Presentation on theme: "On the CUSP: Stop CAUTI National Content Webinar 1 Welcome to the National Content Webinar! Today’s Topic: 2015 NHSN CAUTI Definition Changes Access slides,"— Presentation transcript:
On the CUSP: Stop CAUTI National Content Webinar 1 Welcome to the National Content Webinar! Today’s Topic: 2015 NHSN CAUTI Definition Changes Access slides, audio recording and transcript of today’s webinar on the national project website: cauti/educational-sessions/content-calls/
Katherine Allen-Bridson, BSN, RN, MScPH, CIC Nurse Consultant Division of Healthcare Quality Promotion Centers for Disease Control and Prevention On the CUSP: Stop CAUTI March 10, 2015 Changes to NHSN Catheter-Associated Urinary Tract Infection Surveillance in 2015 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
Objectives Identify the major changes for 2015 for CDC/NHSN CAUTI surveillance and general surveillance changes that will impact CAUTI reporting. Apply the CAUTI definitions to case studies. Identify the limitations on anticipating changes to CAUTI rates. Identify ways that facilities may appreciate the effects that some of the measurable changes may have on their CAUTI rates.
For More Information….. Please see the following for more in-depth guidance: –NHSN Definition and Rules Changes for 2015 –CAUTI: Definition Changes for 2015 –Device-associated Denominator Sampling for 2015 Available at care-hospital/CAUTI/index.htmlhttp://www.cdc.gov/nhsn/acute- care-hospital/CAUTI/index.html UTI protocol available at CAUTIcurrent.pdf CAUTIcurrent.pdf
GENERAL NHSN HAI CHANGES FOR 2015
General NHSN HAI Changes for 2015 Addition of the following surveillance rules: –Infection Window Period –Repeat Infection Timeframe (RIT) –Secondary BSI Attribution Period (not pertinent) Date of event Optional weekly denominator sampling
Major UTI Changes for 2015 Requirement for ≥ 100,000 CFU/ml organisms in urine culture Exclusion of non-bacteria as sole pathogens Use of same pathogen list for symptomatic UTI (SUTI) and asymptomatic bacteremic UTI (ABUTI)
What Hasn’t Changed for 2015 Present on Admission Healthcare-associated infection Timeframe for associating use of indwelling urinary catheter to UTI Transfer Rule Symptoms for SUTI (except removal of dysuria from infant) Fever still cannot be excluded as due to another source of infection Definition of indwelling urinary catheter
UTI Infection Window Period Infection Window Period 1 3 days before 2 3 Date of urine culture 1 st positive Diagnostic Test 1 3 days after 2 3
UTI Repeat Infection Timeframe (RIT) 14 day timeframe No new UTIs are reported Date of event = Day 1 Additional pathogens from urine cultures during RIT are added to the event
14 Day Repeat Infection Timeframe (RIT)
NHSN CAUTI DEFINITIONS FOR 2015 (NON-INFANTILE)
UTI Overview SUTI 1 A: Catheter- associated B: Non-catheter associated SUTI 2 Catheter- associated Non-catheter- associated ABUTI Catheter- associated Non-Catheter- associated Any Age Infant ≤ 1 yr Any Age
SUTI 1a (catheter in place) Patient must meet 1, 2, and 3 below: 1.Patient has an indwelling urinary catheter in place for the entire day on the date of event and such catheter had been in place for >2 calendar days, on that date (day of device placement = Day 1). 2.Patient has at least one of the following signs or symptoms: fever (>38.0°C) suprapubic tenderness* costovertebral angle pain or tenderness* 3.Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period.
SUTI 1a (catheter recently removed) Patient must meet 1, 2, and 3 below: 1.Patient has an indwelling urinary catheter in place for greater than 2 days which was removed on the day of or the day before the date of event. 2.Patient has at least one of the following signs or symptoms: fever (>38.0°C) suprapubic tenderness* costovertebral angle pain or tenderness* urinary urgency* urinary frequency* dysuria* 3.Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period.
