep, you wouldn’t
base it on just where the findings because of a candida in the superficial area. If that infection progressed into the deep
level, regardless if the culture is negative. You don’t know if it’s the
result of antibiotics. If it’s meeting, you know, there are
culture negatives that will not meet. So you just have to — now that I’ve
showed you those definitions of opening and a culture negative, you know, that.>>Right.>>Make sure you’re not hitting that definition. I would love to talk with you
afterwards, I’m extremely visual, if you could see how I workout
these questions that come to me. It’s very difficult to do and it’s that
case standing without me mapping out date of procedure, date of symptoms,
I like to really see them all. But I can talk with you if you want to
make sure I’ve got the description right, but again I would prefer not to actually answer
like case questions because I need to see those in writing so I make sure
I have all the details.>>Okay, thank you.>>You can grab me afterwards. Yes?>>[Inaudible] from Primary Children’s. I have a question about height
and weight for all procedures. So in our NICU, these babies
can stick around forever. Because it’s a surgical NICU, what
height and weight are we using? Birth weights or at the time of the surgery?>>Yeah, it’s most recent. When you look at the definition, it’s the height and weight most recent to
the operative procedure. So it’s not like, some of our state, their
birth weight is a category they fit into.>>Right.>>But for this when you look at the reporting
instructions and the table of instructions. It’s most recent that you have
to that operative procedure.>>So even if they haven’t weighed in. Well weights we usually get, but maybe we
haven’t measured their length for a long time, we might have a length that’s off. Is it no big deal?>>Well, again, if the baby’s right
there, there isn’t any problem if you realize they haven’t been
measured in a while you can add — especially if they’re there a long
time, you might have four more inches. So but I’m just saying.>>Right, right.>>If the baby’s still there you could
probably stretch that little tape measure out and see what they’re doing now.>>We just don’t get our procedures
until after they’ve been coded. Because it’s all done electronically.>>Oh okay.>>So it’s way out.>>You’ll just have to take
them what it is the most recent. And that’s where you can again have an
education opportunity for folks who know this is for risk adjusted data and say can
we start having in some checklist, pre-op check list that we’ve
got a recent height and weight and it can work very well just
at the bedside, pre-op level.>>Okay, great, thank you.>>Thank you.>>Hi. I’m April with Banner Health. Mine’s an acute question too. We do some surgeries in the
bedside — at the bedside in NICU. And I noticed in your definition you
included operating suites so to speak, and those types of rooms
that meet that criteria. So does that exclude those surgeries
that are done within the NICU because it is not an operating room?>>Yes. That’s a great question. And I’ve had that already a couple times. Because with the little babies, they often — the ones I’m seeing coming
in are cardiac surgeries and they can’t close them right
away due to swelling or whatever and so they have to leave that open. So that is in your denominator
as a CARD with an open. And then they close that incision a week
later, a few days later at the bedside. So what’s happened now, you
have done a procedure, that’s an invasive procedure at the bedside. So the clock stopped ticking. And if after that closure at the bedside occurs,
the baby develops an SSI, it is not attributable to that CARD that was done in a
perfect, beautiful OR setting. Because you did an actually an operative
procedure at a bedside that was not an OR.>>Okay, so we exclude those.>>Yeah.>>Thank you.>>I have a question about a podiatry procedure. Would we follow that for 30 or 90
days if it involves an implant?>>Good question. I am 90% sure, but again, I’m very ICD-9
code based and implant does not matter. Podiatry procedures are all —
oh I can answer that actually. Okay, first of all it’s not
because there’s an implant. Podiatry procedures are not in table one. And if they even are an NHSN
operative procedure — so what you want to go do is look at that
wonderful ICD-9 mapping list I showed you. It’s very likely that they are a big
no and you wouldn’t be calling an SSI. If they happen to actually
be in the other OTH category, all of those are only followed
for 30 days regardless. Remember implant doesn’t come into effect
in terms of our surveillance period anymore. So everything in that 30-day list is 30 days
and you’ll see at the bottom of it OTH, other. They’re all followed for just
30-day surveillance period.>>Okay.>>Okay?>>Hi. I’m Brenda from Western
Maryland Health System. I have a very simple question. Do we have permission to use
your son’s beautiful illustration about the closure [laughter]?>>I will have to tell him that. You know, I don’t see any reason if you have
an ability to snag it go for it, you know. Unless there’s someone can tell me
that I’m telling you something illegal, where’s Courtney, can they grab it? I’ll have to put a shout out to him. I’ll call him tonight and tell him
up there in New York City doing his.>>Thank you.>>Thank you.>>Hi. I’m Joellen. I would just like for you to re-clarify around
the surgical site infections for organ space and C-section that endometriosis can be
possible for part of the diagnosis, correct?>>Oh, absolutely. If you look at that other evidence on exam that
the patient may have an infection that’s going to be things like really fever, and extreme
fundal tenderness and then you’ll go look at your endometritis definition, if
it fits you call that an organ space. Yes?>>Yes, Kathleen Quan [assumed
spelling] from UC Irvine in California. Actually may I ask a question about a
CDA methodology of procedure upload?>>You know, I’ll be honest with you, I can try. But I am not a CDA expert.>>Sure.>>My colleagues, Paul, Malpiedi, and
Mindy Durrance actually–>>No this is a conceptual question.>>Okay.>>Okay [laughter]. So the CDA upload, which is done through usually
a third party vendor does not allow for upload of non-required fields or custom fields.>>Right.>>Which makes it basically useless if we want
to use it for physician specific follow-up.>>So for like surgeon codes?>>Correct.>>Okay.>>Will there ever be a time when
we will be allowed to do that? Because it really diminishes our ability to
use that methodology, which is very helpful in capturing missing data and things like that.>>Right. So excellent question. I know that we’ve been asked this a lot. I believe they are trying
to move forward with that. But I don’t know what the time line is
for actually allowing it on the NHSN side. So I can’t answer it definitively. I just know that from our side we’re trying to
make that work, I just don’t know at what stage. Because there’s only certain points in
time that we can allow updates for CDA. I think it’s just about — well
actually, I don’t even want to say when. I just — I don’t know.>>But the intention is to allow?>>Yes. And so actually what I can
do — I’ll make a note, and you know, for our next newsletter perhaps I can ask
my colleague Paul to make a CDA update in the newsletter just to let everybody
know how we are going in the process.>>That’s be great.>>Is that all right? All right thank you.>>Thank you.

2018 NHSN Training – Secondary BSI and NHSN Site-specific Infections


>>Good afternoon. My name is Kathy Allen-Bridson
and I’m here to present to you information regarding distinguishing
primary from secondary bloodstream infections, or BSIs, for the NHSN National
Patient Safety Component. We’re going to review some important
foundational concepts from chapter two and chapter four from the NHSN
Patient Safety Component Manual. We’re also going to identify the
relationship between site-specific infections and secondary bloodstream infections. We’ll also review Appendix B which is
the Secondary BSI Guide found in the BSI or bloodstream infection protocol. And we’ll reference some tables
from that chapter as well. And then, finally, as we’re going along, and
then at the end, we’ll also have a chance to practice to applying some of the secondary
BSI Guidelines to some educational case studies. I’m going to pause slightly so that viewers can
pause their own video before I provide answers to the questions in case studies, so if you
are interested in trying to formulate an answer and see how well you understand the information
that’s your opportunity to just pause the video and then once you’ve made a determination
to go ahead and start the video again. So, first of all, let’s do some basic
definitions and the very important one that we need to make a — distinguish
between are primary and secondary BSIs. And simply put, a primary BSI for NHSN purposes
is a laboratory-confirmed bloodstream infection, or LCBI, where an eligible BSI
organism is identified in the blood and the BSI is not secondary to a
site-specific infection at another body site. And what do we mean by secondary? Well, for a secondary BSI, we mean that that
BSI is associated with a site-specific infection at another body site and it could
have seeded the bloodstream. And we’ll talk about very specific scenarios
that allow you to determine that the BSI is in fact associated with another
site of infection. Specifically, where this information is
contained in the BSI definition is the line that says that “Organisms identified in the blood cannot be related
to infections at another site.” All right. If they are, then we would
consider those to be secondary. And for NHSN purposes, LCBIs need to be primary
in nature and that’s because we use that data to inform prevention efforts
aimed at bloodstream infections. Those prevention efforts are not aimed
at other primary sites of infection because there are a lot of other
potential primary sites of infections. But, for the most part, we’re interested in
central line associated bloodstream infections so we want to make sure that
there’s a good chance that infection prevention practices related to
central lines can impact the BSI rate or SIR. So here’s our first question. Why is it important to distinguish
a primary BSI from a secondary BSI when performing CLABSI surveillance? You choices are, that the secondary
BSIs are not reported to NHSN, that primary BSIs are more difficult
to prevent than secondary BSIs, or, c, that to identify those BSIs for which
performing central line insertion and maintenance practices
may reduce the incidence. And here is the first example of where
I’ll pause so that you can pause the video if you want to, formulate an answer,
and then you can turn it back on. So the correct answer here
is c as we just discussed. These are the bloodstream infections
that we’re trying to identify with our LCBI definition are those that,
and especially with our CLABSI definition, are those that, by improving our
central line insertion practices or even our maintenance practices for central
lines, we can reduce the incidence of CLABSI. Secondary BSIs are never
reported to NHSN as LCBIs. They can be reported, and should be reported, if
you’re reporting the primary site of infection. So, for instance, if you have a urinary
tract infection with a secondary BSI that you’re reporting to NHSN, you would
include information about the secondary BSI. And there really are four types of infections
that a BSI could be secondary to in NHSN. They could be secondary to urinary
tract infections, to pneumonias, to surgical site infections, or to one
of the infection types that are listed in the CDC’s NHSN surveillance definitions
for specific types of infections, and that’s also known as
chapter 17 inNHSN Manual. That site, if you’re not familiar
with it, has all the various types of infections that can occur in a patient. For instance, cardiovascular infections
such as vascular infections or meningitis, bone infections, just to name a few. We really have just two scenarios
in which a BSI could be deemed to be secondary to another site of infection. Scenario one, which we’re going to talk
about first, and we’ll talk pretty in-depth about both of these types of scenarios. Scenario one involves a matching site-specific
specimen, and when we say matching we mean that it matches an organism
identified in the blood and that site-specific specimen is
an element of the infection criterion for the specific type of infection. In scenario two, an organism is
actually identified in the blood, and that positive blood specimen is used itself
as an element of the infection criterion. So, again, there’s two, and only
two, secondary BSI scenarios. There’s a little bit more information
that we should share about the — both of the scenarios, some time
periods that go along with it. So, for scenario one, where we have at
least one organism from the blood specimen that matches an organism identified
from the site-specific infection, that has to be collected during the
secondary BSI attribution period. We also call that the SBAP. And the SBAP is, as you may know
from previous presentations, the infection window period plus
the repeat infection timeframe. In scenario two, where you’re actually
using a positive blood specimen to meet one of the elements, because that blood
specimen is an element of the criterion, it has to be collected during the
site-specific infection window period. So let’s talk a little bit
