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IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013

IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013 Applying NHSN Protocol Definitions. Carole Van Antwerpen , RN, BSN, CIC. Objectives:

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IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013

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  1. IPRO HAI LAN Meeting New York City, November 6, 2013 Schenectady NY, November 7, 2013 Applying NHSN Protocol Definitions Carole Van Antwerpen, RN, BSN, CIC

  2. Objectives: • Use of case studies to improve and/or validate competency in applying 2013 NHSN surveillance protocol criteria for: • Select Surgical Procedure SSI’s • ICU associated CAUTI’s • ICU associated CLABSI’s • Inpatient Facility-Wide CDI Lab ID Events • Utilization of surveillance definitions (not clinical), which are designed to minimize case finding subjectivity

  3. Applying the NHSN Surgical Site Infection (SSI) Protocol Definitions Surgical Site Infection (SSI) Case Studies Adapted from CDC-NHSN Training Slides http://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html

  4. Navigating NHSN SSI Reporting Rules • Resources • NHSN Website “Favorite” www.cdc.gov/nhsn • 2013 Reporting Protocols: • HAI Definitions (Chapter 17) • SSI Criterion (Chapter 9 and April /July 2013 erratums) • Table 1: Operative Procedure Categories • Table 3: Procedure Categories (30/90day surveillance) • Table 4: Specific Organ space Sites • Table 5: Principle Operative PriorityProcedure List • Use 2012 NHSN SSI criteria protocols for 2012 procedures • NHSN email address (nhsn@cdc.gov)

  5. Depth of SSI: used for both primary and secondary incisions (no changes) 2012 1 yr surveillance period for deep and organ space SSI for all procedures with non-human implant Primary incision closure excluded all procedures where a drain or other material was extruding from the incision. Skin incision completely closed Priority list abdominal procedures- small bowel, rectal then colon 2013 Surveillance period 30 day for all, plus 90 day for deep and organ space SSI for just 14 procedures (table 3) Primary Incision closure includes procedures where a drain or other material was extruding from the incision. Gaps between skin incision closure included as an NHSN procedure (4/13 erratum) Priority list abdominal procedures- colon above small bowel and rectal Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG.; CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp E pidemiol 1992;13(10):606-8.

  6. Surveillance Determination Trumps Clinical Determination

  7. SSI Case Study 1 • Patient is admitted to the hospital on 4/12 for elective surgery and active MRSA screening test is positive. • On the same day, patient undergoes total abdominal hysterectomy (HYST). • Postoperative course is unremarkable; patient discharged on 4/16. • On 4/29, patient is readmitted with complaints of acute incisional pain since day before. Surgeon opened the wound into the fascial level and sent drainage specimen for culture and sensitivities. • On 5/1, culture results are positive for MRSA

  8. SSI Case Study 1 Is this an HAI? 1. Yes 2. No 3. Don’t know 0 0 / 100 Cross-tab label

  9. SSI Case Study 1 What infection type should be reported? • SSI-SIP • SSI-SIS • SSI-DIP • SSI-DIS • SSI-IAB 0 Cross-tab label 7 / 100

  10. SSI Case Study 1 Reported as occurring: • A= on admission • P= Post Discharge • RF= Readmission to this facility • RO= Readmission “other” facility 0 Cross-tab label 7 / 100

  11. SSI Case Study 1 – Answer • Deep Incisional SSI - Criterion b • Infection occurs within 30 or 90 days after the NHSN operative • (4/12-4/29) procedure according to the list in Table 3 and • involves deep soft tissues of the incision (e.g., fascial and muscle • layers) and • patient has at least one of the following: • a. purulent drainage from the deep incision • b. a deep incision that spontaneously dehisces or is deliberately opened • by a surgeon and is culture-positive or not cultured • and • patient has at least one of the following signs or symptoms: fever • (>38°C); localized pain or tenderness. A culture-negative finding does • not meet this criterion. • c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during invasive procedure, or by • histopathologic examination or imaging test. • d. diagnosis of a deep incisional SSI by a surgeon or attending physician

  12. SSI Case Study 1 - Answer If so, what is the date of event? 4/29, the date the last element used to meet the infection criterion occurred (i.e., date of deliberate wound opening and positive drainage specimen obtained) Reported as: RF= Readmission to this facility

  13. SSI Case Study 2 • Patient admitted on 9/10 and underwent a hemi-colectomy. • Wound class = 4 and incision primarily closed. • 9/13: Temp up to 38.7°C, abdominal pain. Ultrasonography shows abscess along the abdominal wall. • 9/14: Radiology fluoroscopy percutaneous I&D of the abdominal wall abscess. Abscess specimen collected for culture. Antibiotics begun. • 9/18: Discharged from hospital on oral antibiotics. Abscess culture positive for E.coli.

