Applying NHSN Surveillance

Definitions: Updates & Case Studies Definitions: Updates & Case Studies

Stephanie Kreiling, RN, BSN, MPH, CIC

Kim Newman, RN, BSN, CIC

Disclosures

Stephanie Kreiling and Kim Newman have

nothing to disclose.nothing to disclose.

Objectives

1. Participants will describe the latest

changes to NHSN HAI surveillance

criteria.

2. Participants will correctly apply NHSN 2. Participants will correctly apply NHSN

surveillance criteria in identifying HAI’s.

Review of Key Terms

2014 Clarifications and Updates2014 Clarifications and Updates

HAI Definition

(Healthcare Associated Infection)

• Localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility.admission to the acute care facility.

• All elements of infection criterion were first present together on or after the 3rd calendar day of admission to the facility

• An element may be present during the first 2 calendar days as long as it is also present on or after calendar day 3

HAI: Gap Day Definition

•All elements must occur within a

timeframe that does not exceed a gap of 1

calendar day between any two adjacent calendar day between any two adjacent

elements

•A gap day is a calendar day during which

no infection criterion elements are

present.

Gap Day Examples

Day 1 Day 2 Day 3 Day 4 Day 6 Day 7Day 5

POA Definition

(Present on Admission)

• All of the elements of an infection criterion are present during

the two calendar days before the day of admission, the first

day of admission and/or the day after admission

• Elements must be documented in the medical record during

the POA time frame

– Pt’s self-reported symptoms do not meet criterion

– MD’s diagnosis must be an element of the surveillance

definition or it does not meet criterion

Multiple vs. Single Episode of Infection

(POA or HAI)

• No set time period during which only 1

infection of the same event type may be

reported for the same patient

– Utilize clinical information to determine resolution– Utilize clinical information to determine resolution

– Review of S/S, antimicrobial therapy, diagnostic

testing may be helpful in determination

Infection Event Date

• The date of event is the date when the last

element used to meet the infection definition

• Paired common commensal blood cultures • Paired common commensal blood cultures

are considered a single element of LCBI 2.

– The date of the first of the two positive blood

cultures is the date of event.

Transfer Rule

• If all elements of the infection are present on

the day of transfer or the next day, in the

same facility or a new facility the infection is same facility or a new facility the infection is

attributed to the transferring location or

facility.

Revew of SUTI and ABUTI

DefinitionsDefinitions

SUTI Criteria 1a and 1b

SUTI Criteria 2a and 2b

ABUTI Criteria

CAUTI Scenarios

(hand outs provided during

presentation)presentation)

2014 CLABSI Updates

LCBI 1 and 2 Definition

LCBI 3 Definition

Central Line Catheter Exclusion

• Hemodialysis reliable outflow (HeRO) dialysis

catheters are NOT considered central lines

Admission with Central Line

• If the patient is admitted or transferred into a

facility with a tunneled or implanted line, day

of first access as an inpatient is Day 1.

• “Access” is defined as line placement, infusion • “Access” is defined as line placement, infusion

or withdrawal through the line.

Line Manipulation

• Patients who access their own IV lines are not

excluded from CLABSI surveillance.

• Facility is responsible to protect the line • Facility is responsible to protect the line

– May include use of patient sitters, removal of the

catheter, etc.

Updated MBI Definition

• All CLABSI reporting must indicate which of

the underlying conditions of the MBI-LCBI

criterion was met, if any

• All CLABSI (LCBI or MBI-LCBI) must be • All CLABSI (LCBI or MBI-LCBI) must be

reported if CLABSI is part of your Monthly

Reporting Plan

Updated MBI Definition

• Time frame for neutropenia has been expanded:

– At least 2 separate days with values of absolute – At least 2 separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC) <500 cells/mm3 within a seven-day time period which includes the date the positive blood culture was collected (Day 1), the 3 calendar days before and the 3 calendar days after

Updated MBI Definition

MBI, Con’t.

Primary or Secondary LCBI?

• Blood and site-specific specimens do not have

to be collected on the same day but there

must be evidence of infection at the specific must be evidence of infection at the specific

site at the time of blood culture collection

Blood Culture Common Commensals:

Event Date?

• Matching common skin commensals represent

a single element;

– Collection date of the first common commensal is

the date of the element.the date of the element.

