On the CUSP: Stop CAUTI Cohort 8 Onboarding Webinar Series

1. On the CUSP: Stop CAUTICohort 8 Onboarding Webinar Series Welcome to Cohort 8! Today’s Topic: Outcome Data: Application of NHSN CAUTI Criteria Access slides, video recording, and transcript of today’s webinar on the national project website: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/on-boarding-calls/

2. Outcome Data: Application of NHSN CAUTI Criteria Kathy Allen-Bridson, RN, BSN, MScPH, CIC Nurse Consultant Div. of Healthcare Quality and Promotion Centers for Disease Control Tina L. Adams, RN Clinical Content Development Lead Health Research & Educational Trust American Hospital Association

3. Learning Objectives • Learn key terms and definitions used for the program • Project background • Overview of CDC’s NHSN • Learn what type of data is collected • Outcome data • Process data (optional-strongly encouraged)

4. Key Terms • HAI – health care-associated infection • POA- Present on admission • CAUTI – catheter-associated urinary tract infection • SUTI – symptomatic urinary tract infection (CA-SUTI=catheter-associated SUTI) • ABUTI – asymptomatic bacteremic UTI (CA-ABUTI=catheter-associated ABUTI) • NHSN – National Healthcare Safety Network

5. Polling Question #1 Are you the person responsible for determining if a patient’s case meets the definition criteria for a symptomatic CAUTI? Answer choices: Yes Sometimes No, it is done by the Infection Preventionist

6. Why CAUTI? • Increased morbidity, mortality (attributable mortality = 2.3%), hospital cost, and length of stay • 12 to 16% of adult hospitalized patients may receive short-term indwelling urinary catheters • CAUTI is the second most common site of HAI • Infection is the most important adverse outcome of urinary catheter use • 17% to 69% of CAUTI may be preventable with recommended infection prevention measures • Up to 380,000 infections and 9,000 deaths related to CAUTI per year could be prevented Gould CV, et al. Guideline for prevention of CAUTIs, 2009 Magill S, et al. Prevalence of HAIs inacute care hospitals in Jacksonville, FL. ICHE. March 2012, Vol. 33, No.3. Lo, E, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infection in Acute Care Hospitals: 2014 SHEA Update.

7. Where are we now? • 2011 NHSN CAUTI rate on adult floors: • 0.2-4.8 / 1000 cathdays • 2011 NHSN CAUTI rate on adult ICUs: • 1.2-4.5 / 1000 cathdays Lo, E, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infection in Acute Care Hospitals: 2014 SHEA Update.

8. CMS Incentives: Pay for ReportingCMS 2012 IPPS Final Rule. Released August 18, 2011, Federal Register 76 (no.160)

9. The Joint Commission NPSG.07.06.01: Implement evidence-based practices to prevent CAUTI (2012=Planning year; By January 2013=full implementation) http://www.jointcommission.org/assets/1/6/NPSGs_CAUTI-VAP_HAP_20101119.pdf

10. HAI Surveillance http://www.cdc.gov/nhsn/

11. NHSN Background • NHSN has a standardized set of criteria and definitions. • Consistency in application of criteria by Infection Preventionists (IPs) is vital. • NHSN CAUTI data collection tool will assist in data collection at point of care. • Today’s presentation will include NHSN CAUTI surveillance and protocols for 2014.

12. Comparison of Definition Types Surveillance definitions… (aka “analytical epidemiology”) Establish uniform criteria to report a disease, ensure usefulness in aggregating and analyzing population-based data affecting policy change and public health actions. These types of definitions should not be used as the sole criteria for establishing clinical diagnoses or for determining the standard of care necessary for a particular patient Surveillance case definitions and clinical diagnoses. Paediatric Child Health 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805969/?log$=activity Clinical definitions… (aka “clinical epidemiology) Are specific to a patient and can manifest progressively during an illness.The use of additional clinical, epidemiological, and lab data may enable a provider to diagnose a disease even when the formal surveillance definition may not be met. Failure to meet the surveillance criteria of the formal case definition should never impede or override clinical judgment during the diagnosis, management or treatment of patients.

