Pennsylvania Department of Health (PADOH) – CLABSI, CAUTI, and SSI Auditeoplugin.commpartners.com/APIC/120119/120119 CLABSI CAUTI and S… · Mary Andrus, BA, RN, CIC Infection

Mary Andrus, BA, RN, CICMary Andrus, BA, RN, CICInfection Preventionist ConsultantInfection Preventionist Consultant

APIC CONSULTING SERVICES, INC.APIC CONSULTING SERVICES, INC.

Pennsylvania Department of Pennsylvania Department of Health (PADOH) Health (PADOH) –– CLABSI, CLABSI,

CAUTI, and SSI AuditCAUTI, and SSI Audit

Provisional CLABSI ResultsProvisional CLABSI Results


A total of 120 records were

reviewed


Auditors reviewed 23 patients that had been

reported to NHSN


Bloodstream infections that

were reported by hospitals and confirmed by

auditors



were reported by hospitals and not

confirmed by auditors


Total number of positive blood cultures reviewed

by audit.



were identified as CLABSI by audit

but were not reported to NHSN


Positive blood cultures that were not identified

as CLABSI by audit and were not reported

by the hospital to NHSN

CLABSI Misreported CasesCLABSI Misreported Cases

• Under-reported (5)– 3 cases were not reported because the hospital identified the

BSI as secondary to another infection. In each case, the criteria for the primary infection were not met

– 2 cases were missed by the hospital

• Over-reported (4)– 2 cases were reported as a primary BSI (CLABSI) when criteria

for an infection at another site with the same organism was identified by the auditor

– 1 case was reported by the hospital, but it appears to be associated with a CLABSI on an earlier date

– 1 case was reported as CLABSI, but no corresponding blood culture was identified by the auditor

LaboratoryLaboratory --confirmed Bloodstream Infection (LCBI) confirmed Bloodstream Infection (LCBI)

LCBI Criterion 1

Notes about Criterion 1Notes about Criterion 1

� Common commensal� Diphtheroids

(Corynebacterium spp.)

� Bacillus spp. (not B.anthracis)

� Proprionibacterium spp.

� Coagulase-negative staphylococci (including S. epidermidis)

� Viridans group streptococci

� Aerococcus spp.� Micrococcus spp.

LaboratoryLaboratory --confirmed bloodstream infection confirmed bloodstream infection (LCBI)(LCBI)

LCBI Criterion 2

commensal

Two or more blood cultures on separate occasionsTwo or more blood cultures on separate occasions

“Two or more blood cultures drawn on separate occasions”means

1.Blood from at least 2 blood draws were collected within two days of each other and

2.At least one bottle from each draw is reported as having grown the same common commensal

““ SamenessSameness ”” of organismof organism

If the common skin contaminant is

identified to the species level from one culture, and a companion culture

is identified with only a descriptive name (i.e., to the genus level), this it

is assumed that the organisms are the

same

Example: If a culture grows Staphlycoccus epidermidis

and a companion culture grows Coagulase-negative staphyloccocci, then you can report that the common

skin contaminants are the same and that they are S. epidermidis

““ SamenessSameness ”” of organismof organism

If common skin contaminants from the

two cultures are speciated (e.g., both are Bacillus spp.) but no antibiograms

are done or they are done for only one of the isolates, assume that the

organisms are the same

Blood Culture Specimen CollectionBlood Culture Specimen Collection

Ideally, blood specimens for culture should be

obtained from two to four blood draws from separate venipuncture sites, not through the

vascular catheter.

These blood draws should be performed

simultaneously or over a very short period of time (i.e., within a few hours).

If your facility does not currently obtain

specimens using this technique, you may still report BSIs using these criteria, but you should

work with appropriate personnel to facilitate better specimen collection practices for blood

cultures

� Common commensals� Diphtheroids

(Corynebacterium spp.)� Bacillus spp. (not

B.anthracis)� Proprionibacterium spp.� Coagulase-negative

staphylococci (including S. epidermidis)

� Viridans group streptococci

� Aerococcus spp.� Micrococcus spp.

LaboratoryLaboratory --confirmed bloodstream infection confirmed bloodstream infection (LCBI)(LCBI)

LCBI Criterion 3

commensal

CDC/NHSN Surveillance Definition of HealthcareCDC/NHSN Surveillance Definition of Healthcare --Associated Infection and Criteria for Specific Type s of Associated Infection and Criteria for Specific Type s of Infections in the Acute Care SettingInfections in the Acute Care Setting

This chapter contains the CDC/NHSN surveillance definition of healthcare-associated infection (HAI) and criteria for all specific types of HAI. These criteria include those for the “Big Four” infection types (surgical site infection [SSI], pneumonia [PNEU], bloodstream infection [BSI] and urinary tract infection [UTI]), outlined in earlier chapters of this manual, as well as criteria for other types of HAI. Of particular importance, this chapter provides further required criteria for the specific event types that constitute organ/space SSIs (e.g., mediastinitis [MED] that may follow a coronary artery bypass graft, intra-abdominal abscess[IAB] after colon surgery). Additionally, it is necessary to refer to the criteria in this chapter when determining whether a positive bl ood culture represents a primary BSI or is secondary to a different type o f HAI. A BSI that is identified as secondary to another site of infectio n must meet one of the criteria of HAI detailed in this chapter. Secondary BSIs are not reported as separate events in NHSN, nor can nor should they be associated with a central line.

