NHSN Surveillance Case Studies - apicin.starchapter.com · • Applies to POA and HAI determination • DOE is Day 1 of the 14-day RIT • If criteria for the same type of infection

NHSN Surveillance Case

Studies

Rachel Cathey, MPH, CIC

Healthcare-Associated Infections Epidemiologist

April 25, 2019

Central Line-Associated Bloodstream Infections

Key Terms and Definitions

Present on Admission (POA) vs.

Healthcare-Associated Infection (HAI)

Hospital DayDate of Event

AssignmentClassification

2 days before admit Hospital Day 1

POA1 day before admit Hospital Day 1

1 Hospital Day 1

2 Hospital Day 2

3 Hospital Day 3

HAI4 Hospital Day 4

5 Hospital Day 5

Infection Window Period (IWP)

7 day period in which all site-specific

infection criteria must be met

Infe

cti

ou

s W

ind

ow

Pe

rio

d

3 days

before

Date of first positive diagnostic test that is used as an element

of the site-specific criterion

OR

In the absence of a diagnostic test, use the date of the first

documented localized sign or symptom that is used as an

element of the site-specific criterion

3 days

after

Repeat Infection Timeframe (RIT)

• 14-day timeframe during which no new infections of the same type are reported

• Applies to POA and HAI determination

• DOE is Day 1 of the 14-day RIT

• If criteria for the same type of infection are met and the date of event is within the 14-day RIT, a new event is not identified or reported

• Additional pathogens identified are added to the event

• RIT does not carry over from one admission to another

Example: Miss Lady

• June 3 – Miss Lady was admitted to the ICU

• June 4 – A blood culture was collected that resulted in E. coli

• June 10 – A subsequent blood culture resulted in K. pneumonia

• The June 4 culture is found to be a primary BSI

Should the June 10th

specimen be reported as a

new event?a. Yes

b. No

• June 3 – admitted to ICU

• June 4 – BC+ E. coli

• June 10 – BC+ K. pneumonia

Hospital

DayDate First Diagnostic Test IWP POA RIT Notes

-2 6/1

I

W

P

P

O

A

-1 6/2

1 6/3 Admitted

2 6/4 Blood cx: E. coli

R

I

T

3 6/5

4 6/6

5 6/7

6 6/8

7 6/9

8 6/10 Blood cx: K. pneumonia

9 6/11

10 6/12

11 6/13

12 6/14

13 6/15

14 6/16

15 6/17

16 6/18

17 6/19

LCBI 1 Criterion

• Patient of any age has a recognized

pathogen identified from one or more blood

specimens by a culture or non-culture based

microbiologic testing method

AND

• Organism(s) identified in blood is not related

to an infection at another site

DOE: date of the blood specimen collection identifying an

organism in the blood; no symptom required

Example: Mr. Shannon

• June 3 – Mr. Shannon was admitted to CCU after having a heart attack

• June 4 – A central line was placed

• June 7 – A blood culture was collected because he became confused and was having chills

– Culture resulted Serratia marcescens (a recognized pathogen)

• No other source of infection was identified

Is this an LCBI 1?

a. Yes

b. No

Hospital Day Date DOE IWP Notes

1 6/3 Admitted

2 6/4 Central Line inserted, CCU

3 6/5

4 6/6

5 6/7 Blood culture: S. marcescens

6 6/8

7 6/9

8 6/10

9 6/11

10 6/12

• June 3 – admitted to CCU

• June 4 – central line placed

• June 7 – BC+ S. marcescens

LCBI 2 Criterion

• Any age patient have at least one: fever (>38.0◦C), chills, or hypotension

AND

• Organism(s) identified in blood is not related to an infection at another site

AND

• The same NHSN common commensal is identified from two or more blood specimens drawn on separate occasions by a culture or non-culture based microbiologic testing method

LCBI 2 Criterion

• All elements must occur within the 7-day IWP

– Collection date of the positive blood specimen

– 3 days before

– 3 days after

• The two matching CC specimens represent a single element for use in meeting the criteria and the collection date of the first is used to determine the BSI IWP

• At least one element (fever, chills, or hypotension) is required to meet LCBI 2

Date of Event (DOE)

