C. difficile Infection and C. difficile Lab ID Reporting...
Transcript of C. difficile Infection and C. difficile Lab ID Reporting...
C. difficile Infection and C. difficile Lab ID Reporting
in NHSN
MARY ANDRUS, BA, RN, CICInfection Preventionist Consultant
Learning Objectives• Review the structure and of
the MDRO/CDAD Module within the Patient Safety Component of NHSN
• Describe the rationale for monitoring MDRO/CDAD
• Identify the methodology, protocols and definitions used in the data collection of MDRO/CDAD
Goal of CDAD (CDI) Module
• Monitoring C. difficile infection (CDI) will help to evaluate local trends and changes in the occurrence of these pathogens and related infections
• Provide a mechanism for facilities to report and analyze CDI data
Note: The term CDI is replacing CDAD. Both terms represent thesame illness and are used interchangeably.
Introduction
• C. difficile infection has increased in prevalence in U.S. hospitals over the last 30 years
• C. difficile has important implications for patient safety
• Options for treating patients with C. difficile are often extremely limited
• C. difficile infections are associated with increased lengths of stay, costs and mortality
If you choose to monitor C. difficile, you must select at least one of these two reporting options!
•Adherence to Hand Hygiene•Adherence to gown/glove use
CDI Infection Surveillance
An HAI is a localized/systemic condition resulting from an adverse reaction to the presence of an infectious agent or its toxin.
There must be no evidence that the infection was present or incubating at the time of the hospital admission.
C. difficile infections must meet NHSN-defined criteria for gastroenteritis or gastrointestinal tract infection
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Reporting Requirements CDI Infection Surveillance
Reporting Method
For Infection Surveillance , use either:•A – Facility-wide by location•B- Selected locations in the facility
NICU locations are not included in CDI surveillance!
CDI Infection Surveillance
Forms
Reporting Infections:Facility-wide by location
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Report separately from every location in the facility
Medical
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CDI Infection Surveillance
Reporting Infections:Facility-wide by location
CDI Infection Surveillance
Reporting Infections:Selected Locations Only
Report separately for one or more specific location s of a facility
Medical
CDI Infection Surveillance
Reporting Infections : Selected Locations Only
CDI Infection Surveillance
Definitions
http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
NHSN Reportable Infections for C.difficile
• GI – GE: Gastrointestinal System Infection – Gastroenteritis
• GI – GIT: Gastrointestinal System Infection – Gastrointestinal Tract
If the patient develops both GI-GE and GI-GIT, report only GI-GIT, using the date of onset as that of GI-GE C. difficile infection.
Option #1 – CDI Infection Surveillance
GI-GE (Gastroenteritis) must meet at least one of the following criteria:1.Patient has an acute onset of diarrhea (liquid stools for more than 12 hours) with or without vomiting or fever (>38°C) and no li kely noninfectious cause (e.g., diagnostic tests, therapeutic regimen other than antimicrobial agents, acute exacerbation of a chronic condition, or psychological stress)2.Patient has at least two of the following signs or symptoms with no other recognized cause: nausea, vomiting, abdominal pain, fever (>38°C), or headache and at least one of the following:
a. an enteric pathogen is cultured from stool or rectal swabb. an enteric pathogen is detected by routine or electron microscopyc. an enteric pathogen is detected by antigen or antibody assay on blood
or fecesd. evidence of an enteric pathogen is detected by cytopathic changes in
tissue culture (toxin assay)e. diagnostic single antibody titer (IgM) or 4-fold increase in paired sera
(IgG) for pathogen
Option #2 – CDI Infection Surveillance
GI-GIT (Gastrointestinal tract) infection excluding gastroentereitis and appendicitis, must meet at least one of the following criteria:1.Patient has an abscess or other evidence of infection seen during a surgical operation or histopathologic examination2.Patient has at least 2 of the following signs or symptoms with no other recognized cause and compatible with infection of the organ or tissue involved: fever (>38°C), nausea, vomiting, abdominal pain, or tenderness and at least one of the following:
a. organisms cultured from drainage or tissue obtained during a surgical operation or endoscopy or from a surgically placed drain
b. organisms seen on Gram’s or KOH stain or multinucleated giant cells seen on microscopic examination of drainage or tissue obtained during a surgical operation or endoscopy or from a surgically placed drain
c. organisms cultured from bloodd. evidence of pathologic findings on radiographic examinatione. evidence of pathologic findings on endoscopic examination (e.g.,
Candida esophagitis or proctitis).
CDAD Complications
• Additional details if the following are identified:
• Severe CDI in patient within 30 days after CDI symptom onset and at least one of the following:– Admission to ICU for CDAD complications– Surgery for CDAD complications– Death caused by CDAD within 30 days after symptom
onset and during the hospital admission
Monthly Reporting Plan
Our Infection Prevention Team at Community Memorial Hospital, initiated an infection surveillance program for C. difficile infection in MEDICU and 3 West in June 2011.
Because they are performing surveillance in 2 areas of her facility, the reporting method they have chosen is:
B. Selected locations
The next slide shows an example of how the Monthly Reporting Plan was completed.
