1. NHSN CASE STUDIES or… Russ’s title NHSN Jeopardy Allison Gibson Murad, MPH aka Allie “Trebek” NHSN Epidemiologist Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit Michigan Department of Community Health MuradA@michigan.gov & Russ Olmsted – MSIPC Fundamentals Faculty

2. NHSN: Not Just for Acute Care www.cdc.gov/nhsn

3. 2011 CAUTI – Acute Care ICUs (except NICUs) (Jan.) CAUTI – LTCH, IRF, Cancer Hospitals (Oct) SSI – Colon Surgeries and Abdominal Hyst. – Acute Care (Jan) Dialysis Events – ESRD (Jan) CLABSI – LTCH, Cancer Hospitals (Oct) 2012 2013 HCP Influenza Vaccination – ASCs (Oct.) SSI – Cancer Hospitals (Jan.) HCP Influenza Vaccination – IRF (Oct.) 2014 CLABSI – Acute Care ICUs (Jan.) C. Diff LabID Events – Acute Care (Jan.) MRSA Bacteremia LabID Events – Acute Care (Jan.) HCP Influenza Vaccination – Acute Care (Jan.) HCP Influenza Vaccination – LTCH (Jan.) 2015 Federal HAI Reporting To NHSN Under Inpt. Quality Reporting: Past/present & Future CLABSI – Acute Care Med, Surg, Med/Surg Units (Jan.) CAUTI – Acute Care Med, Surg, Med/Surg Units (Jan.) MRSA Bacteremia LabID Events – LTCH (Jan.) C. Diff LabID Events – LTCH (Jan.) APIC. Federal HAI Reporting to NHSN resource update. www.apic.org 9/17/13

4. All case studies and responses are derived from slides developed by CDC or are approved by CDC NHSN staff.

5. CAUTI Module (1) 84 year old patient is hospitalized with a GI bleed. Day 3: Patient has an indwelling urinary catheter in place but has no signs or symptoms of infection. Day 9: Patient becomes unresponsive, is intubated and CBC shows WBC count of 15,000. Temp is 38.0 C. Patient is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes. Urine culture shows > 100,000 CFU/ml.

6. CAUTI Module (1 – part A) Is this a UTI? A CAUTI? If so, what type? A.No UTI because the blood seeded the urine. B.Yes, this is an ABUTI [asymtomatic, bacteremic UTI]. C. Yes, this is a SUTI [symptomatic UTI] NHSN Criterion 1a with a secondary BSI.

7. CAUTI Module (1- Part B) What if the organism in both cultures had been a Micrococcus? Would it be a UTI? Would it still be an ABUTI?

8. CLABSI Module (1 ) 5/15: 79 year old male, admitted with gastric cancer. Central line placed day of admission for total parenteral nutrition. 5/16: Partial gastrectomy performed. 5/21: Pt progressing well until fever spike of 101.3 F (38.5 C) Blood cultures sent. 5/22: Increasing abd pain. CT scan of abd shows small fluid collection posterior to stomach. Fluid collection fully drained by ultrasound-guided needle aspiration, & fluid sent for culture. Blood cultures repeated.

9. CLABSI Module (1- Part A) 5/23: Blood cultures from 5/21: 1 of 2 positive for Staph epidermidis. Abd fluid growing gram positive cocci. Antibiotics begun. 5/24: Abd culture: Enterobacter cloacae. Blood cultures from 5/22: 2 of 2 positive for coagulase- neg. staphylococcus. Does this pt have an infection? If yes, is it an HAI?

10. CLABSI Module (1- Part B) Does this patient have a CLABSI? Options: A.Yes, the patient has a CLABSI with S. epidermidis. B.No, the BSI is secondary to the abdominal infection. C. Not sure.

