1. Stop CAUTI: C6 Onboarding Webinar #2
Outcome Data:
Application of NHSN CAUTI Criteria
Kathy Allen-Bridson, RN, BSN, MScPH, CIC – Nurse Consultant, Div. of Healthcare Quality and Promotion, Centers for Disease Control
Tina L. Adams, RN, Clinical Content Development Lead,
American Hospital Association-Health Research & Educational Trust

2. Presentation Link
Slides for today’s presentation can be found at:

3. Outline Key terms Background NHSN overview
Collaborative outcome metrics
SUTI and ABUTI definitions
Case studies

4. Key Terms HAI – health care-associated infection
POA- Present on admission
CAUTI – catheter-associated urinary tract infection
SUTI – symptomatic urinary tract infection (CA-SUTI=catheter-associated SUTI)
ABUTI – asymptomatic bacteremic urinary tract infection (CA-ABUTI=catheter-associated ABUTI)
NHSN – National Healthcare Safety Network

5. Why CAUTI?
Increased morbidity, mortality (attributable mortality = 2.3%), hospital cost, and length of stay
15% to 25% of hospitalized patients may receive short-term indwelling urinary catheters
CAUTI is the second most common site of HAI
17% to 69% of CAUTI may be preventable with recommended infection prevention measures
Up to 380,000 infections and 9,000 deaths related to CAUTI per year could be prevented
Gould CV, et al. Guideline for prevention of CAUTIs, 2009
Magill S, et al. Prevalence of HAIs in acute care hospitals in Jacksonville, FL. ICHE. March 2012, Vol. 33, No.3.

6. Business Case for CAUTI Prevention: Reservoirs of Resistance
We’ve seen that antibiotic resistance can travel the globe. Klebsiella pneumoniae carbapenemase (KPC) infections, a type of resistant bacteria known as CRE, were once seen in limited locations in the United States but are now found throughout the country.
Another type of CRE, caused by New Delhi metallo‐beta‐lactamase (NDM‐1), was initially identified in India, but is now present in several other countries.
Last accessed 5/10/12

7. CMS Incentives: Pay for Reporting CMS 2012 IPPS Final Rule
CMS Incentives: Pay for Reporting CMS 2012 IPPS Final Rule. Released August 18, 2011, Federal Register 76 (no.160)
HAI Event
Facility Type
Reporting Start Date
Acute Care Hospitals
CAUTI
Adult and Pediatric ICUs
January 2012
Others
Long Term Care Hospitals* - all locations (*These are called Long Term Acute-care Hospitals in NHSN.)
October 2012
Inpatient Rehabilitation Facilities - all locations
IPPS Exempt Cancer Hospitals
January 2013

8. The Joint Commission
NPSG : Implement evidence-based practices to prevent CAUTI (2012=Planning year; By January 2013=full implementation)

9. HAI Surveillance NHSN Patient Long Term Care Biovigilance Safety
Healthcare
Personnel
Biovigilance
Long Term Care

10. NHSN Background
NHSN has a standardized set of criteria and definitions.
Consistency in application of criteria by Infection Preventionists (IPs) is vital.
NHSN CAUTI data collection tool will assist in data collection at point of care.
Today’s presentation will include NHSN CAUTI surveillance and protocol updates for 2013.
NHSN criteria are designed to look at a population at risk. It is critical to identify patients meeting the criteria and consistently apply them. This ensures comparability of the data.
Criteria are not perfect. Valid clinical arguments may be made against the criteria, but as the NHSN manual states, “The definitions used in this manual are the only criteria that should be used when identifying and reporting NHSN events. While all participants may not agree with all the criteria, it is important that NHSN participants consistently use them for reporting infections, so that rates between hospitals can be appropriately compared.” This may take some getting used to…but is necessary comparable data. Keep in mind that these are surveillance case definitions, not clinical case definitions.

11. Comparison of Definition Types
Surveillance definitions…
(aka “analytical epidemiology”)
Establish uniform criteria to report a disease, 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
Surveillance case definitions and clinical diagnoses. Paediatric Child Health
Clinical definitions…
(aka “clinical epidemiology)
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.