more about scenario one first. So there really are three must-haves
for a CSI scenario one for secondary. That is that the blood and the
site-specific specimen must have at least one eligible matching pathogen. Now, it is possible that the blood specimen may
have other organisms that are not identified from the site-specific, and that’s okay. We would consider the whole blood specimen to
be secondary if all of the criteria are met, including the non-matching organisms. The blood specimen is used as an element
to meet the primary infection criterion. And the blood specimen is collected within
the SBAP of the site-specific infection. And I’m reading — there’s a typo on here. It should say that the site-specific
specimen is used as an element to meet the primary infection’s criterion. So please make a note of that on your slides. Number two is the site-specific specimen. So, for instance, if you are meeting
a urinary tract infection criterion, the urine culture that matches the blood
culture or blood specimen would have to be used as an element of the UTI definition
which UTI does have a criterion. All criterions require a primary
or a positive urine culture. And there’s an important
point to follow that up with. If an organism in the blood is ineligible
for the specific infection type then that organism cannot be considered to be caused
by or secondary to that type of infection. So, again, falling back on the UTI example, we
have one here, Candida are excluded pathogens that cannot be used to meet
the NHSN UTI definition. Candida in the urine is usually accepted
to be not necessarily a cause of infection but oftentimes colonization in patients
unless they’re severely immunocompromised. For that reason, among others,
it’s an excluded pathogen for UTI. So, therefore, if a patient has a
UTI and the only organism is Candida, then that patient actually will not
meet the UTI definition and, therefore, there could not be a secondary
BSI to UTI with Candida. Pneumonia also has some excluded pathogens. So those are the two main types of
infections where we’ll run into that. So, unless there is another source of
infection for that Candida in the blood, it’s possible that the patient
may have a primary BSI. So let’s look then another example. We have a patient that was admitted, and
this is actually — speaks to this point — a patient that was admitted on the 12th of
January with a chronic history of sinusitis, submitted to the Medical/Surgical unit. And on the 15th the patient is
sent to special procedures unit for functional endoscopic sinus
evaluation, and they aspirate fluid from the sinus cavity and send it for culture. And the results are that it’s
positive for strep pneumoniae. One-nineteen, the patient has —
is febrile to 102 Fahrenheit, and they draw a blood specimen and culture
that, and the patient is also positive for the same organism, Strep
pneumo in the blood. So, in this case, we have a positive
specimen in the sinus fluid that matches. And that organism is eligible
for sinus infection. And it matches at least one
organism in the blood. In this case, it’s the only organism. The blood is collected in the
secondary BSI attribution period and that sinus fluid culture is actually used as
an element to meet the site-specific definition. So I have a graphic of that in the next slide. So you can see that, in this case, we have — the patient has met the criteria
for sinus infection or sinusitis. Criterion one, which really only requires
that there’s an organism identified from the fluid or tissue of the sinus cavity. That occurred on 1/15. And the patient at that point
meets the criteria, and so this is considered a healthcare
associated sinusitis just based on the date of admission of 1/12 and that
this is on hospital day four. So this becomes an HAI. And then, as you can see on the right-hand side,
we have outlined both repeat infection timeframe for you as well as a secondary
BSI attribution period. And the secondary BSI attribution period or
SBAP involves both the infection window period, which is in green here, and the
repeat infection timeframe or RIT. And during that SBAP a blood
culture is collected. That has a matching organism to the
site-specific infection that was used to meet the sinusitis definition. So, in this case, the patient has a healthcare
associated sinusitis with a date of the event, 1/15, with strep pneumo and also a
secondary BSI, the same organism. So, a question. Must the staph aureus be investigated in
this case as a potential LCBI or CLABSI? So in this case that we have
here, this very brief information, which is something that you might see. In some cases infection preventionists
will see that a patient is admitted. In this case, for instance, on 1/12 was admitted
with a positive blood culture for E. coli. And they don’t necessarily work that up because
it’s clear that the patient came in with that. But then, if there’s a second blood
culture collected on 1/22, 10 days later, that’s positive with a different organism,
in this case staph aureus, what happens then? Do you need to — does the IP need to work
that up or does the IP just simply say, well, it was during the repeat infection
timeframe for the bloodstream infection, so it doesn’t have to be investigated. It’s really important to remember
that a positive blood culture on admission doesn’t necessarily
set a BSI RIT and that’s because the blood culture might
be representing a secondary BSI. And only primary bloodstream infections
set a bloodstream infection RIT. Secondary bloodstream infections actually
don’t set an RIT but an RIT would be set for the primary type of infection. So it would be necessary in this case
to determine if the E. coli was primary or secondary to another site of infection to
then determine if the staph aureus BSI needed to be investigated as a possible
LCBI and also possibly as a CLABSI. So let’s look at a schematic of this. As you can see, patient was admitted on 1/12
and at that time had a positive blood culture, but the patient also had a
positive urine culture and a fever. And this is a 55-year-old patient, so even
though there’s no Foley present, a fever can be used in the UTI criteria. Patient actually meets the UTI criteria on
that date with fever and positive urine culture of greater than 100,000 of E. coli, and so
this is a UTI that’s present on admission. And in this case, the patient has
a secondary BSI related to that. They have a matching organism
in both the blood and the urine. A UTI repeat infection timeframe
is set as is noted here, 14 days. But what is not set is a BSI RIT
because this is a secondary BSI. So date of event for the SUTI 1b, which
is a non-catheter associated UTI, is 1/12, and there’s a secondary E. coli BSI. But you’ll notice that on 1/22 the patient
has a positive blood culture also collected. I’m noting that it says 1/22
on here, in here, but it was — actually been checked as 1/21,
so we’ll go with the 1/21. In this case that staph aureus, because it
does not match the organism in UTI criteria in the urine culture, has to be investigated. So if no other type of infection is
identified to which it could be attributed, that would have to be considered a primary BSI
and it could be — potentially be a CLABSI. So it’s important not to simply
assume that because a patient comes in with a positive blood
culture that a BSI RIT is set. If no subsequent blood cultures are collected
then it’s possible that no investigation of that original BSI would be necessary,
but if another blood culture is collected that has a different organism then it may be
that you need to investigate that first BSI. So let’s talk about secondary blood
stream infections in scenario two. And this is the scenario whereby you’re actually
using a positive blood specimen as an element to meet the NHSN site-specific
infection criterion. And it’s collected during the
site-specific infection window period because it is an element, so
there’s really two must-haves — the blood positive organism has to be used as
an element to meet the infection criterion, and it has to be collected during
the infection window period. Or in the case of a surgical site infection
during the surveillance period for SSIs. So let’s look at an example of this. In this case, we have a patient that’s admitted
again on 1/12 and the patient was the victim of a fireworks accident and had first and
second degree burns to the right hand. The wound assessment on that day
showed that the patient had pale pink to red glistening mild swelling with
small blisters between the fingers. Three days later, a wound assessment showed
a marked increase in swelling of fingers, purplish eschar with right index
fingertip noted to be black. And three days after that, the
patient is running a fever of 101 and has a blood specimen
collected, actually two of them that are positive for Pseudomonas aeruginosa. So, in this case, the patient
actually meets the burn criteria. They had criterion one. Patient has a change in the burn
wound appearance or character. They give some examples such as a rapid
eschar separation, which we don’t have. But we do have the violaceous
discoloration if eschar. And there is an organism
identified from the blood. Since the blood culture is the
diagnostic test in this case, and that is used to set the
infection window period on 1/18. And then the three days before
that and the three days after make up the infection window period. And, as you can see, the first elements of
the infection criterion was met on 1/15. And so since, again since this patient came
in more than two days before, so on day three or after it is considered a
healthcare associated infection. And in this case, this patient has a burn
infection, HAI, with Pseudonymous aeruginosa. Date of event is 1/15, and the
patient has a secondary BSI. So your next question is, what if neither
scenario one nor scenario two can be met? Your choices are that no event is identified,
that it represents a primary BSI, or that, c, you should email NSHN for guidance. And I’ll pause. The correct answer is that
it would be a primary BSI. Now you can always email NHSN for guidance,
but our answer will be that if there’s — if neither scenario one nor scenario two
can be met, then it will be a primary BSI. So let’s look at an example. In this case, on 1/15, the patient had a breast
fluid collected during an invasive procedure that was positive for staph aureus. And on the 18th the patient had a fever
of 100.6, had blood cultures times two, positive for coag negative Staph. So in this case the patient met the breast or
mastitis infection criteria, Criterion One — organisms identified from infected breast tissue
or fluid obtained by an invasive procedure. It was Staph aureus. The patient does not match
scenario one nor scenario two. He doesn’t match scenario one because
he doesn’t have a specimen from the site of infection that matches the blood specimen. In this case, we had Staph
aureus in the blood — I’m sorry, at the site, and the patient
had — I’ll try to recall what the — and had coag negative Staph
from the blood cultures. So we don’t have a match there. And there is no breast criterion
that includes the identification of an organism from a blood specimen. And so, therefore, the patient
does not meet scenario two either. And so this is actually a
primary BSI for NHSN purposes. Now there is one exception. There’s always one exception, at
least, isn’t there, for everything? One exception to a patient meeting — neither
meeting — neither a scenario one or two, but being able to identify a BSI as secondary. And that’s our Necrotizing
Enterocolitis criteria. Our NEC criteria includes neither of
the elements, a site-specific specimen or organism identified in the blood. Neither of those are used
as part of the criteria. And so, therefore, we’ve made an accommodation. And the guidance is presented that if the
patient meets one of the two NEC criteria and also has an organism in that blood that’s
collected during the SBAP we’ll consider that BSI secondary. Now, you’ll see there’s other information
here that it has to be a recognized pathogen or two common commensals
collected on separate occasions. And the reason for that is that we would just
— you know, before you called a BSI secondary, we would want to make sure that
the patient actually met criteria for LCBI in all other variables. So if they had a single common commensal,
you wouldn’t call a secondary BSI. So we’re going to talk a little bit about
assigning pathogens in secondary BSIs. This can be somewhat — a little
bit confusing in some cases. But what we have done in writing these
rules is to just try to have consistency in how we assign pathogens and so if you
always keep that in mind that is helpful. So a couple of rules. An organism can be attributed as secondary
to more than one type of infection, so you might have a patient that had
met criteria for a UTI with E. coli and had a positive blood culture with E. coli. And also, at the same time, had an intra-
abdominal infection that was identified and they cultured E. coli from
the intra-abdominal cavity. And the patient met criteria using that. So in that case we would say that
E. coli is actually — could be — it would simply be recorded
as secondary to both. And, again, that’s just to be consistent. It’s also possible that in scenario
one there are additional organisms in the blood besides the one
that matches the organism in the site-specific [inaudible] infection, and those additional organisms
would also be considered secondary. I’ll show you a case to kind