11. SSI Module (1) 4/12: Pt is admitted to hospital for elective surgery and an active MRSA screening test is positive. On same day, pt undergoes total abd hysterectomy. 4/16: Post-operative course is unremarkable. Pt is discharged to home. 4/29: Pt is readmitted with complaints of acute incisional pain since day before. Surgeon opens wound into the fascial level and sends drainage specimen for culture & sensitivity. 5/1: Culture results are positive for MRSA.

12. SSI Module (1 – Part A) Does this patient have an HAI? Options: 1. Yes. If yes, then what type of infection should be reported to NHSN? SSI-SIP? SSI-SIS? SSI-DIP? SSI-DIS? Or SSI-IAB? 2. No HAI.

13. SSI Module (1 – Part B) What is the date of the event (SSI)? Options: A.4/12 B.4/16 C.4/29 D.5/1

14. MDRO/CDI Module (1) 3/1: 55 year old patient with end stage pancreatic cancer with liver & bone metastasis is admitted to inpt unit 3E from hospice facility. The pt has no previous history of inpt admission to this facility. Upon admission to 3E, pt is noted to have foul loose stools. After three episodes of loose stools over the course of 24 hours, an unformed specimen is collected and test positive for C. difficile toxin.

15. MDRO/CDI Module (1 – Part A) For FacWideIN LabID reporting, should this be entered into NHSN as a LabID event? Options: A.Yes. Specimen was collected from 3E inpatient location. B.No. This infection belongs to the hospice facility. C.No. This is not a HAI, therefore it should not be reported into NHSN.

16. MDRO/CDI Module (1 – Part B) How will NHSN categorize the CDI event? A.Community-Onset (CO) B.Healthcare Facility-Onset (HO) C.Community-Onset Healthcare Facility-Associated (CO-HCFA) D.NHSN will not categorize the event; the user will need to make the decision.

17. MDRO/CDI Module (1 – Part B) Correct Response: A. Community-Onset (CO) Rationale: The patient has no previous history of admission to this facility and the stool specimen was collected as an inpatient less than 4 days after admission to the facility. Note: Community-Onset Healthcare Facility- Associated (CO-HCFA) is based on previous discharge from index facility. Also…………….(next slide)

18. MDRO/CDI Module (2 – Part A) January 1 st, 10:30am: 75-year old male presents to the ED from a LTAC with the chief complaints of shortness of breath, abdominal cramping, and a three day history of multiple episodes of diarrhea. Medical history: myocardial infarction and a three vessel coronary artery bypass grafting procedure performed on Dec. 2 at this hospital, which was complicated by a prolonged post- operative stay in the ICU.

19. During the stay, he was treated for a UTI with Levofloxacin. He was discharged to undergo rehabilitation at the LTAC on Dec. 23 where he had his onset of diarrhea While in the ED on Jan. 1, a chest X-ray reveals bilateral pleural effusions and pulmonary edema. Before being admitted to an inpatient location, aggressive diuresis is initiated and a diarrheal stool specimen is collected and sent to the lab for C.diff toxin testing. MDRO/CDI Module (2 – Part A)

20. Test result indicates positive C.diff toxin A/B. Patient is admitted to 2N telemetry at 3:45pm on Jan. 1. Jan. 2: during the night, patient has respiratory deterioration requiring mechanical ventilation, and is subsequently transferred to the ICU. Continues to have abdominal cramping and multiple episodes of diarrhea. Another diarrheal stool specimen is collected and sent form the ICU for C.diff toxin testing. Result is positive for C.diff toxin A/B. Flagyl is started. MDRO/CDI Module (2 – Part A)

21. Would you identify the Jan. 1 st C.diff toxin positive assay as a CDI LabID Event for facility-wide inpatient (FacWideIn) reporting? A. No. The patient was admitted with diarrhea form the LTAC and the transfer rule applies. B. Yes. The result would be identified as a CDI LabID Event for 2N. C. Yes. The result would be identified as a CDI LabID Event for the ED. D. No. Since the patient presented to the ED with diarrhea suggestive of CDI, this is considered community-onset, and therefore should not be considered a CDI LabID Event for FacWideIn reporting. MDRO/CDI Module (2 – Part A)