• First date an element that is used to

meet the LCBI 2 or 3 criteria (symptom

or the first of 2 cultures with matching

CC) occurs within the BSI IWP

ExampleDate Element IWP Notes

6/3

6/4

6/5 Fever > 38.0◦F LCBI 2 DOE

6/6

6/7 Blood culture: S. epidermidis (1 of 2) Date of 1st diagnostic test

6/8 Blood culture: S. epidermidis (2 of 2)

6/9

6/10

6/11

6/12

ExampleDate Element IWP Notes

6/3

6/4

6/5

6/6

6/7 Blood culture: S. epidermidis (1 of 2)Date of 1st diagnostic test;

DOE

6/8 Blood culture: S. epidermidis (2 of 2)

6/9

6/10 Fever > 38.0◦F

6/11

6/12

Ms. Lady (LCBI 2 Scenario)

• June 3 – Ms. Lady was admitted to the oncology ward and a central line was placed

• June 4 – She developed a fever (102◦F)

• June 6 – Blood culture was collected that grew S. epidermidis

• June 7 – Repeat blood culture collected grew S. epidermidis

• No other source of infection was identified

What is Ms. Lady’s Date of

Event?

a. 6/6

b. 6/4

c. 6/7

• June 3 – admitted; CL placed

• June 4 – fever (102◦F)

• June 6 – Positive blood culture

• June 7 – matching repeat blood

culture

Is it POA or HAI?

a. POA

b. HAIHospital Day Date First Diagnostic Test IWP POA Notes

-2 6/1

P

O

A

-1 6/2

1 6/3

I

W

P

Admitted

2 6/4 Fever 102F

3 6/5

4 6/6 Blood cx – S. epidermidis

5 6/7 Blood cx – S. epidermidis

6 6/8

7 6/9

8 6/10

• June 3 – admitted; CL placed

• June 4 – fever (102◦F)

• June 6 – Positive blood cultures

• June 7 – matching repeat blood

cultures

LCBI 3 Criterion

A patient ≤ 1 year of age have at least one: fever (>38.0◦C), apnea, hypothermia (<36.0 ◦C), or bradycardia

AND

Organism(s) identified in blood is not related to an infection at another site

AND

The same NHSN common commensal is identified from two or more blood specimens drawn on separate occasions by a culture or non-culture based microbiologic testing method

LCBI 3 Criterion

• LCBI 1 and 2 can be used for this population

• All elements must occur within the 7-day IWP– Collection date of the positive blood specimen

– 3 days before

– 3 days after

• The two matching CC specimens represent a single element for use in meeting the criteria and the collection date of the first is used to determine the BSI IWP

• At least one element (fever, hypothermia, apnea, or bradycardia) is required to meet LCBI 3

Date of Event (DOE)

• First date an element that is used to

meet the LCBI 2 or 3 criteria (symptom

or the first of 2 cultures with matching

common commensal) occurs within the

BSI IWP

– Symptom required

Baby Girl (LCBI 3 Scenario)

• March 1 – 4 mo. old baby girl was

admitted; afebrile with no symptoms of an

infection

• March 2 – She developed a fever and

periods of bradycardia; 2 blood cultures

were collected – one specimen grew

Micrococcus spp. (a common commensal)

and the other had no growth

What criteria does baby girl

meet?

a. LCBI 2

b. LCBI 3

c. This is a trick question – she doesn’t

meet criteria

Baby Boy (LCBI 3 Scenario)

• June 5 – baby boy was admitted to the NICU

• June 7 – central line is placed

• June 8 – new onset of apnea

• June 9 – he developed a low grade fever and 2 sets of blood cultures were drawn separately both growing Streptococcus viridans

• No other source of infection identified

What criteria does baby boy

meet?

a. LCBI 2

b. LCBI 3

Explanation

Hospital Day Date First Diagnostic Test IWP DOE Notes

1 6/5 Admitted

2 6/6

I

W

P

3 6/7 CL inserted

4 6/8 DOE Apnea onset

5 6/9 Blood cx: S. viridans x2

6 6/10

7 6/11

8 6/12

+BC sets the IWPDOE because

apnea is the first

element met

Central LineAn intravascular catheter that terminates at or close to the heart OR in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring

Types of Central Lines

• Temporary: a non-tunneled, non-implanted catheter

• Permanent: a tunneled catheter or implanted catheter (including port)