  14. SSI Case Study 2 • SSI-SIP • SSI-DIP • SSI-IAB • SSI-GIT What type of SSI does this patient have? 0 Cross-tab label 7 / 100

  15. SSI Case Study 2 – Answer • Infection occurs within 30 or 90 days after the NHSN operative procedure • (9/10-9/14)according to the list in Table 3 and • involves any part of the body, excluding the skin incision, fascia, or muscle • layers, that is opened or manipulated during the operative procedure and • patient has at least one of the following: • a. purulent drainage from a drain that is placed into the organ/space • b. organisms isolated from an aseptically-obtained culture of fluid or • tissue in the organ/space • c. an abscess or other evidence of infection involving the organ/space • that is found on direct examination, during invasive procedure, or • by histopathologic examination or imaging test • d. diagnosis of an organ/space SSI by a surgeon or attending • physician • and • meets at least one criterion of a specific organ/space infection site listed in Table 4

  16. SSI Case 2 Answer (continued) • IAB Criterion 2: • Patient has abscess or other evidence of intraabdominal infection seen during an invasive procedure histopathologic exam • Rationale: • 2 different criteria need to be met for Organ/Space SSI • – SSI organ/space criteria AND • – Those of the specific site of the organ/space operated on

  17. SSI Case Study 2 – Answer (continued) • Why not GIT as the specific site of SSI? • – The abscess is in the abdominal wall • – GIT focuses on organs of the GI tract • Esophagus • Stomach • Small, Large bowel and Rectum • Excludes gastroenteritis and appendicitis • – Therefore, IAB is the appropriate choice site of SSI in this case

  18. SSI Case Study 2 (Continued) Let’s change the scenario and say that at the time of the I & D, it was discovered that the patient had suffered an anastomotic leak from which the abscess developed. Does this change your determination of an SSI-IAB? • Yes • No • Don’t know 0 Cross-tab label 7 / 100

  19. SSI Case Study 2- Answer •  Let’s change the scenario and say that at the time of the I & D, it was discovered that the patient had suffered an anastomotic leak from which the abscess developed. • Does this change your determination of an SSI -IAB? • No Although an anastomotic leak can be a complication of surgery, the fact remains that this patient meets the criterion for an SSI. If the surgery had not been performed there would not have been an anastomotic leak.

  20. SSI Case Study 3 On 5/15 a 45-year-old female undergoes an abdominal hysterectomy (HYST) and colectomy (COLO) performed through the same incision. If both of these procedures are in your Monthly Reporting Plan in May The colectomy is performed as the result of a ruptured diverticulum. The operative note states “ cloudy peritoneal fluid aspirated from the abdomen and sent for culture”. The ASA score is 2 and the operative wound class is recorded as clean contaminated (2). The surgical time (incision to incision close) is 3.10 hrs . 1. Which procedure(s) do you enter into NHSN? 2. How do you record the surgical time? 3. What about the Wound Class?

  21. SSI Case Study 3 • Colon only • Hysterectomy only • Both colon and hysterectomy • Not sure Which surgical procedure is entered in NHSN? 0 Cross-tab label 7 / 100

  22. SSI Case Study 3 What about the assigned intraoperative wound class 2? • Enter in NHSN as 2 • Enter in NHSN as WC 3 or 4 • Discuss WC assignment with the Surgeon and/or OR staff • Answers 2 and 3 • Not sure 0 Cross-tab label 7 / 100

  23. SSI Case Study 3 How do you record the surgical time for each procedure? • Divide in half incision to incision close time • Total incision to incision close time • Time identified for each procedure • Not sure 0 Cross-tab label 5 / 100

  24. SSI Case Study 3- Answer • How do you record the surgical time for each procedure? • 1. Divide in half incision to incision close time • Total incision to incision close time • Time identified for each procedure. • Not Sure 3.10 hrs The surgical time (incision to incision close) is 3.10 hrs .