12. Cohort 6: What do we need to collect?
Outcome and Process data will be collected
Data are collected per the Cohort 6 specific schedule
Today’s presentation will focus on Outcome (CAUTI Rate & Device Utilization Ratio) data
For purposes of this collaborative, only Catheter-associated Symptomatic Urinary Tract Infection (CA-SUTI) will be tracked. (CMS and NHSN reporting requires CA-SUTI and CA-ABUTI)
For a detailed data collection calendar, visit the On the CUSP Website:

13. What you enter depends on where you enter…
Via MHA Care Counts, enter
CA-SUTI only
Via NHSN, enter both
CA-SUTI and
CA-ABUTI

14. Specific data 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 NHSN-defined Symptomatic CAUTIs (CA-SUTIs) (and if reporting through NHSN, Asymptomatic Bacteremic CAUTIs [ABUTIs]) for that month - numerator
Outcome Metrics: CAUTI Rate and device utilization ratio (DUR- catheter prevalence in the unit[s] under surveillance)

15. Cohort 6: When and Where Do We Enter?
Enter monthly for 5 months and then 1 month per quarter thereafter (first 3 months are considered baseline)
Where:
Manual data entry into Care Counts, or,
Manual entry or electronic transfer of data from infection control software into NHSN. Hospitals need to join their state group and accept the confer rights template.

16. Submission Date Expectations…
If submitting into 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 Apr’13 data – complete entry by 5/31/13.
If submitting directly into MHA Care Counts:
Submit aggregate data (numerator – CA-SUTIs), denominators (pt. days and urinary cath. days) by the end of the month following the one under surveillance. E.g. for Apr’13 data – complete entry by 5/31/13.

17. NHSN Training
NHSN Training is required prior to collecting and entering data into NHSN. If you are responsible for collecting and submitting data to NHSN and have not yet gone through the formal NHSN training, you may access this training at the above website.

18. CAUTI Surveillance Methods
Concurrent, lab-based surveillance
Use retrospective model only when absolutely necessary
Non-IPs can screen cultures, but trained IP must make final call
Non-IPs can collect denominator data, but IP needs to review
Pt. and cath days should be collected at the same time of day each day, including weekends and holidays.
Need to ensure device days do not exceed patient days
It is not required to monitor for CAUTIs after the patient is discharged from the facility. However, should a CAUTI meet criteria on the day of discharge or the next day, it must be reported. No additional indwelling catheter days are reported in this situation.
Ensure that audience understands that “collected at the same time daily” not only means together, but also consistently at the same time of day

19. CAUTI Surveillance Criteria
Use June 2013 definitions/criteria which will be posted at: and HAI: An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were first present on or after the 3rd calendar day of admission to the facility (day of hospital admission is day 1). For an HAI, an element of the infection criterion may be present during the first 2 calendar days of admission, as long as it is also present on or after calendar day 3. All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between any 2 elements.

20. CAUTI Surveillance Criteria
POA: If all of the elements of an infection definition are present during the two calendar days before the day of admission, the first day of admission (day 1) and/or the day after admission (day 2) and are documented in the medical chart, the infection would be considered POA. Infections that are POA should not be reported as HAIs. Acceptable documentation does not include self-reported symptoms by the patient (e.g., patient reporting having a fever prior to arrival to the hospital). Instead, symptoms must be documented in the chart by a healthcare professional during the POA time frame (e.g., nursing home documents fever prior to arrival to the hospital). Physician diagnosis can be accepted as evidence of an infection that is POA only when physician diagnosis is an element of the specific infection definition. For example, the admission history could indicate that the physician suspects a UTI. The patient was documented to have a fever in the nursing home the day before admission to the hospital, and upon admission to the hospital (day 1) a urine sample was collected and cultured yielding >100,000 cfu/ml of a pathogen. This infection would be considered a POA because the required elements of the infection definition (for symptomatic urinary tract infection [SUTI]) were first present during the two calendar days before admission, the day of admission, or the day after admission NOTE: For POA, the temperature value does not need to be known to establish the presence of a fever. NOTE: Physician diagnosis of a UTI does not contribute to satisfying POA definition since physician diagnosis is not an element used to meet SUTI criteria. NOTE: This should not be applied to SSI, VAE, or LabID Events.

21. CAUTI Criteria
CAUTI-A Urinary Tract Infection (UTI) meeting the HAI definition is considered a CAUTI if the indwelling urinary catheter was in place for >2 calendar days when all CDC/NHSN UTI elements were first present. UTIs occurring on the day of catheter discontinuation or the following calendar day are considered CAUTIs if the catheter had been in place already for >2 calendar days. If an indwelling urinary catheter was in place for >2 calendar days and then removed, the UTI criteria must be fully met on the day of discontinuation or the next day.