Monthly Reporting Plan
Completing the CDI Infection Event Form
Event Form (cont.)
Enter the Event Type
here (will always be GI)
Enter the date the first clinical symptoms of
infection or the date the first positive specimen
was collected, whichever came first.
Event Form (cont.)
Circle “Yes” if the infection occurred after
an NHSN-defined procedure, but before
discharge from the hospital
Enter “Yes” if C.difficileinfection is being
followed for infection surveillance in that
location in the Monthly Reporting Plan
Event Form (cont.)
Event Form (cont.)
Enter date patient admitted to facility
Enter the Nursing care area where the patient was assigned when the C. difficile infection was acquired. If the CDI developed in a patient within 48 hours of discharge from another inpatient location, indicate the discharging location.
Event Form (cont.)
Indicate the specific CDC-defined infection event type
Using the criteria in Chapter 17 (CDC HAI Definitions), check all signs and symptoms used to confirm the diagnosis of this infection event for this patient.
CDI Flow Diagram
Event Form (cont.)
Circle “Yes” to indicate admission to ICU for complications of C.difficile (e.g., shock that requires vasopressor therapy)
Event Form (cont.)
Circle “Yes” to indicate surgery for C. difficile complications. Surgery might include colectomy for toxic megacolon, perforation of refractory colitis, etc.
Event Form (cont.)
If there is a culture-confirmed BSI during this admission secondary to this C. difficile infection, circle “Yes”
Circle “Yes” if the patient died during this hospitalization
Circle “yes” only if the patient died within 30 days after C.difficile infection symptoms onset and during the current hospitalization
Event Form (cont.)
Optional field. Enter the date the patient was discharged from the facility. If the patient died, the date of death is entered here
Enter “Yes” if pathogen is identified If the pathogen is
C. difficile, enter it on the back under Other Organisms but do not include antibiogram
Form used to report denominator.Total patient days for the location
Form used to report denominator.Total patient days for the location
During the monitoring month the IP Team identified a patient in MEDICU with gastroenteritis due to C. difficile that had not been present when the patient was admitted to the hospital.
The next slides show how the IP completed the NHSN form.
Example, cont.
The patient was identified as meeting Criterion #1 for GI-GE because he had liquid stools for 17 hours and a temp of 100.8°F
At the end of the month, the IP Team completed the Prevention Process and Outcome Measures Monthly Monitoring form that includes denominators.
A separate form for each of the 2 units that were monitored were completed.
Because they are performing infection surveillance the denominator is patient days.
Even though they did not identify any C. difficile infections on 3 West, a denominator form for that location was also completed
CDAD Infection Incidence Rate
If you choose to monitor C. difficile, you must select at least one of these two reporting options!
Allows laboratory testing data to be used without clinical evaluation of the patient, allowing for a much less labor intensive method to track C. difficile.
Definitions• Laboratory-Identified (LabID) Event: Any non-
duplicate CDI-positive lab assay.
• CDI-positive Lab Assay: Positive lab assay for C. difficile toxin A and/or B, or toxin-producing organism detected from stool culture or other lab means
• Duplicate C. difficile-positive test: CDI-positive assay from same patient within 2 weeks of previous positive assay.
Required Minimum Reporting
• All non-duplicate CDI-positive lab assays per patient per month
• At least three consecutive months in a calendar year
C. difficile testing performed routinely in lab, only on unformed (conforming to the shape of the container) stool samples
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Prior C. difficile positive in ≤ 2
weeks
Duplicate Test
Not a LabID Event
Test on unformed stool sample
Positive for C. difficile
Not C. difficile
Not a LabID Event
No
Yes
Reporting Method
For CDI LabID Event reporting, use either:•A – Facility-wide by location•B -- Selected locations in the facility •C – Facility-wide
CDI LabID Event
Reporting
Settings: 1) Inpatient locations 2) Outpatient locations –where care provided to patients post-discharge OR prior to admission
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•No Newborn locations•No outpatient dialysis centers
Forms for LabID Data Collection
Reporting Location Options –LabID Events
Facility-wide by location: Report every location in the facility separately• Patient days• Admissions•CDAD data
Selected locationsYou choose the specific locations in your facility•Patient days•Admissions•CDAD data
Overall / Facility-wideReport all locations together•Patient days•Admissions•CDAD data
You can collect C. difficile Lab ID Event data:
Reporting Infections:Facility-wide by location
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Report separately from every location in the facility
Medical
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CDI LabID Reporting
CDI LabID Reporting
Reporting Infections:Selected Locations Only
Report separately for one or more specific location s of a facility
Medical
CDI LabID Reporting
CDI LabID Reporting
Reporting Infections:Facility-wide
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+Medical
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CDI LabID Reporting
Report data for entire facility together.
If you would like to monitor a specific location
in addition to the entire facility, you may do so.
CDI LabID Event Form
CDI LabID Event Form
Select “yes” if the LabID Event is being reported from an outpatient location where there are no admissions (e.g., emergency department, wound care, etc.)
