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Stop CAUTI: C6 Onboarding Webinar #2

Stop CAUTI: C6 Onboarding Webinar #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,

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Stop CAUTI: C6 Onboarding Webinar #2

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  1. Stop CAUTI: C6 Onboarding Webinar #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, American Hospital Association-Health Research & Educational Trust

  2. Presentation Link Slides for today’s presentation can be found at: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/on-boarding-calls/

  3. Outline • Key terms • Background • NHSN overview • Collaborative outcome metrics • SUTI and ABUTI definitions • Case studies

  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 urinary tract infection (CA-ABUTI=catheter-associated ABUTI) • NHSN – National Healthcare Safety Network

  5. Why CAUTI? • Increased morbidity, mortality (attributable mortality = 2.3%), hospital cost, and length of stay • 15% to 25% of hospitalized patients may receive short-term indwelling urinary catheters • CAUTI is the second most common site of HAI • 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.

  6. Business Case for CAUTI Prevention: Reservoirs of Resistance http://www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/resistance.html Last accessed 5/10/12

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

  8. 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

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

  10. 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 protocol updates for 2013.

  11. Comparison of Definition Types

  12. Cohort 6: What do we need to collect? • Outcome and Process data will be collected • Data are collected per the Cohort 6 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/CAUTI_Manuals_and_Toolkits/CAUTI+Cohort+6+Calendar+20121018.pdf https://s3.amazonaws.com/CAUTI_Manuals_and_Toolkits/CAUTI_C6_Data_Submission_Schedule.ppt

  13. 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

  14. 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)

  15. Cohort 6: When and Where Do We Enter? 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.

  16. 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 Apr’13 data – complete entry by 5/31/13. 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 Apr’13 data – complete entry by 5/31/13.

  17. NHSN Training http://www.cdc.gov/nhsn/training.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.

  18. 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.

  19. CAUTI Surveillance Criteria Use June 2013 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 HAI: An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were first present on or after the 3rd calendar day of admission to the facility (day of hospital admission is day 1). For an HAI, an element of the infection criterion may be present during the first 2 calendar days of admission, as long as it is also present on or after calendar day 3. 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.

  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 chart, 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 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 when all CDC/NHSN UTI elements were first present. UTIs occurring on the day of catheter discontinuation or the following calendar day are considered CAUTIs if the catheter had been in place already for >2 calendar days. 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.

  22. 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

  23. 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.

  24. Important Notes for Step 1 • Transfer rule for CAUTI: If all elements of CAUTI were present within 2 calendar days of transfer from one inpatient location to another in the same facility (i.e., on the day of transfer or the next day), the CAUTI is attributed to the transferring location. Likewise, if all elements of a CAUTI were present within 2 calendar days of transfer from one inpatient facility to another, the CAUTI is attributed to the transferring facility. 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.

  25. 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).

  26. 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.

  27. 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

  28. 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

  29. 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

  30. 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).

  31. Assigning to a Unit Assign the CAUTI to the location where the patient was located on the date of event. Exception: The Transfer Rule If all elements of a CAUTI were present within 2 calendar days of transfer from one inpatient location to another in the same facility (i.e., on the day of transfer or the next day), the CAUTI is attributed to the transferring location. Likewise, if all elements of a CAUTI were present within 2 calendar days of transfer from one inpatient facility to another, the infection is attributed to the transferring facility. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting. Example: A patient with a Foley which has been in place > 2 days is transferred from SICU to the step-down unit on Friday [1/04/12]. Saturday [01/05/12] afternoon, fever of 38.5 C is observed, UC is obtained which finds >105K. pneumoniae CFU/ml. CAUTI identified and assigned to the SICU.

  32. Special Considerations • If the patient has a UTI POA, then has a change in the uropathogenand symptoms which strongly suggest the acquisition of a new infection, this should be considered as an HAI. • A positive urine culture with no matching blood culture is NOT considered an infection, even if an MD diagnoses a UTI.

  33. 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.

  34. 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

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

  36. Frequently Asked Questions + urine cx + urine cx 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 elements. Ex. 1. Fever on 1/1/13 with positive urine culture collected on 1/3/13 = meets criteria. Ex. 2. Fever on 1/1/13 with positive urine culture collected on 1/4/13 = does not meet criteria.