Secondary BSISecondary BSI• A culture-confirmed BSI associated with a documented

HAI at another site• If a primary infection is cultured, the Secondary BSI must

yield culture of same organism as the primary HAI site

Example: Mrs. Jones has a fever and grows E. coli in her urine (>100,000 col/cc) and in her blood. She has both a femoral central line and an indwelling urinary catheter. A CAUTI (SUTI) is reported with a secondary BSI.

Example: Mr. Smith grows A. baumanii in his surgical wound which is resistant to amikacin and levofloxin but sensitive to other tested antimicrobials. He is also growing A. baumanii in his blood, but it is susceptible to amikacin. The SSI is reported with a secondary BSI.

When determining if a bloodstream infection is

the primary infection site or secondary to an

infection at another site, there will be no

requirement for the antibiograms of the blood

culture isolate(s) and antibiograms of the

isolate(s) from the primary infection site culture

to match. The isolate(s) must only match at the

genus/species level for the bloodstream

infection to be considered secondary to the

primary infection site.

Secondary BSI (cont.)Secondary BSI (cont.)

• If an infection is identified and no culture is used to meet the infection criteria and a blood culture is positive, then the first infection is considered primary and the bloodstream infection is reported as secondary. The organism cultured from the blood is reported as the organism for the primary site.

Example: 6 days postoperatively, Miss Green has an abdominal abscess, confirmed by CT scan. On the same day, her blood is drawn and grows Bacteroides fragilis. The infection is reported as an SSI-GIT (organ space SSI) with a secondary BSI. The organism is reported as B. fragilis

Positive blood culture

Does patient meet the criteria for HAI at another site? (If infection is CA, or if NHSN criteria for the specific site HAI has not been met, answer “No”.)

No Yes

CA or HA

Is blood isolate a common pathogen for this site?

HA CA

This CA infection with secondary BSI is not reported through NHSN nor is the BSI.

Primary BSI

NoYes

Site infection with secondary BSI

Primary BSI

QUESTIONS?QUESTIONS?

CAUTICAUTI

Provisional CAUTI ResultsProvisional CAUTI Results


Total number of records reviewed


Auditors reviewed a total of 38 patients that were reported to

NHSN by the hospitals as CAUTI


CAUTIs that were reported by hospitals

and confirmed by auditors


CAUTIs that were reported by hospitals and not confirmed by auditors. These are

over-reported cases


Total number of unreported positive urine cultures reviewed

by audit


Urine cultures that were identified as

CAUTI by auditors. This is an under-reported case.


Positive urine cultures that were not identified as

CAUTI by audit and were not reported

by the hospital

CAUTI Misreported CasesCAUTI Misreported Cases

• One case was under-reported. The hospital indicated that the UTI was pre-existing, but the evidence does not support this

• 12 cases were over-reported– 4 patients were reported as CAUTI when no indwelling catheter

was in place

– 4 patients were reported as CAUTI, but patients were asymptomatic

– 1 patient was asymptomatic and there was no culture on the date CAUTI reported

– 2 patients had no urine culture on the target date

– UTI on this date is not a new UTI, but an extension of a previous CAUTI

Patient with or without an indwelling urinary catheter

Patient of any age�None of the following:

•Fever (>38°C)•Urgency•Frequency•Dysuria•Suprapubic pain•Costovertebral angle pain or tenderness

Patient ≤ 1 year of age�None of the following:

•Fever (>38°C Core)•Hypothermia (<36°C)•apnea•bradycardia•lethargy•Vomiting

A positive urine culture of ≥105 CFU/ml with no more than 2 species of microorganism

A positive blood culture with at least 1 matching uropathogen microorganism to the urine culture

Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)

CAUTICAUTI CriteriaCriteria

Provisional SSI ResultsProvisional SSI Results

* Differences in Specific Event not considered


*


A total of 240 records were

reviewed



70 patients were reported as having SSI

by the hospital


*

60 of the SSI cases reported

by hospitals were also

identified as SSIby the audit

* Differences in Specific Event SSI not considered


10 of the SSI cases reported by hospitals did

not meet SSI criteria during

the audit

* Differences in Specific Event SSI not considered


* Differences in Specific Event are identified as “No SSI”