Ch. 17, Table 1 Update: Applying HAI Definitions

GI-GIT Definition

• GIT-Gastrointestinal tract infection

(esophagus, stomach, small and large bowel,

and rectum) excluding gastroenteritis and

appendicitis appendicitis

– GI-GIT criterion 2:

• Patient has at least 2 of the following signs or

symptoms compatible with infection of the organ or

tissue involved: fever (>38°C), nausea*, vomiting*,

abdominal pain*or tenderness*, or diarrhea *

IAB Definition

• IAB-Intraabdominal infection, not specified elsewhere including gallbladder, bile ducts, liver (excluding viral hepatitis), spleen, pancreas, peritoneum, subphrenic or subdiaphragmatic space, or other subdiaphragmatic space, or other intraabdominal tissue or area not specified elsewhere

– 1. Patient has organisms cultured from abscessand/or purulent material from intraabdominalspace obtained during an invasive procedure

CLABSI Scenarios (Handouts)

Surgical Site Event

Review

Definition Clarification for Operative

Procedures

An NHSN Operative Procedure Includes:

• An operation where at least one incision is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure

AndAnd

• Takes place in an OR, defined as a patient care area that meets the FGI or AIA criteria for an OR

* Exclude eligible procedures that are assigned an ASA score of 6

* Incisional closure is NO LONGER a part of the definition

Incisional Closure

Primary Closure

• Closure of all tissue levels during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision. This category includes surgeries where the skin is closed by some means, including incisions that are described as being "loosely closed" at the skin level. Thus, if any portion of the incision is closed at the skin level, by any manner, a portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.

Non-primary Closure

• Includes surgeries where superficial layers are left completely open

*What if this is not included in my operative record?

2014 Highlights

• Diabetes – yes or no for all procedures

• Height & weight entered for all procedures

• MD diagnosis removed from deep incisional &

organ space definitionsorgan space definitions

• Duration recorded in hours and minutes

• Clarification of attending physician

Duration

• Recorded in hours and minutes

– Start time defined as: time when incision made

– Stop time defined as: time when all instruments,

sponge counts are verified and correct, all sponge counts are verified and correct, all

radiological studies completed, all dressings and

drains secured and surgeon has completed all

activities.

Attending Physician

• Attending physician – includes surgeon,

infectious disease, other physician on the

case, emergency physician or physician’s

designee (NP/PA)designee (NP/PA)

Important Cliff-Notes

• If more than one NHSN operative procedure is

performed during the same trip to the OR,

report a denominator form for each

procedure.procedure.

– record the combined duration of all procedures,

which is the time from skin incision to primary

closure.

Notes (cont.)

• For bilateral operative procedures (e.g.,

KPRO), two separate Denominator for

Procedure records are completed. To

document the duration of the procedure, document the duration of the procedure,

indicate the incision time to closure time for

each procedure separately or, alternatively,

take the total time for both procedures and

split it evenly between the two.

Notes (cont.)

• NOTE: If the patient goes to the OR more than once during the same admission and another procedure is performed through the same incision within 24 hours of the original operative incision, report only onedenominator for procedure form for the original procedure, combining the durations for both procedure, combining the durations for both procedures. – If the wound class has changed, report the higher wound

class.

– If the wound class has changed, report the higher wound class

– If the ASA class has changed, report the higher ASA class.

Notes (cont.)

• Secondary incision sites are monitored for 30 days.

• If a patient with an organ/space infection is operated on, subsequent continuation of this infection during the remaining surveillance period is considered an organ/space SSI.

• If the post-surgical site develops an infection after an • If the post-surgical site develops an infection after an invasive manipulation/accession for diagnostic or therapeutic purpose, do not report as an SSI.

• An SSI that meets the NHSN definition should be reported without regard to post-op accidents, fall, inappropriate showering or bathing practices, presence of certain skin conditions or “seeding” from unrelated procedures.

SSI Scenarios

• To be distributed during presentation.

Ventilator Associated Event

ReviewReview

VAE

• In-plan surveillance for VAP will be restricted to patient of any age in non-NICU pediatric locations

• In-plan surveillance for mechanically • In-plan surveillance for mechanically ventilated patient in adult locations (regardless of age) will use the VAE protocol

• Exclude patients on ECMO

• PNEU definition can be used for conducting off-plan surveillance

VAE Hierarchy

• If a patient only meets criteria for VAC

VAC

• If a patient meets criteria for VAC and IVAC

IVACIVAC

• If a patient meets criteria for VAC, IVAC and Possible VAP

Possible VAP

• If a patient meets criteria for VAC, IVAC and Probable VAP, Probable VAP

• If a patient meets criteria for VAC, IVAC, Possible VAP and Probable VAP

Probable VAP

VAE Calculator*

*http://www.cdc.gov/nhsn/VAE-calculator/index.html

VAE (cont.)

VAE (cont.)

VAE (cont.)

VAE (con.)

VAE Important Cliff-Notes

• The patient must be mechanically ventilated for >2 calendar days.

• Day 4 is the earliest day that VAE criteria can be met.

• You must use all definitions in the hierarchy for VAE.

• Pathogens are not reported for VAC or IVAC.• Pathogens are not reported for VAC or IVAC.

• Secondary BSIs are not reported for VAC or IVAC.

• Pathogens may be reported for possible and probable VAP events.

– May then report as Secondary BSI if at least there is one matching organism.

VAE Scenarios

• To be distributed during presentation.