• Umbilical catheter: inserted through the umbilical artery or vein in a neonate

NOT Central Lines

• Arterial catheters

• Arteriovenous fistula

• Arteriovenous graft

• Atrial catheters

• Extracorporeal membrane oxygenation

• Hemodialysis reliable outflow dialysis catheter

• Intra-aortic balloon pump

• Peripheral IV or midline

• Ventricular Assist Device

Central Line Access

The performance of any of the following activities during the current inpatient admission:

• Line placement

• Use of (entering the line with a needle or needless device) any central line for:

– Infusion

– Withdrawal of blood

• Use for hemodynamic monitoring

Eligible Central Line

• Has been in place > 2 consecutive

calendar days following the first access

of the CL in an inpatient location during

the current admission

• Eligible for CLABSI events until the day

after removal from the body or patient

discharge, whichever comes first

Central Line-Associated BSI

(CLABSI)

A laboratory-confirmed bloodstream

infection where the eligible BSI organism

is identified and an eligible central line is

present on the LCBI DOE or the day

before

Examples of Associating the Use of Central

Lines to BSI Events

Date April 1 April 2 April 3 April 4 April 5 April 6 April 7

Patient A:

Port Status

Port in Port in Port in Port in Port in Port in Port in

Accessed No No Yes Yes Yes Yes Yes

Eligible for

CLABSI

event?

No

-

No

-

No

CL Day 1

No

CL Day 2

Yes

CL Day 3

Yes

CL Day 4

Yes

CL Day 5


Patient B:

CL Status

CL in CL in CL in CL in CL in /

CL out

No device No device

Accessed No No Yes Yes Removed No No

Eligible for

CLABSI

event?

No

-

No

-

No

CL Day 1

No

CL Day 2

Yes

CL Day 3

Yes

-

No

-


Lines to BSI Events


Patient C:

CL Status

CL in CL in CL in /

CL out

CL in CL in CL in /

CL out

No device

Accessed Yes Yes Removed Placed Yes Removed -

Eligible for

CLABSI

event?

Yes

CL Day 3

Yes

CL Day 4

Yes

CL Day 5

Yes

CL Day 6

Yes

CL Day 7

Yes

CL Day 8

Yes

-


Patient D:

CL Status

No device CL in CL in CL in CL in CL in CL in

Accessed - Placed Yes Yes Yes Yes Yes

Eligible for

CLABSI

event?

-

-

No

CL Day 1

No

CL Day 2

Yes

CL Day 3

Yes

CL Day 4

Yes

CL Day 5

Yes

CL Day 6

*Admitted on March 30 with central line in place


Lines to BSI Events


Patient E:

CL Status

CL in CL in CL in /

CL out

No device CL in CL in CL in

Accessed Yes Yes Removed - Placed Yes Yes

Eligible for

CLABSI

event?

Yes

CL Day 3

Yes

CL Day 4

Yes

CL Day 5

Yes No

CL Day 1

No

CL Day 2

Yes

CL Day 3

*Admitted on March 30 with central line in place

Counting Denominator Days

• Count begins on the first day of CL (of any type) is present in an inpatient unit– Day of placement (during current admission)

– Day of admission (if patient is admitted with a CL in place)

• Count only one device day for each day that patient has at least one CL in place, regardless of how many CLs the patient has in place on the same day

• Continue counting until: – Device is removed

– Patient is discharged

Examples of Denominator Day Counts


Patient A: Inpatient

Location ICU

CL inserted

ICU CL

in

ICU CL

in

ICU CL

in

ICU CL

in

ICU CL

in

ICU CL

in

Denominator

Day Counts

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7


Patient B: ED CL in

place at time

of admission

Admitted

to ICU

CL in

ICU CL

in

ICU CL

in

ICU CL

in

ICU CL

in

ICU CL

in

Denominator

Day Counts

- Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

Examples of Denominator Day Counts


Patient C: Inpatient

Location ICU

Pt. admitted

with non-

accessed

port

ICU Port

not

accessed

ICU Port

not

accessed

ICU Port

accessed

ICU Port

accessed

ICU Port

accessed

ICU Port

accessed

Denominator

Day Counts

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

BREATHE… WE’RE HALFWAY

THERE!