When the Specific SSI Event was evaluated, only 42/70 matched


*


28/70 records reviewed were

either over-reported or reported an

incorrect Specific SSI Event



170 operative procedures were

reviewed in cases where an

SSI was not reported



4/170 were identified as SSI

by the auditor (under-reported)



166/170 were not identified as SSI and were correctly not reported to

NHSN

SSI Misreported CasesSSI Misreported Cases

• Under-reported (4)– 1 not reported because case was infected at the time of surgery

– 3 cases were missed (undetermined)

• Over-reported (10)– 1 reported case should have been associated with a different

surgery date

– 8 cases were reported to NHSN where event criteria for SSI were not met

– 1 case reported as DIP was actually SIP, but it was >30 days so should not have been counted

Discrepancies to SSI Specific EventsDiscrepancies to SSI Specific Events

Hospital Determination Auditor Determination Number of Cases

SIP DIP 4

SIP Organ/Space 1

SIP DIS 1

SIS DIS 1

DIP Organ/Space 5

DIP DIS 1

Organ/Space SIP 1

Organ/Space DIP 1

Organ/Space Organ/Space (different O/S)

2

SSI DefinitionsSSI Definitions

Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13(10):606-8.

Superficial Incisional SSISuperficial Incisional SSI

Deep Incisional SSIDeep Incisional SSI

DIP and DISDIP and DIS

Deep incisional primary (DIP)

A deep incisional SSI that is identified in the primary incision in a patient that

has had an operation with one or more incisions

(e.g., C-section incision or chest incision for coronary artery bypass graft with a

donor site [CBGB])

Deep incisional primary (DIP)

A deep incisional SSI that is identified in the primary incision in a patient that

has had an operation with one or more incisions

(e.g., C-section incision or chest incision for coronary artery bypass graft with a

donor site [CBGB])

Deep incisional secondary (DIS)

A deep incisional SSI that is identified in the

secondary incision in a patient that has had an

operation with more than one incision (e.g., donor

site [leg] incision for coronary artery bypass graft with a donor site

[CBGB])

Deep incisional secondary (DIS)

A deep incisional SSI that is identified in the

secondary incision in a patient that has had an

operation with more than one incision (e.g., donor

site [leg] incision for coronary artery bypass graft with a donor site

[CBGB])

Organ/Space SSIOrgan/Space SSI

Specific event types that must

be used to differentiate

organ/space SSI

BONE Osteomyelitis JNT Joint or bursa

BRST Breast abscess/mastitis LUNG Other infections of respiratory tract

CARD Myocarditis/pericarditis

MED Mediastinitis

DISC Disc space ORAL Oral cavity

EAR Ear, mastoid OREP Other respiratory

EMET Endometritis OUTI Other urinary

ENDO Endocarditis SA Spinal abscess

EYE Eye, other than conjunctivitis

SINU Sinusitis

GIT GI tract UR Upper respiratory

IAB Intraabdominal, NOS VASC Arterial or venous

IC Intracranial VCUF Vaginal cuff

Organ/Space SSIOrgan/Space SSI

Denominator for Procedure Denominator for Procedure –– Wound ClassWound Class

C = CleanCC = Clean ContaminatedCO = ContaminatedD = DirtyU = Unknown

Wound class is an assessment of the likelihood and degree of contamination of a surgical wound at the time of the operation

Wound ClassWound Class

Clean

� Uninfected wound with no inflammation� Respiratory, alimentary, genital or uninfected urinary tract are notentered� Primarily closed� Closed drainage, if needed

Clean-Contaminated

� Respiratory, alimentary, genital, or urinary tracts entered under controlled conditions and without unusual contamination�Include operations on biliary tract, appendix, vagina, oropharynx if no evidence of infection or major break in technique

Wound ClassWound Class

Contaminated

� Open, fresh, accidental wounds�Major breaks in sterile technique or gross spillage from the GI tract�Includes incisions into acute, nonpurulent inflamed tissues

Dirty� Old traumatic wounds with retained devitalized tissue�Wounds involving existing clinical infection or perforated viscera

Procedure Details Procedure Details ––DurationDuration

Duration:Record the hours and minutes between the skin incision and skin closure.Do not record anesthesia time!

Duration:Record the hours and minutes between the skin incision and skin closure.Do not record anesthesia time!

Additional Rules about DurationAdditional Rules about Duration

• If more than one NHSN operative procedure is done through the same incision during the same trip to the OR, create a record for each procedure and use the total time for the duration of both

Example: Mr. Jones goes to the OR and has a coronary artery bypass graft with a [leg] donor site (CBGB) and also a mitral valve replacement (CARD). The time from the first incision until skin closure is 5 hours. A Denominator for Procedure record is completed for the CBGB and another for the CARD. The duration for each is recorded as 5 hours and 0 minutes.

