APIC Questions with Answers NHSN FAQ Webinar Wednesday

APIC Questions with Answers
NHSN FAQ Webinar
Wednesday, September 9, 2015 2:00-3:00 PM EST
General Questions
We are an acute general hospital - psych,
do we need to be reporting anything to
NSHN?
Yes, please see the operational guidance for reporting healthcare personnel influenza
vaccination data at http://www.cdc.gov/nhsn/pdfs/cms/operational-guidance-ipf-hcp-flufinal.pdf
BSI/ RIT Questions
Once the 14 days have passed, can a
patient have a new infection after that
even if it is the same pathogen and same
infection type?
Yes. The patient is eligible to have another infection of the same type the day after the last
day of the RIT, even if that pathogen is the same pathogen previously identified. The RIT is
simply an objective time period developed for surveillance to avoid the subjectivity of
determining whether a previous infection has unresolved.
Does the RIT timeframe have to occur in
that admission, not from before admit or
from transfer from other HCF?
Yes. RITs do not carry over from one admission to another. However, if the date of
infection occurs on one of the 2 days before the day of admission, i.e., during the Present
on Admission timeframe, the date of event will be the day of admission, and that day will
set an RIT.
How is the BSI span determined?
The Secondary BSI Attribution Period is the period in which a positive blood culture must be
collected to be considered a secondary bloodstream infection to a primary site infection.
This period includes the Infection Window Period combined with the Repeat Infection
Timeframe (RIT). It is 14-17 days in length depending upon the date of event. Please see
examples of determining the secondary BSI attribution period on page 2-7 of the NHSN
manual at
http://www.cdc.gov/nhsn/pdfs/pscmanual/2psc_identifyinghais_nhsncurrent.pdf
What if more than 2 organisms are
identified during the 14 day RIT? Only 2
can be entered, so do you ignore the
others?
3 pathogens can be entered for BSI. Only 2 pathogens can be entered for UTIs, unless there
is a secondary BSI, in which case 3 pathogens can be entered. In the case where additional
pathogens identified during the RIT exceed the number of organisms that can be entered,
simply do not enter the additional organisms.
We are an IRF. The closest acute facility
frequently transfers patients on treatment
for UTI without a C&S--having only a UA+--if we culture after the 2 days post admit
but cannot match it to another pathogen
(because they didn't do one) is this a
repeat infection or our HAI?
In these cases, if the patient meets the UTI criteria and the date of event is on day 3 or later
for this admission, the UTI will be attributable to your facility. Only if the date of event is
during the Transfer Rule time period (day of transfer or next day) may the infection be
attributed to the transferring facility.
Please note however, that repeat infection timeframes do NOT extend between
admissions. This simply means that if a patient meets criteria for an infection in the acute
care facility, and then is transferred to your facility, there will be no RIT for the infection.
Any infection that occurs within your facility and which has an event date of day 3 of
admission or later will be attributed to your facility.
Question related to NEC with secondary
BSI. Can you have a secondary BSI since a
BC is not part of the NEC definition? When
there is documented
Pneumatosis/pneumoperitoneum, it is
common to get a positive BC also.
Following the NEC criteria there is a Reporting Instruction that outlines how BSIs may be
considered secondary to NEC. Please see that guidance. It is found on page 18 of this
document http://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf
If a patient has a BSI on admission and
does not have a central line and then a
central line is placed and another
pathogen grows in the blood culture, is
this a CLABSI? Or does the BSI without a
central line start the RIT for the
subsequent positive blood culture making
this a BSI and not a CLABSI?
A primary BSI on admission, sets a BSI RIT, regardless of whether or not the BSI was centralline related. Any positive blood cultures collected during that BSI RIT will not be reported
as another BSI. So, no CLABSI will be reported for the subsequent BSI in your example.
If a patient has a BSI on admission- 13
days later the patient has repeat positive
blood cultures- does this second BSI get
reported, or is it an RIT, since the first one
did not get reported initially because it
was POA?
A primary BSI on admission, sets a BSI RIT, even if it was present on admission (POA). Any
positive blood cultures collected during that BSI RIT will not be reported as another BSI.
Please note that a BSI that is present on admission, but is secondary to another site of
infection sets an RIT for the other site of infection but does NOT set a BSI RIT. This means
that subsequent BSIs will need to be considered for any BSI surveillance being performed.
Please note that a BSI that is present on admission, but is secondary to another site of
infection sets an RIT for the other site of infection but does NOT set a BSI RIT. This means
that subsequent BSIs will need to be considered for any BSI surveillance being performed.