HAI CASE STUDY 1

Ms. Polly Microbial

Ms. Polly Microbial

• 2/4: 32yo admitted to the ED with fever (102F) and abdominal pain. Patient has a port in place at time of admission. Past medical history includes cervical cancer.

• 2/5: Admitted to oncology floor and port is flushed

• 2/6: Patient complains of pain at the port site and insertion site is red.

• 2/8: blood cultures collected; positive for Candida albicans (a recognized pathogen)

• No other source of infection is identified

Question 1

What criteria did Ms. Polly meet?

a. LCBI 2

b. LCBI 1

c. Ms. Polly did not meet any criteria• 2/4: Admitted to the ED with fever (102F) and

abdominal pain.

• 2/5: Admitted to oncology floor and port is

flushed

• 2/6: Complains of pain at the port site and

insertion site is red

• 2/8: blood cultures collected; positive for

Candida albicans

Question 2

What is the date of event?

a. 2/5

b. 2/6

c. 2/8• 2/4: Admitted to the ED with fever (102F) and

abdominal pain.

• 2/5: Admitted to oncology floor and port is

flushed

• 2/6: Complains of pain at the port site and

insertion site is red

• 2/8: blood cultures collected; positive for

Candida albicans

Question 3

Is this a POA or HAI?

a. POA

b. HAIDate

Hospital

DayDOE Classification Notes

2/5 1 POA Admitted;

port flushed

2/6 2 POA

2/7 3 HAI

2/8 4 Blood

culture +

HAI

2/9 5 HAI

2/10 6 HAI

HAI CASE STUDY 2

Mr. Dude

Mr. Dude

• 2/11 – 55yo male admitted to the ED with rectal bleeding. Peripheral IV line placed. Past medical history shows end-stage renal disease (ESRD) and diabetes. He has a permanent HD catheter in place. Last HD performed, 2/10.

• 2/12 – Admitted to Renal floor

• 2/13 – Patient refused HD

• 2/14 – Patient consented to HD. HD performed.

• 2/17 – Fever 102◦F; Blood cultures collected – Pseudomonas putida x 1 (a recognized pathogen)

• 2/18 – HD central line removed.

• 2/19 – New HD central line replaced

No site-specific infection identified

Question 1

What criteria did Mr. Dude

meet?

a. LCBI 2

b. LCBI 1

c. Mr. Dude is fine.

Pseudomonas putida

doesn’t mean anything.

• 2/11 – admitted to the ED;

Peripheral IV line placed; has a

permanent HD catheter in

place. Last HD performed, 2/10.

• 2/12 – admitted to Renal floor

• 2/13 – Pt. refused HD

• 2/14 – Pt. consented to HD; HD

performed

• 2/17 – Fever 102◦F; blood

cultures collected; positive for

Pseudomonas putida

• 2/18 – HD CL removed.

• 2/19 – New HD CL replaced in

RIJ

Question 2

Is this a POA or HAI

event?

a. POA

b. HAI








performed



Pseudomonas putida



RIJ

Question 3

Is this event central line

associated?

a. Yes

b. No

c. No event was

identified








performed



Pseudomonas putida



RIJ

Question 4

What is the date of

event?

a. 2/16

b. 2/17

c. 2/18

d. I already told you…

he is FINE.








performed



Pseudomonas putida



RIJ

Hospital

DayDate First Diagnostic Test IWP DOE RIT

HAI/POA

ClassificationNotes

1 2/11POA

Admitted to ED

2 2/12 Admitted to Renal Floor

3 2/13

HAI

Refused HD

4 2/14

I

W

P

Consented HD; HD performed

5 2/15

6 2/16

7 2/17 Blood cx – P. putida DOE

R

I

T

Fever 102◦F

8 2/18 HD central line removed

9 2/19 New HD central line replaced in RIJ

10 2/20

11 2/21

12 2/22

13 2/23

14 2/24

15 2/25

16 2/26

17 2/27

18 2/28

19 3/1

20 3/2

21 3/3

HAI CASE STUDY 3

January 1, 2018 (HD 1)

• 23yo male with paraplegia secondary to T1 transverse myelitis is admitted to inpatient ward