22. Would you identify the Jan 2 nd positive C.diff toxin result as a CDI LabID Event for FacWideIn Reporting? A. No. His symptoms started <4 days after admission. B. Yes. As there were no other CDI positive specimens for this patient and location (the ICU) in ≤ 2weeks, the result would be identified as a CDI LabID Event for the ICU. C. Yes. The result would be identified as a CDI LabID Event for 2N since the patient was in that location within the prior 2 calendar days and the transfer rule applies. D. No. Since this is the second positive C. difficile isolate collected from this patient within 14 days, it is considered a duplicate CDI LabID Event. MDRO/CDI Module (2 – Part B)

23. If the Jan 1 st positive C.diff toxin result is a CDI LabID Event, how will the event be categorized by the NHSN application? A. Community-Onset (CO) B. Healthcare- Facility-Onset (HO) C. Community-Onset Healthcare Facility-Associated (CO-HCFA) D. The NHSN application will not categorize the event. MDRO/CDI Module (2 – Part C)

24. The patient remains in the ICU until Jan 14 th when he is transferred back to 2N telemetry. He has completed a course of Flagyl, has no abdominal complaints and his stools are formed with no further C.diff toxin testing having been performed. Jan. 16 th : he has an episode of diarrhea after eating breakfast and another episode of diarrhea in the afternoon. A sample is sent for C.diff toxin testing and the result is positive for C.diff toxin A/B. MDRO/CDI Module (2 – Part D)

25. Would you identify the Jan 16 th positive C.diff toxin result as a CDI LabID Event for FacWideIn reporting? A. Yes. The result would be identified as a CDI LabID Event for 2N since the specimen was collected in a location with no prior C. difficile specimen reported within 14 days for the patient and location. B. No. The result would be considered a duplicate episode of C. difficile and would not be reported as a separate CDI LabID Event for FacWideIN reporting. C. Yes. The result would be identified as a CDI LabID Event for the ICU since the specimen was collected 14 days after the last positive specimen for the ICU and the patient was in that location within the previous 48 hours and the transfer rule applies MDRO/CDI Module (2 – Part D)

26. CLABSI Module (2 – Part A) 8/14: 41 year old female presents to ER in diabetic coma and with anemia. She has a subclavian catheter inserted in the ER. The next day, in the ICU she has a midline catheter inserted and receives a blood transfusion. 8/17: Pt develops fever of 39 C and shaking chills. Two sets of blood cultures sent to lab. 8/19: Blood cultures positive for Pseudomonas aeruginosa. Neither insertion site shows inflammation and there is no other documented infection.

27. CLABSI Module (2 – Part A) Does Ms. E have a Laboratory-Confirmed Bloodstream Infection (LCBI)? Options: A.No, the pt does not have an LCBI. B.Yes, the pt has an LCBI with P. aeruginosa. C.Not sure.

28. CLABSI Module (2 – Part B) If Ms. E has an LCBI, which criterion of LCBI applies? Options: A.LCBI criterion 1 – recognized pathogen cultured from 1 or more blood cultures. B.LCBI criterion 2 – pt has fever, chills and 2 or more positive blood cultures.

29. CLABSI Module (2 – Part C) What unit should be indicated for the location of the device insertion? Options: A.The ED should be recorded as the location of device insertion. B.The ICU should be recorded as the location of device insertion. C.Neither location. D.Not sure.

30. Thank You! Any Questions? Contact: Allie Murad, MPH, NHSN Epidemiologist murada@michigan.gov 517-335-8199 Judy Weber, MPH, Healthcare Facility Liaison weberj4@michigan.gov 517-335-8331 SHARP Website: www.michigan.gov/haiwww.michigan.gov/hai