Surveillance Branch, DHQP

Surveillance Branch, DHQP
NHSN Potpourri Mary Andrus Nurse Epidemiologist Surveillance Branch, DHQP

Objectives Identify CLABSI cases using appropriate infection definitions and key terms Identify VAP cases using appropriate infection definitions and key terms Review components and modules of NHSN with future enhancements identified

Healthcare-associated Infection (HAI) Definition
A localized or systemic condition that resulted from adverse reaction to the presence of an infectious agent or its toxin Not present or incubating on admission to the facility

Surveillance Definitions
Radiologic criteria Signs and symptoms Laboratory findings

Physician Diagnosis Alone
Acceptable for some infections, unless compelling evidence to the contrary

Clinical vs. Surveillance Definitions
Individualized; used for making therapeutic decisions Surveillance Population-based Must be applied uniformly and consistently

Central Line-associated Bloodstraem Infections (CLABSI)

Patient Safety Component Modules
Device-associated Procedure-associated SSI PPP Medication-associated AUR MDRO/CDAD Patient Influenza Immunization CLABSI VAP CAUTI CLIP DE MDRO/CDAD Infection Lab ID Processes Method A Method B 9

Introduction 250,000 CLABSIs occur in the United States each year
Most bloodstream infections are associated with the presence of a central line or umbilical catheter (in neonates) at the time of or before the onset of the infection Estimated mortality is 12-25% for each CLABSI Cost to the healthcare system is approximately $25,000 per episode

Key Terms Definition: CLABSI Central Line-Associated Bloodstream Infection (CLABSI) is a primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI NOTE: There is no minimum time period that the central line must be in place in order for the BSI to be considered central line-associated

Definition: Central Line
Key Terms Definition: Central Line A vascular infusion device that terminates at or close to the heart or in one of the great vessels. The following are considered great vessels for the purpose of reporting central line infections and counting central line days Aorta Pulmonary artery Superior vena cava Inferior vena cava Brachiocephalic veins Internal jugular veins Subclavian veins External iliac veins Common femoral veins

In neonates, the umbilical artery is considered a great vessel
Key Terms In neonates, the umbilical artery is considered a great vessel Neither the location of the insertion site nor the type of device may be used to determine if a line qualifies as a central line Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices.

Key Terms Infusion Introduction of a solution through a blood vessel via a catheter lumen Includes: Continuous infusions such as nutritious fluids or medications, or Intermittent infusions such as flushes or IV antimicrobial administration Administration of blood or blood products in the case of transfusion or hemodialysis

Transfer Rule Key Terms
If the BSI develops in a patient within 48 hours of transfer from one inpatient location to another, indicate the transferring location on the infection report. NOTE: It is not required to monitor for CLABSIs after the patient is discharged from the facility. However, if discovered, they should be reported to NHSN. No additional central line days are recorded. Example: A patient with a central line is transferred from the Orthopedic ward to the Medical-Surgical ICU on Monday. On Tuesday afternoon, he spikes a fever and is determined to have a CLABSI. The location of the CLABSI is recorded as the Orthopedic Ward.

* See NHSN Patient Safety Component Protocol
CLABSI Numerator Data Use Primary Bloodstream Infection (BSI) form for each CLABSI that is identified during the month. Indicate the specific type of BSI* Laboratory-confirmed Bloodstream Infection (LCBI) - can be used for any patient, including patients < 1 year of age. Clinical Sepsis (CSEP)- is only used for -Neonates (< 30 days old) -Infants (<12 months old) * See NHSN Patient Safety Component Protocol

LCBI – Criterion #1 Example: Jon Smith had a PICC line inserted on admission (June 1). On hospital day 4, he became confused and experienced chills. Blood cultures were drawn which grew E. faecalis. Mr. Smith meets the criteria for LCBI Criterion #1.

One or more blood cultures means that at least one bottle from a blood draw is reported by the laboratory as having grown organisms (i.e., is a positive blood culture). Recognized pathogen does not include organisms considered common skin contaminants. A few of the recognized pathogens are Staph aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp., etc.

