c. difficile infection and c. difficile lab id reporting...

C. difficile Infection and C. difficile Lab ID Reporting

in NHSN

MARY ANDRUS, BA, RN, CICInfection Preventionist Consultant

Learning Objectives• Review the structure and of

the MDRO/CDAD Module within the Patient Safety Component of NHSN

• Describe the rationale for monitoring MDRO/CDAD

• Identify the methodology, protocols and definitions used in the data collection of MDRO/CDAD

Goal of CDAD (CDI) Module

• Monitoring C. difficile infection (CDI) will help to evaluate local trends and changes in the occurrence of these pathogens and related infections

• Provide a mechanism for facilities to report and analyze CDI data

Note: The term CDI is replacing CDAD. Both terms represent thesame illness and are used interchangeably.

Introduction

• C. difficile infection has increased in prevalence in U.S. hospitals over the last 30 years

• C. difficile has important implications for patient safety

• Options for treating patients with C. difficile are often extremely limited

• C. difficile infections are associated with increased lengths of stay, costs and mortality

If you choose to monitor C. difficile, you must select at least one of these two reporting options!

•Adherence to Hand Hygiene•Adherence to gown/glove use

CDI Infection Surveillance

An HAI is a localized/systemic condition resulting from an adverse reaction to the presence of an infectious agent or its toxin.

There must be no evidence that the infection was present or incubating at the time of the hospital admission.

C. difficile infections must meet NHSN-defined criteria for gastroenteritis or gastrointestinal tract infection

JAN FEB MAR APR

MAY JUN JUL AUG

DECSEP OCT NOV

Reporting Requirements CDI Infection Surveillance

Reporting Method

For Infection Surveillance , use either:•A – Facility-wide by location•B- Selected locations in the facility

NICU locations are not included in CDI surveillance!


Forms

Reporting Infections:Facility-wide by location

+ +

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Report separately from every location in the facility

Medical

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Reporting Infections:Selected Locations Only

Report separately for one or more specific location s of a facility

Medical


Reporting Infections : Selected Locations Only


Definitions

http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf

NHSN Reportable Infections for C.difficile

• GI – GE: Gastrointestinal System Infection – Gastroenteritis

• GI – GIT: Gastrointestinal System Infection – Gastrointestinal Tract

If the patient develops both GI-GE and GI-GIT, report only GI-GIT, using the date of onset as that of GI-GE C. difficile infection.

Option #1 – CDI Infection Surveillance

GI-GE (Gastroenteritis) must meet at least one of the following criteria:1.Patient has an acute onset of diarrhea (liquid stools for more than 12 hours) with or without vomiting or fever (>38°C) and no li kely noninfectious cause (e.g., diagnostic tests, therapeutic regimen other than antimicrobial agents, acute exacerbation of a chronic condition, or psychological stress)2.Patient has at least two of the following signs or symptoms with no other recognized cause: nausea, vomiting, abdominal pain, fever (>38°C), or headache and at least one of the following:

a. an enteric pathogen is cultured from stool or rectal swabb. an enteric pathogen is detected by routine or electron microscopyc. an enteric pathogen is detected by antigen or antibody assay on blood

or fecesd. evidence of an enteric pathogen is detected by cytopathic changes in

tissue culture (toxin assay)e. diagnostic single antibody titer (IgM) or 4-fold increase in paired sera

(IgG) for pathogen

Option #2 – CDI Infection Surveillance

GI-GIT (Gastrointestinal tract) infection excluding gastroentereitis and appendicitis, must meet at least one of the following criteria:1.Patient has an abscess or other evidence of infection seen during a surgical operation or histopathologic examination2.Patient has at least 2 of the following signs or symptoms with no other recognized cause and compatible with infection of the organ or tissue involved: fever (>38°C), nausea, vomiting, abdominal pain, or tenderness and at least one of the following:

a. organisms cultured from drainage or tissue obtained during a surgical operation or endoscopy or from a surgically placed drain

b. organisms seen on Gram’s or KOH stain or multinucleated giant cells seen on microscopic examination of drainage or tissue obtained during a surgical operation or endoscopy or from a surgically placed drain

c. organisms cultured from bloodd. evidence of pathologic findings on radiographic examinatione. evidence of pathologic findings on endoscopic examination (e.g.,

Candida esophagitis or proctitis).

CDAD Complications

• Additional details if the following are identified:

• Severe CDI in patient within 30 days after CDI symptom onset and at least one of the following:– Admission to ICU for CDAD complications– Surgery for CDAD complications– Death caused by CDAD within 30 days after symptom

onset and during the hospital admission

Monthly Reporting Plan

Our Infection Prevention Team at Community Memorial Hospital, initiated an infection surveillance program for C. difficile infection in MEDICU and 3 West in June 2011.

Because they are performing surveillance in 2 areas of her facility, the reporting method they have chosen is:

B. Selected locations

The next slide shows an example of how the Monthly Reporting Plan was completed.