of flesh this out a little bit. But, on the other hand, if there is no
matching organism in the site-specific specimen or in the blood, if blood was used as
an element earlier to meet the criteria, then the BSI cannot be considered secondary. So let’s see what that looks like. So, in this case we have a 60-year-old patient
that’s admitted to the hospital with a fiver of 101 Fahrenheit, and has a central
line and Foley both placed on 1/13. And then the next day the patient has a urine
culture collected, and it is final for greater than 100,000 colony-forming
units per liter of E. coli. They remove the Foley. The next day the patient complains of dysuria. The central line is removed and positive
blood cultures are growing E. coli. They were collected that day, and
are growing E. coli and E. faecalis. On the 16th and the 17th, the patient
has two other blood cultures collected, each one growing E. faecalis and Staph aureus. So, schematically, let’s see how this looks. And for those of you that are not aware,
this common format that I’m using is actually from our HAI and POA worksheet generator
which is online and which can help you to map out these different timeframes. So I would encourage you all to look
into that if you haven’t done that yet. In this case, again we had a patient
admitted on the 13th with a fever. And on the 14th they did a positive — or
they did a urine culture that was positive for E. coli, meeting the requirements. And patient also ended up
having dysuria the next day. And this patient had also
a blood culture collected on the 15th with E. coli and E. faecalis. So you’ll note that the patient meets SUTI
1b criterion, a non-catheter-associated UTI with a date of 1/13, which makes it
a present-on-admission infection. And, because there is a matching organism,
that E. coli, to both the urine culture used to meet the UTI definition and in the blood
culture, that whole blood culture is going to be considered secondary to the UTI. So we would say it’s a secondary
BSI with E. coli and E. faecalis. But the patient then had a couple more
blood cultures that were collected. Each of the following days the patient had
blood cultures collected containing no E. coli, but E. faecalis and Staph aureus on both days. So, in this case, there was no Staph aureus in the original urine culture nor
in the previous blood culture. And there was no E. faecalis in
the previous urine culture either. And remember that we said that there has to be a
matching organism to the site-specific infection in order to say that the matching
organism in the blood is secondary. So in this case we needed to have an E. coli
in the blood specimen, and we don’t have that. so, for that reason, if there
are no other sources of infection to which this could be attributed, this
is a primary LCBI-1 with a date of event on 1/16, and both organisms are listed. The blood culture that’s collected on
the following day occurs in that BSI RIT so a BSI RIT is set beginning
on 1/16 and going through 1/29. That would be a BSI repeat infection timeframe and the second blood culture
would not be recorded separately. So we’re going to talk just a little
bit, very briefly, about some case — about some tools that we have to
make your life a little bit easier in making these determinations, some
educational offerings that we have in references before we get
into our case studies. And the first tool that I want to bring your
attention is Table B1 from the BSI Protocol. And this Table is the primary sites
that are eligible for secondary BSIs. And you’ll see that we have listed out — these
are — they’re obviously shortened versions, but these are lists of all of the types of
infections, infection criterion, and whether or not they can be used to meet
Scenario One or Scenario Two. So just in the little data
that you have available to you, you’ll see that for Scenario One, which, again,
remember, is that there’s a matching organism in the site-specific specimen and the blood. We could say, oh, I have a blood culture —
or I have a — I have a culture from a bone. I wonder if I can see if they meet Scenario One. I could look at this tool and see yes, Criterion
One is the only criteria that would be — criterion that would be available for
me to meet the secondary BSI scenario. Likewise, I could say, oh, darn. I looked into it and the organism from
the bone and the blood are not the same. I wonder if I could meet Scenario Two. And then I could go to Scenario Two column and
say, oh, I could meet, possibly, Criterion 3A. I need to go and look at Criterion 3A and see
if the patient meets that — those requirements. If they do, I may be able
to say this is secondary. If they don’t, then I know those are my only
two options to say that this is secondary to the bone infection, and I would
either have to find another site to which it could be attributed,
or the BSI would be primary. So, depending on your situation,
this can be very helpful. Another tool that we have is for
those people that are very kind of — visually like to step down through a flowchart,
is the Figure B1, also from the BSI chapter which starts at the position that you have
a positive blood specimen and you suspect that there might be another source of
infection to which it could be attributed. And it will then walk you
down through certain — a set of questions as to make a
final determination of whether or not the BSI is primary or secondary. And you’ll probably notice that what
actually happens is that one arm of this flowchart here is actually Scenario
One and the other one is Scenario Two. So, if you don’t meet one, then
you’re going to end up having to go to two to see if that, in fact, meets. And if the answer to no is both, you’re going
to wind up with a primary BSI determination. I want to ask you to keep your eyes
open for some new training resources for BSI and secondary BSI in particular. This presentation will be posted
to the NHSN website as soon as we have been finished
getting closed captioning done and some other requirements
that we have at the CDC. So, hopefully, in the next month
or so this one will be going up. And I would also tell you I’ve
provided a couple of URL’s here. We actually have a quick-learn video that is
nine minutes in length that is specifically for determining or distinguishing
between primary and secondary BSIs. So, nine minutes isn’t hard to find in your day. And if you feel like you need
a little bit more information, I would really encourage you
to go and to look at that. Additionally, we have Frequently
Asked Questions and when you log onto the BSI site you’ll find
options for training protocols and then Frequently Asked Questions. And when you choose that, you
get a page that looks like this. And this is really nice now because
we actually have the topics listed, and you can click on the topic and it will
take you right to that answer on the page. So you can see that we have
site-specific criteria and secondary BSI. There’s also a wealth of other information,
and I would encourage you to take a peek at what’s here — lots of little tips
that you can pick up and something that you might not really understand that you — you’ve got a misunderstanding
about and you’re not aware of it. So take a look. So, we’ve covered all of the information that
we needed to cover, and now we’re going to get to the fun part which is
going over some cast studies. And, again, feel free to pause the
video after the questions are asked and try to make a determination yourself and
then start the video again for the answer. So, our first case study is a 40 — I’m
sorry, a 35-year-old woman who was admitted on February 1st with complaints
of right scapular pain and fever. She had a superficial laceration
to her right scapula from falling into an outdoor grill five days earlier. Wound is scabbed over in places, but there
is purulent drainage noted from the center. She is admitted for IV antibiotics. Two days later it’s not really
showing any improvement in her wound with the broad spectrum antibiotic coverage, it’s
swelling, is red and warm to the touch and some of the drainage is actually sent for
culture, and is positive for Strep pyogenes. Five days later, the patient’s fever continues. Hmm, this must be a tough bug. And the WBCs are continuing to increase
and she’s — they’re now at 20,000 WBCs. Blood cultures are collected and
the final results are positive for a methicillin-resistant Strep pyogenes. So, is this Case Study One a Primary LCBI? Your choices are, yes, this is a primary
LCBI with Strep pyogenes that’s identified on hospital day three, which
is February 4th, or no, this is a primary skin infection
with a secondary BSI. The correct answer is that this is a
primary skin infection with a secondary BSI. And let’s look at that and a
little bit more information. The patient, as you can see, actually
meets a couple of criterion for skin. Patient had purulent drainage from the site
which is enough to meet skin criterion one. But the patient additionally had two of the
following localized signs or symptoms — pain, swelling, erythema, and heat. And had an organism identified from
aspirate or drainage from the affected site. And, again, we’re looking for
those organisms that are pathogens. But there actually is some information or
common commensals but there are some organisms that are — would not be
considered eligible for use. And those are listed here. But for the sake of purposes for
this case, we don’t need to worry about those because we have Strep pyogenes. And as you can see, we’ve taken a snippet
from Table B1 I believe it was which is — shows that there indeed is a
scenario one option for skin, and that is criterion 2A which we have met. But it’s important to note that in cases like
this where there is more than one criterion that can be met, we want you to
use the infection window period that provides the earliest date of event. And that’s important. And it’s actually in your
favor to make sure that you do that because it can be the difference between
identifying an infection as present at admission or identifying it as a healthcare
associated infection. So, again, patient met POA Skin One on the
day of admission with the purulent drainage, so that would be the earliest
date of event that you could use, and that would be to your benefit, obviously, to
call that, or to use that criterion as opposed to criterion 2A which was the skin
culture with swelling, redness, and heat, and a positive blood culture, because if you
use that, you would not have a date of event until 2/3, and that would actually
be a healthcare-associated-infection. So you wouldn’t want to do that. So, always use the earliest infection window
period when you have a scenario like this. In this case, this is, however,
a case of secondary BSI with multi-resistant Strep pyogenes. So even though you have a — you’ve set
a secondary BSI attribution period here, and a repeat infection timeframe, this 2A is
occurring during the repeat infection timeframe, and so that’s why you can say that this is —
you know, it’s all one event and it’s secondary. Hopefully that makes good
clinical sense as well. And really, this just, again, drives home
the fact that you would not want to call — use the wrong infection window period as
a later infection window period and have to call this a healthcare-associated infection. So let’s look at a couple of
other examples of meeting more than one criteria of the same type of infection. In this case, two, we have a 67-year-old female
that’s admitted for abdominal hysterectomy and, unfortunately, the patient suffers an
intraoperative stroke and is admitted to the neuro ICU and placed on a ventilator. On the 31st, so about 15 days later, the
patient spikes a fever to 38.1 degrees Celsius, has elevated WBCs and has
coarse breath sounds throughout. The chest x-rays, however, just show
pulmonary edema, but no evidence of pneumonia. The patient does grimace on suprapubic
palpation during the assessment. A vaginal exam is performed and purulent
drainage is noted at the vaginal cuff. They do collect cultures from
the vaginal cuff, the blood, and the urinary tract — urine cultures. On the second, the final
results of the cultures are in. The UA — I’m sorry, the
urine culture grew nothing, but the blood cultures both grew Acineto
baumannii and a culture of the pus from the vaginal cuff is
positive for Group B Strep. So we have different organisms in
the blood than what is collected from the vaginal cuff, or the site of infection. So you might actually think that this might be
— not be able to say that this is secondary, but let’s look at that in more detail. So what’s your first feeling? Which of the following is
the correct attribution? The patient has a VCUF infection
with secondary BSI, or, b, the patient has a laboratory-confirmed
bloodstream infection, or, c, the patient has both — an LCBI and a surgical
site infection which is a VCUF organ space. And the correct answer is c. They have both. So let’s look at why that is. In this case, the patient
meets two criteria for a VCUF. They have purulent drainage from the vaginal
cuff on gross anatomic exam, post-hysterectomy. So that’s criterion one. They’ve met that. And they met that on 1/31. And they had organisms identified from
fluid or tissue from the vaginal cuff. And that is also — that is criterion three,
and that was also met on the same date. So in this case it doesn’t matter which one
you choose from a date of event standpoint. Both dates of events. So they have a primary LCBI with A.