13. Cohort 8: What Data Do We Collect? • Outcome data is required • Process data is optional but strongly encouraged • Data are collected per the Cohort 8 specific schedule • Today’s presentation will focus on Outcome (CAUTI Rate & Device Utilization Ratio) data • For purposes of this collaborative, only Catheter-associated Symptomatic Urinary Tract Infection (CA-SUTI) will be tracked. (CMS and NHSN reporting requires CA-SUTI and CA-ABUTI) For a detailed data collection calendar, visit the On the CUSP Website: https://s3.amazonaws.com/Toolkits_and_Resources/CAUTI+Cohort+8+Data+Schedule_V2.ppt https://s3.amazonaws.com/Toolkits_and_Resources/CAUTI+Cohort+8+Data+Calendar_20140206.pdf

14. What You Enter Depends on Where You Enter • Via MHA Care Counts, enter • CA-SUTI only • Via NHSN, enter both • CA-SUTI and • CA-ABUTI

15. Specific Data to Collect For the entire month (not just M-F) each enrolled unit must collect: • Total # of patient days for unit/month - denominator • Total # of indwelling urinary catheter days for unit/month - denominator • Total # of NHSN-defined Symptomatic CAUTIs (CA-SUTIs) (and if reporting through NHSN, Asymptomatic Bacteremic CAUTIs [ABUTIs]) for that month - numerator Outcome Metrics: CAUTI Rate and device utilization ratio (DUR- catheter prevalence in the unit[s] under surveillance)

16. Cohort 8: When and Where Do We Enter Data? When: Enter monthly for 5 months and then 1 month per quarter thereafter (first 3 months are considered baseline) Where: • Manual data entry into Care Counts, or, • Manual entry or electronic transfer of data from infection control software into NHSN. Hospitals need to join their state group and accept the confer rights template.

17. Submission Date Expectations… If submitting into NHSN: • Complete entry of all CAUTIs + denominators (patient and urinary catheter days) by the end of the month following the one under surveillance. E.g. for April 2014 data – complete entry by 5/31/14 If submitting directly into MHA Care Counts: • Submit aggregate data (numerator – CA-SUTIs), denominators (pt. days and urinary cath. days) by the end of the month following the one under surveillance. E.g. for April 2014 data – complete entry by 5/31/14

18. NHSN Training http://www.cdc.gov/nhsn/Training/patient-safety-component/index.html NHSN Training is required prior to collecting and entering data into NHSN. If you are responsible for collecting and submitting data to NHSN and have not yet gone through the formal NHSN training, you may access this training at the above website.

19. CAUTI Surveillance Methods • Concurrent, lab-based surveillance • Use retrospective model only when absolutely necessary • Non-IPs can screen cultures, but trained IP must make final call • Non-IPs can collect denominatordata, but IP needs to review • Pt. and cath days should be collected at the same time of day eachday, including weekends and holidays. • Need to ensure device days do not exceed patient days • It is not required to monitor for CAUTIs after the patient is discharged from the facility. However, should a CAUTI meet criteria on the day of discharge or the next day, it must be reported. No additional indwelling catheter days are reported in this situation.

20. CAUTI Surveillance Criteria POA: If all of the elements of an infection definition are present during the two calendar days before the day of admission, the first day of admission (day 1) and/or the day after admission (day 2) and are documented in the medical record, the infection would be considered POA. Infections that are POA should not be reported as HAIs. Acceptable documentation does not include self-reported symptoms by the patient (e.g., patient reporting having a fever prior to arrival to the hospital). Instead, symptoms must be documented in the chart by a healthcare professional during the POA time frame (e.g., nursing home documents fever prior to arrival to the hospital). Physician diagnosis can be accepted as evidence of an infection that is POA only when physician diagnosis is an element of the specific infection definition. For example, the admission history could indicate that the physician suspects a UTI. The patient was documented to have a fever in the nursing home the day before admission to the hospital, and upon admission to the hospital (day 1) a urine sample was collected and cultured yielding >100,000 cfu/ml of a pathogen. This infection would be considered a POA because the required elements of the infection definition (for symptomatic urinary tract infection [SUTI]) were first present during the two calendar days before admission, the day of admission, or the day after admission NOTE: For POA, the temperature value does not need to be known to establish the presence of a fever. NOTE: Physician diagnosis of a UTI does not contribute to satisfying POA definition since physician diagnosis is not an element used to meet SUTI criteria. NOTE: This should not be applied to SSI, VAE, or LabID Events.

21. CAUTI Surveillance Criteria HAI: An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were not present during the POA time period, but were all present on or after the 3rd calendar day of admission to the facility (day of hospital admission is day 1).  All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between any 2 elements. • Use January 2014 definitions/criteria which will be posted at: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf and http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

22. CAUTI Criteria CAUTI-A Urinary Tract Infection (UTI) meeting the HAI definition is considered a CAUTI if the indwelling urinary catheter was in place for >2 calendar days on the date of event and the indwelling urinary catheter was in place on the date of event or the next day. Day of device placement (or admission with catheter) is considered day 1. If an indwelling urinary catheter was in place for >2 calendar days and then removed, the UTI criteria must be fully met on the day of discontinuation or the next day.