Monthly Reporting Plan

Completing the CDI Infection Event Form

Event Form (cont.)

Enter the Event Type

here (will always be GI)

Enter the date the first clinical symptoms of

infection or the date the first positive specimen

was collected, whichever came first.

Event Form (cont.)

Circle “Yes” if the infection occurred after

an NHSN-defined procedure, but before

discharge from the hospital

Enter “Yes” if C.difficileinfection is being

followed for infection surveillance in that

location in the Monthly Reporting Plan

Event Form (cont.)

Event Form (cont.)

Enter date patient admitted to facility

Enter the Nursing care area where the patient was assigned when the C. difficile infection was acquired. If the CDI developed in a patient within 48 hours of discharge from another inpatient location, indicate the discharging location.

Event Form (cont.)

Indicate the specific CDC-defined infection event type

Using the criteria in Chapter 17 (CDC HAI Definitions), check all signs and symptoms used to confirm the diagnosis of this infection event for this patient.

CDI Flow Diagram

Event Form (cont.)

Circle “Yes” to indicate admission to ICU for complications of C.difficile (e.g., shock that requires vasopressor therapy)

Event Form (cont.)

Circle “Yes” to indicate surgery for C. difficile complications. Surgery might include colectomy for toxic megacolon, perforation of refractory colitis, etc.

Event Form (cont.)

If there is a culture-confirmed BSI during this admission secondary to this C. difficile infection, circle “Yes”

Circle “Yes” if the patient died during this hospitalization

Circle “yes” only if the patient died within 30 days after C.difficile infection symptoms onset and during the current hospitalization

Event Form (cont.)

Optional field. Enter the date the patient was discharged from the facility. If the patient died, the date of death is entered here

Enter “Yes” if pathogen is identified If the pathogen is

C. difficile, enter it on the back under Other Organisms but do not include antibiogram

Form used to report denominator.Total patient days for the location

Form used to report denominator.Total patient days for the location

During the monitoring month the IP Team identified a patient in MEDICU with gastroenteritis due to C. difficile that had not been present when the patient was admitted to the hospital.

The next slides show how the IP completed the NHSN form.

Example, cont.

The patient was identified as meeting Criterion #1 for GI-GE because he had liquid stools for 17 hours and a temp of 100.8°F

At the end of the month, the IP Team completed the Prevention Process and Outcome Measures Monthly Monitoring form that includes denominators.

A separate form for each of the 2 units that were monitored were completed.

Because they are performing infection surveillance the denominator is patient days.

Even though they did not identify any C. difficile infections on 3 West, a denominator form for that location was also completed

CDAD Infection Incidence Rate


Allows laboratory testing data to be used without clinical evaluation of the patient, allowing for a much less labor intensive method to track C. difficile.

Definitions• Laboratory-Identified (LabID) Event: Any non-

duplicate CDI-positive lab assay.

• CDI-positive Lab Assay: Positive lab assay for C. difficile toxin A and/or B, or toxin-producing organism detected from stool culture or other lab means

• Duplicate C. difficile-positive test: CDI-positive assay from same patient within 2 weeks of previous positive assay.

Required Minimum Reporting

• All non-duplicate CDI-positive lab assays per patient per month

• At least three consecutive months in a calendar year

C. difficile testing performed routinely in lab, only on unformed (conforming to the shape of the container) stool samples

JAN FEB MAR APR

MAY JUN JUL AUG

DECSEP OCT NOV

Prior C. difficile positive in ≤ 2

weeks

Duplicate Test

Not a LabID Event

Test on unformed stool sample

Positive for C. difficile

Not C. difficile

Not a LabID Event

No

Yes

Reporting Method

For CDI LabID Event reporting, use either:•A – Facility-wide by location•B -- Selected locations in the facility •C – Facility-wide

CDI LabID Event

Reporting

Settings: 1) Inpatient locations 2) Outpatient locations –where care provided to patients post-discharge OR prior to admission

31

•No Newborn locations•No outpatient dialysis centers

Forms for LabID Data Collection

Reporting Location Options –LabID Events

Facility-wide by location: Report every location in the facility separately• Patient days• Admissions•CDAD data

Selected locationsYou choose the specific locations in your facility•Patient days•Admissions•CDAD data

Overall / Facility-wideReport all locations together•Patient days•Admissions•CDAD data

You can collect C. difficile Lab ID Event data:


+ +

+

Report separately from every location in the facility

Medical

+

CDI LabID Reporting

CDI LabID Reporting

Reporting Infections:Selected Locations Only

Report separately for one or more specific location s of a facility

Medical

CDI LabID Reporting

CDI LabID Reporting

Reporting Infections:Facility-wide

+ +

+Medical

+

CDI LabID Reporting

Report data for entire facility together.

If you would like to monitor a specific location

in addition to the entire facility, you may do so.

CDI LabID Event Form


Select “yes” if the LabID Event is being reported from an outpatient location where there are no admissions (e.g., emergency department, wound care, etc.)