baumannii and an SSIV cuff on 1/31. And, again, that’s because we do not have
a matching blood and vaginal cuff cultures to meet scenario two, and we don’t
have — I’m sorry, scenario one. And we don’t have a positive blood specimen that
could be used as an element of the infection. There is no VCUF criterion that uses
positive organisms identified from blood, so in this case this is an LCBI-1
unless we can find another source of infection to attribute the blood specimen. Case Study Three is another example of where
you may have a patient that might meet more than one scenario — or criterion, I should say. In this case, on January 1st we
had a patient that’s admitted with abdominal pain and distension. A PICC is placed on the next day. On the 4th, ultrasound-guided
drainage of five liters of purulent peritoneal fluid is performed, and that peritoneal fluid is
positive for Kleb pneumo and E. coli. On January 10th, abdominal pain is increased. The next day they do a CT scan and
identify multiple liver abscesses. They collect some blood cultures
which are positive times two for Candida glabrata and L. casei. And on the 13th the patient has
jaundice and has fever of 101.2. Again, you get to try your hand. Which of the following is
the correct attribution? A, the patient has an LCBI-1. B, she has an SSI, surgical site infection,
intra-abdominal infection with secondary BSI. Or, C, she has an intra-abdominal infection with
a secondary BSI, not a surgical site infection. And the correct answer is C, again. She has an intra-abdominal
infection with secondary BSI. Let’s look at why this is. The patient came in and did not
have any surgery from the history. They just came in with abdominal
pain and distension. And an ultrasound-guided drainage
was performed which was positive for the two organisms, Kleb pneumo and E. coli. And so on that date the patient actually met
IAB criterion one which is hospital day four. Patient had organisms identified from purulent
material from the intra-abdominal space. They did say it was purulent peritoneal fluid. Additionally, the patient had during that
same IAB RIT, the patient had abdominal pain and they did a CAT scan and found that
the patient had some liver abscesses and the patient also had blood
cultures with two organisms. In this case that were different from what
was identified from the peritoneal fluid. So some individuals would
say, oh, there’s no way. I can’t say that that is
secondary because they don’t match. But, really, as long as you
can meet the requirements, and in this case this patient meets the
criterion three for fever and jaundice. Two of the following had both of those. He actually also had abdominal pain. And at least one of the following
— organisms identified from blood, and it has to be a blood —
at least one MBI organism. In this case, it is — Candida glabrata, and
has evidence by imaging test of infection. And in this case we had a CAT
scan that showed liver abscesses. So the patient met criterion three, and in
so doing that they also met scenario two of the secondary BSI rules,
meaning that, you know, they have a blood culture
that’s used as an element. So this patient can be deemed to have an IB3,
3B, with a secondary BSI of the organisms here. And those organisms are different in this case
from those identified in the other criterion. Because these are both IABs, you would not
record two separate intrabdominal infections if you’re reporting this. You would instead simply add these
organisms onto the first reported event. Moving along, we have Case Study Four. This is a 45-year-old that has colon cancer
who was admitted and undergoes a colectomy. The patient’s tunneled central line for
hemodialysis is accessed today in the unit. The patient has nausea on January 9th,
vomiting, an increase in abdominal pain, and fever of 38.3 degrees Celsius. Blood cultures are collected and
are positive for Candida albicans. And the next day the patient continues to have
pain and fever and has two episodes of vomiting. A CT scan of the abdomen shows a small bowel
obstruction, and the physician documents says that the source of the positive blood
cultures is the gastrointestinal tract. So, what do you think? Which definition should be applied in this case? Should we be looking at the
gastrointestinal tract infection or GIT, the intra-abdominal infection, the
other reproductive infection or OREP, or none, because this is a primary BSI? The correct answer is that we should
be looking to GIT, and why is that? This is something that sometimes
infection preventionists have a little bit of trouble understanding, so we
want to make sure that it’s clear. In this case, this patient has colon
cancer and has a small bowel obstruction, and the physician notes that
there’s a GI tract source. Our gastrointestinal tract infection
definition includes the esophagus, the stomach, the small and large bowel, and the rectum. And then we have guidance that
says it excludes gastroenteritis, appendicitis, and C. difficile infection. So, really what’s included here is
the lumen of the intestinal tract. It’s the inside of the intestinal tract. That’s in contrast to the intra-abdominal
infection which includes the gall bladder, the bile ducts, the liver, the spleen, pancreas,
peritoneum, retroperitoneal, or subphrenic or subdiaphragmatic space, or other intraabdominal tissue
or area not specified elsewhere. So we’re really looking inside of the
intraabdominal cavity here for infections. We also have the option of the OREP definition,
and that’s one that’s not always thought about by infection preventionists,
but it should be if the infection is involving the deep
pelvic tissue or infection of the male or female reproductive tract,
the epididymis, the testes, the prostate, vagina, ovaries, or uterus. It does include chorioamnionitis,
but it excludes vaginitis, endometritis, or vaginal cuff infections. We have a separate vaginal cuff infection
definition as we mentioned earlier. So, in this case, what we’re really looking at
is the gastrointestinal tract because the — it didn’t involve the intraabdominal
space or the deep pelvic tissue. Oops, it went backwards. But, does the patient meet criteria? So let’s look at the GIT. In this case, the patient doesn’t really
end up meeting any of the criteria, and this ends up being a primary LCBI-1, a
CLABSI with Candida albicans on January 9th. And we’ve highlighted here,
you know, what are met. Just — we did have an organism in the blood
for criterion one, but we didn’t have evidence of an abscess or gastrointestinal
tract in any way. The notation by the physician that he believes
it’s the source of the infection is not enough. We have to actually have evidence of infection. And the patient also doesn’t meet two. Again, we had organisms — we did not
have organisms identified from drainage. We have some of the symptoms that were
required, but we did not have the imaging test that was needed to go along with
the positive blood specimen. Okay. Case Study Five. We have a 41-year-old female that’s been on
your unit for two weeks on February 14th. She has a central line through which she has
been receiving hemodialysis since admission. On the 17th her central line insertion site is
red, and has purulent drainage which is cultured and positive for Pseudomonas aeruginosa. She develops fever of 39 degrees
Celsius and shaking chills on the 19th. And two sets of blood cultures are sent. On the 21st, her blood culture results
are positive for Pseudomonas aeruginosa. This is probably a scenario
that you’ve all run into. So your questions are, is this an LCBI
— or question is, is this an LCBI? And your choices are yes, the patient has a
laboratory-confirmed bloodstream infection with Pseudomonas aeruginosa. No, the patient has a skin
infection with Pseudomonas aeruginosa and a secondary BSI with the same organism. Or, no, the patient has a VASC
infection with Pseudomonas aeruginosa and a secondary BSI with the same organism. And the correct answer here
is A, the patient has an LCBI. So let’s look at why this is. In short, the infection will not
be considered a skin infection if a vascular access site is involved. It will either be a vascular infection or
VASC, or it would be an LCBI in the cases where there’s also a positive blood specimen. And you’ll note that the skin
infection criterion here has under the Reporting Instructions, report a
localized infection at a vascular access site as a VASC unless there’s an organism
identified from blood, meeting the LCBI criteria which should instead be reported as an LCBI. And that’s the case that we have here. Let’s look at the VASC criteria. You’ll note that we have right underneath
the VASC definition or description, which is arterial or venous infection, we
have, “Note, if a patient meets the criteria for an LCBI in the presence of an intravascular
infection, report as an LCBI not as a VASC.” And then there is also under the VASC
Infection criteria another reporting instruction that mentions the case where you have both
pus at the insertion site and a culture of that pus that’s collected during the
LCBI infection window period matches at least one organism in the blood specimen. That can be considered not a central
line associated bloodstream infection if a central line is involved. But — and then a list of devices
is included for the exception. But you’ll notice that the one that involves
a central line requires that that access, that central line not have been accessed
nor inserted during the hospitalization. And, in this case, we said that
the central line had been accessed. So, in short, the best way to think
about this is that if there — in this case there is an infection
at an eligible central line site which caused a bloodstream infection. And, therefore, we would want
to collect that and to recognize that that is a central line
associated bloodstream infection rather than call that a vascular infection. Our prevention efforts at both insertion and
maintenance should be effective in some way to help try to prevent these
types of infections. Okay. We’re getting close. We’ve done quite a few studies. We have just a couple more. We have Cast Study Six in
which a patient is admitted to the PICU four months status post allogeneic
stem cell transplant for acute myeloid leukemia. A port was in place and was
accessed on the day of admission. Her current weight is 25 kilograms. On the 8th, the patient becomes
disoriented and hypotensive. And two sets of blood are collected for culture. Both resulted as positive
for Enterococcus faecium. On the 9th, the patient complains of nausea,
emesis, diarrhea, and abdominal pain. And on the 10th she is diagnosed with Grade
Three graft-versus-host disease by an endoscopy. Your question. True or False? This BSI is secondary to GIT
and, therefore, is not an LCBI. You can say True or you can say False. This is an LCBI. It’s actually a mucosal barrier injury-LCBI. The correct answer is B.
This is actually an MBI-LCBI. And here’s the rationale for this. the GIT criteria reads that the patient has at
least two of the following signs or symptoms — compatible with infection of
the organ or tissue involved. In this case, it’s fever, nausea, vomiting,
pain or tenderness, odynophagia or dysphagia. And you’ll notice that all that
fever have an asterisk after them. And that asterisk is related to the
statement “With no other recognized cause.” In this case, the patient had three of them. He had nausea, vomiting,
pain — vomiting and pain. And the patient has to also have
at least one of the following, one of which is organisms
identified from blood and that it has to be an MBI organism, and
in this case that is true. The organism involved, which
I’ve forgotten already, which is Enterococcus faecium,
is actually an MBI organism. And patient also has to have
imaging test evidence suggestive of gastrointestinal infection. And we did not have that. We had evidence of graft versus host
disease by endoscopy, but not of infection. So, as you’ll recall, before a patient
can meet the MBI-LCBI criteria they have to first meet the LCBI criteria
which includes, again, determining that the BSI is not related
to an infection at another site. The patient did not meet the GIT criteria because the infection was not
identified by an imaging test. And, additionally, graft versus host disease —
neutropenia and chemotherapy can cause symptoms such as nausea, vomiting, and abdominal pain. And so we would in most cases say that those symptoms should be
excluded in cases such as this. So the MBI-LCBI criterion — patient
meet Criterion One, which they did. It was an MBI organism. And, in this case, the patient is an
allogeneic hematopoietic stem cell transplant within the past year, and had
Grade III or IV GIGVHD documented. One final pearl of wisdom for
— regarding the GE criteria — and those criteria mention an enteric pathogen
being identified from stool or rectal swab. Examples of enteric pathogens include things
that you would normally think about such as Campylobacter, Shigella, any
of the Enterohemorrhagic E. coli or Enteropathogenic E. coli, Salmonella,
Listeria, Yersinia, Vibrio, and Giardia. It does not include organisms such
as enterococcus and pseudomonas. Those organisms, although they’re
found in the gut, that’s true, they’re also very important environmental
pathogens and not ones that we think of as causing, for the most
part, gastroenteritis. So, in summary, before we do just a couple
of more case studies that were put together for some small group work, there are only two
ways to make a secondary BSI determination. Scenario One, as we said, where there
is a site-specific specimen that’s used to meet the criteria. And then we have a blood specimen that
has at least one matching organism as collected during the secondary
BSI attribution period. Or Scenario Two where having
identified an organism in the blood specimen is actually used itself
as an element to meet that infection criteria. And, therefore, because it’s an
element, it has to be collected in the infection window period
for that infection. If neither of those scenarios are met,
it has to be considered a primary BSI. The only exception that we have is the
NEC criteria whereby as long as a criteria for NEC is met, an organism identified from the
blood during that SBAP is considered secondary. Sometimes blood cultures or organisms that
are identified in the blood during the present and admission timeframe will
need to be investigated because you’ll have a subsequent bloodstream
infection, and you need to determine whether or not that first BSI was primary or secondary so you can determine whether
or not a BSI RIT was set. If it’s secondary, then that BSI, the second
BSI, will certainly have to be investigated and if the — whereas if the first BSI was
primary in nature, it would set a BSI RIT and you would only have to an investigation
after that 14-day period has passed. Blood specimens that occur in the SBAP have
to contain at least one matching organism to the site-specific specimen, and
that specimen had to have been used to meet the definition initially. Otherwise you’re going to have to investigate it
as being either primary or secondary in nature. And remember that sometimes a patient will meet
more than one criterion for a type of infection. And if that occurs, you need to consider all
of the potential infection window periods to identify another possible
criterion that can account for that bloodstream infection as secondary. So look at all of the criteria
that are available to you. Remember the tools that we have provided to you. They’re all valuable and they
can help understand your — help your understanding of the HAI surveillance. Okay, we’re in the homestretch. We’re going to do two final case
studies looking at secondary BSIs. These are a little challenging on purpose and,
unfortunately, the reality is that you are faced with challenging cases all the time. So we have to follow — we have to
address those scenarios as well. So Case Number One. In this scenario, we have a patient
that’s admitted on January 7th. Patient has a history of bradycardia
and had a pacemaker placed in 2016. On February 4th, the patient
has a positive blood culture, actually two, for Enterococcus faecium. One positive on the 5th for the same organism. Another two collected on February 6th. Positive again for E. faecium. On 2/7, another single positive
blood culture for E. faecium. On the 12th they’ve placed a PICC line,
a Peripherally Inserted Central Catheter. On the 16th, the patient has another
blood culture that’s collected, and this time it’s positive — one
of them’s positive for Staph aureus. And on the 22nd, they are investigating those
and they note that there is a vegetation on a pacemaker lead that they collect
a specimen from and send for culture, and that is positive for Candida albicans. And on the 25th we now has a — I have a