23. Removal and Reinsertion If the patient is without the device for at least 1 full calendar day (NOT to be read as 24 hours), then the device day count will start anew. If instead, a device is reinserted before a full calendar day has passed, the device day count will continue. • See article at this link for example: http://www.cdc.gov/nhsn/PDFs/Newsletters/March-2014.pdf

24. Indwelling Urinary Catheter (aka, “Foley” catheter) Drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system • Does NOT include: • Intermittent (straight) cath. • External (condom) cath. • Suprapubic cath. (surgically placed) However, if pt. has both a suprapubic cath and a Foley, INCLUDE in surveillance for CAUTI. Gould CV, et al. Guideline for Prevention of CAUTIs, 2009. Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html

25. Steps for Identifying Cases of CA-SUTI • Start with review of + urine cultures (UCs) – e.g. daily report from your facility’s micro lab • Pull out + UCs from the unit(s) under surveillance Important: the unit on the lab result is location at the time of specimen collection – may not reflect recent transfers to or from the unit(s) under surveillance (In some facilities, once pt. is discharged, lab may assign location of specimen to all one location for the patient. Know your lab’s practices and review accordingly to capture needed specimens.) • Cultures taken on day of admission or next day should be assessed for evidence of infection on admission. Cultures must be assessed with the Transfer Rule in mind.

26. Important Notes for Step 1 • Transfer rule for CAUTI: If the date of event of a CAUTI is on the day of transfer or discharge or the next day, the CAUTI is attributed to the transferring/discharging location. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting. • Example: Ms. Jones is transferred from CCU to 8A Cardiac Stepdown on 5/12/12 w/Foley. On 5/13, she develops suprapubic pain and urine culture collected grows E. coli. Her CAUTI should be assigned to CCU.

27. Important Notes for Step 1-continued • Verify with your facility’s information technology personnel that reporting rules applied to the Laboratory Information System do not preclude your receipt of certain positive cultures. I.E: some custom facility-specific reporting rules or data mining systems remove results where colony counts are < 105. (Impact – removes possible cases of CAUTI from detection during review, e.g. criterion 2a).

28. Step 2 for Identifying Cases of CA-SUTI • Review criteria for SUTI and ABUTI based on presence or discontinuation of Foley catheter, CFU/ml of urine culture and pertinent blood cultures matching the urine culture.

29. CA-SUTI with Indwelling Catheter http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf Note: If fever is present in Signs & Symptoms, continue down flow chart – fever is a nonspecific symptom; do not try to distinguish other possible causes

30. CA-SUTI with catheter removed in prior 2 days… http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf Note: If fever is present in Signs & Symptoms, continue down flow chart – fever is a nonspecific symptom; do not try to distinguish other possible causes

31. CA-ABUTI with or without catheter http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf ABUTI not counted for Collaborative but must be reported for NHSN and CMS purposes

32. Determining Date of Event Date of Event = the date when the last element used to meet the CAUTI criterion occurred (cannot be earlier than Day 3 of catheter use).

33. Assigning to a Unit Assign the CAUTI to the location where the patient was located on the date of event. Exception: The Transfer Rule

34. Special Considerations • Serial Infections? If the patient has a previous UTI (POA or HAI) which resolves and then has a return of symptoms (with or without pathogen change) this should be considered the acquisition of a new infection, and an HAI. • See http://www.cdc.gov/nhsn/PDFs/faqs/FAQs-V-6_CAUTI.pdf • Asymptomatic bacteriuria? A positive urine culture with no matching blood culture is NOT considered an infection, even if an MD diagnoses a UTI.

35. Denominator Data • Make sure CAUTI is included in your monthly NHSN reporting plan for the unit(s) included in this collaborative. • Engage personnel in unit(s) identified in your surveillance plan to collect catheter days and patient days at the same time each day of the month.

36. Automated Device Denominator Collection STOP! Have you validated accuracy of urinary catheter days collated automatically if this is available via your facility’s electronic medical record (EMR)? Urinary catheter days from EMR need to be within 5% of those identified from manual collation method, e.g. monthly device log. Minimum 3 month validation required by NHSN. There are successful examples of use of EMR for device days: • Burns AC, et al. Accuracy of a urinary catheter surveillance protocol. AJIC 2011 (in press) • Choudhuri JA, et al. An Electronic Catheter-Associated Urinary Tract Infection Surveillance Tool. ICHE 2011;32:757-62. • Wright MO, et al. The electronic medical record as a tool for infection surveillance: successful automation of device-days. AJIC 2009; 37(5):364-70

37. Calculating CA-SUTI Rates Data elements required to calculate Collaborative outcomes: • Numerator: # of CA-SUTIs/ month • Denominator: # of indwelling catheter days/month Equation to calculate: CAUTI Rate = # of CA-SUTIs/month X 1,000 # Catheter Days/month

38. Frequently Asked Questions Q: What is the time period for associating symptoms or U/A to a positive urine culture? A: All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between any two adjacent elements. Ex. 1. Catheterized patient :Fever on 1/1/13 with positive urine culture ≥ 100,000 E. coli collected on 1/3/13 = meets criteria. Ex. 2. Catheterized patient Fever on 1/1/13 with positive urine culture ≥ 100,000 E. coli collected on 1/4/13 = does not meet criteria.