LCBI – Criterion #2

The phrase “two or more blood cultures drawn on separate occasions means:
That blood from at least two blood draws were collected within two days of each other, and That at least one bottle from each blood draw is reported by the laboratory as having grown the same common skin contaminant organism (i.e., is a positive blood culture) Note: If special pediatric blood culture bottles are used, only one bottle may be inoculated per blood draw. Therefore, to meet this part of the criterion, two would have to be culture-positive.

LCBI – Criterion #3 Note also – although Criterion #3 can only be used for infants and neonates, Criteria 1 and #2 can also be used in this population.

Determining “sameness” of two organisms
If the common skin contaminant from one culture is identified to both genus and species level (e.g., S. epidermidis) and the companion culture identifies only the genus with or without other attributes (in this example, coagulase negative staphylococci), then it is assumed that the organisms are the same. The more specific organism should be reported in NHSN -- in this example S. epidermidis, would be reported. See other examples below:

Determining “sameness” of two organisms
If common skin contaminant organisms are speciated (e.g., both are B. cereus), but no antibiograms are done, or they are done for only one of the isolates, it is assumed that the organisms are the same.

Determining “sameness” of two organisms (cont.)
If the common skin contaminants from the cultures have antibiograms that are different for two or more antimicrobial agents, it is assumed that the organisms are not the same. Example:

Collecting Blood Culture Specimens
Ideally, blood specimens for culture should be obtained from two to four blood draws from separate venipuncture sites (e.g., right and left antecubital veins), not through a vascular catheter. These blood draws should be performed simultaneously or over a 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 the NHSN criteria, but you should work with appropriate personnel to facilitate better specimen collection practices for blood cultures.

Clinical Sepsis Alternate criteria for BSI in infants (<12 months old) and neonates (<30 days old) NOT used for adults or children

Bloodstream Infection Definitions Summary
Laboratory confirmed bloodstream infection (LCBI)– all patients Recognized pathogen Skin organisms: >2 blood cultures drawn on separate occasions positive for the same organism + clinical symptoms Infant/neonate: >2 blood cultures drawn on separate occasions positive for the same organism + clinical symptoms Clinical Sepsis (CSEP) – infants and neonates only Clinical symptoms + no positive blood culture + antimicrobial therapy instituted

Collecting Summary (Denominator) Data for Device-associated Infections
Summary data is collected at approximately the same time every day Train someone on the unit to collect the denominators – valuable IP resources are not required for this task Both patient days and device days are collected daily

Electronic Data Collection
If your facility has automated (electronic) systems available for collecting denominator data, please do the following: Collect patient days and device days manually, using the CDC recommended methodology for a month or two Compare the manually collected data with the electronic data If the electronic data are within 5% of the manually-collected data, the electronic data may be used

Counting Patient Days Every day at the same time, count the number of patients on the unit All patients on the unit are included Example: A medical ICU at St. Someplace Hospital has 15 beds. Today, when patient days are counted, there are 11 medical patients, 2 surgical patients, 1 trauma patient and 1 empty bed. For this unit today, 14 patients are recorded for patient days count.

Counting Device Days in ICU or Inpatient Wards
Every day at the same time, count the number of patients with one or more of the devices being monitored on the unit If a patient has multiple central lines, count one central line day If, at the time of the count, a patient has just had a device removed, do not count that device If a device will be used, but has not yet been inserted, do not count that device.

You can monitor only those devices that you choose

NICU summary data are stratified into birthweight groups

SCA locations – temporary and permanent line days are collected separately

Analysis: CLABSI Rate #CLABSIs identified* CLABSI X 1000 Rate =
# central line days* X 1000 CLABSI Rate = Stratify by: Location SCA Permanent vs. temporary NICU Birthweight category Umbilical vs. non-umbilical This is the formula that is used to calculate the VAP rate for a given unit. In the NICU, this is calculated separately for each birthweight category.

Example of CLABSI Rate Table

Example of CLIP Line List

Ventilator-associated Pneumonia (VAP)
This portion of today’s training will describe the protocols and definitions for the Ventilator-associated Pneumonia option of the Device-associated Module of the Patient Safety Component of the NHSN.