• Implanted port and suprapubic catheter are POA

• Unaccessed port is scheduled for removal on 1/3/18 due to history of recurrent polymicrobialbacteremias

• Late November 2017 – BSI treated with 4-week course of antibiotics completed on 12/31/17– Blood cultures positive for Candida albicans,

Chryseobacterium indolegenes, and Enterococcus faecalis

January 3, 2018, 12:23a.m. (HD 3)

• Patient complains of ‘itching at port insertion site’

• Port insertion site is red, warm, and tender

• Port is accessed for the first time during this admission to collect blood cultures– One set collected from port

– One set collected from peripheral venipuncture

• Port is de-accessed after collection and scheduled removal is postponed pending culture results

• Peripheral IV is placed for temporary access


• Blood cultures from 1/3/18 are

preliminarily resulted as no growth

• Port is removed


• Patient pulls out IV

• PICC is inserted at 1:30pm

• Chart shows “Patient continues to be non-compliant with medical care. The nurse witnessed tampering with PICC line.”

• Low-grade fever 99.8◦F is noted at 8:00pm


• 11:00am – patient complains of pain, severity 10/10, 15mg oxycodone is given. Patient is requesting to leave the unit to smoke with visitors.

• 11:20am – nurse disconnected CL and caps; patient leaves unit to smoke

• 12:40pm – patient returns to unit slurring words and unable to open eyes– Marked change in level of consciousness (LOC) since

leaving

– Safety cap is missing from the secondary port

– CL is un-clamped

January 6, 2018 (continued)

• 1:30pm – physician assesses patient

and concludes that condition is

inconsistent with current narcotic order

and previous response to ordered pain

medications

• Physician orders discontinuation of

PICC and all narcotics

• 5:15pm – PICC is removed


• Fever spikes to 101.2oF

• Two sets of blood cultures are collected,

and one bottle from each set is positive

for Staphylococcus hominis, Klebsiella

oxytoca, and Enterococcus faecium

• The blood cultures collected on January

3rd are still showing no growth

Question

On January 7th, how many CL days have occurred to determine if the BSI is a CLABSI?

a. 6 CL days

b. 4 CL days

c. 2 CL days

d. 0, the BSI is not CL associated

Jan. 1 Jan. 2 Jan. 3 Jan. 4 Jan. 5 Jan. 6 Jan. 7

CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed

Port removed RUA PICC

placed

RUA PICC

removed

Blood

Specimen

BC x2

No growth

+BC x2

K. oxytoca,

E. faecium,

S. hominis

Eligible Central Line

• Has been in place > 2 consecutive

calendar days following the first access

of the CL in an inpatient location during

the current admission

• Eligible for CLABSI events until the day

after removal from the body or patient

discharge, whichever comes first

ExplanationJan. 1 Jan. 2 Jan. 3 Jan. 4 Jan. 5 Jan. 6 Jan. 7

CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed


placed

RUA PICC

removed

Blood

Specimen

BC x2

No growth

+BC x2

K. oxytoca,

E. faecium,

S. hominis

• 1/3/18: The port is accessed and then de-accessed. This is CL day 1 for CLABSI attribution.

• 1/4/18: The port is removed, but has been present for some portion of the calendar day. Because the port was

accessed during the current admission, it continues to count towards central-line attribution until the day after

removal from the body or the day after patient discharge. This is CL day 2 for CLABSI attribution.

• 1/5/18: A PICC is placed (during current admission). Because a full calendar day did not pass without a CL in

place between device removal and placement of the new device, CL day count for device attribution continues

uninterrupted. The device is now an eligible CL (eligible for CLABSI event) as this is CL day 3 for CLABSI

attribution.

• 1/6/18: The PICC is removed but has been present for some portion of the calendar day. This is CL day 4 for

CLABSI attribution.

• 1/7/18: No CL is in place for any part of this calendar day, therefore, no device day for denominator data is

counted.