  25. SSI Case Study 3 • 5/15 Intraoperative cultures reported as no growth • 5/19: Patient spikes temp to 38°C, has abdominal pain and emesis. Ultrasound shows fluid collection in abdominal cavity. Fluid specimen for culture is obtained by needle aspiration. • 5/20: Culture positive for E. faecium, manyneutrophils seen • Is this an HAI? • Yes • No • Not sure 0 Cross-tab label 5 / 100

  26. SSI Case Study 3 (continued) What type of an SSI? • SSI-Deep Incisional Primary • SSI-Deep Incisional Secondary • SSI Organ/Space, specific site IAB • This is an IAB but there is no SSI infection 0 Cross-tab label 5 / 100

  27. SSI Case Study 3 • HYST • COLO • Both HYST and COLO • Not sure To which procedure is the SSI attributed? 0 Cross-tab label 5 / 100

  28. SSI Case Study 3-Answer • Rationale for procedure SSI attribution • HYST • COLO • Both HYST and COLO If a procedure from more than one NHSN operative procedure category was done through a single incision, attempt to determine the procedure that is thought to be associated with the infection. If it is not clear (as is often the case when the infection is a superficial incisional SSI),or if the infection site being reported Is not an SSI, use the NHSN Principal Operative Procedure Selection Lists (Table 5) to select which operative procedure to report.

  29. SSI Case Study 4 • 1/22: Patient had a total laparoscopic abdominal hysterectomy. Discharged 1/24 • 2/1: Abdominal pain with purulent drainage in 2 of 3 trocar sites; Temp 38.4°C • 2/3: Surgeon opened wounds in the ER and noted purulent material in the fascial layer; specimens to lab for culture; Urine culture sent; antibiotics begun • 2/5: Wound cultures positive for Pseudomonas aeruginosa • Urine culture >105 P. aerugensa, E. coli and CNS

  30. SSI Case Study 4 cont. • Is this an SSI? • ‒ Yes • ‒ No • What Type • ‒ SIP • ‒ SIS • ‒ DIP • ‒ DIS • Identified: • ‒ (A)Admission • ‒ (P)Post Discharge • ‒ (RO) Readmit other. • Met one of the following criteria: •  Infection occurs within 30 or 90 days after the NHSN operative (1/22-2/3) according to the list in Table 3. and •  involves deep soft tissues of the • incision (e.g., fascial and muscle • layers) of the incision and • patient has at least one of the following: •  a. purulent drainage from the deep • incision •  b. a deep incision spontaneously • dehisces… •  c. And abscess or other evidence of • infection is found… •  d. diagnosis by surgeon or physician Event Date: 2/3

  31. SSI Case Study 4 How many SSIs should be reported? • One • Two • Three • Four 0 Cross-tab label 5 / 100

  32. SSI Case Study 4 -Answer • How many SSIs should be reported? • 1. One Rationale Following laparoscopic surgeries, if more than one of the incisions should become infected, only report as a single SSI. If one is superficial incisional and one is deep incisional, report only as a deep incisional SSI. What about the urine culture. UTI? ‒ NO (>3 pathogens)

  33. Applying the NHSN Central Line Associated Blood Stream Infection (CLABSI) Definitions CLABSI Case Studies Adapted from CDC-NHSN Training Slides† http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html †

  34. Navigating NHSN CLABSI Reporting Rules • Basic Resources • NHSN Website “Favorite” www.cdc.gov/nhsn • Reporting Protocols: • HAI Definitions (Chapter 17) • CLABSI Criterion (Chapter 4) • Appendix 1. (Jan. 2013, pp.14-17) • April/July 2013 erratum’s • NHSN email address (nhsn@cdc.gov)

  35. Surveillance Determination Trumps Clinical Determination

  36. Ms. A. CLABSI Case Study 1 • April 1: Ms. A is transferred to your facility with pancreatic cancer, ICU admission and a PICC which is first accessed on Day 1. • April 7: Blood culture collected on April 5th is growing Providencia stuartii. No other organisms isolated. Patient started on antibiotics. • Additional laboratory values as follows: • Apr 1 Apr 2 Apr 3 Apr 4 Apr 5 Apr 6 Apr 7 • WBC 900 800 600 400 600 700 800 • ANC --- --- --- --- 400 --- 600 • Does patient meet criteria for an HAI? • What is the Event Date?

  37. Ms. A. CLABSI Case Study 1 • Yes, Event date 4/7 • Yes, Event date 4/5 • No • Not sure Does patient meet criteria for an HAI? 0 Cross-tab label 5 / 100

  38. Ms. A. CLABSI Case Study 1 What specific type of HAI does Ms. A have? • LCBI 1 • LCBI 2 • MBI-LCBI 1 • MBI-LCBI 2 0 Cross-tab label 5 / 100

  39. Ms. A. CLABSI Case Study 1-Answer • What specific type of HAI does Ms. A have? • LCBI 1 • LCBI 2 • MBI-LCBI 1 • MBI-LCBI 2 Yes. all elements of a CDC/NHSN site specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1).