22. 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) However, if pt. has both a suprapubic cath and a Foley, INCLUDE in surveillance for CAUTI.
Gould CV, et al. Guideline for Prevention of CAUTIs, Available at:

23. Steps for Identifying Cases of CA-SUTI
Start with review of + urine cultures (UCs) – e.g. daily report from your facility’s micro lab
Pull out + UCs 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 (In some facilities, once pt. is discharged, lab may assign location of specimen to all one location for the patient. Know your lab’s practices and review accordingly to capture needed specimens.)
Cultures taken on day of admission or next day should be assessed for evidence of infection on admission. Cultures must be assessed with the Transfer Rule in mind.

24. Important Notes for Step 1
Transfer rule for CAUTI: If all elements of CAUTI were present within 2 calendar days of transfer from one inpatient location to another in the same facility (i.e., on the day of transfer or the next day), the CAUTI is attributed to the transferring location. Likewise, if all elements of a CAUTI were present within 2 calendar days of transfer from one inpatient facility to another, the CAUTI is attributed to the transferring facility. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting.
Example: Ms. Jones is transferred from CCU to 8A Cardiac Stepdown on 5/12/12 w/Foley. On 5/13, she develops suprapubic pain and urine culture collected grows E. coli. Her CAUTI should be assigned to CCU.

25. Important Notes for Step 1-continued
Verify with your facility’s information technology personnel that reporting rules applied to the Laboratory Information System do not preclude your receipt of certain positive cultures. I.E: some custom facility-specific reporting rules or data mining systems remove results where colony counts are < (Impact – removes possible cases of CAUTI from detection during review, e.g. criterion 2a).

26. Step 2 for Identifying Cases of CA-SUTI
Review Criteria for SUTI and ABUTI based on presence or discontinuation of Foley catheter, CFU/ml of urine culture and pertinent blood cultures matching the urine culture.

27. CA-SUTI with Indwelling Catheter
Note: If fever is present in Signs & Symptoms, continue down flow chart – fever is a nonspecific symptom; do not try to distinguish other possible causes

28. CA-SUTI with catheter removed in prior 2 days…
Note: If fever is present in Signs & Symptoms, continue down flow chart – fever is a nonspecific symptom; do not try to distinguish other possible causes

29. CA-ABUTI with or without catheter…
ABUTI not counted for Collaborative but must be reported for NHSN and CMS purposes

30. Determining Date of Event
Date of Event = the date when the last element used to meet the CAUTI criterion occurred (cannot be earlier than Day 3 of catheter use).

31. Assigning to a Unit
Assign the CAUTI to the location where the patient was located on the date of event. Exception: The Transfer Rule If all elements of a CAUTI were present within 2 calendar days of transfer from one inpatient location to another in the same facility (i.e., on the day of transfer or the next day), the CAUTI is attributed to the transferring location. Likewise, if all elements of a CAUTI were present within 2 calendar days of transfer from one inpatient facility to another, the infection is attributed to the transferring facility. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting. Example: A patient with a Foley which has been in place > 2 days is transferred from SICU to the step-down unit on Friday [1/04/12]. Saturday [01/05/12] afternoon, fever of 38.5 C is observed, UC is obtained which finds >105 K. pneumoniae CFU/ml. CAUTI identified and assigned to the SICU.

32. Special Considerations
If the patient has a UTI POA, then has a change in the uropathogen and symptoms which strongly suggest the acquisition of a new infection, this should be considered as an HAI.
A positive urine culture with no matching blood culture is NOT considered an infection, even if an MD diagnoses a UTI.

33. Denominator Data
Make sure CAUTI is included in your monthly NHSN reporting plan for the unit(s) included in this collaborative.
Engage personnel in unit(s) identified in your surveillance plan to collect catheter days and patient days at the same time each day of the month.

