Transcript NHSN National Healthcare Safety Network

NHSN
NATIONAL HEALTHCARE
SAFETY NETWORK
Catheter-Associated Urinary Tract
Infection (CAUTI)
ELSA SANTOS-CRUZ, CIC
MOUNT SINAI MEDICAL CENTER
(INFECTION CONTROL)
TOPICS DISCUSSED
1.
CMS Reporting
2.
Definition and Protocol
3.
Clean-up Issue regarding definition
4.
Attendees partake in Case Studies
5.
Data Entry & Analysis
6.
Preventive Measures of different infection
PATIENT SAFETY COMPONENT
1.
Device – Associated Module
2.
Procedure-Associated Module
3.
Medication Associated Module
4.
MDRO and C. difficile Infection
Module
5.
Vaccination Module
DEVICE-ASSOCIATED MODULE
1.
CLABSI – Central line-associated
Bloodstream Infection
2.
CAUTI – Catheter-Associated Urinary
Tract Infection
3.
VAP – Ventilator Associated Pneumonia
4.
CLIP – Central Line Insertion Practices
5.
DE – Dialysis Event
METHODS OF SURVEILLANCE


LABORATORY BASSED
Case – finding based on positive laboratory
results
PATIENT – BASED
Monitoring patients for events, risk factors,
procedures and practices related to patient care.
Review patient charts
― Visit patient care areas
― Discuss with caregivers
―
METHODS OF SURVEILLANCE


PROSPECTIVE
Monitoring patients while still in the facility,
hospital; includes post-discharge period for SSI
RETROSPECTIVE
Case-finding based solely on chart review after
patient discharge.
WHY CAUTI SURVEILLANCE?
History:

Most common Healthcare Associated Infection (HAI)

Most of UTIs are associated with indwelling catheter
Other reasons:

Mandatory Reporting

Denial of CMS dollar reimbursement
MONTHLY REPORT
CAUTI must be included in monthly NHSN
Report by the following facility/institution;

Acute Care Hospitals: Adult and Pediatric ICUs

Long Term Care Hospitals: All inpatient location

Inpatient Rehabilitation Facilities: All inpatient
locations
MONTHLY REPORT
Report complete and accurate data in a timely
manner.

Report each CAUTI indentified

Indicate NO CAUTI detected for specific location

Report total device days for specific location

Report total patient days in specific location
DEFINITION
Healthcare – Associated
Infection (HAI)
A localized or systemic condition
resulting from an adverse reaction to
the presence of an infectious agent(s)
or its toxin(s) that


Occur in a patient in a healthcare
setting and
Was not present or incubating at the
time of admission, unless the
infection was related to a previous
admission
DEFINITION
Indwelling Catheter
A drainage tube that is inserted into the
urinary bladder through the urethra, is
left connected to a closed collection
system.


Also called a Foley catheter
Does not include (among others):



Straight in and out catheters
Suprapubic catheters
Nephrostomy tubes
DEFINITION
CAUTI
A UTI in a patient who had an indwelling
urinary catheter is in place at the time of or
within 48 hours prior to infection onset.
NOTE: There is no minimum period of time that
the catheter must be in place in order for the UTI
to be considered catheter-associated
DEFINITION
Location
CAUTIs are attributed to inpatient location at
time of urine collection or symptom onset,
whichever comes first.
Exception: If a CAUTI develops within 48 hours
of transfer from one inpatient location to another
in the same facility or a new facility, the infection
is attributed to the transferring location
(Transfer Rule).
DEFINITION
Transfer Rule:
Mr. Smith is transferred from SICU with a Foley and 36
hours after transfer has a fever of 38.20C. The next day a
urine culture collected has >105 CFU/ml of E. coli. This
CAUTI is attributed to the SICU
DEFINITION
Urinary Tract Infection
Definition
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI)
 Asymptomatic Bacteremic UTI (ABUTI)