Criterion Rationale – SUTI 1a Catheter removed UTIs with event date on the day of device discontinuation or the following calendar day are considered device-associated UTIs if the device had been in place already for >2 calendar days. For this criterion urgency, frequency and dysuria are symptoms. Day 1Day 2Day 3Day 4CAUTI? Foley placedFoley in place Foley in place for part of day only then removed Date of eventYes Foley placed Foley in place for part of day then removed No FoleyDate of eventNo Foley placed Foley in place for part of day then removed Date of eventNo
Asymptomatic Bacteremic UTI (ABUTI) Patient must meet 1, 2, and 3 below: 1.Patient with* or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age. (Note: Patients > 65 years of age with a non-catheter-associated ABUTI may have a fever and still meet the ABUTI criterion.) 2.Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥10 5 CFU/ml. 3.Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meets LCBI criterion 2 (without fever) and matching common commensal(s) in the urine. All elements of the ABUTI criterion must occur during the Infection Window Period. *Patient had an indwelling urinary catheter in place for >2 calendar days, with day of device placement being Day 1, and catheter was in place on the date of event or the day before.
ABUTI Note:Only events with catheters in place for >2 calendar days prior to date of event are catheter-associated.
UTI Flow Diagram
OPTIONAL DENOMINATOR SAMPLING
Collecting Summary Denominator Data Options: ● Manually collected every day ● Electronically collected every day Following validation of the electronic method against the manual method 3 months concurrent data collection with both methods Difference between methods must be within +/- 5% of each other ● Weekly sampling
Denominator Sampling Summed sampling data for month
Denominator Sampling If weekly sampling is used, upon entry of the monthly data into NHSN, an estimate of central-line days or urinary-catheter days will be automatically calculated and used as CLABSI and CAUTI denominator data. Estimated urinary catheter days = # sample UC days # sample pt. days X Total pt. days
Denominator Sampling To ensure the accuracy of the estimated denominator data, only non-oncology ICU and ward location types with 75 or more device days per month are eligible to use the alternative method. Review of each location’s prior year (i.e., 12 months) of CLABSI or CAUTI denominator data in NHSN will help determine which locations are eligible.
Resources for NHSN
Resources for Surveillance NHSN Forms : Monthly Reporting Plan : Urinary Tract Infection : Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
Available Resources and Training Resource –CDC/HICPAC Guideline for Prevention of Catheter- associated Urinary Tract Infections 1 Training –Device-Associated Module –Pre-recorded Webinars –Lectoras (interactive with knowledge checks) 1 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections Infect Control Hosp Epidemiol. 2010;31(4):
HOW MIGHT THESE CHANGES AFFECT CAUTI DATA?
Background Information NHSN serves multiple purposes. UTI changes were made alongside other HAI definitional changes for Changes make trend analysis challenging. Incorporated NHSN user and internal and external subject matter input. Non-arbitrary
Limitations in Quantifying Effects Effects of some changes cannot be quantified. –Variables are not measured E.g., Infection Window Period, Date of Event: do not collect dates of cultures or symptoms.
Locations and Facilities are Unique Variations in proportions of: –Non-bacterial vs bacterial CAUTIs –High colony count vs low colony count CAUTIs Variations in: –Urine culturing practices –Laboratory reporting practices –Antimicrobial use
Possible Directional Effects of Changes Exclusion of non-bacterial pathogens for UTI –Decrease the numbers of reported UTIs Institution of minimum urinary colony count of 100,000 CFU/ml –Decrease the numbers of reported UTIs
Possible Directional Effects of Changes Infection Window Period –Increase the numbers of reported UTIs as IWP > “no more than a single gap day between adjacent elements” Date of Event –Decrease number of reported UTIs More POA vs HAI More non-catheter-associated UTI vs CAUTI Repeat Infection Timeframe –Decrease the numbers of events reported
So what’s a guy/girl/IP/ facility to do????
Assess the likely effect of major changes for your location/facility Assess frequency of yeast CAUTIs Assess frequency of CAUTIs with < 100,000 CFU/ml NHSN can assist users with creating output options to measure the impact of these variables.
What will this mean for SIRs reported to CMS? 2015: SIRs submitted to CMS this year will use existing, historical baseline. 2016: Data reported to NHSN for events in 2015 will be used as the new baseline for SIRs.
