Cohort 3Stop CAUTI Collaborative Measurement:

Outcome Data

Application of NHSN CAUTI Definitions & Surveillance for CAUTI – Deep Dive into the

mechanics of surveillanceRussell Olmsted, MPH, CIC – Director, Infection Prevention & Control Services, SJMHS, Ann Arbor, MI

Shelby Lassiter, RN, BSN, CPHQ, CIC - Performance Improvement Specialist, NC Center for Hospital Quality and Patient Safety, Cary, NC

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Why CAUTI? According to Rodney…”these just don’t get any respect!”

• Increased morbidity, mortality (attributable mortality = 2.3%), hospital cost, and length of stay.

• 15% - 25% of hospitalized patients may receive short-term indwelling urinary catheters.

• CAUTI is the most common site of HAI• 17% to 69% of CAUTI may be preventable with

recommended infection prevention measures– Up to 380,000 infections and 9000 deaths related to

CAUTI per year could be prevented • Gould CV, et al. Guideline for prevention of CAUTIs, 2009

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Building the Business Case for Prevention of CAUTIs: Reservoirs of Resistance

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• NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) - Planning year; 2012 / full implementation; 2013

Getting Paid for Reporting: CMS Incentives – Current & Coming Attractions for 2012

CMS 2012 IPPS final rule released; August 18 2011 Federal Register 76 (no. 160)

HAI Event Facility Type Reporting Start Date

CLABSIAcute Care Hospitals

Adult, Peds, and Neonatal ICUsJanuary 2011

CAUTIAcute Care Hospitals

Adult and Pediatric ICUsJanuary 2012

SSIAcute Care Hospitals

Colon and abdominal hysterectomyJanuary 2012

CLABSI Long Term Care Hospitals * October 2012

CAUTI Long Term Care Hospitals * October 2012

CAUTI Inpatient Rehabilitation Facilities October 2012

* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN

Surveillance of HAIs

Patient SafetyHealthcare Personnel

SafetyBiovigilance*Research &

Development

What is the National Healthcare Safety Network (NHSN)?

• Voluntary, secure, web-based database• Implemented by the CDC in 2006• Integrates patient and healthcare personnel

safety surveillance systems• Managed by the Division of Healthcare Quality

Promotion (DHQP) at CDC• Expanded in 2008 to include most types of

healthcare settings in addition to acute care. http://www.cdc.gov/nhsn/

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State-specific NHSN Patient Safety Component, 26 States and DC

CO

2007 2008 2009 2010 20112006 2012

SCNY TNOK VA

PAVT WACT DE

MDMACA

NJ WVILORNH NV TX

ALDC AR ME

HI NC

Background on NHSN

• NHSN HAI site criteria are intended for population-based, epidemiologic surveillance – not for clinical care of an individual patient

• NHSN criteria have been validated and are reproducible. • Consistency in application of criteria by infection preventionists

for HAI sites is vital.• NHSN CAUTI data collection tool will assist in data collection at

point of care.• For purposes of this collaborative, only Symptomatic Catheter-

associated Urinary Tract Infection (SUTI) will be tracked.

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Comparison of Surveillance vs. Clinical Case Definitions

Surveillance definitions establish uniform criteria to be used to report a disease to better ensure usefulness in aggregating and analyzing population-based data affecting policy change and public health actions. These types of definitions should not be used as the sole criteria for establishing clinical diagnoses or for determining the standard of care necessary for a particular patient. (aka “analytical epidemiology”)

Clinical definitions are specific to a patient and can manifest progressively during an illness. The use of additional clinical, epidemiological, and lab data may enable a provider to diagnose a disease even when the formal surveillance definition may not be met. Failure to meet the surveillance criteria of the formal case definition should never impede or override clinical judgment during the diagnosis, management or treatment of patients. (aka, “clinical epidemiology”)

10Surveillance case definitions and clinical diagnoses. Paediatric Child Health 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805969/?log$=activity

