nhsn and public reporting · nhsn and public reporting linda r. greene, rn,mps,cic manager...

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NHSN and Public Reporting

Linda R. Greene, RN,MPS,CIC

Manager Infection Prevention

Highland Hospital

Rochester, NY

linda_ [email protected]

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Objectives

• Describe challenges and opportunities related to pay for

performance and pay for reporting

• Identify changes to NHSN definitions for 2015

• Apply definitions to case scenarios

• Interpret NHSN data and illustrate ways it can be used to drive

improvement using the current evidence

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Reported Measures

Who Gets HAIs? 1/25 on any given day in U.S.

hospitals; many are older adults

Magill SS, et al. NEJM 2014

How Big of a Problem are Healthcare

Associated Infections (HAIs) in the U.S.?

• Point Prevalence Survey;

National Healthcare Safety

Network (NHSN) N=183

hospitals, 2011

• Patients at risk = 11,282

– 452 (4.0%) with > one HAI

– Distribution by site – see pie chart

– C. difficile = 70% of GI infections

• Nationwide estimates:

– 648,000 patients with 721,800

HAIs/year

Magill SS et al. NEJM 2014;370:1198-208

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HHS Action Plan

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Challenges

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Hospital Compare

U.S. National Benchmark = 1

Central line-associated bloodstream infections (CLABSI)

State

My Hospital

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HAC Reduction

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NHSN

TAP Reports

5 Star System

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NHSN Data is Important

• Surveillance vs. Clinical Definitions

• Future move to algorithmic surveillance

• CMS validation

• Many changes in 2015 . Will become the new baseline year.

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General Changes

Infection Window Period*†

Date of Event*

Present on Admission (POA) Infections*†

Healthcare-Associated Infections(HAI)*†

Repeat Infection Timeframe (RIT)*†

Secondary BSI Attribution Period*†

Pathogen assignment*†

*Does not apply to VAE, LabID Event Surveillance

†Does not apply to SSI Surveillance

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NHSN

NHSN Course

Slides Posted

NHSN Webinar

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No Longer Used

• Gap days

• Date last element was met

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Infection Window Period


A 7 day period during which all site-specific infection

criterion must be met. It includes the date of the first

positive diagnostic test, that is an element of the site-

specific criterion, 3 calendar days before and 3 calendar

days after

For site-specific criterion that do not include a diagnostic test, the

first documented localized sign or symptom that is an element of

the infection criterion will be used

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Example


Diagnostic test examples:

Laboratory specimen collection

Imaging test

Procedure or exam

Localized sign and/or symptom examples:

Diarrhea

Site specific pain

Purulent exudate

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Date of Event

The date the first element used to meet the CDC NHSN site-specific

infection criterion occurs for the first time within the seven day infection

window period

Fever

Positive cultureDate

of Infection

2015

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Date of Event

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Present on Admission (POA) vs. Healthcare-Associated Infection

(HAI)

Present on Admission - date of event* occurs on the day of

admission or the day after admission.

The POA time period continues to include the day of admission, 2 days

before and the day after admission.

Healthcare-Associated Infection - the date of event* occurs on or

after the 3rd calendar day of admission.

POA

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Repeat Infection Timeframe (RIT)

• A 14-day timeframe during which no new infections of

the same type are reported

• The date of event is Day 1 of the 14-day Repeat

Infection Timeframe

• Additional pathogens identified are added to the event

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RIT

The RIT will apply at the level of specific type of infection with the

exception of Bloodstream Infection (BSI), Urinary Tract Infection (UTI)

and Pneumonia (PNEU) where the RIT will apply at the major type of

infection

• Patients will have no more than one BSI (e.g., LCBI1, LCBI2, MBI-LCBI1etc.)

• Patients will have no more than one UTI (e.g., SUTI, ABUTI)

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Test Your Knowledge

Mrs. X is admitted to your hospital on Oct 1st . A

urinary catheter is inserted at that time. On Oct 3rd,

she spikes a temp of 38.2. The next day, a urine

culture is sent which grows 100,00 ecoli.

Is this an HAI?

Why or why not?

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Another One

Mr. Y developed a CAUTI on 11/01/14 which grew 100,000

pseudomonas

On 11/13/14, he has a second urine culture sent which grows

100,000 proteus. How is this classified?