NOTE: The specific site “Other Urinary Tract Infection”
(OUTI) can also be used to identify an infection in the
urinary tract, however OUTI are not associated with
urinary catheters and therefore cannot be CAUTI events.
CRITERIA
Symptomatic UTI
SUTI 1a
1a . Patient had an indwelling urinary catheter in place at the time of specimen
collection and at least 2 of the following signs or symptoms with no other recognized
cause: fever (>380C), suprapubic tenderness, or costovertebral angle pain or
tenderness and
a positive urine culture of ≥ 105 colony-forming units (CFU)/ml with no more than
2 species of microorganisms.
----------------------------------------------------------OR----------------------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to
specimen collection
and
at least 1 of the following signs or symptoms with no other recognized cause:
fever (>380C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral
angle pain or tenderness
and
a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than
2 species of microorganisms
CASE 1





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50 year old patient with end stage pancreatic cancer with liver
and bone mets admitted to hospital with advance directive for
comfort care and antibiotics only; Foley catheter, peripheral IV
and nasal cannula inserted.
Day 4: patient is febrile to 38.00C and has suprapubic tenderness;
IV ampicillin started after urine obtained for culture.
Day 5: difficulty breathing; CXR = infiltrate L lung base
Day 6: urine culture results = 105 CFU/ml E. coli.
Day 7: WBC/mm3 = 3400; patchy infiltrates in both lung bases;
continued episodes of dyspnea; rales noted in LLL.
Day 11: Patient expired
Q: Does this patient have a UTI? If, so what type?
1.
2.
3.
4.
Yes, SUTI Criterion 1a.
Yes, SUTI Criterion 2a.
Yes, ABUTI
No UTI
CRITERIA
Symptomatic UTI
SUTI 2a
2a. Patient had an indwelling urinary catheter in place at the time of specimen collection and
at least 2 of the following signs or symptoms with no other recognized cause: fever (>38 0C), suprapubic tenderness, or
costovertebral angle pain or tenderness and
a positive urinalysis demonstrated by at least 1 of the following findings:
a.
Positive dipstick for leukocyte esterase and/or nitrite
b.
Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 of unspun urine or ≥3 WBC/high power field of
spun urine)
c.
Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms.
----------------------------------------------------------OR----------------------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and
at least 1 of the following signs or symptoms with no other recognized cause:
fever (>380C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and
a positive urinalysis demonstrated at least 1 of the following findings:
a.
Positive dipstick for leukocyte esterase and/or nitrite
b.
Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 of unspun urine or ≥3 WBC/high power field of
spun urine)
c.
Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms.
CASE 2
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POD 3: 66 y.o. patient in the ICU with a Foley catheter s/p
exploratory lap; patient noted to be febrile (38.90C) and
complained of diffuse abdominal pain.
WBC increased to 19,000. He had cloudy, foul-smelling urine and
urinalysis showed 2+ leukocyte esterase, WBC – TNTC, and 3+
bacteria. Culture was 10,000 CFU/ml E. Coli. The abdominal pain
seemed localized to surgical area.
Q: Is this a UTI? If so, what type?
1.
2.
3.
4.
No UTI.
Yes, SUTI Criterion 1b.
Yes, SUTI Criterion 2a.
Yes, ABUTI
CRITERIA
Symptomatic UTI
Criteria 3 & 4 (≤ 1 year old)
3. Patient ≤ 1 year of age with or without an indwelling urinary catheter has at least 1 of the
following signs or symptoms with no other recognized cause: fever (>380C core), hypothermia
(<360C core), apnea, bradycardia, dysuria, lethargy, or vomiting and
a positive urine culture of ≥ 105 CFU/ml with no more than 2 species of microorganisms.
…………………………………………………………………………………………………………...
4. Patient ≤ 1 year of age with or with an indwelling urinary catheter has at least 1 of the following
signs or symptoms with no other recognized cause: fever (>380C core), hypothermia (<360C core),
apnea, bradycardia, dysuria, lethargy, or vomiting
and
a positive urinalysis demonstrated by at least one of the following findings:
a.
Positive dipstick for leukocyte esterase and/or nitrite
b.
Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of unspun urine or ≥3
WBC/high power field of spun urine)
c.
Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of
microorganisms.
CASE 3
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3 week old infant born at 27 weeks gestation. Umbilical
catheter in place. HR 100, RR 32, and core temperature
ranges between 37.80C and 36.20C. Baby is lethargic.
Straight cath urine culture yields >105 CFU/ml
Enterococcus faecium.
1 blood culture collected same day, also positive for E.
faecium. Susceptibilities match.
Is this a UTI?
If so what type?
CRITERIA
Is this a CAUTI? If so,
what type?
1.
Yes, CA-SUTI Criterion 3.
2.
Yes, CA-SUTI Criterion 1a.
3.
Yes, CA-SUTI Criterion 2b
4.
Not a CAUTI.
CRITERIA
Asymptomatic Bacteremic UTI
(ABUTI)
Patient with or without an indwelling urinary catheter ahs no signs or symptoms(i.e., for any age patient, no
fever (>380C ), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness,
OR hypothermia (<360C core), apnea, bradycardia, dysuria, lethargy, or vomiting)
and
a positive urine culture of > 105 CFU/ml with no more than 2 species of uropathogen microorganisms
and
a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture, or at least 2
matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant.
Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta hemolytic
Streptococcus spp., Enterococcus spp., G. Vaginalis, Aerococcus urinae, and Corynebacterium (urease positive).
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C.
urealyticum (CORUR) if so speciated.
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note: All ABUTIs will have a secondary bloodstream infection
CASE 4
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84 year old patient is hospitalized with GI
bleed.
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Day 3: Patient has indwelling catheter in
place and no signs or symptoms of infection
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Day 9: Patient becomes unresponsive, is
intubated and CBC shows WBC of 15,000.
Temp 38.0 C. Patient is pan-cultured. Blood
culture and urine both grow Streptococcus
pyogenes – urine > 105 CFU/ml
CRITERIA
Is this a UTI? If so, what type?
1.
2.
3.
No, because the blood seeded the urine and
therefore there is no UTI
Yes, ABUTI
Yes, SUTI Criterion 1a with secondary BSI
What if the organism in both cultures had
been Micrococcus? Is it a UTI?
1.
Yes, this is an ABUTI
2.
No, this is not an ABUTI
QUESTION & ANSWER