Would you please review how the "7-day
window" is defined for an event?
The Infection Window Period is defined and examples provided on page 2-2 of the NHSN
manual. Please visit and review that information and let us know if you have further
questions at [email protected]
http://www.cdc.gov/nhsn/pdfs/pscmanual/2psc_identifyinghais_nhsncurrent.pdf
If a positive culture is not a criteria to
meet a site-specific criteria - i.e. EPIS and a
patient has the same pathogen in a blood
culture and purulent drainage from the
episiotomy - can this be called a secondary
BSI?
No. There are only 2 ways in which a BSI may be attributed as secondary to another site of
infection. Those are, 1) having an organism in the blood which matches at least one
organism in a site-specific culture that is used to meet the site-specific infection criteria, or
2) using the positive blood culture as an element of the site-specific infection criteria.
Neither of these are possible for EPIS, so a BSI cannot be secondary to EPIS. The rationale
for this is that these infections are considered to rarely cause a BSI.
Do we need to contact a nursing home to
ask about sign and symptoms if they were
brought in EMS from NH?
You may use information supplied by the EMS to make infection determinations. However,
if you believe you have not received all pertinent information necessary to make a
determination, it may be helpful for you to contact the nursing home.
The UMB-oomphalitis definition does have
1b. Organisms cultured from blood.
Doesn't this mean that it meets part 2
"The blood culture must be an element
used to meet the site specific infection
criterion."?
Good question. This patient actually may meet 2 means of attributing the BSI as secondary
to UMB. The patient meets UMB criterion 1a using the site specific culture and that site
culture matches a blood culture organism collected within the secondary BSI attribution
period. However, the patient may also meet UMB criterion 1b, using the blood culture as
an element of that criterion provided there is still erythema or serous drainage present in
the 3 days before or 3 days after the blood culture. If neither of those symptoms are
present during that time period (the infection window period) the UMB criterion 1b will not
be met and the BSI could not be considered secondary for this reason.
I review all cases with our Infectious
disease specialist. At times his decision
(and mine) does not agree with NHSN as
to whether it is a HAI or a line related BSI
just because the patient has a line
present... etc.
Do we go by NHSN definitions vs ID
specialist decision?
In-plan data reported to NHSN is used to determine benchmarking data, which is in turn
used to calculate Standardized Infection Ratios (SIR). SIRs are used to determine some
Centers for Medicare and Medicaid Services reimbursements. Consistency of data reporting
is necessary for these reasons. Therefore, any reporting that is made to NHSN for data that
is included in your monthly reporting plan, MUST adhere to the NHSN criteria and
protocols. This includes reporting all events that meet criteria. Physician adjudication and
exclusion of events from data reported to NHSN due to clinical disagreement represents a
breach of the NHSN Agreement to Participate which all enrolling facilities sign. This breech
could result in facility exclusion from NHSN, and may in turn affect federal reimbursement.
Bloodstream infection RIT question: if
positive blood cultures with the same
organism begin within the 14 day RIT time
period and continue past the 14 day
window, will this be a new bloodstream
infection?
Yes. Any BSIs with date of event on the first day following the BSI RIT, will be eligible for BSI
attribution, even if the patient had a positive blood culture with the same organism, during
the RIT. The RIT is a simply an objective time period developed for surveillance to avoid the
subjectivity of determining whether a previous infection is unresolved.
Is the date of event for blood cultures the
day it was drawn or the date the results
came back, when looking at RIT?
The date of culture collection is used for NHSN surveillance, not the date culture results are
reported. For LCBI 1, the date that the blood culture is collected is the date of event. For
LCBI 2, the date of event is the date the first LCBI 2 element occurred during the LCBI RIT.
This may be the date of a symptom, e.g., fever, chills, hypotension or the date of the
positive blood culture collection, whichever comes first.
If you have MRSA positive blood cultures
on admission and central line inserted on
same day; then 6 days later have VRE
growing in blood culture and still have
Central line, do you not count the second
set of cultures due to POA criteria?
If the MRSA BSI is primary in nature, it will set a BSI RIT. If another blood culture with the
same or different organisms is collected during that BSI RIT, it will not be considered a new
BSI for NHSN reporting purposes.
Do you use elements occurring in the POA
period to meet criteria?
Yes, elements occurring in the POA time period may be used to meet infection criteria.
Please note if the MRSA BSI that is present on admission is secondary to another site of
infection that will set an RIT for the other site of infection but will NOT set a BSI RIT.