Example: Mr. Jones goes to the OR and has a coronary artery bypass graft with a [leg] donor site (CBGB) and also a mitral valve replacement (CARD). The time from the first incision until skin closure is 5 hours. A Denominator for Procedure record is completed for the CBGB and another for the CARD. The duration for each is recorded as 5 hours and 0 minutes.

March 11-12, 2009

• If the patient goes to the OR more than once during the same admission and another procedure is performed through the same incision within 24 hours of the original incision, report the combined duration of operation for both procedures

Example: Fred Smith had a small bowel resection (SB) done on Tuesday morning which had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to the OR where an exploratory laparotomy was done through the same incision to repair a leaking anastamosis. The cut time for this surgery was 1 hour and 10 minutes.

Report only one procedure – SB combining the two durations. The duration reported is 4 hours and 20 minutes

Example: Fred Smith had a small bowel resection (SB) done on Tuesday morning which had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to the OR where an exploratory laparotomy was done through the same incision to repair a leaking anastamosis. The cut time for this surgery was 1 hour and 10 minutes.

Report only one procedure – SB combining the two durations. The duration reported is 4 hours and 20 minutes

Additional Rules about DurationAdditional Rules about Duration

March 11-12, 2009

Denominator for Procedure Denominator for Procedure –– ASA ClassASA Class

ASA Class :An assessment score by the anesthesiologist of the patient’s preoperative physical condition using the American Society of Anesthesiologists Classification of Physical Status schema

ASA Class :An assessment score by the anesthesiologist of the patient’s preoperative physical condition using the American Society of Anesthesiologists Classification of Physical Status schema

ASA ClassASA Class

1. Normally healthy patient2. Patient with mild systemic disease3. Patient with severe systemic disease

that is not incapacitating4. Patient with an incapacitating systemic

disease that is a constant threat to life5. Moribund patient who is not expected

to survive for 24 hours with or without operation

1. Normally healthy patient2. Patient with mild systemic disease3. Patient with severe systemic disease

that is not incapacitating4. Patient with an incapacitating systemic

disease that is a constant threat to life5. Moribund patient who is not expected

to survive for 24 hours with or without operation

March 11-12, 2009

NHSN Basic Risk IndexNHSN Basic Risk Index

The patient’s SSI risk category is simply the number of these factors present at the time of the operation

SSI RateSSI Rate* Stratify by:

•Type of NHSN operative procedure•Basic NHSN Risk Index

SSI Rates have been moved to the “advanced” section of the output options. Note that while these options are available, youwill only be able to obtain your facility’s SSI rates

Comparison to the previously-published NHSN pooled means will no longer be available

2008 NHSH Report 2008 NHSH Report –– SSI RatesSSI Rates

Standardized Infection Ratio (SIR)Standardized Infection Ratio (SIR)• The new SSI SIRs use risk adjustment

calculated through logistic regression modeling• Allows for all available risk factors to be

considered• Each risk factor’s “weight” will vary according to

its significant contribution to the risk for that SSI• For all NHSN procedures, the models predicted

SSI risk better than the basic risk index

Predictive Risk FactorsPredictive Risk FactorsNHSN Operative Procedure

Risk Factor(s) – All SSIs

AAA Duration

CBGB/C Age, ASA, duration, gender, number of beds*

COLO Age, anesthesia, ASA, duration, endoscope, medical school affiliation*, number of beds*, wound class

FUSN Approach, ASA, diabetes, duration, medical school affiliation*, spinal level, trauma, wound class

HPRO Age, anesthesia, ASA, duration, HPRO type, number of beds* trauma

HYST Age, anesthesia, ASA, duration, endoscope, number of beds*

KPRO Age, anesthesia, ASA, duration, gender, KPRO type, number of beds*, trauma

LAM Anesthesia, ASA, duration, endoscope

PVBY Age, ASA, duration, gender, medical school affiliation*

RFUSN Approach, diabetes, duration

VSHN Age, medical school affiliation*,number of beds*, wound class

Overall SSI SIROverall SSI SIR

• During 2009, there were 524 procedures performed an d 13 SSIs identified.

• Based on the NHSN 2006-2008 baseline data, 6.687 SS Is were expected.

• •This results in an SIR of 1.94 (13/6.687), signify ing that during this time period our facility identified 94% more SSIs than expected.

• The p-value and 95% Confidence Interval indicate th at the number of observed SSIs is significantly higher tha n the number of expected SSIs.

Documents

Pennsylvania Department of Health (PADOH) – CLABSI, CAUTI, and SSI Auditeoplugin.commpartners.com/APIC/120119/120119 CLABSI CAUTI and S… · Mary Andrus, BA, RN, CIC Infection