34. Automated Device Denominator Collection
STOP!
Have you validated accuracy of urinary catheter days collated automatically if this is available via your facility’s electronic medical record (EMR)?
Urinary catheter days from EMR need to be within 5% of those identified from manual collation method, e.g. monthly device log. Minimum 3 month validation required by NHSN.
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:
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

35. Calculating CA-SUTI Rates
Data elements required to calculate Collaborative outcomes:
a. Numerator: # of CA-SUTIs/ month
b. Denominator: # of indwelling catheter
days/month
Equation to calculate:
CAUTI Rate = # of CA-SUTIs/month X 1, # Catheter Days/month

36. Frequently Asked Questions
Q: What is the time period for associating symptoms or U/A to a positive urine culture? A: All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between any two elements. Ex. 1. Fever on 1/1/13 with positive urine culture collected on 1/3/13 = meets criteria. Ex. 2. Fever on 1/1/13 with positive urine culture collected on 1/4/13 = does not meet criteria.
1/1/13
1/2/13
1/3/13
1/4/13
fever
+ urine cx
+ urine cx

37. Frequently Asked Questions
Q: If a patient has a positive U/A on admission are subsequent UTIs considered present on admission? A: Unless all elements of a UTI criterion are met within the 2 days before admission (if healthcare documentation) and/or the first 2 days of admission (admission day = day 1) the UTI is considered healthcare associated.

38. Frequently Asked Questions
Q: What if a patient is not able to sense or verbalize symptoms? A:
-Some sedated patients may be able to communicate pain non-verbally.
-Ensure that adequate assessment is being performed. This may necessitate education of staff.
-Always apply the definitions as written. If patient does not meet the surveillance definition do not report a UTI.

39. Case Study # 1
Mrs. J, a 62-yo female was transferred to unit 4 East from CCU four 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 4 East, she spiked a temp to F (38.1°C). A UA and UC were sent. UA showed 3 WBCs from an unspun sample. The UC came back growing 102 CFU/ml of E. coli.
Answer: No. UA WBC count too low to meet criteria, CFUs too low to meet criteria. Additionally, if this patient had met criteria for a UTI, it would not have been catheter-associated as full criteria were not met within 2 days of Foley discontinuation.

40. Does this case meet the criteria for a catheter-associated SUTI?
Yes No
Does not meet CA-SUTI criteria but is a HAI UTI.
B. No, the patient does not meet the minimum microbial growth for culture requirements for UTI. Likewise, the catheter was not in place in the 2 days prior to the criteria being met.

41. Case Study # 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 palpation. A UA showed >10 WBCs/mm3 of unspun urine and UC grew 10,000 CFU/ml Pseudomonas aeruginosa.

42. Is this a catheter-associated SUTI?
Yes No
Yes, this patient meets SUTI criterion 2a: suprapubic tenderness, U/A positive for sufficient WBCs and positive UC with sufficient organisms. Foley was in place > 2 days before the UTI criteria were met, therefore the infection is catheter-associated.

43. Case Study # 3
9/1: 68-year-old female admitted to 6E from OR, status post left KPRO. Foley placed in the OR is draining pink urine. PACU nurse reports difficulty with Foley placement. Bulb suction to left knee via stab wound draining small amount bloody drainage. IV in left forearm, site without redness and dressing dry. Patient controlled analgesia via pump.
9/2: Drain removed. Patient up to bathroom with help of physical therapist. Foley removed. IV continues. Afebrile. Complains of burning on urination after Foley discontinued.

44. Case Study # 3, continued…
9/3: Patient to physical therapy. Suprapubic pain upon palpation. Temp 37.8°C. Urine collected and sent for culture and U/A; + for 10+ WBCs by HPF of unspun urine, + leukocyte esterase. Empiric antibiotics begun.
9/4: Urine culture with >100,000 CFU/ml S. epidermidis.

45. Does this patient have a health care-associated UTI?
No, patient’s UTI was present on admission since the patient had dysuria on Day 2.
No, patient does not have a UTI.
Yes, patient has a SUTI 1a attributable to 6E.
A. Yes, patient has a SUTI 1a attributable to 6E. Foley removed in last 2 days: Urgency, (frequency, suprapubic pain); sufficient number organisms in UC.

46. Does this patient have a CAUTI?
No, patient’s SUTI 1a is not catheter-associated by NHSN criteria.
Yes, patient’s SUTI 1a is catheter-associated.
A. No. Patient’s SUTI 1a is not catheter-associated because the catheter was not in place for >2 days before the UTI criteria were fully met.

47. Case Study # 4 84 year old patient is hospitalized with GI bleed.
Day 3: Patient’s indwelling catheter has been in place since admission and no signs or symptoms of infection are present.
Day 9: Patient becomes unresponsive, is intubated and CBC shows WBC of 15,000. Temp 38.0°C. Patient is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes – urine >105 CFU/ml.