Subsequent blood cultures will need to be included in all BSI surveillance being
performed and, if primary in nature, included in BSI data.
If it is not a Primary BSI/CLABSI, do you
Only primary BSIs are reported for CLABSI surveillance.
report it to NHSN (do not report secondary
BSI etc.)?
A blank worksheet is available at this location listed under Supporting Materials
Is there access to a blank work sheet that
http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html
is used by you in the presentation for
CAUTI/CLABSI case examples?
NHNS is developing an electronic worksheet generator which will be available on line and
will assist in determining and documenting the Infection Window Period, Repeat Infection
Timeframe and Secondary BSI Attribution Periods for infections. Please watch your email
for announcements.
CAUTI Questions
Can we use "flank pain” as costovertebral
pain?
Please reference question # 17 in the April 2015 UTI FAQ document.
Yes, left or right lower back or flank pain is acceptable for Costovertebral angle (CVA)
pain or tenderness.
A patient has a Foley inserted in surgery
and was discharged with the catheter to
allow for the bladder healing. The patient
spikes a fever of 101 on day 7 post op in
the clinic. A culture was done and was >
100,000cfu of enterococcus. Is this a
CAUTI-HAI- even though the patient was
discharged? I am confused on what to do
with infections if the patient is discharge.
It is not required to monitor for CAUTIs after the patient is discharged from the facility.
However, if discovered, any CAUTI with the date of event on the day of discharge or the
next day should be reported to NHSN. Please reference the Transfer Rule: If the date of
event for a CAUTI is on the date of transfer or discharge, or the next day, the infection is
attributed to the transferring/discharging location.
In the presentation for CAUTI, Case #1,
why would the second urine culture be
considered HAC when the exact same
organism was cultured in the POA time
period?
IF there are no applicable UTI symptoms or matching blood culture to the urine organism
within the Infection Window Period (IWP) of the POA 4/16 urine culture (IWP is 4/13 –
4/19), then NHSN UTI criteria is not met and this is not considered an infection present on
admission according to the NHSN surveillance definition. Therefore, no Repeat Infection
Timeframe (RIT) is set.
The 4/16 asymptomatic bacteriuria which does not meet NHSN UTI criteria may be
considered colonization of the bladder. A Foley catheter that remains in place puts the
patient at greater risk for this to develop into a symptomatic UTI, which is what occurred
during the Healthcare-associated infection (HAI) timeframe in this case example.
VAE Questions
Would a VAE apply for intermittent
mechanical ventilation or a patient that
requires vent support at night only?
Any patient that is ventilated for some portion of each calendar day is eligible for inclusion
in VAE surveillance in locations where in plan VAE surveillance is conducted. You would
select the daily minimum PEEP and daily minimum FiO2 values that used for making VAC
determinations using those ventilator settings that are documented while the patient is
receiving ventilator support (in this case at night).
VAE surveillance was meant to be done
electronically, how are we supposed to
capture an H&P that states the patient has
been ventilated for 3 months?
VAE is a potentially automatable event. The capture of an event attributable to your facility
will not necessarily be missed if the date of initiation of mechanical ventilation is
inaccurately stated. If the date represents a date prior to admission to your facility and is
not an able to be captured electronically AND the MV initiation date is defaulted to the
facility admission date, the event will not be missed. The point of accuracy (as best as
possible) is to attribute the event to the correct location and also to allow for the correct
application of the VAE window period. The latter will ensure correct specific event
determination (VAC, IVAC, PVAP). A VAC will be detected if the VAC definition is met even if
in lieu of a MV initiation date an admission date is used. It may however require that you
manually review captured events (which hopefully will not be a large number and therefore
not burdensome) to assure the MV initiation date has been assigned as accurately as
possible.
Long Term Acute Care Hospital - can I use
the date of MV Initiation date from
outside transferring hospital? Or do I use
date of admit?
MV initiation date is to represent the actual or proxy date in which the patient was
originally ventilated for the current episode of mechanical ventilation. If MV initiation
occurred at a facility other than your own or if it occurred “in the field” by EMS, the date of
that occurrence is the date you are to use. Date of admit is only to be defaulted to in
situations where it is not possible to obtain the actual date of MV initiation or not possible
to estimate a date such that you can provide a proxy date of MV initiation.
ICD-10-PCS Questions
For ICD 10 OTH-other – can they still be
used for SSI denominator counts for rates
of other things?
The OTH-other was not mapped and does not have NHSN operative procedure groups
associated with it. But if the patient develops an infection after a non-NHSN operative
procedure you can still review to see if the infection meets HAI criteria, for example a HAI
skin or soft tissue infection. It just won’t be an SSI.
