Kentucky Webinar Series NHSN: CLABSI

6/2/2015Kentucky Webinar Series ‐NHSN: CLABSIJune 2, 2015Sponsoredd by:bQsource and the Atom AllianceKentucky Department for Public HealthKentucky Hospital Association1Welcome and Instructions For audio, join by telephone at 877-594-8353,participant code: 56350822 Your line is OPEN. Please do not use the holdfeature on your phone but do mute your line bydialing *6. If you are having technical difficulties, emailddmeador@kyha.comd @k h Please ask questions through the chat box or wait tothe end of each section to ask the presenter21

6/2/2015Presentation provided by:Ruth Belflower, MPH, BS, BSN, RN, CICInfection PreventionistHardin Memorial Hospital - Elizabethtown, KYNHSN 2015 Surveillance Definitions:Central Line-Associated Blood Stream Infections(CLABSI)Presented By:Ruth Belflower, MPH, BS, BSN, RN, CICInfection PreventionistHardin Memorial Hospital - Elizabethtown, KYSlides Developed By:Susan Morabit, MSN,PHCNS-BS, CICNurse ConsultantNational Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion2

6/2/2015Objectives1.Define key terms for device-associated infectionsand CLABSI2.IdentifyIdtif device-associatedd ii t d infectionsi f tisurveillanceillchanges3.Describe how to collect central line and patient daydata4.Identify data collection forms2New Reporting RequirementsIn addition to ICU, reportCLABSI from all patientcare location that aremapped as adult andpediatric medical surgical medical/surgical -3-eNL-Sept-2014.pdf3

6/2/2015CLABSI Epidemiology In recent prevalence study1: 28% of acute care patients had a central line 14% of HAIs were BSI All BSIs identified were CLABSI Estimated 41,000 CLABSI annually hospital-wide2 18,000 CLABSI annuallyy in ICUs 123Cost varies (2007 dollars)3: 7,000 to 29,000 perepisodeMagill ss, Hellinger w, et. al. Prevalence of Healthcare Associated Infections in Acute Care Hospitals in Jacksonville, Florida. Infection Control andHospital Epidemiology, Vol. 33, No. 3 (March 2012), pp. 283 91Vital Signs: Central line associated bloodstream infections United States, 2001, 2008, and 2009. MMWR March 4, 2011; 60(08);243 248.Scott, Douglas II (2008). The Direct Medical Costs of Healthcare Associated Infections in U.S. Hospitals and the Benefits of Prevention. March2009. http://www.cdc.gov/hai/pdfs/hai/scott costpaper.pdfThe Essentials of Infection Surveillance Know protocol/criteriaConsistently apply the criteriaReport events meeting criteria; exclude those that don’tFailure to do so: Decreased usefulness of national comparative dataUnfair comparisons between facilitiesPossible validation discrepanciesPotential impact of CMS Inpatient Quality Reporting score & facilityreimbursementConcerns about the criteria should be sent to NHSN-4

6/2/2015Key PointsAt times surveillance determinations and clinical diagnosesgwill notmatch.Surveillance determinations always “trump” in epidemiologicsurveillance.Surveillance definitions should never be used to dictate clinicaldiagnosis or treatment.Use comments section and optional data fields of event form to trackinfo useful for internal quality improvement.BSI Key TermsINFECTIONWINDOWPERIODDATEOFEVENT Blood Culture The date the first element used to meet the CDCNHSN site-specific infection criterion occurs for thefirst time within the seven day infection windowperiodNHSN PS Manual Chapter 2 Identifying , pp. 2, Table 25