48. Is this a CAUTI? If so, what type?
No, because the blood seeded the urine and therefore there is no UTI.
Yes, CA-ABUTI.
Yes, CAUTI Criterion 1a with secondary BSI.
B. Yes, CA-ABUTI. Urinary catheter in place > 2 days when criteria met. No symptoms (Tmax not > 38°C); matching uropathogen* in blood and urine culture (≥ 105 CFU/ml).
*(S. pyogenes is beta-hemolytic Strep spp.)

49. What if the organism in both cultures had been Micrococcus?
There would be an ABUTI.
There would not be an ABUTI.
B. There would not be an ABUTI.

50. Case Study # 5
9/1: 73 y.o. patient in neurosurgical ICU. Admitted 7 days ago following cerebrovascular accident. Ventilated, subclavian catheter and Foley catheter in place since admission. Patient reacts only to painful stimuli.
9/2: WBCs slightly elevated, at 12,000/mm3, temp 37.4°C, urine cloudy. Lungs clear to auscultation.
Answer: No. Foley was discontinued >48 hours before temp, UA WBC count too low to meet criteria, CFUs too low to meet criteria.

51. Case Study # 5, continued…
9/3: WBC 15,800/mm3. Temperature: 37.6°C. Breath sounds slightly coarse, minimal clear sputum. Urine unchanged. Blood, endotracheal and urine cultures collected. No suprapubic tenderness or CVA pain or tenderness noted.
9/4: Blood and endotracheal cultures no growth. Urine with 100,000 CFU/ml E. faecium.
Answer: No. Foley was discontinued >48 hours before temp, UA WBC count too low to meet criteria, CFUs too low to meet criteria.

52. Does this patient have a UTI? If so, what type?
Yes, ABUTI.
Yes, SUTI Criterion 1a.
Yes, SUTI Criterion 1b.
No UTI.
Answer: No. Foley was discontinued >48 hours before temp, UA WBC count too low to meet criteria, CFUs too low to meet criteria.
D. No UTI. No symptoms, and no matching blood culture to urine culture.

53. Case Study # 6
What if on 9/5, the patient from Case #5 had a temp. of 38.1°C and the patient also met the criteria for a PNEU including a bronchoalveolar lavage for P. aeruginosa?

54. Would this patient have a CAUTI? If so, what type?
Yes, CA-ABUTI.
Yes, CA-SUTI Criterion 1a.
Yes, CA-SUTI Criterion 1b.
No UTI.
B. Yes, CA-SUTI Criterion 1a. Fever > 38.0°C*, positive urine culture of sufficient quantity. Foley present > 2 days before UTI criterion fully met. No more than 1 day gap between criterion elements. (*Not possible to
exclude source of fever as urine.)
Answer: No. Foley was discontinued >48 hours before temp, UA WBC count too low to meet criteria, CFUs too low to meet criteria.

55. Catheter Prevalence
AKA: DUR (Device Utilization Ratio) Data elements required to calculate: 1. Catheter days 2. Patient days Equation: DUR = # Catheter Days/month # Patient Days/month

56. (50 Catheter days ÷ 100 Patient days = 0.50)
What does it mean?
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.
Must be analyzed in conjunction with rates. No magic number to determine where it should be. If rates are acceptable, DUR is most likely OK. If rates are not good, DUR should be assessed to determine if utilization is too high. This is where comparative data can help along with a good understanding of the patient population in your unit. Under-utlization can result in other untoward outcomes so balance must be assessed. Assessment of compliance to appropriate insertion/necessity criteria should be included when DUR data are analyzed, along with quality of these criteria. (E.g. if compliance to criteria is high but DURs and/or rates are high, the criteria should be assessed to ensure they are not overly liberal.) Compare to NHSN and eventually NC CAUTI Collaborative. Expect to come down with insertion criteria and daily assessments for necessity in most cases. NOTE: CAUTI rate may go up if device days go down. Therefore, important to report raw numbers along with rates to key stakeholders.

57. Questions?
NHSN Training Resources:

58. Cohort 6: Onboarding Webinar Series
Date(s)
Time/Duration
Topic
07/02/13
and
07/09/13
11:00 am – 12:00 am CT
(60 minutes)
Onboarding Call #3 –
Care Counts Data Entry and Report Training (Offered twice)
07/16/13
07/23/13
Onboarding Call #4 –
HSOPS Training
(Offered twice)
08/06/13
11:00 am – 12:15 pm CT
(75 minutes)
Onboarding Call #5 –
Assess and Adapt: Understanding the Science of Safety and Reliability

59. Your Feedback is Important
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