Summary Significant changes for NHSN UTI surveillance for Changes made following thorough review of issues and with input from NHSN users and subject matter experts. Decrease subjectivity, increase consistency.
Summary A national projected effect on CAUTI rates is not possible. –Limitations of data variables collected –Facility practice variations Facilities/groups can analyze past data to anticipate some major effects.
Investigating a Positive Urine Culture as Possible CAUTI Proceed in this order*: 1. Determine infection window period (IWP). 2. Determine if all criteria occur within IWP, i.e., is it an event? Yes= continue; No = Stop, no event. 3. Determine date of event (DOE). 4. Determine if present on admission (POA) or healthcare-associated (HAI). If POA, previously discharged that day or day before? Yes = UTI attributable to discharging location; No = Stop, POA. If HAI, continue 5. Determine if device-associated. 6. Determine attributable location/facility. 7. Determine Repeat Infection Timeframe. 8. Determine Secondary BSI Attribution Period (if necessary).
Device Associated Example #1
Polling Question Is this an NHSN CAUTI? Yes No
Device Associated Example #2
Polling Question Is this an NHSN CAUTI? Yes No
Device Associated Example #3 Day 1 – Admit to ICU Day 4 – Foley inserted Day 8 – Foley removed; asymptomatic Day 9 – No Foley in place; Fever º F Day 10 – Fever 100.5º F; Urine (+) 100,000CFU/ml E. faecium Rationale: This is a CAUTI. The date of event (day 9) was the day after catheter removal and catheter in place >2 calendar days.
Device Associated Example #4
Case 1 Patient is transferred to your hospital from inpatient rehabilitation facility with a Foley catheter that has been in place for 2 weeks. He had a fever of 38.5°C and a change in mental status the day before transfer, reported by a health care worker. He is afebrile on admission. Urine cultures collected on admission are positive for 10,000 CFU/ml of E. coli and U/A is positive for nitrites.
Polling Question Which of the following is most accurate? 1. Patient does not have an NHSN CAUTI. 2. Patient has a CAUTI attributed to the new hospital. 3. Patient has a CAUTI attributable to the rehab facility and POA to the hospital.
Case 1 Rationale Answer: Patient does not have an NHSN CAUTI. Urine cultures must have a minimum of 100,000 CFU/ml to be used as an element of 2015 NHSN UTI criteria.
What If? Patient is transferred to your hospital from inpatient rehabilitation facility with a Foley catheter that has been in place for 2 weeks. He had a fever of 38.5°C and a change in mental status the day before transfer, reported by a health care worker. He is afebrile on admission. Urine cultures collected on admission are positive for 10,000 ≥ 10, ,000 CFU/ml of E. coli and U/A is positive for nitrites.
Polling Question Which is the best determination of whether an NHSN CAUTI is present? 1. Patient does not have an NHSN CAUTI. 2. Patient has a CAUTI attributed to the new hospital. 3. Patient has a CAUTI attributable to the rehab facility and POA to the hospital. 4. Determination cannot be made without understanding the laboratory’s reporting protocols.
Case 1 Rationale Answer: Determination cannot be made without understanding the laboratory’s reporting protocols. Check with laboratory to determine if they can confirm that at least 100,000CFU/ml of E. coli is present in culture. –If yes, CAUTI Is attributable to the rehab facility. –If not, no NHSN UTI as required minimal colony count cannot be confirmed.
Case 2 February 1, hospital day 4. Foley has been in place for >2 days and patient spikes temp of >38.0°C. Urine culture collected and positive for 10 5 CFU/ml of Klebsiella pneumoniae, and Citrobacter freundii (2 species) February 3, urine culture collected and positive for 10 5 CFU/ml Klebsiella ornithinolytica
Polling Question Which of the following is correct: 1. Patient does not have an NHSN CAUTI because there are more than 2 organisms in the urine culture. 2. Patient has a CAUTI with date of February 1.