If the patient was an outpatient, Date Admitted to Facility and Date Admitted to Location are not required.
CDI LabID Event Form
CDI LabID Event Form
If the LabID Event was reported from an
outpatient location, leave this blank
Enter the patient care area where the patient
was assigned when the LabID specimen
was collected
Note: the “Transfer Rule” does not apply to LabID Events
CDI LabID Event Form
Note: Because of existing business rules for edit
checks in NHSN, the date of specimen collection must
be the same date or later than the admission date.
CDI LabID Event Form
Circle “Yes” if the patient has been an inpatient and
discharged from your facility in the past 3 months
CDI LabID Event Form
If the patient was discharged from your facility in the past 3 months, enter the most recent date of discharge.
CDI LabID Data Entry Screen
Non-editable field. Will be auto-filled by the system only, depending on whether there is prior LabID Event entered for the same organism and same patient. If there is a previous LabID Event for this organism entered in NHSN in a prior month, the system will auto-populate with “Yes.
Denominator Data (LabID)
If you are using Method A or B, complete a Denominator Record for each location
Denominator Data (LabID)
If this is a single inpatient location, enter the total
number of patient days for the month.
If this is a single inpatient location, enter the total
number of admissions for this location for the month
Denominator Collection (LabID)
Check C.difficile as the organism that will be
monitored in this location
FacWideIN DenominatorsThis number would be the total number of patient days for the
entire facility for the month minus any patient days for
NICU or Well Baby Nurseries
This number would be the total number of admissions for the
entire facility for the month minus any admissions to
NICUs or Well Baby Nurseries
Denominators – Outpatient Location
FacWideOUT Denominators
If LabID C. difficile Events are being monitored at the
FacWideOUT level, then Total Encounters minus any
encounters for Well Baby Clinics must be entered here
CDI Metrics
Note!
The following categories
and prevalence and
incidence calculations
are built into the
analysis capabilities of
NHSN.
Incidence vs. Prevalence
• Incidence Rate: measures the occurrences of new cases or events in a specific population during a given time period
• Prevalence Rate: measures the occurrence of existing (old and new) cases in a specific population during a given time period
Categories of CDI LabID Events
• Community Onset (CO): LabID Event collected as an outpatient or an inpatient ≤3 days after admission to the facility (i.e., days 1, 2, or 3)
• Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from the facility ≤ 4 weeks prior to current date of stool specimen collection
• Healthcare Facility-Onset (HO): LabID Event collected >3 days after admission to the facility (i.e., on or after day 4)
CDI Prevalence RatesAdmission Prevalence Rate
By single locationBy facility
# non-duplicate CDI LabID Events per patient per month identified ≤ 3 days after admission to the facility
# patient admissions to the facility
X 100
# non-duplicate CDI LabID Events per patient per month identified ≤ 3 days after admission to the specific location X 100
# patient admissions to the same location
Location Percent Admission Prevalence that is CO
Note: the numerator in this formula does not include Admission Prevalent LabID Events that are CO-HFCA
# Admission Prevalent LabID Events to a location that are CO
Total # Admission Prevalent LabID Events
X 100
Location Percent Admission Prevalence that is CO-HFCA
# Admission Prevalent LabID Events to a location that are CO-HFCA
Total # Admission Prevalent LabID Events
X 100
Location Percent Admission Prevalence that is HO
# Admission Prevalent LabID Events to a location that are HO
Total # Admission Prevalent LabID Events
X 100
Overall Patient Prevalence Rate
Number of 1st CDI LabID Events per patient per month for the location*, regardless of time spent in that location*
Number of patient admissions to the location*
* or facility
Outpatient Reporting
X 100
# all non-duplicate CDI LabID Events per patient for the location
# of patient encounters for the location
# all non-duplicate CDI LabID Events per patient for the facility
X 100# of patient encounters for the location
By specific location : Facility-wide (FacWideOUT)
CDI Incidence Rates
Location CDI Incidence Rate
# of Incident CDI LabID Events per month identified >3 days after admission to the location
# of patient days for the location
X 10,000
Facility CDI Healthcare Facility-Onset Incidence Rate
# of all Incident HO CDI LabID Events per month in the facility
# of patient days for the facility
X 10,000
Note: this calculation is only accurate for Overall Facility-Wide Inpatient reporting
Facility CDI Combined Incidence Rate
# of all Incident HO and CO-HCFA CDI LabID Events per month in the facility
Number of patient days for the facility
X 10,000
Note: this calculation is only accurate for Overall Facility-Wide Inpatient reporting
Metrics Summary – CDI LabID Events
Question
• I don’t have a strong statistics background and I’m not sure I have time to separate out the Healthcare Onset (HO) from the Community Onset (CO) MDROs. What should I do?
No problem. The NHSN analysis tool automatically c alculates therates based on the information you provide using th e reporting plan, event, and denominator information.
No problem. The NHSN analysis tool automatically c alculates therates based on the information you provide using th e reporting plan, event, and denominator information.