Patient Safety Component Modules
Device-associated Procedure-associated SSI PPP Medication-associated AUR MDRO/CDAD Patient Influenza Immunization CLABSI VAP CAUTI CLIP DE MDRO/CDAD Infection Lab ID Processes Method A Method B 39

Pneumonia Second most common HAI in the U.S.
VAP – attributable mortality rates 20-33% have been reported 2007, pooled mean VAP rates per 1000 ventilator days in NHSN hospitals ranged from 2.1 in Pediatric Med-Surg ICUs to 10.7 in Burn ICUs In one study, patients receiving continuous mechanical ventilation had 6-21 times the risk of developing HAI pneumonia compared with patients not receiving mechanical ventilation. CDC/HICPAC Guideline for Prevention of Nosocomial Pneumonia Recommends surveillance for bacterial pneumonia for trends and for interhospital comparison Pneumonia is the second most common healthcare associated infection in the United States and is associated with substantial morbidity and mortality. Patients with mechanically assisted ventilation have a high risk of developing pneumonia. Prevention and control of healthcare-associated pneumonia is discussed in the CDC/HICPAC document, Guideline for the Prevention of Nosocomial Pneumonia. The guideline strongly recommends that surveillance be conducted for bacterial pneumonia in ICU patients who are mechanically ventilated to facilitate identification of trends and for interhospital comparisons

Pneumonia Key Terms VAP Ventilator PNU1 PNU2 PNU3
The following slides outline the various definitions and assessment criteria that you’ll need to understand the surveillance criteria used for ventilator associated pneumonia. We’ll define VAP, Ventilator, and the three criteria that can be used to define pneumonia.

Key Terms Definition: VAP Pneumonia (PNEU) that occurs in a patient who was intubated and ventilated at the time of or within 48 hours before the onset of the pneumonia. If the PNEU develops in a patient within 48 hours of transfer from a location, indicate the transferring location on the infection report, not the current location of the patient So…when is a pneumonia considered ventilator-associated? A ventilator associated pneumonia is a pneumonia that occurs in a patient who was intubated and ventilated at the time of or within 48 hours before the onset of the pneumonia.

Key Terms NOTE: There is no minimum period of time that the ventilator must be in place in order for the PNEU to be ventilator-associated Please notice that there is no requirement that the patient be on a vent for 48 hours before the pneumonia is vent-associated. What this means is that when the patient meets the criteria for pneumonia, you take a look-back at the previous 48 hours. If the patient was on the ventilator continuously at any time during that 48 hours, then the developing pneumonia is ventilator-associated. Just to better clarify the location to which the VAP is attributed, if the patient develops the pneumonia within 48 hours of discharge from a location, indicate the discharging location on the infection report, not the current location of the patient

Definition: Ventilator
Key Terms Definition: Ventilator A device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation. What, then, is a ventilator? You may think it’s obvious, but we don’t leave this definition open to interpretation. A ventilator is a device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation.

* See NHSN Manual: Patient Safety Component Protocol
Key Terms Pneumonia Criteria PNEU is identified using a combination of x-ray, clinical and laboratory criteria. Three specific sets of criteria used: PNU1 – Clinically Defined Pneumonia PNU2 – Pneumonia with Common Bacterial Pathogens PNU3 - Pneumonia in Immunocompromised Patients So now that we’ve defined a VAP, and we’ve defined a Ventilator, it’s time to move to the definition of Pneumonia. The CDC has defined pneumonia using three specific sets of criteria. Pneumonia 1 is clinically defined pneumonia, Pneumonia 2 is pneumonia with common bacterial pathogens, and Pneumonia 3 is used for Immunocompromised patients. These criteria use a combination of radiologic, clinical, and laboratory criteria. We’ll cover each criterion briefly, and I suggest that you review this after the training using the Pneumonia Flow Diagram in the NHSN Users Manual/Patient Safety Protocol. Until you become more familiar with the pneumonia criteria, the flow diagram is definitely the easiest way to work your way through the surveillance definition. I think it’s also helpful to read through all the comments and footnotes that accompany the pneumonia in order to make certain that you’re using them correctly. * See NHSN Manual: Patient Safety Component Protocol