Case 3 Day 1: 58-year-old patient is admitted to the ED with GI bleed. Foley inserted. Day 2: Patient spikes temp of 38.6°C. Indwelling catheter remains in place. Day 3: Urine specimen is collected. Day 4: Culture results 100,000 CFU/ml Pseudomonas aeruginosa. Antibiotics started. Day 5: Patient asymptomatic and afebrile. This is a SUTI that is present on admission for NHSN purposes. Date of event = day 2.
Case 3 – Continued Day 15:Foley remains in place. Patient completed treatment for UTI on hospital day 11 and has been afebrile since. Temperature today 38.1°C. Cough productive of yellow phlegm. Rhonchi present. Day 16:Urine cloudy. Fever 37.9°C. Cough continues. Sputum specimen collected. Day 17:Urine specimen collected. Day 18: Urine and sputum cultures both positive for S. aureus with > 100,000 CFU/ml in urine.
Should another CAUTI be reported? No, the date of event for a UTI related to this culture occurs during the RIT of previous UTI.
Hosp Day Dev- ice UTI Criterion 1Foley (F) 2F Temp 38.6°C 3F Urine culture (“+” 10 5 CFU/ml P. aeruginosa) 4F 5F 6F 7F 8F 9F 10F 11F 12F 13F 14F 14 Day Repeat Infection Timeframe (RIT) Date of event Infection Window Period
Case 3 Rationale Unlike CLABSI, CAUTIs may NOT be excluded as secondary to another infection. Fever cannot be attributed to another source of infection. ‡ The date of event for this UTI would be Day 15 (date of fever) which is within RIT for POA UTI from Day 2. If earlier UTI was HAI and was reported, S. aureus would be added as pathogen to that event. ‡ See March 2012 Newsletter; also note the lack of “*” following fever in criteria.
Case 4 04/05/15:Patient admitted from LTAC at 8 a.m. for surgical debridement of sacral decubitus. Routine admission U/A performed, positive for leukocyte esterase, and 3 WBC by HPF of spun urine. Patient afebrile, denies urinary urgency, frequency or pain. No suprapubic or CVA pain. Foley catheter present on admission. Admit postoperatively to telemetry unit. 04/06/15:Wound clean. Temperature 37.4°C. Foley draining cloudy urine.
Case 4 – Continued 04/07/15:Transfer to surgical unit. WBCs 12,100/mcL. Temp of 37.9°C. Foley removed. Urine sent to lab for culture and sensitivity. 04/08/15:Dysuria and suprapubic tenderness. Bactrim started. 04/09/15:04/07 urine culture positive for Candida albicans 100,000 CFU/ml. Patient afebrile.
Polling Question As of 4/9 does this patient have a UTI and if so, is it a CAUTI? 1. No. UTI criterion not yet met. 2. No, UTI was present on admission. 3. Yes, patient has a SUTI 1a. and it is a CAUTI.
Case 4 – Continued What if everything was the same except that the urine culture result was positive for S. aureus 100,000 CFU/ml and Candida albicans 100,000 CFU/ml? Answer: CAUTI
Case 4 Rationale DOE = 4/7 – Date of urine culture No more than 2 organisms in urine, 1 of which was bacteria > 100,000 CFU/ml. SUTI 1a criterion met; Infection Window Period = 4/4 - 4/10. Foley had been in > 2 days on DOE and removed that day = catheter-associated.
Hosp DayDeviceUTI Criterion 1 (4/5) Telemetry unit Foley (F) 2F 3 (4/7) Telemetry ►surgical unit F discont. Urine culture: (“+” 10 5 CFU/ml S. aureus and Candida albicans) 4 (4/8) Dysuria and suprapubic tenderness 5 6 (4/10) Discharged 7 14 Day Repeat Infection Timeframe (RIT) (abbreviated due to facility discharge) Date of event Infection Window Period
Questions: user support NHSN website:
Next Steps Review and reference the guidance documents and Kathy provided: – NHSN Definition and Rules Changes for 2015 – CAUTI: Definition Changes for 2015 – Device-associated Denominator Sampling for 2015 To help determine what impact these changes may have on your facility: – Assess frequency of yeast CAUTIs – Assess frequency of CAUTIs with < 100,000 CFU/ml
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