1. Not a new CAUTI- no further data is added to NHSN

2. New CAUTI- Different organism

3. Not a new CAUTI, but add proteus to the pathogen list of the

pre-existing infection.

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Definitions

Secondary Bloodstream Infection (BSI) Attribution Period

The period in which a positive blood culture must be collected to

be considered as a secondary bloodstream infection to a primary

site infection.

The period is 14 – 17 days in length depending upon the date of

event

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Blood Culture Ecoli

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Secondary BSI

Secondary bloodstream infections may be attributed to a primary

site infection as per the Secondary BSI Guide of the BSI event

protocol

Blood culture pathogen matches at least one organism found in

the site-specific infection culture used to meet the primary site

infection criterion

OR

The positive blood culture is an element used to meet the

primary site infection criterion

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Pathogen Assignment

Pathogen Assignment

Additional eligible pathogens identified within a Repeat Infection

Window are added to the event

Pathogens exclusions for specific infection definitions (e.g., UTI,

PNEU)* also apply to secondary bloodstream infection pathogen

assignment

Excluded pathogens must be attributed to another primary site-specific

infection as either a secondary BSI or identified as a primary BSI

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Pathogen Assignment

BSI pathogens may be assigned to more than

one infection source

Assigned as a secondary BSI pathogen to a site-specific

infection (e.g., UTI) and assigned as an additional

pathogen to a primary BSI event

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New CAUTI Definition

Definitional Changes:

The Urinary Tract Infections (UTI) definitions will no longer

include:

Symptomatic UTI (SUTI) criteria 2 and 4 due to removal of

the following elements:

• Colony counts of less than 100,000 CFU/ml

• Urinalysis results

• Urine cultures that are positive only for yeast, mold,

dimorphic fungi, or parasites

• Uropathogen List for Asymptomatic Bacteremic UTI (ABUTI)

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CAUTI

What These Changes Mean for Facilities Reporting UTIs to

NHSN in 2015

Only urine cultures with a colony count of at least 100,000

CFU/ml for at least one bacteria will be used to meet NHSN UTI

criteria.

Only bacteria will be accepted as causative organisms of UTI.

ABUTI criteria will use the same pathogen list as SUTI.

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Question

Mrs. X is admitted to your unit on 11/6/2014. She has a PICC

line in place and a urinary catheter is inserted.

On 11/10/2014 she spikes a temperature of 38.5, the physician

orders blood and urine cultures. Both the blood and urine grow

1,000 candida.

How do you classify this infection?

1. CAUTI with secondary BSI

2. Primary BSI and CAUTI

3. CLABSI only

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SSI Definition

Infection Present at Time of Surgery

Infection present at time of surgery (PATOS) will be a new field on the SSI Event form. PATOS denotes that an infection is present at the start of, or during, the index surgical procedure (in other words, it is present preoperatively).

PATOS doesn’t apply if there is a period of wellness between the time of a preoperative condition and surgery.

The infection must be noted/documented preoperatively or found intra-operatively in a pre-operative or intraoperative note.

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SSI Continued

The patient does not have to meet the NHSN definition of an SSI

at the time of the primary procedure but there must be surgeon

notation that there is evidence of infection or abscess present at

the time of surgery.

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PATOS

Only select PATOS = YES if it applies to the depth of SSI that is

being attributed to the procedure (e.g., if a patient had evidence

of an intra-abdominal infection at the time of surgery and then

later returns with an organ space SSI the PATOS field would be

selected as a YES.

If the patient returned with a superficial or deep incisional SSI

the PATOS field would be selected as a NO).

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Question

19 year old patient admitted with an acute abdomen, to OR for

XLAP with finding of an abscess due to ruptured appendix, and

an APPY is performed. Patient returns 2 weeks later and meets

criteria for an organ space IAB SSI.

How would you mark the PATOS field?

1.Yes

2. No

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Question

Patient is admitted with a ruptured diverticulum and the surgeon

notes that there are multiple abscesses in the intra abdominal

space. Patient returns 3 weeks later and meets criteria for a

superficial SSI ?

How would you mark the PATOS field?

1. Yes

2. No

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SSI

Diabetes Documented

Along with the current NHSN definition of diabetes, assignment

of the discharge ICD-9 codes in the 250 to 250.93 range will be

acceptable for use to answer YES to this diabetes field question.

