Transcript CLABSI CASE STUDIES

NHSN CASE STUDIES
or… Russ’s title
NHSN Jeopardy
Allison Gibson Murad, MPH aka Allie “Trebek”
NHSN Epidemiologist
Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit
Michigan Department of Community Health
[email protected]
& Russ Olmsted – MSIPC Fundamentals Faculty
NHSN: Not Just for Acute Care
www.cdc.gov/nhsn
Federal HAI Reporting To NHSN Under Inpt.
Quality Reporting: Past/present & Future
2011
• CLABSI – Acute Care ICUs (Jan.)
2012
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CAUTI – Acute Care ICUs (except NICUs) (Jan.)
CAUTI – LTCH, IRF, Cancer Hospitals (Oct)
SSI – Colon Surgeries and Abdominal Hyst. – Acute Care (Jan)
Dialysis Events – ESRD (Jan)
CLABSI – LTCH, Cancer Hospitals (Oct)
2013
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C. Diff LabID Events – Acute Care (Jan.)
MRSA Bacteremia LabID Events – Acute Care (Jan.)
HCP Influenza Vaccination – Acute Care (Jan.)
HCP Influenza Vaccination – LTCH (Jan.)
2014
• HCP Influenza Vaccination – ASCs (Oct.)
• SSI – Cancer Hospitals (Jan.)
• HCP Influenza Vaccination – IRF (Oct.)
2015
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CLABSI – Acute Care Med, Surg, Med/Surg Units (Jan.)
CAUTI – Acute Care Med, Surg, Med/Surg Units (Jan.)
MRSA Bacteremia LabID Events – LTCH (Jan.)
C. Diff LabID Events – LTCH (Jan.)
APIC. Federal HAI Reporting to NHSN resource update. www.apic.org 9/17/13
All case studies and
responses are derived from
slides developed by CDC or
are approved by CDC NHSN
staff.
CAUTI Module (1)
• 84 year old patient is hospitalized with a GI bleed.
• Day 3: Patient has an indwelling urinary catheter in
place but has no signs or symptoms of infection.
• Day 9: Patient becomes unresponsive, is intubated
and CBC shows WBC count of 15,000. Temp is 38.0 C.
• Patient is pan-cultured . Blood culture and urine
both grow Streptococcus pyogenes. Urine culture
shows > 100,000 CFU/ml.
CAUTI Module (1 – part A)
Is this a UTI? A CAUTI? If so, what type?
A. No UTI because the blood seeded the urine.
B. Yes, this is an ABUTI [asymtomatic, bacteremic UTI].
C. Yes, this is a SUTI [symptomatic UTI] NHSN Criterion
1a with a secondary BSI.
CAUTI Module (1- Part B)
What if the organism in both cultures had been a
Micrococcus?
Would it be a UTI?
Would it still be an ABUTI?
CLABSI Module (1 )
• 5/15: 79 year old male, admitted with gastric cancer.
Central line placed day of admission for total
parenteral nutrition.
• 5/16: Partial gastrectomy performed.
• 5/21: Pt progressing well until fever spike of 101.3 F
(38.5 C) Blood cultures sent.
• 5/22: Increasing abd pain. CT scan of abd shows
small fluid collection posterior to stomach. Fluid
collection fully drained by ultrasound-guided needle
aspiration, & fluid sent for culture. Blood cultures
repeated.
CLABSI Module (1- Part A)
• 5/23: Blood cultures from 5/21: 1 of 2 positive for
Staph epidermidis. Abd fluid growing gram positive
cocci. Antibiotics begun.
• 5/24: Abd culture: Enterobacter cloacae. Blood
cultures from 5/22: 2 of 2 positive for coagulaseneg. staphylococcus.
Does this pt have an infection?
If yes, is it an HAI?
CLABSI Module (1- Part B)
Does this patient have a CLABSI?
Options:
A. Yes, the patient has a CLABSI with S.
epidermidis.
B. No, the BSI is secondary to the abdominal
infection.
