Presentation on theme: "On the CUSP: Stop CAUTI National Content Webinar"— Presentation transcript:
1On the CUSP: Stop CAUTI National Content Webinar Welcome to theNational Content Webinar!Today’s Topic:2015 NHSN CAUTI Definition ChangesAccess slides, audio recording and transcript of today’s webinar on the national project website:
2Katherine Allen-Bridson, BSN, RN, MScPH, CIC Changes to NHSN Catheter-Associated Urinary Tract Infection Surveillance in 2015Katherine Allen-Bridson, BSN, RN, MScPH, CICNurse ConsultantDivision of Healthcare Quality PromotionCenters for Disease Control and PreventionOn the CUSP: Stop CAUTIMarch 10, 2015National Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion
3ObjectivesIdentify 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.
4For More Information…..Please see the following for more in-depth guidance:NHSN Definition and Rules Changes for 2015CAUTI: Definition Changes for 2015Device-associated Denominator Sampling for 2015Available atUTI protocol available at
6General NHSN HAI Changes for 2015 Addition of the following surveillance rules:Infection Window PeriodRepeat Infection Timeframe (RIT)Secondary BSI Attribution Period (not pertinent)Date of eventOptional weekly denominator sampling
7Major UTI Changes for 2015Requirement for ≥ 100,000 CFU/ml organisms in urine cultureExclusion of non-bacteria as sole pathogensUse of same pathogen list for symptomatic UTI (SUTI) and asymptomatic bacteremic UTI (ABUTI)
8What Hasn’t Changed for 2015 Present on AdmissionHealthcare-associated infectionTimeframe for associating use of indwelling urinary catheter to UTITransfer RuleSymptoms for SUTI (except removal of dysuria from infant)Fever still cannot be excluded as due to another source of infectionDefinition of indwelling urinary catheter
9UTI Infection Window Period 13 daysbefore23Date of urine culture1st positiveDiagnostic TestafterA positive urine culture is always required for NHSN UTI criteria and therefore it is used for the diagnostic test to set the infection window period. The patient then has the date of the culture and the 3 days before and after the culture to meet the other UTI elements. This is the 7-day UTI infection window period.
10UTI Repeat Infection Timeframe (RIT) 14 day timeframeNo new UTIs are reportedDate of event = Day 1Additional pathogens from urine cultures during RIT are added to the eventNote: Can add only 1 additional unless also has secondary BSI then can enter a 3rd organism.
1114 Day Repeat Infection Timeframe (RIT) Gen Def changes24/13/2017Hospital DaySUTICriterion891011Temp = 101.5° F12Temp = 102.1° F13Urine culture: >100,000 cfu/ml, E. coli1415161718192021222324Timeframe14 Day Repeat Infection Timeframe (RIT)
13SUTI 1 SUTI 2 ABUTI UTI Overview Any Age Infant ≤ 1 yr Any Age A: Catheter-associatedB:Non-catheter associatedSUTI 2Non-catheter-associatedABUTINon-Catheter-associatedAny AgeInfant ≤ 1 yrAny AgeThe 2 types of UTIs, can be categorized by the age of eligible patients, and their association with indwelling urinary catheters.Patients of any age (including infants) are eligible to meet SUTI criterion 1 and ABUTI. Only infants that are 1 year of age or less are eligible to meet SUTI criterion 2.Each type of UTI, SUTI 1, 2 and ABUTI, can be either catheter-associated or non-catheter-associated. It is only the catheter-associated (animate) SUTIs and ABUTIs that are reportable as part of CMS quality reporting programs for CAUTI.
14SUTI 1a (catheter in place) Patient must meet 1, 2, and 3 below: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).Patient has at least one of the following signs or symptoms:fever (>38.0°C)suprapubic tenderness*costovertebral angle pain or tenderness*Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥105 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period.