Question

What is the correct determination for the positive blood specimens collected on January 7th and how should the field for CL be completed?

a. LCBI 1; CL=No due to self injection DOE 1/7

b. LCBI 1; CL=Y (CLABSI) DOE 1/7

c. LCBI 2; CL=No due to self injection DOE 1/5

d. LCBI 2; CL=Y (CLABSI) DOE 1/5

e. No LCBI because patient is non-compliant and tampering with line


CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed


placed

RUA PICC

removed

Blood

Specimen

BC x2

No growth

+BC x2

K. oxytoca,

E. faecium,

S. hominis

Explanation: LCBI and DOE

• LCBI 1 criteria met on 1/7 with +BC (DOE) and BSI is attributed to the eligible CL (CLABSI)– E. faecium and K. oxytoca are recognized pathogens

– No other site-specific source of infection is identified that the BSI can be attributed as secondary ---- primary BSI is identified

• DOE for LCBI 1 is always the collection date of the first positive blood specimen


CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed


placed

RUA PICC

removed

Blood

Specimen

BC x2

No growth

+BC x2

K. oxytoca,

E. faecium,

S. hominis

Explanation: CL=Y (CLABSI)

• Device became an eligible CL on CL day 3 (1/5)

because it was in place >2 consecutive calendar days

and is still in place on the BSI DOE or the day before

• The BSI DOE occurs the day after removal of an eligible

CL, therefore, a CLABSI is identified and reported

• Documentation does not meet the patient injection

exclusion, therefore, ‘CL=No’ cannot be reported


CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed


placed

RUA PICC

removed

Blood

Specimen

BC x2

No growth

+BC x2

K. oxytoca,

E. faecium,

S. hominis

Question

But wait… on 1/7 he had a fever and

matching blood cultures for S. hominis.

Shouldn’t this be reported as LCBI 2?

a. Yes

b. No

c. I don’t know Rachel, you’re confusing

me

Explanation: LCBI 2

• LCBI 2 criteria met on 1/7 with fever spike and common commensal– Fever spikes to 101.2oF

– Organism not related to an infection at another site

– S. hominis is a matching common commensal from +BC x2

• Since both LCBI 1 and LCBI 2 are met → LCBI 1 is reported


CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed


placed

RUA PICC

removed

Blood

Specimen

BC x2

No growth

+BC x2

K. oxytoca,

E. faecium,

S. hominis

Reporting LCBI 1 and 2

• If a patient meets both LCBI 1 and LCBI

2 criteria, always report LCBI 1

• Enter the recognized pathogen as

pathogen #1 and the common

commensal as pathogen #2


• Left upper arm (LUA) PICC is placed for

treatment of polymicrobial bacteremia

• Repeat blood cultures are collected

• Patient has personal sitter assigned


• Blood cultures from 1/8 are positive for

Enterococcus faecium and

Pseudomonas aeruginosa

January 11, 2018 (HD 11)

• Progress notes state:

– Patient continues with non-compliant

behavior

– Likely represents on-going contamination

of CL from patient injecting illicit drugs

– In the patient’s best interest to discontinue

the CL and change to oral antibiotics

– Left upper arm PICC removed at 2:40 p.m.

January 13, 2018 (HD 13)

• Repeat blood cultures are collected and

all are negative for growth

• Progress note states: “PICC removed

January 11th, recent blood cultures

clear”

QuestionHow many device days should be reported for this patient for the January CL summary denominator data?

a. 6 device days

b. 8 device days

c. 9 device days

d. 10 device days

Jan. 1 Jan. 2 Jan. 3 Jan. 4 Jan. 5 Jan. 6 Jan. 7 Jan. 8 Jan. 9 Jan. 10 Jan. 11

CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed

Port

removed

RUA

PICC

placed

RUA

PICC

removed

LUA

PICC

placed

LUA

PICC

LUA

PICC

LUA

PICC

removed

CL d

ay

for

CLA

BS

I

dete

rmin

ation CL day 1 CL day 2 CL day

3; CL is

eligible

CL day

4;

CLABSI

event

eligible

Remains

CLABSI

event

eligible

CL day 1 CL day 2 CL day 3 CL day 4

Devic

eday

for

denom

inato

r

data

CL day 1 CL day 2 CL day 3 CL day 4 CL day 5 CL day 6 - CL day 7 CL day 8 CL day 9 CL day

10

Explanation

• Business rule changed in 2017 for how denominator summary data is counted

– Pre-existing CL weren’t included in denominator counts until the day the line was first accessed during inpatient admission

• NHSN changed the rule so that it is now consistent with other device-associated events (UTI’s and VAE’s)