Change in “Scope” Field Reporting Instruction

The reporting instruction for answering the SCOPE risk factor

field will be updated. The instruction regarding the extension of a

scope site will be removed. New instruction in the Table of

Instructions will be: Check Y if the NHSN operative procedure

was coded as a laparoscopic procedure performed using a

laparoscope/robotic assist, otherwise check N.

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MRSA/ VRE Continued

• MDRO and CDI LabID Event reporting for facility-wide inpatient

(FacWideIN) will also require location-specific surveillance for

that same organism in each emergency department(s) (pediatric

and adult) and 24-hour observation location(s).

• Facilities participating in FacWideIN LabID Event reporting will be

required to map and report outpatient LabID Events from emergency

departments and 24-hour observation locations for the same

organism and LabID Event type (i.e., All Specimens or Blood

Specimens only). This means facilities will no longer assign the

admitting inpatient location to LabID Events when specimens are

collected in the emergency department or 24-hour observation

location on the same calendar day as inpatient admission.

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VAE

Combining possible / probable VAP

Ability to enter episodes of mechanical ventilation

Pathogen reporting and secondary bloodstream attribution

specific to pneumonia 1 will not be allowed

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VAE Surveillance Definition Algorithm Summary

Patient on mechanical ventilation > 2 days

Baseline period of stability or improvement, followed by sustained period of worsening oxygenation

Ventilator-Associated Condition (VAC)

General evidence of infection/inflammation

Infection-Related Ventilator-Associated Complication (IVAC)

Positive results of microbiological testing

Possible or Probable VAP

• Respiratory status component

• Additional evidence

• Infection / inflammation component

No CXR needed!

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Case 1

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MV Day Min

PEEP

Min

FiO2

1 8 100

2 7 70

3 6 50

4 6 70

5 5 60

6 6 50

7 6 70

8 5 80

9 5 50

10 5 50

54 yr old male admitted to the ICU transferred on ventilator from the ED. Review vent settings below to see if VAE criteria are met. If so, on what day?1. No VAC2. Day 43. Day 74. Day 8

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Case 2

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54 yr old male admitted to the ICU transferred on ventilator from the ED. Would the criteria be met with these settings? If so, on what day?1. No VAC2. Day 43. Day 74. Day 8

MV

Day

Min

PEEP

Min

FiO2

1 8 100

2 7 70

3 6 50

4 6 70

5 5 50

6 6 50

7 6 70

8 5 80

9 5 50

10 5 50

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The Data

Our job is to turn data into meaningful information which can be

used by care providers to improve outcomes

Let’s look at this scenario:

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Which answer(s) best describes this data?

1. Both the CAUTI rate and the SIR are higher statistically

higher than the NHSN mean

2. The rate difference is due to chance

3. Only 14% of like ICU’s reporting to NHSN have a higher

infection rate

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Evidence Based Practices

Look at the evidence

Conduct a gap analysis

Evaluate what processes are already in place

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Recent Guidelines

Only 2 recommendations with

high level of Evidence:

1.Do not ROUTINELY use antiseptic

catheters to prevent CAUTI

((quality of evidence: I).

2. Do not treat asymptomatic

bacteriuria in catheterized

patients except before invasive

urologic procedures

(quality of evidence: I).

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Appropriate Indications for Catheter Use

Appropriate Indications

Patient has acute urinary retention or obstruction

Need for accurate measurements of urinary output in critically ill patients.

Perioperative use for selected procedures:

•urologic surgery or other surgery on contiguous structures of genitourinary

tract,

•anticipated prolonged surgery duration (removed in post-anesthesia unit),

•anticipated to receive large-volume infusions or diuretics in surgery,

•operative patients with urinary incontinence,

•need to intraoperative monitoring of urinary output.

To assist in healing of open sacral or perineal wounds in incontinent patients.

Requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar

spine)

To improve comfort for end of life care if needed.

Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

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Driving Performance

Most CAUTIs occur from day 7-10

Yeast is the primary pathogen in 30% of the CAUTIs

Most patients are transferred out of the ICU with a catheter

Which of the following actions would not be a first step?

• 1) Institute nurse driven removal protocols, automatic stop

orders ,etc.

• 2) Ensure catheters are inserted for appropriate indications

• 3) Develop a competency program to ensure all care providers

insert urinary catheters aseptically

• 4) Develop culturing guidelines

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SSIs

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Changes

2008

Wash and clean area around incision site using appropriate antiseptic agent( A- 2).