positive blood culture for Candida albicans. So, as I said, this is a little
bit complicated case history. But not all that unusual. So we have a series of four
questions to consider. Number one, which infection
definition should be used in this case? Number two, is the — is this a primary
or secondary bloodstream infection? Number three, which event creates a BSI RIT
— a primary BSI, a secondary BSI, or both? And what is the final determination
for this case? So let’s look at the answers. The definition that should be considered
in this case, given the positive vegetation on the pacemaker lead and the
blood cultures is Endocarditis. And as far as whether this is
a primary or secondary BSI, it really depends on which one
you’re talking about — 2/4 of 2/22. We’ll look at that. And which event creates a BSI RIT? Of course, only primary BSIs create a
BSI RIT, and, therefore, in this case, that would be the 2/4 BSI, and
we’ll talk about why that is. And then let’s look at what the
final determination is for the case. Now, we need to remember a few things as we talk
about endocarditis and the definition in NHSN. Endocarditis has a longer
infection window period. It actually, instead of having a seven-day
infection window period, has a 21-day period. That includes the day of the diagnostic
test, 10 days before and 10 days after. And the reason for that is that
it does sometimes take a period of time before the picture is complete enough
that the suspicion on endocarditis arises or that all of the requirements for
making the determination can be performed. Likewise there’s an extended secondary
BSI attribution period for ENDO, and that include the 21-day infection
window period and all subsequent days of that patient’s current admission. And this is to recognize that endocarditis
is sometimes very slow to resolve, that multiple blood cultures are often collected
during the patient’s admission in order to determine the effectiveness of the treatment
which can be lengthy, and not wanting facilities to have to report multiple CLABSIs in a
patient that actually has endocarditis. There is one caveat that — and that is that
the secondary BSI attribution period is limited to the organisms that are
identified in the blood specimen that matched the organisms used
to meet the ENDO definition. And what do we mean by this? We don’t expect that a patient
coming in with Endocarditis with one organism during their admission — their admission, are going to have other
organisms be recovered from that Endocarditis. Now, the scenario that comes to mind that
might be the exception of that is a patient that is accessing their own IV line for
illicit purposes, in which case you may find — may very well have polymicrobial
blood cultures in that patient. But we have accounted for that scenario in
the BSI chapter related to making an exclusion for patients that are accessing their lines. So I would refer you to the
BSI chapter to look into that and the time period that is related to that. So, in this case, there are no other elements
present during an ENDO infection window period set by the 2/4 BSIs, so using the blood
stream — the blood specimen and 2/4, that would give us an infection window
period of 21 days of 1/25 through 2/14. And we don’t have any other elements during
that time to fulfill the ENDO criterion. And as long as no other type of
infection is suggested and criteria met, that means that this would be a primary BSI. So in that case we would have a BSI, primary
BSI with the organism of E. faecium on 2/4. But this patient had multiple blood cultures
collected as they will in these types of cases. So now what we need to consider — the
next positive blood culture that is — this outside of the BSI RIT, and
that’s true in this case because all of the other blood specimens that are collected
within the BSI RIT are of the same organism. We don’t have, you know, a
E. Faecium collected on 2/4 and then a Staph aureus collected
on — and, actually, I’m sorry. Let me take that back. Because we set a BSI RIT, it doesn’t
matter what the organisms are. In this case, it ends up being that
they are all the same organisms that are identified but that’s not required. Actually, we have 2/16. We have a Staph aureus so that gets rolled up
into the BSI RIT from the 2/4 blood culture. But now we need to look to
the 2/25 blood culture which has not been accounted
for with Candida albicans. So we had a pacemaker lead that had
vegetation and a culture on 2/22. And that culture was positive
for Candida albicans. And that is going to set a potential ENDO
infection window period of 2/12 through 3/4. Again, 21 days. So let’s look at this graphically. We have — here on the left-hand
side we’ve accounted for all of the blood cultures from 2/4 through 2/16. The repeat infection timeframe as we identified
as 2/14 through 2/17, because this is a BSI RIT. And because this is a BSI RIT,
during that RIT you don’t have to investigate any other
positive blood specimens. You simply roll those up and
consider this a primary LCBI of — with both E. faecium and Staph aureus. Date of event, 2/4. And in this case, because the culture wasn’t
collected until day four of the hospitalization, this is categorized as a
healthcare-associated BSI. Then we have a period of time where we
don’t have any blood cultures collected, but we have another blood
culture collected on 2/25, which is outside of the BSI RIT, said earlier. So we have to investigate it. In this case, the patient met ENDO
criterion one with Candida albicans on 2/22 because they had a positive lead, a
vegetation, and positive blood culture. And so this is a secondary
BSI to ENDO criterion one. Our second and last Small
Group Case Study is Case Two. In this scenario we have a
patient that is admitted on 2/2 with fever and chills of unknown origin. The patient’s knee has been sore the last few
days, but there is no obvious specific symptoms. On the eighth, we do have some symptoms. The knee is actually drained of fluid,
sent for culture, which grew Staph aureus. On the 14th, patient continues to
have increased pain of the left knee. Is not able to bend it because it’s swollen. On the 17th we have a positive
blood specimen for Staph aureus. On the 22nd — I’m sorry, 22nd, we
have another positive blood specimen with Staph aureus and Strep pneumo. And on the 24th we have another
positive blood specimen with Strep pneumo and Neisseria gonorrhea. So, your two questions are, which
definition should be used in this case, and what is the final determination
for the case? So this patient actually meets again, as we’ve
seen before, he actually meets two criteria for Joint, which is JNT or
Joint or Bursa Infection. The patient meets criterion one with
organisms identified from the joint fluid. And the patient actually also meets
criterion three which involves two symptoms and the patient has two of those symptoms
— swelling pain — actually, three. And a limitation of motion all in the IWP. And patient has organisms —
oops, this should be 3C — organisms identified from blood by culture
or non-culture-based micro-testing. Sometimes those — we’ll work on these slides. Those little circles get shifted, so that should
be C. Make that — if you’ll make that note. So let’s look at this determination. This patient has an increased
left knee pain on the 14th. Is unable to bend it due to swelling. And the patient has a positive
blood culture on the 17th. That positive blood culture will
set the infection window period — three days before and three days after. And that is enough to meet the
joint 3C criteria with Staph aureus. Now during the secondary BSI attribution period,
the patient has another blood culture collected on the 22nd which has Staph
aureus and Strep pneumo. And because there is a matching organism,
the Staph aureus, to the blood that was used to meet joint 3C criterion,
we’re simply going to add on the Strep pneumo to that determination. So a joint infection on 2/14 with
Staph aureus and Strep pneumo. Well, we have another blood culture that
was collected on the 24th that we have to investigate because it has another
organism in it, Neisseria gonorrhea. And neither the Strep pneumo nor the
Neisseria gonorrhea were included in this blood culture here that
was used to meet this criterion. And as a result, we cannot say that this
BSI is secondary to the joint infection. We do not have a matching organism to the
specimen that was used to meet the criterion. So we would have to investigate this
blood culture to determine whether or not there was another potential
secondary site of infection. If we cannot find that other — I
should say primary site of infection. If we cannot find that criterion, then that infection wouldn’t have
to be considered a primary BSI. That concludes the presentation today. I want to commend you for sticking with
us, and hopefully you’ve worked through all of the case studies that we presented. And, as always, if you have questions
for us, you can email us at [email protected], and we’ll be happy to answer
those questions for you. Great job!

2019 NHSN Training – Central Line-associated Bloodstream Infection (CLABSI)

2019 NHSN Training – Central Line-associated Bloodstream Infection (CLABSI)


>>Good morning. My name is Dominique
Godfrey-Johnson. I’m one of the subject
matter experts for the BSI event chapter. Welcome to all our participants,
whether you are joining us in person or via webstream. So let’s continue
with– With day 2 and move to a
hot topic, primary BSIs. This may take– This
presentation may take one cup of coffee or two but we will
get through it together. I will discuss laboratory
confirmed bloodstream infections or primary BSIs. My colleague, LaTasha Powell, will discuss secondary
BSIs in a later session. So what are my expectations? I have expectations of you. I expect that everyone is alert
and excited about primary BSIs, after all, it’s our
favorite topic. What I do not expect
is an audience that has fallen asleep before
we reach the exciting topics. And believe you me, there
are some exciting things in this presentation. So what are the objectives? The objectives are to
provide an overview of the training resources,
protocol and supporting materials. Define key terms for device-associated
infections specifically CLABSIs. Discuss device-associated
infection surveillance changes for 2019. And provide an overview of
the data collection process for mapped NHSN locations and this will include both
the numerator and denominator. And finally, we will
assess our knowledge about current BSI
through case studies. This is just a plug for the
Healthcare-Associated Infections Progress Report. Since this presentation
was posted to the website, the 2017 HAI report
has been published. I would like to highlight a
few important points related to the report and
specifically CLABSIs. As you know, CDC is working
towards the elimination of HAIs. The infection data included in this report are those
data reported to NHSN. US hospitals reported a
significant decrease in CLABSIs between 2016 and 2017. And the HAI progress report
provides summary of select HAIs across four healthcare settings. These settings are your acute
care, your critical access, inpatient rehabilitation
facilities and long-term acute
care hospitals. So where can I find
the BSI protocol? Under the protocols tab, the
BSI chapter is– listed first. Next is the bloodstream
infection link and this will open
the BSI protocol. We will discuss this protocol
in great detail today. You should also familiarize
yourselves with Chapter 2 which was presented yesterday. This last highlighted
area is the link that would take you
to Chapter 2. This chapter provides
the foundation on how to identify HAIs including BSIs. Under the training tab, you will
find numerous training videos and accompanying slides. These resources are kept
current and new content is added when it becomes available. For example, our
newest BSI quick learn on denominator device day counts
and central line day counts for making a CLABSI
determination was posted on December of 2018. What about the frequently
asked questions? The frequently asked questions
tab contains those pressing questions we receive from IPs
about bloodstream infections– bloodstream infection
surveillance, analysis and annual surveys. These are just examples of the
information found on this page. The BSI FAQ is an invaluable
document that contains answers to most of the– to some
of the most frequent and more difficult concepts
related to BSI surveillance. As you can see from
the screenshot, the FAQs are sorted by topic. Finally under the
supporting material section, you will find important
resources such as key terms or Chapter 17 which is the site
specific infection definition for secondary BSI determination
and the NHSN organism list that you will need
for BSI surveillance. This organism list is an Excel
file with individual tabs at the bottom listing
all organisms, your common commensals
and your MBI organisms. Please make sure you
are referencing the most recent material. Now we will move on to
definitions that you will use when identifying BSI events. Let’s begin with the
infection window period. The infection window
period in which all– is the period in which
all BSIs must be met. It includes the collection day
of the first blood specimen that identifies an organism,
the three calendar days before and the three calendar
days after. The LCBI date of event is always
the date of the blood specimen. The positive blood specimen with a recognized pathogen
is the only element needed to meet this criteria. So for LCBI 1, no signs
or symptoms are needed. This is in contrast to
LCBI 2 and 3 criteria. For LCBI 2 or 3, the date of event is the date the first
element is used to meet LCBI 2 or 3 criteria and it– That occurs during the BSI
infection window period. There are two elements needed
to meet LCBI 2 and 3, a symptom and two blood specimens that
are matching common commensals or companion cultures. If the two blood specimens are
collected on consecutive days, they are considered
as single element for meeting the criteria. The date of the first blood
specimen will set the IWP. All BSIs are either a primary
source of infection or secondary to another site specific
infection such as your urinary
tract infections, your surgical site infections, your ventilator associated
events, your pneumonias or one of the Chapter 17 definitions. The laboratory confirmed
bloodstream infections or LCBIs are bloodstream
infections that occur when an organism has been
identified in the blood and it is not related to an
infection at another source. All primary BSIs create a 14-day
repeat infection timeframe or RIT. This repeat infection
timeframe is a period of time in which no new infections of
the same type are reported. Secondary BSIs are bloodstream
infections that are not reported as an LCBI because
they are associated with a site specific
infection at another body site which has seeded
the bloodstream. Secondary bloodstream
infections do not create an RIT but rather the primary source of the secondary BSI creates
the RIT and no new infections of that specific type
will be reported. Your secondary BSI
attribution period or your SBAP is the period in which a blood
specimen must be collected for secondary BSI attribution. The SBAP includes the
infection window period and the repeat infection
timeframe. It can be 14 to 17 days
depending on the date of event. Now let’s review an
eligible organism. This is an organism eligible to
meet LCBI or MBI-LCBI criteria. Eligible BSI organisms are
not excluded organisms. The definition of a central line
is an intravascular catheter that terminates at or close
to the heart on in one of the great vessels which
is used for infusion, withdrawal of blood or
hemodynamic monitoring. Neither the type of device
nor the insertion site will determine if a line
qualifies as a central line. Patients must have one or
more qualifying central lines to be included in
CLABSI surveillance. In order to meet the
central line definition, you must ask yourself
two questions. Where does the tip terminate
and how is the line being used. A few points regarding central
lines are patients must have one or more qualifying
central lines for inclusion in CLABSI surveillance,
infection surveillance where NHSN is not aimed
at a particular device but instead is identifying
the risk patients have as a result of using the device. NHSN also does not attribute
any bloodstream infection to a specific device. On the slide you will see a
list of great vessels available for use in making determinations
about central lines for CLABSI reporting
and device day counts. If a line has a lumen and
terminates at or close to the heart or in one of
the great vessels and is used for the purposes listed
above, it is a central line. Once it is deemed a
central line, it continues to be a central line until it is
discontinued which means removal from the body or the