On the CUSP: Stop CAUTI Data

• Both Outcome and Process data are collected• Data is collected according to a cohort-specific

schedule• Today’s presentation will focus on Outcome

(CAUTI Rate & Device Utilization Ratio) data

For a detailed data collection calendar, visit the On the CUSP Website: http://www.onthecuspstophai.org/wp-content/uploads/2011/04/CAUTI-Data-Collection-for-Cohort-3.pdf

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Cohort 3:Surveillance for CAUTI What Do We Need 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 Symptomatic CAUTIs (SUTIs) for that month; NHSN -

numerator

Outcome Metrics: CAUTI Rate; device utilization ratio (DUR) - prevalence of use of indwelling urinary catheters in the unit(s) under surveillance

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Definition: 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)

Gould CV, et al. Guidelinefor Prevention of CAUTIs, 2009. Available at:http://www.cdc.gov/hicpac/cauti/001_cauti.html

Cohort 3: Outcome Data When & Where do we enter?

When:• Collect monthly for 5 months and quarterly thereafter (first

3 months are considered baseline)

Where:• Manual data entry into Care Counts • Automatic data transfer from NHSN

– (note: must convey rights in NHSN to your state collaborative leads for this option)

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Outcome Data

Expectations: – 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 Nov. 2011 data – complete entry by 12/31/2011.

– MHA Care counts• Submit aggregate data (numerator (CAUTIs),

denominators (pt. Days and urinary cath. days) by the end of the month following the one under surveillance

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NHSN Training Resources

http://www.cdc.gov/nhsn/training.html

If you have not already gone through available training with the CDC resources, it is strongly

recommended prior to collecting outcome data for this collaborative.

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Surveillance Methods

• Concurrent, lab-based surveillance• Use retrospective model only when absolutely necessary• Non-IPs can screen cultures but trained IP should make final call• Non-IPs can collect denominator data but IP needs to review

– Patient days and catheter days should be collected at the same time daily

– Need to ensure device days do not exceed patient days• It is not required to monitor for CAUTI infections after the

patient is discharged from the facility, however, if discovered, they should be reported. No additional indwelling catheter days are reported.

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Important Notes

• NHSN has definitions for other types of UTIs e.g. as asymptomatic bacteremic UTI [ABUTI] but this IS NOT included in this collaborative.

• Reporting to CMS also is limited to symptomatic CAUTIs.

• ABUTI typically is infrequent event but has been documented by facilities reporting data to NHSN.

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SUTI: The Numerator

• Symptomatic urinary tract infection (SUTI) associated with use of an indwelling urinary catheter

• Plus (for hospitals using NHSN)

• Asymptomatic Bacteremic UTI (ABUTI)

CAUTISurveillanceCriteria DecisionFlow Chart; SUTI with urinary cath.

If fever is present in Signs & Symptoms continue down flow chart – nonspecific symptom and do not try to distinguish other possible causes

CAUTI SurveillanceCriteria DecisionFlow Chart; SUTI without urinary catheter

If fever is present in Signs & Symptoms continue down flow chart – nonspecific symptom and do not try to distinguish other possible causes

+ Urine Culture of>105 CFU/mL withno more than 2 spp

ABUTISurveillanceCriteria DecisionFlowChart;+/- urinary catheter

Steps For Identifying Cases of SUTI [CAUTI]

1) Start with review/sort of final, positive urine cultures – e.g. daily report of all from your facility’s microbiology lab

Data Traffic Tip:• Pull out positive urine cultures 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

• Can remove cultures taken on day of admission or other units not included in this project do not need to be reviewed.

Automated Laboratory Information System (LIS) Caveat

Verify with your facility’s information technologypersonnel that reporting rules applied to the LISdo not preclude your receipt of certain positivecultures;

Example: some custom facility-specific reportingrules 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

Automated Device Denominator Collection

Have you validated accuracy of urinary catheterDays collated automatically if this is available viaYour facility’s electronic medical record (EMR)?