15SUTI 1a (catheter recently removed) Patient must meet 1, 2, and 3 below: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.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*Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥105 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period. After reviewing, go back to previous slide and Note intention of “entire day”-
16Criterion 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 placeFoley in place for part of day only then removedDate of eventYesFoley in place for part of day then removedNo FoleyNo
17Asymptomatic Bacteremic UTI (ABUTI) Patient must meet 1, 2, and 3 below: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.)Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥105 CFU/ml.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. The bacteria in the urine culture that matches the blood culture must have at least 100,000 CFU/ml.
18ABUTINote: Only events with catheters in place for >2 calendar days prior to date of event are catheter-associated.
19UTI Flow DiagramOriginal colors were hard to read and print. New version coming out in March will be white like this.This flowchart is able to capture what took 3 or 4 flowcharts in All UTI determinations.
21Collecting Summary Denominator Data Options:Manually collected every dayElectronically collected every dayFollowing validation of the electronic method against the manual method3 months concurrent data collection with both methodsDifference between methods must be within +/- 5% of each otherWeekly sampling
22Denominator SamplingSummed sampling data for month
23Denominator SamplingIf 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. daysX Total pt. days
24Denominator SamplingTo 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.
26Resources for Surveillance NHSN Forms57.106: Monthly Reporting Plan57.114: Urinary Tract Infection57.118: Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
27Available Resources and Training CDC/HICPAC Guideline for Prevention of Catheter- associated Urinary Tract Infections1TrainingDevice-Associated ModulePre-recorded WebinarsLectoras (interactive with knowledge checks)1Gould 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):
29Background Information NHSN serves multiple purposes.UTI changes were made alongside other HAI definitional changes for 2015.Changes make trend analysis challenging.Incorporated NHSN user and internal and external subject matter input.Non-arbitraryBefore we discuss what can and cannot be anticipated regarding changes in CAUTI rates, it’s important to remember a few things.The NHSN is a system which serves many purposes including being used by facilities and organizations to measure the success of infection prevention efforts, by agencies to determine reimbursement for patient care, and by individuals in healthcare decisions. All of these purposes are important and must be considered when changes are contemplated. Significant changes were made to several NHSN infection definitions in 2015 to try to bring the definitions closer to clinical determinations and current diagnostic practices as well as to increase the objectivity and consistency of the definitions and their application. We recognize that changes to the definitions make trend analysis challenging. However, we did feel that these changes were necessary given significant NHSN user-input as well as work undertaken over an 18-month period involving internal and external subject matter experts. The decisions were made using NHSN data and published research when available and were not arbitrary.
30Limitations in Quantifying Effects Effects of some changes cannot be quantified.Variables are not measuredE.g., Infection Window Period, Date of Event: do not collect dates of cultures or symptoms.We are limited in being about to quantify the changes that can be expected as a result of the general HAI definition changes as well as the UTI specific definitional changes. The Paperwork Reduction Act of 1995 limits the amount of data that NHSN may collect. Simply put, some of the variables necessary to analyze the effects of such rules as the Infection Window Period and the change in the definition of Date of Event to the date of the first element rather than the last are not collected in NHSN. Therefore no effect can be measured.
31Locations and Facilities are Unique Variations in proportions of:Non-bacterial vs bacterial CAUTIsHigh colony count vs low colony count CAUTIsVariations in:Urine culturing practicesLaboratory reporting practicesAntimicrobial useMore importantly there are variations between facilities and even between locations within the same facility, which will impact the effects that are experienced. For some facilities and some locations a high proportion of their reported CAUTIs are due to yeast alone, as high as 50% or more in some cases, while in others the proportion is quite low. Likewise there is great variation in the proportions of SUTIs meeting criterion 2 (lower colony count) vs 1 (higher colony count). This will also influence the amount of change in a location’s CAUTI rates. Some of these differences can be explained, at least in part by differences in practices of urine culturing, laboratory reporting and antibiotic use (which can increase the proportion of urine organisms that are yeast). So, each location or facility is likely to experience unique effects on their CAUTI rates.