39. Frequently Asked Questions Q: If a patient has a positive U/A on admission are subsequent UTIs considered present on admission? A: Patient must meet the POA definition AND there to be evidence of continuing infection at the time of the second potential UTI to avoid identification of second UTI. See article on page 7 of March 2014 NHSN Newlsetter: “Present on Admission (POA)??? Make Sure!! @ http://www.cdc.gov/nhsn/PDFs/Newsletters/March-2014.pdf Then review FAQ document for serial infection guidance (link provided on slide #33)

40. Frequently Asked Questions Q: What if a patient is not able to sense or verbalize symptoms? A: • Some sedated patients may be able to communicate pain non-verbally. • Ensure that adequate assessment is being performed. This may necessitate education of staff. • Always apply the definitions as written. If patient does not meet the surveillance definition do not report a UTI.

41. Frequently Asked Questions http://www.cdc.gov/nhsn/acute-care-hospital/CAUTI/index.html

42. Case Study # 1 April 1: Mrs. J, a 62-yo female admitted one week ago following MI is now transferred to unit 4 East from CCU. Her Foley, which had been in place the entire hospitalization, was removed at 11 p.m. before transfer. April 3: She spikes a temp to 100.6F (38.1°C). A UA and UC are sent. UA shows 7 WBCs from an unspun sample. The UC result is 102 CFU/ml of E. coli.

43. Does this case meet the criteria for a catheter-associated SUTI? • Yes • No • Does not meet CA-SUTI criteria but is a HAI UTI. B. No, the patient does not meet the minimum # colony forming units in urine culture for UTI. (Note: if UTI criteria had been met on April 3rd , the UTI would not have been catheter-associated because the date of infection (event) was not on the day of catheter removal nor the day after.)

44. Case Study # 2 September 1: Frank, 86, is a stroke patient in your MICU. He has had a Foley in place since admission. September 12: Frank c/o of tenderness upon palpation, just above his pubic area. A UA shows 7 WBCs/mm3 of unspun urine and UC results are 10,000 CFU/ml Pseudomonas aeruginosa.

45. Is this a catheter-associated SUTI? • Yes • No A. Yes, this patient meets SUTI criterion 2a: The infection is not POA, there is suprapubic tenderness, U/A positive for sufficient WBCs in an unspun specimen, and positive UC with sufficient organisms (≥ 1,000 cfu/ml).Foley was in place > 2 days on the date the UTI criteria were met, therefore the infection is catheter-associated.

46. Case Study # 3 • September 14: 68-year-old female admitted to 6E from OR, status post left KPRO. Foley placed in the OR. PACU nurse reports difficulty with Foley placement. • September 16: Foley removed. IV continues. Afebrile. Complains of burning on urination after Foley discontinued. • September 17: Patient to physical therapy. Burning on urination. Temp 37.8°C. Urine collected and sent for culture and U/A; + for >5 WBCs by HPF of spun urine, + leukocyte esterase. Empiric antibiotics begun. • September 18: Urine culture result >100,000 CFU/ml S. saprophyticus.

47. Does this patient have a health care-associated UTI? • No, patient’s UTI was present on admission since the patient had dysuria on Day 2. • No, patient does not have a UTI. • Yes, patient has a SUTI 1a attributable to 6E. C. Yes, patient has a SUTI 1a attributable to 6E. Foley removed in last 2 days: dysuria; >100,000 CFU/ml in urine culture.

48. Does this patient have a CAUTI? • No, patient’s SUTI 1a is not catheter-associated by NHSN criteria. • Yes, patient’s SUTI 1a is catheter-associated. A. Yes, patient’s SUTI 1a is catheter-associated because the catheter was in place for >2 days and though catheter was removed, the date of the UTI (i.e. date of last element used to meet UTI criteria) was the day after Foley removal.

49. Case Study # 4 January 10: 84-year-old patient is hospitalized with GI bleed. January 12: Patient’s indwelling catheter has been in place since admission and no signs or symptoms of infection are present. January 18: Patient becomes unresponsive, is intubated and CBC shows WBC of 15,000.  Foley still in place. Temp 38.0°C. Patient is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes – urine >105 CFU/ml.

50. Is this a CAUTI? If so, what type? • No, because the blood seeded the urine and therefore there is no UTI. • Yes, CA-ABUTI. • Yes, CAUTI Criterion 1a with secondary BSI. B. Yes, CA-ABUTI. Urinary catheter in place > 2 days when criteria met. No symptoms (Tmax not GREATER THAN 38.0°C); matching uropathogen* in blood and urine culture (≥ 105 CFU/ml). *(S. pyogenes is beta-hemolytic Strep spp.)