C. Not sure.
SSI Module (1)
4/12: Pt is admitted to hospital for elective surgery and
an active MRSA screening test is positive. On same day,
pt undergoes total abd hysterectomy.
4/16: Post-operative course is unremarkable. Pt is
discharged to home.
4/29: Pt is readmitted with complaints of acute
incisional pain since day before. Surgeon opens wound
into the fascial level and sends drainage specimen for
culture & sensitivity.
5/1: Culture results are positive for MRSA.
SSI Module (1 – Part A)
Does this patient have an HAI?
Options:
1. Yes. If yes, then what type of infection should
be reported to NHSN? SSI-SIP? SSI-SIS? SSI-DIP?
SSI-DIS? Or SSI-IAB?
2. No HAI.
SSI Module (1 – Part B)
What is the date of the event (SSI)?
Options:
A. 4/12
B. 4/16
C. 4/29
D. 5/1
MDRO/CDI Module (1)
• 3/1: 55 year old patient with end stage
pancreatic cancer with liver & bone metastasis is
admitted to inpt unit 3E from hospice facility.
The pt has no previous history of inpt admission
to this facility. Upon admission to 3E, pt is noted
to have foul loose stools. After three episodes of
loose stools over the course of 24 hours, an
unformed specimen is collected and test positive
for C. difficile toxin.
MDRO/CDI Module (1 – Part A)
For FacWideIN LabID reporting, should this be
entered into NHSN as a LabID event?
Options:
A. Yes. Specimen was collected from 3E inpatient
location.
B. No. This infection belongs to the hospice
facility.
C. No. This is not a HAI, therefore it should not be
reported into NHSN.
MDRO/CDI Module (1 – Part B)
How will NHSN categorize the CDI event?
A. Community-Onset (CO)
B. Healthcare Facility-Onset (HO)
C. Community-Onset Healthcare Facility-Associated
(CO-HCFA)
D. NHSN will not categorize the event; the user will
need to make the decision.
MDRO/CDI Module (1 – Part B)
Correct Response: A. Community-Onset (CO)
Rationale:
The patient has no previous history of admission to
this facility and the stool specimen was collected as
an inpatient less than 4 days after admission to the
facility.
Note: Community-Onset Healthcare FacilityAssociated (CO-HCFA) is based on previous
discharge from index facility. Also…………….(next
slide)
MDRO/CDI Module (2 – Part A)
• January 1st, 10:30am: 75-year old male presents
to the ED from a LTAC with the chief complaints
of shortness of breath, abdominal cramping, and
a three day history of multiple episodes of
diarrhea.
• Medical history: myocardial infarction and a
three vessel coronary artery bypass grafting
procedure performed on Dec. 2 at this hospital,
which was complicated by a prolonged postoperative stay in the ICU.
MDRO/CDI Module (2 – Part A)
• During the stay, he was treated for a UTI with
Levofloxacin. He was discharged to undergo
rehabilitation at the LTAC on Dec. 23 where he
had his onset of diarrhea
• While in the ED on Jan. 1, a chest X-ray reveals
bilateral pleural effusions and pulmonary edema.
Before being admitted to an inpatient location,
aggressive diuresis is initiated and a diarrheal
stool specimen is collected and sent to the lab
for C.diff toxin testing.
MDRO/CDI Module (2 – Part A)
• Test result indicates positive C.diff toxin A/B. Patient
is admitted to 2N telemetry at 3:45pm on Jan. 1.
• Jan. 2: during the night, patient has respiratory
deterioration requiring mechanical ventilation, and
is subsequently transferred to the ICU.
• Continues to have abdominal cramping and multiple
episodes of diarrhea. Another diarrheal stool
specimen is collected and sent form the ICU for
C.diff toxin testing.
• Result is positive for C.diff toxin A/B. Flagyl is
started.
MDRO/CDI Module (2 – Part A)
Would you identify the Jan. 1st C.diff toxin positive assay as a
CDI LabID Event for facility-wide inpatient (FacWideIn)
reporting?
A. No. The patient was admitted with diarrhea form the LTAC
and the transfer rule applies.
B. Yes. The result would be identified as a CDI LabID Event for
2N.
