c. difficile infection and c. difficile lab id reporting...
TRANSCRIPT
7/16/2011
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C. difficile Infection and
C. difficile Lab ID Reporting
in NHSN
MARY ANDRUS, BA, RN, CIC
Infection Preventionist Consultant
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 the
same illness and are used interchangeably.
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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
CDAD Module
CDI Infection Surveillance
CDI LabID Event
ReportingCDI
Prevention Process
Measures
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
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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!
CDI Infection Surveillance
Forms
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Reporting Infections:
Facility-wide by location
+ +
+
Report separately from every location in the facility
Medical
+
CDI Infection Surveillance
Reporting Infections:
Facility-wide by locationCDI Infection Surveillance
Reporting Infections:
Selected Locations Only
Report separately for one or more specific locations of a facility
Medical
CDI Infection Surveillance
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Reporting Infections:
Selected Locations OnlyCDI Infection Surveillance
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.
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Option #1 – CDI Infection
SurveillanceGI-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 likely 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 swab
b. an enteric pathogen is detected by routine or electron microscopy
c. an enteric pathogen is detected by antigen or antibody assay on blood
or feces
d. 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
SurveillanceGI-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 examination
2. 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 blood
d. evidence of pathologic findings on radiographic examination
e. 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
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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 has 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
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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.difficile
infection is being
followed for infection
surveillance in that
location in the Monthly
Reporting Plan
Event Form (cont.)
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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.
Event Form (cont.)
Circle “Yes” to
indicate admission to
ICU for complications
of C.difficile (e.g.,
shock that requires
vasopressor therapy
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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
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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.
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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
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CDAD Infection Incidence Rate
CDAD Module
CDI Infection Surveillance
CDI LabID Event
ReportingCDI
Prevention Process
Measures
If you choose to
monitor C. difficile,
you must select at
least one of these two
reporting options!
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CDI LabID Event Reporting
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
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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
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
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Reporting Location Options –
LabID Events
Facility-wide by location:
Report every location in the facility separately
• Patient days
• Admissions
•CDAD data
Selected locations
You choose the specific
locations in your facility
•Patient days
•Admissions
•CDAD data
Overall / Facility-wide
Report all locations
together
•Patient days
•Admissions
•CDAD data
You can collect C. difficile Lab ID Event data:
Reporting Infections:
Facility-wide by location
+ +
+
Report separately from every location in the facility
Medical
+
CDI LabID Reporting
CDI LabID Reporting
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Reporting Infections:
Selected Locations Only
Report separately for one or more specific locations of a facility
Medical
CDI LabID Reporting
CDI LabID Reporting
Reporting Infections:
Facility-wide
+ +
+
Medical
+
CDI LabID Reporting
Report data for entire facility together.
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If you would like to monitor
a specific location in
addition to the entire
facility, you may do so.
CDI LabID Event Form
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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.
CDI LabID Event Form
CDI LabID Event Form
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
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CDI LabID Event Form
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.
CDI LabID Event Form
Circle “Yes” if the patient
has been an inpatient and
discharged from your facility
in the past 3 months
CDI LabID Event Form
If the patient was discharged from your facility in the past 3
months, enter the most recent date of discharge.
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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
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Denominator Collection (LabID)
Check C.difficile as the
organism that will be
monitored in this location
FacWideIN Denominators
This 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
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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
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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 locationX 100
# patient admissions
to the same location
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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
Total # Admission
Prevalent
LabID Events
X 100
Location Percent Admission
Prevalence that is HO
# Admission Prevalent
LabID Events to a
location that are HO
Total # Admission
Prevalent
LabID Events
X 100
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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
facilityX 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
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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
CDI Prevalence
Rates
Admission
Prevalence
Outpatient Prevalence
Location %
Admission Prevalence
CO
Location %
Admission Prevalence CO-HCFA
Location %
Admission Prevalence
HO
Overall Patient
Prevalence
CDI Incidence
Rates
Location Incidence
Facility HO
Combined Incidence HO and
CO-HCFA
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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 calculates the
rates based on the information you provide using the reporting
plan, event, and denominator information.
CDAD Module
CDI Infection Surveillance
CDI LabID Event
ReportingCDI
Prevention Process
Measures
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