If the patient was an outpatient, Date Admitted to Facility and Date Admitted to Location are not required.



If the LabID Event was reported from an

outpatient location, leave this blank

Enter the patient care area where the patient

was assigned when the LabID specimen

was collected

Note: the “Transfer Rule” does not apply to LabID Events


Note: Because of existing business rules for edit

checks in NHSN, the date of specimen collection must

be the same date or later than the admission date.


Circle “Yes” if the patient has been an inpatient and

discharged from your facility in the past 3 months


If the patient was discharged from your facility in the past 3 months, enter the most recent date of discharge.

CDI LabID Data Entry Screen

Non-editable field. Will be auto-filled by the system only, depending on whether there is prior LabID Event entered for the same organism and same patient. If there is a previous LabID Event for this organism entered in NHSN in a prior month, the system will auto-populate with “Yes.

Denominator Data (LabID)

If you are using Method A or B, complete a Denominator Record for each location

Denominator Data (LabID)

If this is a single inpatient location, enter the total

number of patient days for the month.

If this is a single inpatient location, enter the total

number of admissions for this location for the month

Denominator Collection (LabID)

Check C.difficile as the organism that will be

monitored in this location

FacWideIN DenominatorsThis number would be the total number of patient days for the

entire facility for the month minus any patient days for

NICU or Well Baby Nurseries

This number would be the total number of admissions for the

entire facility for the month minus any admissions to

NICUs or Well Baby Nurseries

Denominators – Outpatient Location

FacWideOUT Denominators

If LabID C. difficile Events are being monitored at the

FacWideOUT level, then Total Encounters minus any

encounters for Well Baby Clinics must be entered here

CDI Metrics

Note!

The following categories

and prevalence and

incidence calculations

are built into the

analysis capabilities of

NHSN.

Incidence vs. Prevalence

• Incidence Rate: measures the occurrences of new cases or events in a specific population during a given time period

• Prevalence Rate: measures the occurrence of existing (old and new) cases in a specific population during a given time period

Categories of CDI LabID Events

• Community Onset (CO): LabID Event collected as an outpatient or an inpatient ≤3 days after admission to the facility (i.e., days 1, 2, or 3)

• Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from the facility ≤ 4 weeks prior to current date of stool specimen collection

• Healthcare Facility-Onset (HO): LabID Event collected >3 days after admission to the facility (i.e., on or after day 4)

CDI Prevalence RatesAdmission Prevalence Rate

By single locationBy facility

# non-duplicate CDI LabID Events per patient per month identified ≤ 3 days after admission to the facility

# patient admissions to the facility

X 100

# non-duplicate CDI LabID Events per patient per month identified ≤ 3 days after admission to the specific location X 100

# patient admissions to the same location

Location Percent Admission Prevalence that is CO

Note: the numerator in this formula does not include Admission Prevalent LabID Events that are CO-HFCA

# Admission Prevalent LabID Events to a location that are CO

Total # Admission Prevalent LabID Events

X 100

Location Percent Admission Prevalence that is CO-HFCA

# Admission Prevalent LabID Events to a location that are CO-HFCA


X 100

Location Percent Admission Prevalence that is HO

# Admission Prevalent LabID Events to a location that are HO


X 100

Overall Patient Prevalence Rate

Number of 1st CDI LabID Events per patient per month for the location*, regardless of time spent in that location*

Number of patient admissions to the location*

* or facility

Outpatient Reporting

X 100

# all non-duplicate CDI LabID Events per patient for the location

# of patient encounters for the location

# all non-duplicate CDI LabID Events per patient for the facility

X 100# of patient encounters for the location

By specific location : Facility-wide (FacWideOUT)

CDI Incidence Rates

Location CDI Incidence Rate

# of Incident CDI LabID Events per month identified >3 days after admission to the location

# of patient days for the location

X 10,000

Facility CDI Healthcare Facility-Onset Incidence Rate

# of all Incident HO CDI LabID Events per month in the facility

# of patient days for the facility

X 10,000

Note: this calculation is only accurate for Overall Facility-Wide Inpatient reporting

Facility CDI Combined Incidence Rate

# of all Incident HO and CO-HCFA CDI LabID Events per month in the facility

Number of patient days for the facility

X 10,000

Note: this calculation is only accurate for Overall Facility-Wide Inpatient reporting

Metrics Summary – CDI LabID Events

Question

• I don’t have a strong statistics background and I’m not sure I have time to separate out the Healthcare Onset (HO) from the Community Onset (CO) MDROs. What should I do?

No problem. The NHSN analysis tool automatically c alculates therates based on the information you provide using th e reporting plan, event, and denominator information.

No problem. The NHSN analysis tool automatically c alculates therates based on the information you provide using th e reporting plan, event, and denominator information.


•Adherence to Hand Hygiene•Adherence to gown/glove use

c. difficile infection and c. difficile lab id reporting...

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