32Possible Directional Effects of Changes Exclusion of non-bacterial pathogens for UTIDecrease the numbers of reported UTIsInstitution of minimum urinary colony count of 100,000 CFU/mlHaving prefaced what we can and cannot say about anticipating the changes to CAUTI rates, what is likely in the way of directional change? Well some are things are easy to predict. Both of the major UTI changes, should result in decreasing numbers of reported UTIs.
33Possible Directional Effects of Changes Infection Window PeriodIncrease the numbers of reported UTIs as IWP > “no more than a single gap day between adjacent elements”Date of EventDecrease number of reported UTIsMore POA vs HAIMore non-catheter-associated UTI vs CAUTIRepeat Infection TimeframeDecrease the numbers of events reportedThe institution of a 7-day infection window period instead of allowing no more than a single gap day between adjacent elements to meet all UTI criteria will likely increase the numbers of UTIs that are reported. On the other hand moving the date of event from the previous definition of the date of the last element to the date of the first element in the infection window period would seem to result in more infections being identified as POA than HAI and non-catheter-associated rather than CAUTI. The RIT is also likely to result in fewer CAUTIs being reported.
34What’s an IP to doSo what’s a guy/girl/IP/facility to do????
35Assess the likely effect of major changes for your location/facility Assess frequency of yeast CAUTIsAssess frequency of CAUTIs with < 100,000 CFU/mlBy running a frequency table of CAUTIs that have a non-bacterial pathogen listed as the sole pathogen and a frequency table that shows the proportion of CAUTIs reported with the lower colony count (≥ 1,000 but < 100,000 CFU/ml) in a location or facility, a crude estimate of the amount of change can be determined. NHSN can assist users who undertake these analyses if they have questions.NHSN can assist users with creating output options to measure the impact of these variables.
36What 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.
37Summary Significant changes for NHSN UTI surveillance for 2015. Changes made following thorough review of issues and with input from NHSN users and subject matter experts.Decrease subjectivity, increase consistency.
38Summary A national projected effect on CAUTI rates is not possible. Limitations of data variables collectedFacility practice variationsFacilities/groups can analyze past data to anticipate some major effects.
40Investigating 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, continue5. Determine if device-associated.6. Determine attributable location/facility.7. Determine Repeat Infection Timeframe.8. Determine Secondary BSI Attribution Period (if necessary).
41Device Associated Example #1 Day 5 –Foley inserted; asymptomaticDay 6 – Foley remains in place; Fever 38.2ºCDay 7 – Fever 38.6°CDay 8 – 100,000 CFU E. coli in urine
45Device Associated Example #3 Day 1 – Admit to ICUDay 4 – Foley insertedDay 8 – Foley removed; asymptomaticDay 9 – No Foley in place; Fever º FDay 10 – Fever 100.5º F; Urine (+) 100,000CFU/ml E. faeciumRationale: This is a CAUTI.The date of event (day 9) was the day after catheter removal and catheter in place >2 calendar days.IWP= day 7-13
46Device Associated Example #4 Day 1 – Admit to ICUDay 4 – Foley insertedDay 8 – Foley removedDay 9 – Foley insertedDay 10 – Temp of 100.6° F; Urine (+) 100,000 CFU E. coli; meets criteria for a symptomatic UTI here.Rationale: This is a CAUTI.This patient has had a Foley in place for some part of > 2 calendar days on the date of event. There was not a full calendar day without a Foley in place.IWP=day7-13
47Case 1Patient 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.
48Polling Question Which of the following is most accurate? Patient does not have an NHSN CAUTI.Patient has a CAUTI attributed to the new hospital.Patient has a CAUTI attributable to the rehab facility and POA to the hospital.
49Case 1 RationaleAnswer: 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.
50What 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.
51Polling QuestionWhich is the best determination of whether an NHSN CAUTI is present?Patient does not have an NHSN CAUTI.Patient has a CAUTI attributed to the new hospital.Patient has a CAUTI attributable to the rehab facility and POA to the hospital.Determination cannot be made without understanding the laboratory’s reporting protocols.