• Effective January 1, 2018

Counting Denominator Days

• Count begins on the first day of CL (of any type) is present in an inpatient unit– Day of placement (during current admission)

– Day of admission (if patient is admitted with a CL in place)

• Count only one device day for each day that patient has at least one CL in place, regardless of how many CLs the patient has in place on the same day

• Continue counting until: – Device is removed

– Patient is discharged

Explanation

Jan. 1 Jan. 2 Jan. 3 Jan. 4 Jan. 5 Jan. 6 Jan. 7 Jan. 8 Jan. 9 Jan. 10 Jan. 11

CL

Unaccessed

Port POA

Unaccessed

port

Port

accessed

then de-

accessed

Port

removed

RUA

PICC

placed

RUA

PICC

removed

LUA

PICC

placed

LUA

PICC

LUA

PICC

LUA

PICC

removed

CL d

ay

for

CLA

BS

I

dete

rmin

ation CL day 1 CL day 2 CL day

3; CL is

eligible

CL day

4;

CLABSI

event

eligible

Remains

CLABSI

event

eligible

CL day 1 CL day 2 CL day 3 CL day 4

Devic

eday

for

denom

inato

r

data

CL day 1 CL day 2 CL day 3 CL day 4 CL day 5 CL day 6 - CL day 7 CL day 8 CL day 9 CL day

10

Question

Which of these documented notes would meet criteria for use of the patient self-injection exclusion, assuming LCBI criteria are met and documentation is within the BSI infection window period (IWP)?

Note: The NHSN BSI protocol states: “A BSI meeting LCBI criteria that is accompanied by documentation of observed or suspected patient injection into the vascular access line, within the BSI Infection Window Period, will be considered an LCBI but not a CLABSI for NHSN reporting purposes”.

1. “Patient is manipulating his CL by scratching around it aggressively and interfering with line maintenance by refusing care”.

2. Patient is very non-compliant with medical care…have witnessed patient tampering with PICC line

3. At 11am, patient complaining of pain 10/10, 15mg oxy given per MAR... Patient left floor at 11:20am to smoke…Patient back on unit at 12:40 pm… slurring words with difficulty keeping eyes open…Safety cap was missing and the line was un-clamped.

4. Changed to PO antibiotics due to misuse and contamination of intravascular line

5. Patient infection likely represents contamination of CL from patient using the line to inject unknown substance …CL removed and recent blood cultures are clear”.

Explanation

• Exclusion is very specific to “injection”

• BSI meeting LCBI criteria must have documentation of observed or suspected patient injection into the vascular access line, within the BSI IWP, to be considered an LCBI and not a CLABSI

• Documentation must state that the patient was “observed injecting” or “suspected of injecting” the device

• Does not meet exclusion:– Manipulating or tampering with the line (biting, picking

at, sucking on, etc.)

– Descriptions that suggest behavior

1. “Patient is manipulating his CL by scratching around it aggressively and interfering with line maintenance by refusing care”.

2. Patient is very non-compliant with medical care…have witnessed patient tampering with PICC line

3. At 11am, patient complaining of pain 10/10, 15mg oxy given per MAR... Patient left floor at 11:20am to smoke…Patient back on unit at 12:40 p.m…slurring words with difficulty keeping eyes open…Safety cap was missing and the line was un-clamped.

4. Changed to PO antibiotics due to misuse and contamination of intravascular line

5. Patient infection likely represents contamination of CL from patient using the line to inject unknown substance …CL removed and recent blood cultures are clear”.

✔

Note on Exclusions

CLABSI Exclusion Exclusion

Field

Marked

Yes or No

Central

Line Field

Marked

Yes or No

Exclusion

Reporting

Requirement

in 2019

Exclusion

Reporting

Requirement

in 2020

Epidermolysis Bullosa (EB) Y N Optional Required

Munchausen’s syndrome by proxy

(MSBP)

Y N Optional Required

Patient self-injection Y N Optional Required

Pus at vascular site Y N Optional Required

Group B Streptococcus BSI- 1st 6

days of life

Y N Optional Required

ERC Updates

TB & LTBI Reporting

TB Reporting

• All TB cases and suspects are reportable within 24 hours of diagnosis

• Anyone starting on RIPE therapy is considered a TB suspect and must be reported