PNU1 X-Ray findings or and
Beginning at the top of the flow diagram, the first criteria for ALL pneumonias is the chest x-ray. On the right side, we see the patient without underlying pulmonary disease – for this patient, the criteria requires one chest x-ray that identifies one of the following: New or progressive and persistent infiltrate, Consolidation, Cavitation, Pneumatoceles, in a patient <1 y.o. On the left, we see that if the patient has underlying pulmonary disease, such as COPD, congestive heart failure, etc. then 2 or more serial chest x-rays are required. If you read through the footnotes and comments in the definition, you’ll find other words that may be acceptable to describe a pneumonia process on chest x-ray. The positive chest x-ray is the first, and most important criteria for all the pneumonia definitions. If you do not meet this criteria, throw it out – it is not a pneumonia according to the surveillance definition. If the patient has underlying pulmonary disease and has one positive chest ray followed by a chest x-ray that shows improvement, throw it out, it does not meet the surveillance definition of pneumonia. and

PNU1 Signs and Symptoms and
After the chest x-ray criterion is met, for Pneumonia 1, move next to the clinical criteria, or signs and symptoms. The patient must have at least one of the symptoms in the left box and at least two of the symptoms in the right box. On the flow diagram, follow the arrows that go down the left side of the page. If these criteria are met, then the patient meets the definition for Pneumonia 1. No other laboratory or other evidence is required. and

PNU1 - Clinical Pneumonia

(exactly the same as PNU1)
X-ray criteria (exactly the same as PNU1) or Beginning at the top of the flow diagram, the first criteria for ALL pneumonias is the chest x-ray. On the right side, we see the patient without underlying pulmonary disease – for this patient, the criteria requires one chest x-ray that identifies one of the following: New or progressive and persistent infiltrate, Consolidation, Cavitation, Pneumatoceles, in a patient <1 y.o. On the left, we see that if the patient has underlying pulmonary disease, such as COPD, congestive heart failure, etc. then 2 or more serial chest x-rays are required. If you read through the footnotes and comments in the definition, you’ll find other words that may be acceptable to describe a pneumonia process on chest x-ray. The positive chest x-ray is the first, and most important criteria for all the pneumonia definitions. If you do not meet this criteria, throw it out – it is not a pneumonia according to the surveillance definition. If the patient has underlying pulmonary disease and has one positive chest ray followed by a chest x-ray that shows improvement, throw it out, it does not meet the surveillance definition of pneumonia. and

PNU2 Signs and Symptoms and… and
Pneumonia 2 still requires that at least one of these signs or symptoms are present. If they are present, then you move down and are also required to have -- and

or Either – one of the laboratory criteria in the left box or one from the right box. The criteria on the left are used to identify a bacterial pneumonia and the one on the right is used for viral, fungal, or more uncommon pathogens. Please take a good look at Comment # 9 on the back of the flow diagram– it clearly states that an endotracheal aspirate does not meet the laboratory criteria – it must be a minimally contaminated specimen,-- a specimen obtained bronchoscopically. If the patient meets the definition of both Pneumonia 1 and Pneumonia 2, it should be reported as Pneumonia 2 PNU2

PNU2 - Common bacterial pathogens

PNU2 - Viral and fungal pathogens

(exactly the same criteria)
PNU3 X-ray findings or Beginning at the top of the flow diagram, the first criteria for ALL pneumonias is the chest x-ray. On the right side, we see the patient without underlying pulmonary disease – for this patient, the criteria requires one chest x-ray that identifies one of the following: New or progressive and persistent infiltrate, Consolidation, Cavitation, Pneumatoceles, in a patient <1 y.o. On the left, we see that if the patient has underlying pulmonary disease, such as COPD, congestive heart failure, etc. then 2 or more serial chest x-rays are required. If you read through the footnotes and comments in the definition, you’ll find other words that may be acceptable to describe a pneumonia process on chest x-ray. The positive chest x-ray is the first, and most important criteria for all the pneumonia definitions. If you do not meet this criteria, throw it out – it is not a pneumonia according to the surveillance definition. If the patient has underlying pulmonary disease and has one positive chest ray followed by a chest x-ray that shows improvement, throw it out, it does not meet the surveillance definition of pneumonia. (exactly the same criteria) and

PNU3 Signs and Symptoms and
Next, identify one of the signs or symptoms listed here. You’ll note that there are symptoms included here, such as hemoptysis and pleuritic chest pain that are more appropriate for the immunocompromised patient. and