Rule of thumb: urinary catheter days from EMR Need to be within 5% of those identified from Manual collation method, e.g. monthly device log.

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

Steps For Identifying Cases of SUTI [CAUTI]

2) For positive culture, review patient’s medical record; Did patient have urinary catheter at time of specimen collection or during 48 hours prior to specimen collection?

Yes – continue review No – stop; no need to continue review

3) Does this patient have at least one of the following signs/symptoms with no other recognized cause ?:

fever >380C (1004F), or suprapubic tenderness, or costovertebral angle pain* or tenderness

AND

4) Urine culture of ≥105 CFU/ml [< 2 different species]? 5) If yes ; this is a SUTI; NHSN criterion 1a – enter into NHSN UTI form or your HAI

data collection system

* area of the back overlying the kidney producing pain in people with an infection around the kidney

Steps For Identifying Cases of ABUTI

Patient with or without an indwelling urinary catheter has no signs or symptoms of UTI:

– i.e., for any age patient, NO fever (>38°C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness,

and • a positive urine culture of >105 CFU/ml with no more than 2 species of

uropathogen microorganisms* and • a positive blood culture with at least 1 matching uropathogen

microorganism to the urine culture– Uropathogens: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-

hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae,and Corynebacterium (urease positive).

SUTI Data Collection Form, NHSN

Collecting Denominator Data

Make sure CAUTI is included in your monthly reporting plan for the unit(s) included in this OntheCUSP collaborative

Engage personnel in unit(s) identified in your surveillance plan to collect urinary catheterDays; same time, each day of the month

1.

2.

Calculation of Catheter-associated SUTI (CAUTI) Rates

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Data elements required to calculate:Numerator: # of Catheter-associated symptomatic Urinary Tract Infections (SUTI) / month

Denominator: # of indwelling urinary catheter days per month

CAUTI Rate = # of SUTIs in unit in month of surv. X 1000 # Catheter Days in unit in month of surv.

CAUTI Surveillance Tips

CAUTI-Catheter-associated urinary tract infection which occurs in a patient who had an indwelling urethral catheter in place within 48 hours prior to specimen collection. There is no minimum period of time that the catheter must be in place for the UTI to be considered catheter-associated.

HAI rule: there must be no evidence that the infection was present or incubating at the time of admission to the care setting

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CAUTI Surveillance Tips

Transfer rule –if the CAUTI develops within 48 hours of transfer from an inpatient location, indicate the transferring location as the location of the CAUTI. Example: A patient with a Foley is transferred from SICU to the step-down unit on Friday [11/04/11]. Saturday [11/05/11] afternoon, fever of 38.5 C is observed, urine culture is obtained which finds >105 K. pneumoniae cfu/ml. CAUTI identified; the location should be listed as the SICU.

Note: There is no requirement to monitor for CAUTI after discharge. However, if discovered, it should be reported. No additional catheter days are recorded.

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Special Considerations for CAUTI Surveillance

• Infections associated with complications or extensions of infections already present on admission (POA) are NOT considered healthcare-associated unless associated with a previous admission.

• If the patient has a UTI POA, then has a change in the uropathogen or symptoms strongly suggest the acquisition of a new infection, this should be considered as an HAI.

• Colonization of the urine (asymptomatic bacteriuria) is NOT considered an infection, even if an MD diagnoses a UTI.

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Assigning to a Unit

Assign the CAUTI to the location where the patient was located on the date of onset of the SUTI event.

Exception: The Transfer Rule If a CAUTI develops within 48 hours of transfer

from one inpatient location to another in the same facility, the infection is attributed to the transferring location.

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Determination of Infection Date

Date of infection = the date when the first clinical evidence of the HAI infection appeared or the date the specimen used to make or confirm the diagnosis was collected, whichever comes first.