Q: Are asymtomatic bacteremic urinary tract infections
(ABUTIs) in patients in adult and pediatric intensive are
units( ICUs) included in the reporting requirements for
CMS’s HIQRP beginning January 2012?

A: YES, if a patient in the ICUs has an indwelling
urinary catheter at the time of or within 48 hours
prior to specimen collection or the onset of
symptoms ( whichever comes first) and meets the
NHSN criteria for ABUTI, this infection is a CAUTI
and is reportable to CMS.
CAUTI NHSN
NUMERATOR
PATIENT INFORMATION
Four (4) Required Fields;
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Facility ID

Patient ID
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Gender

Date of Birth
CAUTI NUMERATOR
EVENT INFORMATION

EVENT TYPE:

DATE OF EVENT:
UTI
Date of Specimen collected
OR
Date of signs/symptoms (whichever comes first)

POST-PROCEDURE:
Mark YES if UTI occurred after
an NHSN defined Procedure.

LOCATION: Enter patient location when UTI was identified.
See TRANSFER RULE

DATE ADMITTED:
Date of Admission to Facility
CAUTI NUMERATOR
Risk Factors:
Urinary Catheter:
In
place remove within 48hrs
neither.
EVENT DETAIL:
SPECIFIC EVENT:
Symptomatic UTI
Lab Diagnostic Test
Signs & Symptoms
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Fever
Urgency
Frequency
Dysuria
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Positive Culture w/>105 CFU
Positive leuko esterase/nitrite
Pyuria
1 positive culture w/ >103 and
<105
EVENT DETAIL
Secondary BSI:
Secondary BSI
ABUTI
YES
One organism from positive urine culture match
the blood culture.
DIED:
YES
If patient died during this hospitalization.
UTI contributed to Death:
Yes
EVENT DETAILS
PATHOGEN: If multiple pathogens,
enter the most important first
#1
E.coli
#2
Enterococcus faecium
SENSITIVITY TEST RESULT:

S – Susceptible

I – Intermediate
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R – Resistant
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N – Not tested
DENOMINATOR
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
Count at the same time each day
Number of patients in ICU
Number of patient with an individually urinary
catheter
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Location code: ICU

Month: January

Year: 2012

Total pt. day: 5 6 7
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Urinary Cath day: 2 3 4
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CAUTI
THANK YOU !!!
For any questions or inquires:
Email: [email protected]
Website: www.cdc.gov/nhsn