52Case 1 RationaleAnswer: 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.
53Case 2February 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 105 CFU/ml of Klebsiella pneumoniae, and Citrobacter freundii (2 species)February 3, urine culture collected and positive for 105 CFU/ml Klebsiella ornithinolytica
54Polling Question Which of the following is correct: Patient does not have an NHSN CAUTI because there are more than 2 organisms in the urine culture.Patient has a CAUTI with date of February 1.
55Case 3Day 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.
56Case 3 – ContinuedDay 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.
57Should another CAUTI be reported? No, the date of event for a UTI related to this culture occurs during the RIT of previous UTI.
5814 Day Repeat Infection Timeframe (RIT) Hosp DayDev-iceUTI Criterion1Foley (F)2FTemp 38.6°C3Urine culture (“+” 105 CFU/ml P. aeruginosa)4567891011121314timelineDate of eventInfection Window Period14 Day Repeat Infection Timeframe (RIT)Although the urine culture was collected outside of the RIT, the date of event was the last day of the RIT. See that when this is done, it is not necessary to work up urine cultures occurring within the RITDate of event
59Case 3 RationaleUnlike 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.
60Case 404/05/15: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.
61Case 4 – Continued04/07/15: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.
62Polling QuestionAs of 4/9 does this patient have a UTI and if so, is it a CAUTI?No. UTI criterion not yet met.No, UTI was present on admission.Yes, patient has a SUTI 1a. and it is a CAUTI.
63Case 4 – ContinuedWhat 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
64Case 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.
65Infection Window Period Timeframe 2Date of eventHosp DayDeviceUTI Criterion(4/5) Telemetry unitFoley (F)2F(4/7) Telemetry ►surgical unitF discont.Urine culture: (“+” 105 CFU/ml S. aureusand Candida albicans)(4/8)Dysuria and suprapubic tenderness5(4/10)Discharged7Infection Window Period14 Day Repeat Infection Timeframe (RIT) (abbreviated due to facility discharge)See that when this is done, it is not necessary to work up urine cultures occurring within the RIT; Infection window period extends to the
67Questions? For questions about CAUTI rates for 2015 vs 2014: 2015 CAUTI SIRs will use 2009 baseline; FY 2017 will use this comparison and facilities will probably look good.After 2015 is complete, a new baseline for 2015 will be computed and this will be used for subsequent SIRs.We understand that changes that we have made and continue to make to HAI definitions can create a tension for participant usability needsMakes trend analysis challengingThe changes are not arbitraryThe system is used for multiple purposesThe changes that can be expected in trends will vary from facility to facility and will be based on several variables:Culturing practicesLaboratory reporting practicesAntimicrobial prescribing practices (may impact the proportion of yeast)We cannot provide an anticipated percent of reduction. Such a reduction would be a national figure and not account for the great amount of variability between facilities which is contained within.Besides the changes due to the UTI definitional changes there will be changes that are due to the general definitions modifications identified earlier. The effects of these changes are not easily quantifiable either.
68Questions: email user support Contact usQuestions: user supportNHSN website:
69Next StepsReview and reference the guidance documents and Kathy provided:NHSN Definition and Rules Changes for 2015CAUTI: Definition Changes for 2015Device-associated Denominator Sampling for 2015To help determine what impact these changes may have on your facility:Assess frequency of yeast CAUTIsAssess frequency of CAUTIs with < 100,000 CFU/ml
70Questions for our presenters? Press *1 to ask a question. Thank You!Questions for our presenters? Press *1 to ask a question.
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72Upcoming National Content Webinars DateTime/DurationTopic4/14/1512 ET/11 CT/10 MT/9 PT(60 minutes)Sustainability & Spread5/12/15Project Report Out
73March National Content Webinar Sustainability & SpreadEugene Chu, MDDirector of Hospital MedicineBoulder Community Hospital