6/2/2015BSI Key Terms Cont’dPOAHAI If date of blood culture is the day of admissionor the day after admission, infection is POA. The POA time period includes the 2 days beforeadmission, the day of and the day afteradmission. If date of blood culture is on or after the 3rdcalendar day of admission, BSI is an HAI.NHSN PS Manual Chapter 2 Identifying , pp. 3, Table 3BSI Key Terms Cont’d:Repeat Infection Timeframe (RIT) A 14-day timeframe during which a patient will have no more than 1LCBI (e.g., LCBI 1, LCBI 2, MBI-LCBI 1, etc.) reported The date of blood culture is Day 1 of the 14-day RIT Additional pathogens identified during RIT are added to initial event Negative cultures do not impact the RIT Central line-association determination does not change during the RIT Example: A non-central line-associated LCBI is identified andi iti t an RIT.initiatesRIT OnO dayd 3 off theth RIT a centralt l liline iis placed.ld OOnday 8 of RIT with central still in place, another blood culture iscollected and with a different pathogen. Add the pathogen to theoriginal LCBI but do not change the non-central line associatedLCBI to CLABSI nor report a separate event.6

6/2/2015Key Terms WorksheetExcel File Available at bottom of i/index.htmlCentral Line-associated Bloodstream Infection(CLABSI)LCBI where a central line (CL) or umbilical catheter (UC) wasin place for 2 calendar days on the date of event, with dayof device placement being Day 1ANDCL or UC was in place on the date of event or the day before,if removedremo ed (discontin(discontinued)ed)NOTE: If a patients is admitted to a facility with an implanted port, day offirst access in an inpatient location is considered Day 1 of device placement.7

6/2/2015Blood Culture Specimen Notes All blood cultures (regardless of collection method)must be included in surveillance if participating inNHSN CLABSI surveillance Blood collected via venipuncture Blood collected through vascular catheters Cannot be considered a contaminant unless single unmatchedcommon commensal (surveillance vs. clinical determination)Blood Culture and Specimen NotesRecognized pathogen does notinclude organisms consideredcommon commensals by NHSN– e.g. Bacillus spp.,Corynebacterium spp.,spp StaphStaph.Epidermidis, Staph. hominis,Streptococcus mutansExcel File Available at bottom of i/index.html8

6/2/2015Laboratory ConfirmedBloodstream Infection CriteriaLCBILCBI 1MBIMBILCBI 1LCBI 2MBIMBILCBI 2LCBI 3MBIMBILCBI 3LCBI Criterion 1 – Recognized Pathogens Patient has a recognized pathogen culturedfrom one or more blood culturesAnd Organism cultured from blood is not related toan infection at another site.249

6/2/2015LCBI Criterion 2 – Common Commensals Patient has at least one of the following signs orsymptoms: fever ( 38.0⁰C), chills, orhypotensionAnd Organisms cultured from blood are not related to aninfection at another siteAnd the same common commensal (i.e. diptheroids[Corynebacterium spp.], Bacillus [not B. anthracis] spp.,Propionibacterium spp., coagulase-negativestaphylococci [including S. epidermidis], viridans groupstreptococci, Aerococcus spp., Micrococcus spp.) iscultured from two or more blood cultures drawn onseparate occasions (same or consecutive days) within19 the 7 day Infection Window PeriodLCBI Criterion 3 – Infants 1 yr. Patient 1 yr of age has at least one of the following signsor symptoms: fever ( 38.0⁰C), hypothermia ( 36⁰C),apnea, or bradycardiaA dAnd Organisms cultured from blood are not related to aninfection at another siteAnd the same common commensal (i.e. diptheroids[[Corynebacteriumyspp.],pp ], Bacillus [[not B. anthracis]] spp.,pp ,Propionibacterium spp., coagulase-negative staphylococci[including S. epidermidis], viridans group streptococci,Aerococcus spp., Micrococcus spp.) is cultured from two ormore blood cultures drawn on separate occasions (sameor consecutive days) within the 7 day Infection WindowPeriod10

6/2/2015REMEMBER! Criteria 1 & 2 may be used forpatients of ANY age, includingthose 1 year or less. Criterion 3 only applies to patientswho are 1 year or less.lessMucosal Barrier Injury Laboratory-ConfirmedBloodstream Infection (MBI-LCBI) Subset of LCBI criteria Must meet LCBI 1, 2 or 3 prior to applying MBIcriteria If an MBI-LCBI is identified, and a subsequent bloodculture during the RIT of the MBI-LCBI is found tohhavean organismithatth t isi excludedl d d fromfMBI criteria,it ithe primary MBI-LCBI event is edited to become anLCBI and the organism is added to the event.11