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Catheter-associated SUTI CriteriaSUTI Criterion #1a,

Patient had an indwelling urinary catheter (UC) removed within the 48 hours prior to specimen collection or onset of signs and symptomsAnd

At least one of the following signs/symptoms with no other recognized cause: fever >380C urgency frequency dysuria suprapubic tenderness costovertebral angle pain or tenderness

AndA positive urine culture of ≥105 CFUs/ml with ≤ 2 species of microorganisms.

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Catheter-associated SUTI Criteria

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SUTI Criterion #2aPt had an indwelling urinary catheter at the time of specimen collection or onset of signs or symptomsAndat least 1 of the following signs/symptoms w/no other recognized cause:fever >38°C, suprapubic tenderness, or costovertebral angle pain/tendernessAnd + urinalysis demonstrated by at least 1 of the following findings:

a. positive dipstick for leukocyte esterase and/or nitriteb. pyuria (urine specimen with >10 white blood cells [WBC]/mm3 of

unspun urine or >3 WBC/high power field of spun urine)c. microorganisms seen on Gram stain of unspun urine

Anda + urine culture of >103 and <105 CFU/ml with ≤ 2 species of microorganisms

Catheter-associated SUTI Criteria

SUTI Criterion #2a, continuedPt had indwelling urinary catheter removed w/in the 48 hours prior to specimen collection or onset of signs or symptomsAndat least 1 of the following signs/symptoms w/no other recognized cause:fever >38°C, suprapubic tenderness, or costovertebral angle pain/ tendernessAnda + urinalysis demonstrated by at least 1 of the following findings:

a. + dipstick for leukocyte esterase and/or nitriteb. pyuria (urine specimen with >10 white blood cells [WBC]/mm3 of unspun

urine or > 3 WBC/high power field of unspun urine)c. microorganisms seen on Gram stain of unspun urine

And+ urine culture of >103 and <105 CFU/ml with ≤ 2 species of microorganisms.

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Application of SUTI Criteria, Case #1

Mrs. J, a 62-yo female was transferred from CCU 4 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 unit 4 East, she spiked a temp to 100.6 F (38.1 C). A UA and UC were sent. UA showed 5 WBCs from an unspun sample. The UC came back growing 102 CFU/ml of E. coli. Does this case meet the criteria for a catheter-associated SUTI?

* Participant response requested

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Application of SUTI Criteria, Case #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 examination. A UA showed >10 WBCs/mm3 of unspun urine and UC grew 10,000 CFU/ml Pseudomonas aeruginosa.

Is this a catheter-related SUTI? Why or why not?

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Urine Specimen Collection

• Urinary catheter tips SHOULD NOT be cultured and are not acceptable for a diagnosis of a UTI.

• Urine cultures must be obtained using appropriate technique, such as clean catch urine or aseptic catheterization.

• Specimens from indwelling catheters should be obtained by aspiration from the disinfected sampling port(s).

• Urine specimens should be processed ASAP, within 1-2 hours. If cannot be processed in this time, should be refrigerated or inoculated into primary isolation medium prior to transport or transported in an appropriate transport preservative.

• Refrigerated specimens should be cultured within 24 hours.

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Catheter Prevalence, also known as Urinary catheter utilization ratio

Data elements required to calculate:1. Catheter days

2. Patient days

Equation: DUR = # Catheter Days # Patient Days

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What does it mean?

• Provides ratio of time in which patients are at risk of developing complications such as infection from an indwelling urinary catheter.

• For example, MICU’s Catheter Utilization Ratio is 0.50 (50 Catheter days ÷ 100 Patient days = 0.50)

• That means that 50% of MICU’s patient days are days in which patients are at risk of device-related complications.

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Reporting CAUTI

• Annotated run chart/control chart to show change over time

• Days/weeks since last CAUTI• Each case reported to CAUTI Project Team

Lead as soon as IP identifies it to facilitate defect analysis as close in time to event as possible.

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Resources

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Days/weeks since last CAUTIhttp://www.timeanddate.com/date/duration.html

Questions?

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