• Submit Report of TB in NBS

• Can be found on tb.in.gov under Information for Health Professionals

https://www.in.gov/isdh/19662.htm

Reporting TB in NBS

• Submit a morbidity report for TB

• Attach current Report of TB form• Don’t need to complete variables

• Add supporting documentation

• Immediately viewable by LHDs and ISDH

• Please do not mail/fax report of TB to ISDH

LTBI Reporting

• Latent TB infection (LTBI) has been reportable in Indiana since December 2015

• Only those with a diagnosis of LTBI by a provider are reportable

• Positive reactors are reportable in Marion County

• Patients can receive LTBI treatment free through LHDs

Reporting LTBI in NBS

• Open an LTBI Investigation within NBS

• Attach supporting documentation under Supplemental Info tab

• Please don’t submit a TB morbidity report for LTBI

• Change investigation status to closed when outcome is reached

Isolation of Infectious TB Patients

Infectious TB patients must be in negative air pressure isolation until:

• Three consecutive AFB smear negative sputa obtained at least eight hours apart with one being an early morning specimen

• Are clinically improving

• Are known to be medically evaluated

• Have completed two weeks of an adequate antituberculosis therapy per Centers for Disease Control and Prevention guidelines

Discharge of TB Patients410 IAC 1-2.5-141 Tuberculosis; specific control measures

Prior to discharge of a tuberculosis case or suspect case, the local health department shall make plans, in writing, for continuation of medical follow-up,

ensuring adherence to therapy and isolation unless the case or suspect case meets the criteria in this subdivision and is deemed to be noninfectious.

Plans shall be developed in cooperation with the treating physician and the patient and must be in

accordance with this rule.

Contact Information

Kelly White, Director TB/Refugee [email protected]

mailto:KeWhite@ isdh.in.gov

Measles & Mumps

Measles

Measles

• New FAQ guide for healthcare providers

– Signs and symptoms

– Risk factors

– Immunization recommendations

– What to do if you suspect measles

– Testing and interpretation of results

– Infection prevention

– When to give PEP for non-symptomatic contacts



Measles/Mumps

IU Mumps

• 20 confirmed cases, as of 4/22/19

• Majority of cases are epi-linked to a fraternity

• Third dose recommendation– Gives boost for one month, return to baseline

immunity after a year

– Takes up to two weeks for immunity after MMR vaccine

• Recommendations– Self-isolate 5 days after onset of parotid swelling

– Discourage sharing of drinks, smoking devices, and utensils

November 20-21, 2019

Marriott East, Indianapolis

2019 Indiana Infectious Disease

Summit: United in Prevention,

Response, and Service

Summit Objectives

• Understand trends and responses to

current and emerging infectious diseases

• Discuss the implementation of

epidemiology preparedness to prevent and

mitigate infectious disease

• List three new partnerships to enhance

infectious disease prevention and

response

Summit will include…

• Keynote speaker - Jay C. Butler, MD (CAPT,USPHS,RET) CDC Deputy Director for Infectious Diseases

• Panel discussions

• Break-out sessions– Infectious disease epidemiology

– Public health preparedness

– Outbreak response

– Emerging infectious diseases and prevention

– Cross-sector collaboration

– Laboratory methods, research and best practices

– Social determinants of health

– Non-traditional partnerships

Call for Presentations

• Call for presentations will be sent out on May 25th to:– Past ID Summit participants

– LHD’s and Indiana state partners

– Other State Health Departments

– Professional organizations listservs (APIC )

– ERC Weekly Digest

Submission Deadline: June 28, 2019

Notification of Acceptance/Denial: July 26, 2019

Break Out Sessions

• Speakers identified by the planning

committee

• Must be in alignment with the ID

Summit objectives and preference given

to those submissions following the

suggested topic guidance

Contact Information

Rachel Cathey, MPH, CIC

Healthcare-Associated Infections Epidemiologist

Infectious Disease Epidemiology

Epidemiology Resource Center

Indiana State Department of Health

Work: 317-234-2805

Email: [email protected]

mailto:[email protected]

Documents

NHSN Surveillance Case Studies - apicin.starchapter.com · • Applies to POA and HAI determination • DOE is Day 1 of the 14-day RIT • If criteria for the same type of infection