C. Yes. The result would be identified as a CDI LabID Event for
the ED.
D. No. Since the patient presented to the ED with diarrhea
suggestive of CDI, this is considered community-onset, and
therefore should not be considered a CDI LabID Event for
FacWideIn reporting.
MDRO/CDI Module (2 – Part B)
Would you identify the Jan 2nd positive C.diff toxin result as a
CDI LabID Event for FacWideIn Reporting?
A. No. His symptoms started <4 days after admission.
B. Yes. As there were no other CDI positive specimens for this
patient and location (the ICU) in ≤ 2weeks, the result would be
identified as a CDI LabID Event for the ICU.
C. Yes. The result would be identified as a CDI LabID Event for 2N
since the patient was in that location within the prior 2 calendar
days and the transfer rule applies.
D. No. Since this is the second positive C. difficile isolate collected
from this patient within 14 days, it is considered a duplicate CDI
LabID Event.
MDRO/CDI Module (2 – Part C)
If the Jan 1st positive C.diff toxin result is a CDI LabID Event,
how will the event be categorized by the NHSN application?
A. Community-Onset (CO)
B. Healthcare- Facility-Onset (HO)
C. Community-Onset Healthcare Facility-Associated (CO-HCFA)
D. The NHSN application will not categorize the event.
MDRO/CDI Module (2 – Part D)
• The patient remains in the ICU until Jan 14th
when he is transferred back to 2N telemetry. He
has completed a course of Flagyl, has no
abdominal complaints and his stools are formed
with no further C.diff toxin testing having been
performed.
• Jan. 16th: he has an episode of diarrhea after
eating breakfast and another episode of diarrhea
in the afternoon. A sample is sent for C.diff toxin
testing and the result is positive for C.diff toxin
A/B.
MDRO/CDI Module (2 – Part D)
Would you identify the Jan 16th positive C.diff toxin result as a
CDI LabID Event for FacWideIn reporting?
A. Yes. The result would be identified as a CDI LabID Event for 2N since
the specimen was collected in a location with no prior C. difficile
specimen reported within 14 days for the patient and location.
B. No. The result would be considered a duplicate episode of C. difficile
and would not be reported as a separate CDI LabID Event for
FacWideIN reporting.
C. Yes. The result would be identified as a CDI LabID Event for the ICU
since the specimen was collected 14 days after the last positive
specimen for the ICU and the patient was in that location within the
previous 48 hours and the transfer rule applies
CLABSI Module (2 – Part A)
• 8/14: 41 year old female presents to ER in diabetic
coma and with anemia. She has a subclavian
catheter inserted in the ER. The next day, in the ICU
she has a midline catheter inserted and receives a
blood transfusion.
• 8/17: Pt develops fever of 39 C and shaking chills.
Two sets of blood cultures sent to lab.
• 8/19: Blood cultures positive for Pseudomonas
aeruginosa. Neither insertion site shows
inflammation and there is no other documented
infection.
CLABSI Module (2 – Part A)
Does Ms. E have a Laboratory-Confirmed
Bloodstream Infection (LCBI)?
Options:
A. No, the pt does not have an LCBI.
B. Yes, the pt has an LCBI with P. aeruginosa.
C. Not sure.
CLABSI Module (2 – Part B)
If Ms. E has an LCBI, which criterion of LCBI applies?
Options:
A. LCBI criterion 1 – recognized pathogen cultured
from 1 or more blood cultures.
B. LCBI criterion 2 – pt has fever, chills and 2 or more
positive blood cultures.
CLABSI Module (2 – Part C)
What unit should be indicated for the location of
the device insertion?
Options:
A. The ED should be recorded as the location of
device insertion.
B. The ICU should be recorded as the location of
device insertion.
C. Neither location.
D. Not sure.
Thank You! Any Questions?
Contact:
• Allie Murad, MPH, NHSN Epidemiologist
• [email protected]
• 517-335-8199
• Judy Weber, MPH, Healthcare Facility Liaison
• [email protected]
• 517-335-8331
• SHARP Website: www.michigan.gov/hai