Any of the laboratory criteria from PNU2
Laboratory Findings: or Any of the laboratory criteria from PNU2 And finally, one of these laboratory findings which identify fungi. Notice that any of the laboratory criteria for PNU2 can also be used for PNU3. PNU3

PNU3 - Immunocompromised patient

Acceptable Specimens for PNU2 and PNU3
Quantitative culture from minimally contaminated LRT specimen Obtained with or without bronchoscope Bronchoalveolar lavage (BAL) Protected specimen brushing Lung parenchyma Open lung biopsy specimens Immediate post-mortem specimens obtained by transthoracic or transbronchial biopsy These are specimens that are acceptable for Pneumonia 2 and 3 Quantitative culture from minimally contaminated LRT specimen Obtained with or without bronchoscope Bronchoalveolar lavage (BAL) Protected specimen brushing Lung par en kai’ma Open lung biopsy specimens Immediate post-mortem specimens obtained by transthoracic or transbronchial biopsy

A Pneumonia form is completed for each patient in a monitored location that develops a VAP. The slide shows a completed Pneumonia form. Today, however, I’d like to focus on the section labeled “Risk Factors. The risk factor for pneumonia is ventilator. If the patient was on a ventilator within the 48 hour period before the pneumonia occurred, circle “yes”. Otherwise, circle “No”. additionally, if this was a NICU patient, you must document the birthweight. Next, look at the section labeled “Event Details”. In this section you’ll choose which of the Pneumonia criteria, 1, 2 or 3 was used to identify the pneumonia in this patient. And finally, the field “Secondary Bloodstream Infection” – answer yes or no depending on whether this patient had a bloodstream infection in addition to the identified pneumonia.

Analysis: VAP Rate #VAPs identified* VAP X 1000 Rate =
# ventilator days* X 1000 VAP Rate = This is the formula that is used to calculate the VAP rate for a given unit. In the NICU, this is calculated separately for each birthweight category. Stratify by: Type Location NICU Birthweight category

Analysis: Device Utilization (DU) Ratio
# Ventilator Days Ventilator DU Ratio = # Patient Days DU Ratio measures the proportion of total patient-days in which ventilators were used The Device Utilization Ratio gives us a measure of how much ventilators are used on a given unit and there are DU ratios available in the NNIS/NHSN Report that you can use for comparison. The DU ratio is calculated by dividing the number of ventilator days by the number of patient days. There is no multiplier used for this.

Example of VAP Analysis
This an example of VAP Analysis that was performed in NHSN. This is a VAP Rate Analysis for a specific time period of your choice. The analysis documents the units being monitored (click), the number of VAPs on the unit, the number of ventilator or device days, the calculated VAP rate for each unit, the NNIS/NHSN VAP pooled mean for comparison the Central Line Device Utilization Ratio for that unit and the NNIS/NHSN DU rate for comparison

Planned Reporting Date
States with Mandatory Reporting of Healthcare Associated Infections via NHSN by Reporting Start Dates Actual Reporting Date Planned Reporting Date New York Jan 2007 Vermont Feb 2007 South Carolina Jul 2007 Colorado Aug 2007 Pennsylvania Feb 2008 Connecticut Jan 2008 Tennessee California Jul 2008 Delaware Maryland Massachusetts Oklahoma Virginia Washington Illinois Nov 2008 New Hampshire Jan 2009 New Jersey West Virginia Jul 2009

What and When States Using NHSN are Reporting
CO MD OK VA NH NY VT SC TN CT PA CA DE MA WA IL NJ OR WV Jan 2009 Jan 2007 Jan 2008 CLABSI CO, CT, DE, IL, MA, MD, NH, NJ, NY, OK, PA, SC, TN, VA, VT, WA CAUTI PA SSI CO, DE, MA, NH, NJ, NY, PA, SC, TN, VT VAP NH, OK, PA, SC, WA Dialysis events CO, PA MDRO* CA, MD, NJ, PA Process measures CA, DE, MD, NH, NJ, PA, VT As of 10/17/2008 *Preliminary Information

NHSN Questions: nhsn@cdc.gov NHSN Required Training:
NHSN Website: NHSN Required Training:

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