  40. Ms. A. : Laboratory Values- Answer (continued) Adm. Date Blood collection BC Report Apr 1 Apr 2 Apr 3 Apr 4 Apr 5 Apr 6 Apr 7 WBC 900 800 600 400 600 700 800 ANC --- --- --- --- 400 --- 600 Patient meets neutropenic definition: Two values of ANC or WBC < 500 on or within 3 calendar days before positive blood culture collection. + Eligible Pathogen (Enterobacteriaceae) + No other pathogen isolated Meets MBI-LCBI 1 Criteria 2

  41. Ms. A. CLABSI Case Study 1 Is the CLABSI attributed to your facility or the transferring facility? • Your facility since the device was accessed there • The transferring facility where the line was placed • Not sure 0 Cross-tab label 5 / 100

  42. Ms. A. CLABSI Case Study 1-Answer • Is the CLABSI attributed to your facility or the transferring facility? • Your facility since the device was accessed there. • If a patient is admitted with a pre-existing central line, the line should be included in the central line day count starting with the first day that the line is accessed and BSIs with date of event on or after Day 3 are attributed to the admitting facility

  43. Mr. D. CLABSI Case Study 2 • May 15: 79 year old male, admitted with gastric cancer. Central line placed day of admission for total parenteral nutrition. • May 16: Partial gastrectomy performed. • May 21: Patient progressing well until fever spike of 101.3. Blood cultures sent. • May 22: Increasing abdominal pain. CT Scan of abdomen shows small fluid collection posterior to stomach. Fluid collection fully drained by ultrasound guided needle aspiration and fluid sent for culture. Blood cultures repeated

  44. Mr. D. CLABSI Case Study 2 (continued) • May 23: Blood cultures from May 21: 1 of 2 positive for Staphylococcus epidermidis. Abdominal fluid growin gram positive cocci. Antibiotics begun. • May 24: Abdominal culture of 4/22: Enterobacter cloacae. Blood cultures from May 22: 2 of 2 positive for coagulase-negative staphylococcus • Does the patient meet criteria for a CLABSI?

  45. Mr. D. CLABSI Case Study 2 Does this patient meet the criteria for a CLABSI? • Yes, HAI, CLABSI with S.epidermidis • No, HAI, CLABSI • No, but HAI abdominal infection with secondary bacteremia • Not sure 0 Cross-tab label 5 / 100

  46. Mr. D. CLABSI Case Study 2 - Answer • Does this patient meet criteria for a CLABSI? • No, but HAI abdominal infection with secondary bacteremia. • CLABSI Module Appendix 1: 4-14 (January 2013) • 2. Blood and a site-specific specimen cultured but the organisms do not match: • if the site-specific culture is an element used to meet the infection site criterion (in this case it is, IAB cr. 1) and • the blood isolate is also an element used to meet another criterion at the same infection site (in this case IAB cr 3c),then • the BSI is considered secondary to that site-specific infection. This is an SSI- IAB with both E. cloacae and CNS. Element (BC) time frame not >1 day gap.

  47. Ms. E. CLABSI Case Study 3 8/14: A 10 year old female presents to the ED diabetic coma and with anemia. She has a subclavian catheter inserted in the ED. The next day (8/15) in the Pediatric ICU, she has a midline catheter inserted and receives blood transfusions. 8/17: She develops fever of 39°C and shaking chills. Two sets of blood cultures sent. 8/19: Blood cultures positive for Pseudomonas aeruginosa. Neither insertion site shows inflammation and there is no other documented infection meeting NHSN criteria.

  48. Ms. E. CLABSI Case Study 3 • No • Yes, ICU associated, P. aeruginosa • Yes, but not ICU associated • Not sure Is there an LCBI? 0 Cross-tab label 5 / 100

  49. Ms. E. CLABSI Case Study 3 Which LCBI criterion apply? • LCBI criterion 1 – recognized pathogen cultured from 1 or more blood cultures • LCBI criterion 2 – with fever, chills and 2 or more skin commensal positive blood cultures • Not sure 0 Cross-tab label 5 / 100

  50. Ms. E. CLABSI Case Study 3 What unit should be indicated for the location of device insertion field? • The ED • The ICU • Neither location • Not sure 0 Cross-tab label 5 / 100

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