6/2/2015MBI-LCBI Organisms Partial List of Eligible igellaYersinaMBI-LCBI Criterion 1 Patient meets LCBI 1 criteria with at least one blood culture growingany of the following intestinal organisms with no other organismsisolated: Bacteroides spp., Candida spp., Clostridium spp.,Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp.,Prevotella spp., Veillonella spp., or Enterobacteriaceae*AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within thepast year with one of the following documented during samehospitalization as positive blood culture: Grade III or IV gastrointestinal graft versus host disease (GI GVHD) 1 liter diarrhea in a 24 hour period (or 20 mL/kg in a 24 hour period for patients 18 years ofage) with onset on or within 7 calendar days before the date the positive blood culture is collected.Is neutropenic, defined as at least 2 separate days with values of absoluteneutrophil count (ANC) or total white blood cell count (WBC) 500cells/mm3 within the 7 day infection window period12

6/2/2015MBI-LCBI Criterion 2 Patient meets LCBI 2 criteria in which blood cultures are growing onlyviridans group streptococci with no other organismsAND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within thepast year with one of the following documented during samehospitalization as positive blood culture: Grade III or IV gastrointestinal graft versus host disease (GI GVHD) 1 liter diarrhea in a 24 hour period (or 20 mL/kg in a 24 hour periodfor patients 18 years of age) with onset on or within 7 calendar daysbefore the date the first positive blood culture was collected. Is neutropenic, defined as at least 2 separate days with values ofabsolute neutrophil count (ANC) or total white blood cell count (WBC) 500 cells/mm3 within the 7 day infection window periodMBI-LCBI Criterion 3 Patient 1 year of age meets criterion 3 for LCBI when the bloodcultures are growing only viridans group streptococci with no otherorganisms isolatedAND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within thepast year with one of the following documented during samehospitalization as positive blood culture: Grade III or IV gastrointestinal graft versus host disease (GI GVHD) 20 mL/kg diarrhea in a 24 hour period with onset on or within 7calendar days before the date the first positive blood culture is collected. Is neutropenic, defined as at least 2 separate days with values ofabsolute neutrophil count (ANC) or total white blood cell count (WBC) 500 cells/mm3 within a 7 day period which includes the date thepositive blood culture was collected (Day 1), the 3 calendar daysbefore and the 3 calendar days after.13

6/2/2015Ms.TrinketMs.Trinket was discharged fromthe ED with antibiotics for aninfected wound on February 5, butreturns on February 10th afterpassing out at a party. Hersymptoms on admission are fever,generalized pain, nausea andhypotension. A central line isinserted in the ED and bloodcultures are drawn, which arenegative. She is admitted to ICU.On hospital day 4, February 13th,repeat blood cultures grow E.coli.DateDate of Event?Infection Window?DeviceLOCRITFeb 5D/C678RIT?ypEvent type?910 CU25CLineICU26CLineICUED/ICUBlood Cultures no growth,fever pain,fever,pain nausea,nauseahypotensionICUBlood Culture E.coli14

6/2/2015DateDate of Event?Date of BC – Feb. 13thFeb 5D/CInfection Window?8RIT?Event type?ypInfection Window?Day of first BC,including 3 days beforeand the 3 days after –Feb. 10th – Feb. 16thRIT?Event type?LOCRIT6792/10Re‐ LineICU26CLineICUDateDate of Event?Date of BC – Feb. 13thDeviceDeviceED/ICUBlood Cultures no growth,fever pain,fever,pain nausea,nauseahypotensionICUBlood Culture E.coliLOCRITFeb 5D/C67892/10Re‐ LineICU26CLineICUED/ICUBlood Cultures no growth,fever pain,fever,pain nausea,nauseahypotensionICUBlood Culture E.coli15