patient is discharged, whichever comes first. We receive a fair number
of questions about a line that has migrated out or sometimes has
intentionally been pulled back and this is seen
on the chest x-ray. This does not eliminate the
line from being an eligible– from being eligible for a CLABSI
event nor does it stop the central day count. When considering a CLABSI
event, you must consider access. Access is defined as
the performance of any of the following activities
during the current inpatient admission, line placement
and use of any central line for infusion with withdrawal of
blood or hemodynamic monitoring. Once a central line has been
accessed in an inpatient unit, it is eligible for a
CLABSI event until the day after is discontinued or
the patient is discharged, whichever comes first. Discontinued in this case means,
again, removal from the body. Access is an important
concept especially when you have a central
line or implanted port that is present on admission. If it was not placed during
the current admission, the first time it is
used as an inpatient for medication administration,
blood draws or fluid administration, the
line is then considered access. An eligible central line is
a central line that has been in place greater than two
consecutive calendar days following the first
access of the central line in an inpatient location
during the current admission. These lines remain eligible
for CLABSI events until the day after removal from the body
or the patient is discharged, whichever comes first. Dialysis patients who have
a line that is only used by dialysis personnel
are included in central line day
counts for the location where they are physically housed and the patients
must be included in any CLABSI surveillance being
performed in that location. For NHSN reporting purposes,
central lines are categorized as temporary, permanent and in
neonate’s umbilical catheters. A temporary line
is a non-tunneled, non-implanted catheter
compared to a permanent line which is a tunneled catheter
including certain dialysis catheters which may
include your implanted port. Finally, an umbilical
catheter is inserted through the umbilical
artery or vein in a neonate. It is only necessary to
distinguish between temporary or permanent lines when
reporting specialty care areas like oncology, dialysis
or your transplants unit. In these locations,
central lines are stratified by line type from monthly
denominator reporting because these specialty
care areas serve high– serve patients with a higher
risk and therefore more likely to use permanent lines
because they have a lower risk of infection compared
to your temporary lines. For specialty care
areas, if a permanent and temporary line are present, report the temporary
line in your denominator. If there is a BSI event, the NHSN application will
attribute the BSI event to the temporary line
and include this line in the denominator count. Other than specialty care
areas, many patients have more than one central line and
can have a combination of different types of lines. For NHSN reporting purposes,
when multiple lines are present in the same patient, report
only one central line per day. This is a list of devices that
are not considered central lines for NHSN reporting purposes. Now let’s briefly
discuss introducers. Introducers may or may not
count as a central line. Most people don’t think of an
introducer as a central line but realize that they are
considered intravascular devices depending on the
location of the tail. The protocol states
that pacing wires and other non-lumen catheters
are not considered central lines and this is true. But there are pacing wires that have a lumen specifically
designed for infusion, withdrawal of blood and
hemodynamic monitoring. If a patient has a line
that you are unsure about, just contact us at [email protected]
and let us know the line type, how it’s being used, and any
other pertinent information and we’ll be happy to provide
guidance regarding the line. So here’s a little note
on excluded organisms. Any organism not on the common
commensal list is considered a recognized pathogen
for reporting LCBIs with the exception of the
organisms listed on the slide. You may notice that all of these
excluded pathogens are enteric or gut bugs. These organisms are
eligible for use in secondary BSI determinations
but will not be reported as the sole pathogen
in a primary BSI. New in 2019 is the removal
of viruses and parasites from the LCBI definition. However, these pathogens
are also eligible for use in secondary BSI determinations. Organisms in the right
column are excluded from all NHSN organism–
from all NHSN definitions. These infections are almost
always community acquired and since they tend to have
really long incubation periods they may be incorrectly
identified. Group B strep remains excluded
as a causative organism for a CLABSI in the
first six days of life. Group B strep often causes
infections in newborns as a result of vertical
transmission or passage through the birth canal. When group B strep– when the
group B strep exclusion is met, these events are considered
LCBIs and will create a BSI RIT but are not central
line associated. We have reviewed the definitions
key to BSI surveillance. Now let’s recap denominator
device day counts and central line day counts for
making a CLABSI determination. So for central lines,
do we count days of admission or days of access? We’ve received questions on how to count denominator
device days. For denominator device
day count, you will start the first day
the central line is present on an inpatient location. If the line is inserted
during the current admission, day one is the first
day– excuse me. For denominator device counts, you will start the first day
the central line is present on an inpatient unit. If the line is inserted
during the current admission, day one is the first day
the central line is present on an inpatient unit. If the central line was
present on admission, day one is the first day
the patient is admitted to an inpatient location
regardless of access. The second count is the
central line day counts for making a CLABSI
determination. To attribute a central
line to a BSI event, you must count the
days of access. A central line becomes
an eligible central line for a CLABSI determination
once the central line has been accessed for greater than two
consecutive calendar days. Let’s look at the
next two slides to further explain
these concepts. Patient A has a central
line inserted in the ICU. Because the central
line was inserted in an inpatient location, day one will begin the
denominator device day count. Patient A will have seven
denominator device days from 3/31 through 4/6. Patient C has a central line at
the time of admission to ICU. Because patient C is
admitted to ICU on 3/31, the denominator device
day count will begin on the day of admission. On day three, the
central line was removed and replaced on day four. Because a calendar day did not
pass without a central line in place, the denominator
device day count will continue until 4/5 when the
central line is removed. On 4/6, there is
no device in place. Patient C will have six
denominator device days beginning 3/31 through 4/5. And lastly, patient E.
Patient E has a non-access port at the time of admission to ICU. The denominator device
day count will begin on the date the patient
is admitted to ICU. Assessing the port on 4/3 does
not change the denominator device day count. Patient E will have seven
denominator device days, 3/31 through 4/6. This is a snippet of the
table from the BSI protocol. The complete table is
pack– found on page 4-22. Now let’s look at
the days of access and the central line day count for making a CLABSI
determination. This is a snippet of
examples from table 4 and illustrates device
association as determined by the presence of an eligible
central line on the BSI date of event or the day before. So patient A becomes
eligible for a CLABSI on 4/4 because an access port had
been in place for some portion of greater than two consecutive
calendar days making it an eligible central line on 4/4. The port remains eligible for
a CLABSI until it is removed or the patient is discharged,
whichever comes first. Patient B becomes eligible
for a CLABSI on 4/4. Central line day
three through 4/5. An access central line
had been in place greater than two consecutive calendar
days making it an eligible central line on 4/4. Please note the central line was in place a portion
of the day on 4/4. A BSI date of event on
the day of or the day after device removal or the patient is discharged
will still be considered a device associated infection
or in this case a CLABSI. And finally, patient C. Patient
C becomes eligible for a CLABSI on 3/31 through 4/6 because
a central line had been in place greater than two
consecutive calendar days. A BSI date of event occurring
on the day of or the day after device removal or patient
discharge is considered a device associated infection
or a CLABSI. Although the central
line was removed on 4/2, the patient remains eligible
for a CLABSI event through 4/6 because a full calendar
day did not pass without a central line in place. Therefore the central
line counts continue. OK. We’ve made it through the
denominator device day counts and central line day counts for making the CLABSI
determinations. If you still have any questions
about that, I would be available after the primary BSI
session and you can come up and ask me then,
or if we have time for Q&A, whichever you prefer. Next we would discuss
changes and revisions in 2019 specifically
CLABSI exclusions. A CLABSI exclusion is provided
if a patient has an ECMO device or a ventricular assist
device in place greater than two consecutive
calendar days on the bloodstream
infection date of event and the device is still
in place on the date of event or the day before. If the patient meets
criteria for either of the above exclusions, you would
enter central line equals yes. There is an LCBI event and
a 14-day BSI RIT is created with day one being
the date of event. The ECMO and VAD data
fields are required in 2019. Please note this is a change in the reporting
instructions from 2018. And I want to put a pin here and say for all of the CLABSI exclusions that
we will discuss, you should keep in mind that the patient has
an eligible organism identified and an eligible central line. There is also a CLABSI
exclusion provided for observed or suspected patient
self injection into their vascular access. Please note that this exclusion
requires an observation or suspicion of patient
injection. Behavior such as biting,
picking at or sucking on the central line access
will not meet this exclusion. The top– the documentation
must indicate the observation or suspicion of injection
occurred during the IWP of the positive blood specimen and must be entered
concurrently. The next exclusion is
for epidermolysis bullosa which is a genetic
connective tissue skin disorder that makes the skin
extremely fragile. This disorder causes the
skin to blister and/or tear. EB patients tend
to develop wounds that are heavily colonized with
bacteria placing individuals with this condition
at an increased risk for blood stream infections. Additionally, clinicians are
unable to collect skin cultures on these patients because
they are so heavily colonized and the culturing
process is painful. And exclusion is provided
for this condition if a clinician documents this
disorder during the patient’s current admission. Munchausen syndrome
by proxy also known as factitious disorder imposed on another is a mental
illness condition in which a caregiver makes up
or causes an illness or injury in a person under his or
her care such as a child, an elderly patient or a
person with disabilities for personal attention. To meet these criteria,
a clinician must document a confirmed or suspected
diagnosis during the patient’s admission. If a patient meets criteria for
any of the above exclusions, you would answer
central line equal no into the NHSN application
or the BSI event form. Entering no in the central line
field will remove these events from the numerator and the
events are not considered central line associated. These events are also LCBIs
and a 14-day BSI RIT is created with day one being
the date of event. These exclusions are available
on the BSI event form. These fields are
optional in 2019 but will become required
in 2020. The last CLABSI exclusion
we will discuss is pus at the vascular access site. If a patient meets all elements
for this exclusion listed on the slide, you would enter
central line is equal to no in the NHSN application. The event again is
considered an LCBI and a 14-day BSI RIT is created with day one being
the date of event. This exclusion is also available
if you’re reporting using the BSI event form. Again, this field
is optional in 2019 but will become required
in 2020. Here is a list of vascular
access devices located in the pus at the vascular
site CLABSI exclusion. This is a summary of the 29– 2019 CLABSI exclusions
previously discussed. This is table 3 on page 4-13. Now I will discuss
LCBI criteria. This is the hierarchy of– for laboratory confirmed
bloodstream infections. As mentioned earlier, all BSIs
are either a primary source of infection or secondary to
another site specific infection like your urinary
tract infections, your surgical site infections, your ventilator associated
events, pneumonia or any of the Chapter 17 definitions. There are three different
LCBI criteria, LCBI 1, LCBI 2 and LCBI 3. This is a step by step
process that may help when making a BSI determination. CLABSI surveillance
will always start with a positive blood specimen, whether it’s culture
or non-culture based. If you determine you have
a POA event as in step 4, there is nothing to report. Step 5 is where you
would determine if the CLABSI definition is met. As a reminder, all
blood specimens, regardless of the
collection site or the reason for collection must be
included in CLABSI surveillance. And LCBIs identify
when a patient of any age has a
recognized bacterial or fungal pathogen
not included on the NHSN common commensal
list identified for one or more blood specimens
by culture or non-culture based
microbiologic testing and the organism identified
in the blood is related– is not related to an
infection at another site. If the BSI is secondary
to another primary source of infection, it will
not be reported to NHSN as an LCBI or as a CLABSI. The primary source may
be reported depending on your monthly reporting
plan and state mandate but the secondary BSI will not. Primary BSIs are identified by
ruling out secondary sources. A bloodstream infection
cannot be secondary to another bloodstream
infection. Therefore a primary BSI will
never have a secondary BSI attribution period. I will not discuss secondary
BSIs in this presentation, however, you must always
consider a primary source for all BSIs. So let’s switch gears and
perform a few knowledge checks. I know you’ve been sitting
for a while and taking in all of this wonderful information. This is what I was talking
about in the beginning. Let’s see if you can
make a determination about this scenario
using Poll Everywhere. If you are joining
us via webstream, please participate as well. OK, are we ready? So, some of you may be
familiar with Poll Everywhere. This is the same slide that
you saw yesterday and many of you have participated
in several of the polls on yesterday. As I reminder, once
I asked the question and list the answer choices,
cellphone users can participate by testing the message
NHSN to 22333 to join. Again, the number is 22333 and the message you
are texting is NHSN. Next you receive– you will
receive a text confirming that you have joined Cheryl
Williams’ polling session. Once you receive that
confirmation text, you can text back the letter
that corresponds to your answer. Lastly, for cellphone users
that join via text message, once you’ve joined the
polling sessions for today, you will not need to rejoin for
the remainder of my presentation or the presentations that
follow throughout the day. If you choose to participate via
web browser on your cellphone, computer or any other
mobile device, here is the websites
that you can visit. You should see the following
welcome screen in your browser. OK, so let’s begin. So we have Mr. OnEdge
who was admitted to MICU after having a heart attack. As denoted by his
name, he’s on edge. On February 4th, a central
line was placed in MICU. On February 7th, a blood culture
was collected due to fever and chills and the blood
culture was positive for Serratia marcescens which
is a recognized pathogen. No other source of
infection was identified. Is this an LCBI? Please choose the
letter that corresponds to the correct response. OK, well, we basically
we all answer that one. And so, yes, this is an LCBI. Let’s look at Mr.