  37. Frequently Asked Questions Q: If a patient has a positive U/A on admission are subsequent UTIs considered present on admission? A: Unless all elements of a UTI criterion are met within the 2 days before admission (if healthcare documentation) and/or the first 2 days of admission (admission day = day 1) the UTI is considered healthcare associated.

  38. 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.

  39. Case Study # 1 Mrs. J, a 62-yo female was transferred to unit 4 East from CCU four days ago, after admission for a MI. Her Foley was removed at midnight on the day of her transfer to unit 4 East. Today, on 4 East, she spiked a temp to 100.6F (38.1°C). A UA and UC were sent. UA showed 3 WBCs from an unspun sample. The UC came back growing 102 CFU/ml of E. coli.

  40. 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 microbial growth for culture requirements for UTI. Likewise, the catheter was not in place in the 2 days prior to the criteria being met.

  41. Case Study # 2 Frank, 86, is a stroke patient in your MICU. He has had a Foley in place since admission. On hospital day 11, he c/o of pain just above his pubic area upon palpation. A UA showed >10 WBCs/mm3 of unspun urine and UC grew 10,000 CFU/ml Pseudomonas aeruginosa.

  42. Is this a catheter-associated SUTI? • Yes • No Yes, this patient meets SUTI criterion 2a: suprapubic tenderness, U/A positive for sufficient WBCs and positive UC with sufficient organisms.Foley was in place > 2 days before the UTI criteria were met, therefore the infection is catheter-associated.

  43. Case Study # 3 9/1: 68-year-old female admitted to 6E from OR, status post left KPRO. Foley placed in the OR is draining pink urine. PACU nurse reports difficulty with Foley placement. Bulb suction to left knee via stab wound draining small amount bloody drainage. IV in left forearm, site without redness and dressing dry. Patient controlled analgesia via pump. 9/2: Drain removed. Patient up to bathroom with help of physical therapist. Foley removed. IV continues. Afebrile. Complains of burning on urination after Foley discontinued.

  44. Case Study # 3, continued… 9/3: Patient to physical therapy. Suprapubic pain upon palpation. Temp 37.8°C. Urine collected and sent for culture and U/A; + for 10+ WBCs by HPF of unspun urine, + leukocyte esterase. Empiric antibiotics begun. 9/4: Urine culture with >100,000 CFU/ml S. epidermidis.

  45. Does this patient have a health care-associated UTI? A. Yes, patient has a SUTI 1a attributable to 6E. Foley removed in last 2 days: Urgency, (frequency, suprapubic pain); sufficient number organisms in UC. 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.

  46. Does this patient have a CAUTI? A. No. Patient’s SUTI 1a is not catheter-associated because the catheter was not in place for >2 days before the UTI criteria were fully met. No, patient’s SUTI 1a is not catheter-associated by NHSN criteria. Yes, patient’s SUTI 1a is catheter-associated.

  47. Case Study # 4 84 year old patient is hospitalized with GI bleed. Day 3: Patient’s indwelling catheter has been in place since admission and no signs or symptoms of infection are present. Day 9: Patient becomes unresponsive, is intubated and CBC shows WBC of 15,000. Temp 38.0°C. Patient is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes – urine >105 CFU/ml.

  48. Is this a CAUTI? If so, what type? B. Yes, CA-ABUTI. Urinary catheter in place > 2 days when criteria met. No symptoms (Tmax not > 38°C); matching uropathogen* in blood and urine culture (≥ 105 CFU/ml). *(S. pyogenes is beta-hemolytic Strep spp.) No, because the blood seeded the urine and therefore there is no UTI. Yes, CA-ABUTI. Yes, CAUTI Criterion 1a with secondary BSI.

  49. What if the organism in both cultures had been Micrococcus? B. There would not be an ABUTI. There would be an ABUTI. There would not be an ABUTI.

  50. Case Study # 5 9/1: 73 y.o. patient in neurosurgical ICU. Admitted 7 days ago following cerebrovascular accident. Ventilated, subclavian catheter and Foley catheter in place since admission. Patient reacts only to painful stimuli. 9/2: WBCs slightly elevated, at 12,000/mm3, temp 37.4°C, urine cloudy. Lungs clear to auscultation.

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