October 1 is in a "couple of weeks"....how
are we supposed to have time to get our
electronic surveillance mechanisms in place
when we are still waiting on
decisions/directions/guidance from CDC?
The ICD-10 codes are available on the SSI website now.
We have been preparing for ICD-10 for
years, so I am not sure I understand why
NHSN is not ready with the application.
The applications releases are performed in January to align with the new protocols. NHSN
was not able to do an October release. The ICD-10 codes are optional fields and NHSN has
released guidance for denominator data for the last quarter of 2015 in the NHSN
Newsletters and NHSN emails regarding the transition.
Is there anything that we need to do on our
end in reference to the ICD-10 mapping?
You should work with your IT department to see if they will need the new codes for any
reports they run for you. If you use a vendor for your surveillance system ensure they are
very aware of the transition.
The Diabetes diagnosis codes and the codes for history of prior infection at hip or knee will
be uploaded shortly and NHSN users will be notified via an email to all NHSN users.
SSI Questions
Are SSI PATOS reported to CMS?
In 2014 and 2015 procedures that were selected as closure other than primary are not
factored into your SIR and for COLO and HYST these procedures and any SSI attributable to
them are not being sent to CMS.
This is stated in the Analysis section of the SSI protocol.
Additional Notes about SSI SIRS:
1. Primary closure: All of the SSI SIRs that use the 2006-2008 SSI baseline data will include
only those procedures that were reported with a primary closure method.3
2. Infection present at time of surgery (PATOS): All of the SSI SIRs that use the 2006-2008
SSI baseline will include SSIs that are reported as present at time of surgery.
Point #2 above is true if the procedure was a primary closure.
In 2016 SSI events that are PATOS = Yes will not be factored into your SIR analysis and for
COLO and HYST the PATOS cases will not be reported. You will still enter you PATOS = YES
SSI events and have them available for internal analysis.
MDRO/CDI Questions
Does the transfer rule apply to MDRO
reporting?
No, the transfer rule does NOT apply to MDRO reporting.
Does a swing bed program for skilled care
get taken out of the numbers for patient
admissions and patient days? This can be
IV therapy, physical therapy, or anything
requiring skilled care that is not acute
care. We are a CAH with no ICU or OB.
If the swing bed program is on a dedicated unit (only swing bed patients are housed on this
unit), these patients are not included in total facility days or total facility admission counts.
If the swing bed program uses beds on an inpatient unit, the swing bed patient counts for
patient days, admissions and device counts for the inpatient location where they are housed
and cared for.
Was the MDRO information as presented
in the webinar to have been entered for
first quarter 2015?
Yes – the information presented covered reporting effective January 2015.
LTC Questions
When working in a LTC facility, are all the
infections subsequent to the second day
of admission to the LTC facility
considered HAI?
If your facility is participating in the NHSN LTCF Component, then you have the option to
report healthcare associated UTI events and/or multi-drug resistant and/or C. difficile LabID
Events. LTCFs should use the current surveillance definitions and reporting protocols specific
for long-term care facilities, which are located on the NHSN LTC website
http://www.cdc.gov/nhsn/LTC/index.html
For the purpose of LTCF HAI surveillance, available for UTI, the protocol does not have a
specific time-period for identifying an HAI, some clinical judgment has to be used. For
example, a UTI should be attributed to a LTCF onset if there is no evidence of an incubating
infection at the time of admission to the facility (on the basis of clinical documentation and
laboratory screening, if applicable), and if the onset of clinical manifestations occurs more
than two calendar days after admission to the LTCF. Of course, the symptoms associated
with the UTI must be new or acutely worse (e.g., change from the baseline). Other
considerations may include ongoing signs and symptoms as well as continuation of
antimicrobial therapy.
Since the NHSN LTCF definitions are based on recommendations from the Society for
Healthcare Epidemiology of America (SHEA), you may be interested in the SHEA/CDC
position paper, which discusses in more detail the LTCF surveillance definitions and rationale
(revised McGeer definitions). This paper can be accessed on the CDC-LTCF Resource Page for
Clinicians - http://www.cdc.gov/longtermcare/staff/index.html
I have a question about reporting. I had a
patient get admitted to the Med/Surg
from Long Term Care. She was diagnosed
with C-Diff. Do I report the C-Diff in the
Acute Care or LTC?
For LabID Event reporting, specimens collected while the patient is housed in your facility
should be reported for your facility.