OnEdge’s rationale. Mr. OnEdge had a
positive blood specimen for Serratia marcescens on 2/7. Because this is the
only element required to meet LCBI 1 criteria,
2/7 is the date of event. The 2/7 blood culture
will create a BSI IWP from 2/4 to 2/10. A BSI RIT is established
from 2/7 to 2/20. The BSI event is
central line associated because the central line was in place four calendar
days on the date of event. Let’s move on to
LCBI 2, 3 criteria. When reviewing LCBI
2 and 3 definitions, these definitions share some
similarities with the exception that the symptoms for meeting
the criteria are based on age. So LCBI 2 is for use
in any age patient and LCBI 3 provide symptoms
that are commonly present in patients less than or
equal to one year of age such as hypothermia,
apnea, and/or bradycardia. Please note, patients less
than or equal to one year of age also may meet
LCBI 1 or LCBI 2 criteria because these criteria
are for any age patient. Additionally, the organisms
identified are not related to an infection at another site and the common commensals
are drawn on separate occasions
and must match. Let’s review matching
organisms or companion cultures. When determining the sameness
of organisms, only the genus and species should be used
to make this determination. If one organism is less
definitively identified than the other, the identification
must be complementary for NHSN reporting purpose. For example, a blood culture
growing a coag negative staph and a blood culture growing
Staph epidermidis are considered a match because Staph
epidermidis is a coag negative staph. In another example, a blood
culture growing coag negative staph and a blood culture
growing staphylococcus are not considered matching because
staphylococcus can either be coag negative or coag positive. The table listed at the bottom
of the page can be found on page 4-20 of the BSI protocol
and can help answer questions about reporting different
lab results. Let’s see. All right, let’s look
at Ms. Positive Polly. On March 18th, Ms.
Positive Polly was admitted to the oncology ward and a port
was placed for chemotherapy. On March 19th, she developed a
fever of 102 degrees Fahrenheit. March 21st, blood
cultures were collected. They grew coagulase-negative
staph times 2. On March 22nd, repeat blood
cultures were collecting– growing the same organism. No other source of
infection was identified. Is this a POA or HAI
bloodstream infection? OK, this is a POA
bloodstream infection. Let’s look at Ms.
Positive Polly’s rationale. Ms. Polly had two positive
blood specimens for CNS on 3/21. The 3/21 positive blood
specimen creates a 3/18 through 3/24 infection
window period. A fever is noted on 3/19. Because the fever is the first
element identified during the IWP, 3/19 is your date of event. Note, the date of event occurs
during the POA timeframe and the patient would
have a POA BSI and a POA BSI RIT is
established from 3/19 to 4/1. Let’s look at the next scenario. On April 1st, 4-month-old Baby
Gray was admitted afebrile with no symptoms
of an infection. On April 2nd, he developed fever
and periods of bradycardia. Two blood cultures
were collected. One specimen grew micrococcus. Does this meet LCBI criteria? Few more seconds. OK. So the correct answer
is C. Baby Gray was admitted with no signs or symptoms. On hospital day 2,
he developed fever and periods of bradycardia. A single common commensal
was identified. Baby Gray does not meet
either LCBI 2 or 3 criteria. Remember, you must have at least
two matching common commensals and only a single
common commensal. Micrococcus was identified
in this case. All right. Now let’s move on to baby
girls Belle and Bella. On 5/5, baby girls Belle and
Bella were admitted to NICU after being born
one month premature. On 5/8, there was
new onset of apnea and a central line was placed. Both developed a low grade
fever of 100 degrees Fahrenheit and two sets of blood cultures
were drawn separately both growing Staphylococcus hominis. No other source of
infection was identified. What LCBI criterion is met by
baby girls Belle and Bella? OK, I hear some discussion
going on. I’ll give you a few more seconds
before we discuss this case. The correct answer is
C, LCBI 3 criterion. Yes. Let’s look at the– Let’s do this question and then
I’ll provide the explanation on the next slide. Is this a POA or HAI infection? So is this POA or HAI for
baby girls Belle and Bella? This infection is a POA. I’m sorry, this infection
should be an HAI. Yeah. You’re correct. Not a POA but an HAI. All right, let’s look at it. On 5/9, Staph hominis blood
cultures were collected times 2. You have a central line
that was inserted on 5/8. The date of event is
5/8 and your IWP is 5– and an IWP is created,
which is 5/6 through 5/12. Apnea is noted on 5/8. 5/8 again is your date of event because that is your
first element used to meet the site
specific infection. This is an HAI, HAI
event because the date of event occurred on
calendar day four. Is this event central
line associated? There’s no poll, just as this
event central line associated? No. No, it’s not. Your central line
was inserted on 5/8 and your positive blood
cultures were collected on 5/9. OK. So now let’s
move on to MBI-LCBIs. MBI-LCBIs are a subset of LCBIs. Before you can determine if
a BSI event is an MBI-LCBI, you must first fully
meet LCBI criteria. The MBI-LCBI category
enables NHSN to identify bloodstream
infections that are believed to be the result of gastrointestinal
translocation due to a patient’s weakened
immune state and alterations of the gut. They are still considered
primary BSIs because there is not an
identifiable infection at another site. However the gut is believed
to be the seeding source of the bloodstream with
colonizing organisms. MBIs are reported to NHSN but
since 2015 with the rebase line, they are removed from
the data shared with CMS for reimbursement
determinations. This is the MBI-LCBI table
which provides an overview of the MBI-LCBI criteria. This table is located
on page 4-10. MBI-LCBI 1 is a patient of an–
includes a patient of any age that meets criterion for LCBI with at least one blood
specimen identified by culture or non-culture based
microbiologic testing– testing with only
intestinal organisms from the MBI organism list. A partial list of MBI organisms
can be found on page 4-31 or you can review the
MBI organisms’ tab on the NHSN organisms list. The patient also must meet at
least one of the following. The patient is an allogeneic
hematopoietic stem cell transplant recipient within
the past year with one of the following documented
during the same hospitalization as your positive culture. Grade III or IV gastrointestinal
graft versus host disease or greater than a liter of
diarrhea in a 24-hour period with onset on or within seven
calendar days before the date the positive culture
is collected. The patient may also meet
the neutropenic element which is defined as two
separate days with values of absolute neutrophil
count or your ANC or total white blood
cell count less than 500 cells per milliliter
cubed within a seven day period which includes the date the
positive blood culture was collected which is day one,
the three calendar days before and the three calendar
days after. For an ANC or WBC value
to be eligible for use, they must occur within the
seven days that includes the day of the positive blood
specimen, the three days before and the three days after. This timeframe looks like an
IWP and sounds like an IWP but in this case it is not. For the purpose of meeting
MBI-LCBI criteria, low ANC and WBC values are indicators
or risk for infections, not symptoms of infection and
therefore not considered elements when applying this definition. This table is in the protocol
and provides guidance on how to correctly determine if an
ANC or WBC value are eligible for use in meeting
MBI-LCBI criteria. In the first example, patient
A first fully meets LCBI 1 with the positive blood culture
growing a recognized passenger. Next, we can consider
the MBI-LCBI criteria because Canada’s species is
also an intestinal organism that is on the MBI list. The patient has the qualifying
neutropenia on two separate days with WC values less
than 500 cells. In this case on day
negative one the WBCs are 320 and on day one are 400. So, the final determination
of this case is MBI-LCBI 1. Now let’s look at patient B.
Patient B fully meets LCBI 2 criteria with two positive blood
specimens growing only viridans group strep plus a
qualifying fever greater than 38 degrees Celsius. This patient is also neutropenic
on at least two separate days with ANC values less than 500. In this example, the value
for day negative 1 is 110 and day negative 2 is 120. So the final determination
in this case is MBI-LCBI 2. Please note, days two, three and
four are also eligible for use as the ANC values are
less than 500 cells. You can use a combination of ANC and WBC values provided they
occur in the seven day timeframe since these values are
considered risk factors and do not affect
the date of event. This table uses WBCs in two
of the examples and ANC values in the other but a
combination of either ANC or WBC values can be used
provided they are collected on different calendar days within the seven day
timeframe previously mentioned. This calculation is
available in the BSI chapter if your laboratory does not
provide an absolute ANC. OK, let’s try this again. Let’s move on to
Ms. Petty Patty. On June 13th, Ms. Patty
had a central line inserted on admission. On June 16 she had
an ANC level of 400 and on June 17 two blood
cultures were drawn that were positive for
Enterococcus faecalis. On June 19 the WBC levels
were 210 cells per millimeter. No other source of
infection was identified. Did the patient meet MBI-LCBI 1? So the correct answer is yes. We first need to determine
if LCBI criterion is met. Ms. Patty is admitted on 6/13 and the positive blood
cultures occur on 6/17. Because E. coli is a
recognized pathogen, LCBI 1 criterion is met on 6/17. Now we can evaluate
for MBI-LCBI 1. The organism identified, E.
