C. difficile Infection and C. difficile Lab ID Reporting...

7/16/2011

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C. difficile Infection and

C. difficile Lab ID Reporting

in NHSN

MARY ANDRUS, BA, RN, CIC

Infection Preventionist Consultant

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 the

same illness and are used interchangeably.

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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

CDAD Module

CDI Infection Surveillance

CDI LabID Event

ReportingCDI

Prevention Process

Measures

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


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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JAN FEB MAR APR

MAY JUN JUL AUG

DECSEP OCT NOV

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!


Forms

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Reporting Infections:

Facility-wide by location

+ +

+

Report separately from every location in the facility

Medical

+



Facility-wide by locationCDI Infection Surveillance


Selected Locations Only

Report separately for one or more specific locations of a facility

Medical


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Selected Locations OnlyCDI 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.

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Option #1 – CDI Infection

SurveillanceGI-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 likely 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 swab

b. an enteric pathogen is detected by routine or electron microscopy

c. an enteric pathogen is detected by antigen or antibody assay on blood

or feces

d. 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

SurveillanceGI-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 examination

2. 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 blood

d. evidence of pathologic findings on radiographic examination

e. 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

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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 has 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

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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.difficile

infection is being

followed for infection

surveillance in that

location in the Monthly

Reporting Plan

Event Form (cont.)

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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.

Event Form (cont.)

Circle “Yes” to

indicate admission to

ICU for complications

of C.difficile (e.g.,

shock that requires

vasopressor therapy

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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

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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.

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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

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CDAD Infection Incidence Rate

CDAD Module


CDI LabID Event

ReportingCDI

Prevention Process

Measures

If you choose to


you must select at


reporting options!

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CDI LabID Event Reporting

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

JAN FEB MAR APR

MAY JUN JUL AUG

DECSEP OCT NOV

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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

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

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Reporting Location Options –

LabID Events

Facility-wide by location:

Report every location in the facility separately

• Patient days

• Admissions

•CDAD data

Selected locations

You choose the specific

locations in your facility

•Patient days

•Admissions

•CDAD data

Overall / Facility-wide

Report all locations

together

•Patient days

•Admissions

•CDAD data

You can collect C. difficile Lab ID Event data:


Facility-wide by location

+ +

+

Report separately from every location in the facility

Medical

+

CDI LabID Reporting

CDI LabID Reporting

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Selected Locations Only

Report separately for one or more specific locations of a facility

Medical

CDI LabID Reporting

CDI LabID Reporting


Facility-wide

+ +

+

Medical

+

CDI LabID Reporting

Report data for entire facility together.

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If you would like to monitor

a specific location in

addition to the entire

facility, you may do so.

CDI LabID Event Form

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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.



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

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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.


Circle “Yes” if the patient

has been an inpatient and

discharged from your facility

in the past 3 months


If the patient was discharged from your facility in the past 3

months, enter the most recent date of discharge.

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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

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Denominator Collection (LabID)

Check C.difficile as the

organism that will be

monitored in this location

FacWideIN Denominators

This 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

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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

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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 locationX 100

# patient admissions

to the same location

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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


Prevalence that is CO-HFCA


LabID Events to a

location that are CO-

HFCA

Total # Admission

Prevalent

LabID Events

X 100


Prevalence that is HO


LabID Events to a

location that are HO

Total # Admission

Prevalent

LabID Events

X 100

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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

facilityX 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

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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

CDI Prevalence

Rates

Admission

Prevalence

Outpatient Prevalence

Location %

Admission Prevalence

CO

Location %

Admission Prevalence CO-HCFA

Location %

Admission Prevalence

HO

Overall Patient

Prevalence

CDI Incidence

Rates

Location Incidence

Facility HO

Combined Incidence HO and

CO-HCFA

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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 calculates the

rates based on the information you provide using the reporting

plan, event, and denominator information.

CDAD Module


CDI LabID Event

ReportingCDI

Prevention Process

Measures

If you choose to


you must select at


reporting options!

•Adherence to

Hand Hygiene

•Adherence to

gown/glove use

C. difficile Infection and C. difficile Lab ID Reporting...

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