Control blood glucose level during the immediate postoperative period for patients undergoing cardiac surgery (AI).

2014

Use alcohol-containing pre-operative skin preparatory agents if no contraindication exists ( New- 1 High)

Maintain post-operative blood glucose ≤ 180 mg/dL.

Cardiothoracic surgical procedures (A-I; NEW=HIGH)

Non-cardiac procedures [Dronge Arch Surg 2006; Golden Diabetes care 1999; Olsen MA JBoneJoint Surg Am 2008] (NEW= 2 MODERATE)

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Changes

2008

Maintain normothermia (temperature higher than 36oC) immediately after colorectal surgery – previous unresolved

Impervious plastic wound protectors-not discussed

2014

Maintain normothermia(temperature > 35.5 °C) during the perioperative period.

(NEW= 1 HIGH)

Impervious plastic wound protectors in gastrointestinal and biliary tract surgery (NEW= 1 HIGH)

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Changes

2008

Maintaining oxygenation with supplemental oxygen during and after colorectal procedures (unresolved issue)

Routine screening for MRSA or routine attempts to decolonize surgical patients with an antistaphylococcal agent in the preoperative setting (unresolved issue)

2014

Maintaining oxygenation with

supplemental oxygen during and

following colorectal procedures

(NEW)

Special populations: recommended

for use in locations and/or populations

within the hospital with unacceptably

high SSI rates despite implementation

of the basic SSI prevention

strategies:

Screen for Staphylococcus aureus

and/or decolonize surgical patients

with an anti-staphylococcal agent in

the pre-operative setting

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Changes

• Check list- not discussed

• Not addressed

• Use the WHO check list (1)

• Optimize tissue oxygenation by

administering supplemental

oxygen during and immediately

following procedures requiring

mechanical ventilation

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Changes - Antibiotics

2008

• Administer prophylaxis within 1

hour before incision

• Discontinue prophylaxis within

24 hours after surgery

2014

Although guidelines suggest stopping the antimicrobial agent within 24 hours of surgery, there is no evidence that agents given after closure contribute to efficacy, and they do contribute to increased resistance

Weight dose antibiotics

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CMS Final Rule for Value Based Purchasing 2017:

Remove from measure set the following process measures as “topped-

out”:

SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients

SCIP-Inf-3: Prophylactic Antibiotic Discontinued Within 24 Hours After

Surgery End Time

SCIP-Inf-9: Urinary Catheter Removed on Postoperative Day 1 or

Postoperative Day 2

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Unresolved Issues

1. Preoperative bathing with chlorhexidine-containing products.

•Preoperative bathing with agents such as chlorhexidine has been shown to reduce bacterial colonization of the skin. Several studies have examined the utility of preoperative showers, but none has definitely proven that they decrease SSI risk. Six randomized controlled trials evaluating the use of 4% chlorhexidine gluconate were included in a Cochrane review, with no clear evidence of benefit noted. It should be noted that several of these studies had methodological limitations and were conducted several years ago. Thus, the role of preoperative bathing in SSI prevention is still uncertain.

•To gain the maximum antiseptic effect of chlorhexidine, adequate levels ofCHG must be achieved and maintained on the skin. Typically, adequate levels are achieved by allowing CHG to dry completely.

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Safety – More than a Model

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Patient

Leadership

Communication

Teamwork

Managing Behavioral

Choices

Organizational Learning

System Design

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Different Direction

• Contextual Journey

• INSIDE OUT

• Observe then define

• Observation for

understanding

• Anthropology foundation

• Solutions are uncovered,

guided by insiders, those

directly involved-creates

ownership

• Traditional Journey

• OUTSIDE IN

• Define, then observe

• Observation for compliance

• Manufacturing foundation

• Solutions are pre-defined, guided

by outsiders, those indirectly

involved-buy-in

Our New Journey

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The Bottom Line

Many changes for 2015

Moving toward clearer definitions and data that can easily be

retrieved from the medical record

Surveillance data is important to drive performance

improvement and assure the accuracy of reported data

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Difficult Job

http://youtu.be/Pk7yqlTMvp8



nhsn and public reporting · nhsn and public reporting linda r. greene, rn,mps,cic manager...

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