coli, is an MBI organism. The risk factor present
is neutropenia. The patient has an ANC value
of 400 and a WBC value of 200, therefore MBI-LCBI
criterion is met. Please note, any combination of ANC and/or WBC
values can be used to meet neutropenic criteria
provided they are collected on separate days within
the seven-day period. That includes the date of
the positive blood specimen, the three calendar days before and the three calendar
days after. We’ve already discussed LBI 2
and 3 criterion, the differences and the symptoms
used based on age. MBI-LCBI 2 and 3 requires
only viridans group strep in Rothia species. These organisms are both common
commensals and MBI organisms. In addition to the organism
requirement, you must meet one of the following elements. The first element, the allogeneic stem
cell transplant patients with gastrointestinal
graft versus host disease or qualifying diarrhea. And the second is
immunocompromised patients as demonstrated by
qualifying neutropenia. These are the same
risk factors identified for MBI-LCBI 1 criterion. It is possible for a patient
to meet both MBI-LCBI 1 and MBI-LBCI 2 at the same time. When this occurs,
report the MBI-LCBI 1 with the recognized
pathogen first in the viridans group strep or
Rothia species as pathogen 2. This is a reporting requirement
of the NHSN application. Please note the phrase no other
organisms and keep in mind that if a single common
commensal is identified, it is considered a contaminant. When this occurs, MBI-LCBI
2 or 3 criteria is not met because the patient would not
meet LCBI 2 or 3 criteria. In addition when a
blood specimen positive for an organism not included on the NHSN MBI organisms list
is collected during the BSI RIT of an MBI-LCBI, the initial
MBI-LCBI then is edited to an LCBI and the identified
non-MBI organism is added. That was a mouthful. So just put a star
on that slide. Review later. It’s like a little
homework here. All right. First, the patient
fully meets LCBI 2 with at least two
blood specimens and matching common commensals, in this case viridans group
strep plus a fever greater than 38.1 degrees Celsius. Because we have neutropenia
on two separate days occurring within the seven-day timeframe, the patient will meet MBI-LCBI
criteria with ANC levels of less than 500 cells. Please note values
on days negative 5 and negative 6 cannot be
used because they are outside of the seven-day timeframe
that includes the day of the positive blood
culture three days before and three days after. So we have performed
knowledge checks over the LCBI and MBI-LCBI criteria, now let’s
look at the information needed when you send in a
BSI email for review. If investigating a
positive blood culture, the BSI team would like for you
to send all organisms identified in the blood cultures signs and
symptoms and associated dates if evaluating for an LCBI 2
or 3, date of the first access in an inpatient location
if the patient was admitted with the central line in place
and your MBI-LCBI risk factors if evaluating MBI-LCBI criteria. This is a new FAQ for 2019. In addition to this, if investigating the
positive blood cultures, all organisms identified in
the blood cultures are needed, signs and symptoms
associated dates if evaluating. Sorry, this is–
slide is a duplicate. All right. So let’s move on to your
CLABSI data and accuracy. The accuracy of NHSN data
is dependent on the accuracy of the surveillance
determinations data collection and entry. It is very important that
we get accurate numerators by strict adherence
to the definitions and reporting instructions. And accurate denominators by mapping your locations
appropriately, collecting device days and
patient days accurately based on the location type which may
have specific requirements. This is the BSI event
data collection form that can be found under the
data collection forms tab. As a reminder, the
fields outlined in orange are the required
CLABSI exclusions beginning in 2019. However, the fields outlined
in teal, greenish-bluish color, are the CLABSI exclusions
that are optional for 2019 but will become required
in 2020. This is just the BSI
event collection form and the NHSN application. The highlighted sections are from the BSI event
data collection form and I’m sure you’re familiar with both the event
information and detail section. What I’d like for you
to pay attention to is that middle section, which
are your risk factors and you will see the required
fields as denoted by asterisks and the conditions that were
added to the BSI form this year. Your denominator requirements
by location and device, remember if you have– if the patient has greater
than two central lines, only report one central
line day. For your specialty care
areas, if both the permanent and temporary line are present,
report the temporary line. This guidance is correct in
the patient safety manual. Patient days report
all inpatient days in all locations and your SCAs. For your patient days
and your NICU location, report the patient
days by birth weight. And this is just your birth
weights highlighted here. I will just briefly mention if your central line
denominator data is incorrect, it can impact your SIR
leading to inaccurate data. Examples of some potential
problems are counting a patient with two central lines as two
rather than one central line day or your electronic data import
is happening twice a day rather than once per day. This is your denominator
for your– denominator form for
your intensive care unit in other locations not including
your NICUs or your SCAs. This is the same information
in the NHSN application. You will want to provide a
sum of your total patient days in central line days
for the month. If you have no CLABSI events, be sure to check the no
event box under CLABSI. For all locations, remember
to report at the same time– remember to count at the
same time each day the number of patients on the unit
and the number of patients with the central line. Apologize for being
cut off at the top. But this is your denominator
form for specialty care areas and your oncology areas. Please report the
number of patients with at least one central line if a patient has
both a temporary and permanent central line. Again, this is the form
in the NHSN application for your denominator counts. Provide the sum for
your total patient days, your temporary central line days and your permanent
central line days. Check no if a CLABSI event– if there are no CLABSI
events reported for– by the type of central line. So, if there are no
CLABSI events reported, you would check no
depending on the type of central line the patient has. The central lines are stratified
by device type so you would look at the number of patients on
the unit, the number of patients with a permanent central
line, number of patients with your temporary central
line and, again, for patients with both, report the
temporary line only. And this is your
denominator reporting form for you neonatal
intensive care units. This is the same form
in the NHSN application. Provide monthly sums for
both your patient days and central line days and
check the appropriate box if there is no CLABSI
events to report in the birth weight category. Patient days and central lines in the NICU are stratified
by birth weight. So the number of patients
on the unit by birth weight, the number of central– the number of patients with a
central line by birth weight, and again your birth
weights are listed here. So, a few words on
electronic data validation. Electronic collection of
summary data is acceptable but you must collect three
months of concurrent data with both electronic and manual
and the difference must be within plus or minus 5, 5%. Once weekly denominator
collection reduces the NHSN data collection burden and is
eligible in ICUs and locate– and ward location types
but you must have 75 or more central line
days per month. For your patient days,
collect the information daily and record both the
total of weekly samples. So for example, if you collect
this information every Tuesday in your monthly total,
which is your total for every day in the month. The central line days
are collected on a– may be collected on a single
day, once a week and, again, we use the example
of every Tuesday. Remember, if you are doing
sampling, you need to fill in both your total patient
days and your central line days for the month and your
sample patient days and central line days. There is a calculation that
requires this information. So let’s recap the 2019
BSI protocol changes. Exclusion of viruses
and parasites occurred in 2019 for LCBI criterion. Your data fields for ECMO
and VAD became required and these are two of
the CLABSI exclusions. Additional data fields were
added that are optional in NHSN for a CLABSI exclusion and these
are your Epidermolysis bullosa, your Munchausen syndrome
by proxy, your patient self-injection or
IVDA, pus at the vascular site and group b strep in the
first six days of life. So in summary, we
know that surveillance and clinical definitions
may not always align. Surveillance definitions
must be adhered to strictly and consistently. CLABSIs result in
significant morbidity and mortality in US hospitals. Progress has been made
but the journey continues. According to the 2017
HAI report, nationally, among acute care hospitals,
there was about a 9% decrease between 2016 and 2017. To wrap up primary BSIs,
we have reviewed the forms, the data collection techniques and data entry requirements
for BSI events. We reviewed key definitions for
BSI and CLABSI surveillance. I’ve also provided an
overview of the 2019 protocol with key changes located through
protocol and training materials on the NHSN website
and we were able to assess our current
knowledge of the BSI protocol through knowledge checks. This year, we are
accepting comments related to the BSI module with a
patient safety component. This is a pilot and
comments can be submitted between February 14th and
April 15th of this year. This is an opportunity to
identify issues in areas for potential improvement
beginning in 2020. If you would like to submit
your comment for review, please use the information
provided in the last bullet. This is a reminder of
the American Journal of Infection Control
NHSN Case-Study Series. Resources that were used
in the presentation. And our– and do you
have any questions? I’m not sure if we have time,
but are there any questions?>>Hi there. So it doesn’t make sense to me that we can count a non-accessed
port say in the denominator but it wouldn’t count
for– in the numerator. Statistically that just
doesn’t make any sense because your denominator
should account for all of the patients eligible
for the risk, which in this case is a CLABSI.>>OK.>>I mean I’m just– Is that
just designed for ease of use because it will be tough to
count your denominator days?>>Yes.>>OK.>>So in several of the other
modules, the device is counted when the– when it is present. For CLABSI surveillance, if you
remember, it used to be counted when the central
line was accessed. And some facilities indicated
that this was difficult to determine whether the
central line was accessed–>>Yeah.>>– or whether
it wasn’t accessed. So in 2018, we made a decision to include all central
lines regardless of access in you denominator
device day count.>>All right.>>For ease of use.>>Well, thank you
because we could– you mean essentially you’re
allowing us to get in the system on patients who say come
in and they’re not– their port is never accessed but they’re adding days
to the denominator.>>Right. It will add
days to your denominator.>>OK, all right. Thank you.>>You’re welcome.>>I have a question
on the eligibility for doing the weekly
denominator collection. In the NICU setting, can
you do that and is also on those 75 days, is it 75 days for all birth weight
categories total or for each birth weight
category you mush have 75 line days?>>OK, so your question is
regarding electronic collection of– no.>>The once weekly–>>This one.
>>– denominator collection. Yes.>>So you can perform your
weekly sampling in the NICU. Whether or not it’s by the–>>Is it 75 per birth
weight category?>>Per birth weight our total. I would have to ask a
member of the BSI team to make sure that–
of that answer. OK, so they are telling me
it is not used in the NICU. You cannot use it in the NICU.>>That’s what– that’s right. OK. Thank you.>>I have a question on
the ECMO and VAD reporting. I know to actually call the BSI,
it has to have been in place on the day of or the day
before and has to have been in place greater than two days. But on the form where you– the data entry form it
just says yes or no. So if it were removed say five
days before your BSI event, is that a yes or no? There was one but it wasn’t
in that two-day period.>>That’s a no.>>OK. Thank you.>>Hello. Hi. So, my– it’s more of a
comment than a question. So in my patient population,
we’re a cancer hospital, 75% of the CLABSIs
that I reported in– we reported in 2018 occurred in
patients who had a median length of neutropenia before
the event of six days. And the reason why we couldn’t– we didn’t meet the MBI criteria
was because they were not on the list, on the MBI list. So what we saw though
is that the majority of these patients were
coag-negative staph, staph aureus, and gram
negatives such as pseudomonas, all of which have been
reported in the literature as being potential
colonizers of the GI tract. So, I would propose that we
tend to look through the lens of a general acute care
hospital, we were looking at these definitions and not
really identifying the truth, the risk that occur
in this population. I would think that the 2,200
square feet of the GI surface and to prevent from the
chemo and the radiation and the profound neutropenia
would have more affect on the– that bloodstream infection
actually the presence of a central line. So my question to you and
that we will be commenting is that what kind of data reports
or what have you would you with the CDC like to
see regarding evidence for expanding that MBI list?>>You– As you said, you
could do plan to comment and the whole thing
with comment–>>Absolutely.>>Right, period. So we would like to see any– in addition to your comment
attached in a literature or evidence-based studies that
would support the use of– that would support
MBI identification with the organisms that you, you
know, that you have indicated, that you see most often, we will
take that information back in and review, because
to me it sounds as if the MBI definition is
not met because in your case and most cases MBI
organisms were not identified.>>Right. They were– They met
everything except for the–>>For the organism, yeah.>>And we often have neutropenia
periods that last for 30 to 60 days while we wait
for our patients and graft.>>Right. OK.>>Thank you.>>Thank you.>>So LCB 2 and LCB
3, their difference. How do you differentiate
the two?>>Between LCBI 2 and LCBI 3?>>Yes.>>For LCBI 2, there are
different signs and symptoms that are required
and their signs and symptoms are available
in the BSI protocol. For LCBI 3, there is an age
limitation of less than or equal to a year of age in addition to
specific signs and symptom seen in that patient population.>>Thank you.>>I just want to remind people that we have tables
of instructions. And so the person that asked the
question about the central line, yes or no, all of that
information we can’t put– we simply can’t put
all of the instructions on the screens that, you
know, you get on the computer. So that’s why it’s
so important to look at the tables of instructions. Because if you look for central
line and central line field, it will tell you that
you only answer yes if the central line has been
in place more than two days and was present on the day
before or the day of the event. So, that is probably the
most underutilized document that we have or those documents, the tables of instructions is
really important to look at them when you’re– So
you have a question.>>Do you have a question
from those viewing via web stream?>>There’s another
question regarding when a patient has
both a permanent and a temporary central line, are we only to count
the temporary line?>>Yes. You should only
count the temporary line in your denominator reporting. And the slides that are
posted on the website and perhaps the slides you
have in front of you, the instructions
provided were incorrect, is only the temporary line that should be reporting
in your denominator.>>OK. And we have
another question. For the denominator validation, if a health system has
multiple facilities, even the same electronic
software, does each individual hospital
have to validate manual counts or can the validation for the
whole be done by manual counts at a few of the entities?>>I would say that
each facility needs to perform the validation
and for the manual and the electronic system.>>And one other question
for LCBI 2 and LCBI 3, where it says blood
specimens drawn on two separate occasions,
what does that mean? Can you not have more
than one full count today between collections?>>So the definition for that or
the guidance provided for that– and I can’t recall
the page number– is that the blood specimen
can either be collected on the same or consecutive days. So you cannot have
a calendar day between the blood collections. And what was the other– was that the only
part of the question? OK. Are there any more questions?>>I have one more. And what is a non-culture based
microbiological test method for CLABSI definition?>>Oh, you know, that’s
a huge question there. I can provide you– we can
provide you with examples but we do not have a list of non-culture-based
microbiologic testing. We do receive questions
regarding that. So some of the testing
methodologies that we see on occasion are your BCID
essays, your Fungitell, PCR, but these are just examples. NHSN does not provide a list of non-culture-based
microbiological testing methodologies.>>OK.