Transcript NHSN Surveillance: What’s New for 2013

NHSN Surveillance:
What’s New for 2013
Andrea Alvarez, MPH
Carol Jamerson, RN, BSN, CIC
Virginia Department of Health
Objectives
Review some of the changes to 2013
NHSN protocols
 Demonstrate some new data entry and
analysis functionality in NHSN
 Direct users to additional NHSN
resources/training
 Provide an open forum for Q&A

Changes to Key Terms
Healthcare-Associated Infection (HAI)
 Device-Associated
 Transfer Rule
 Date of Event
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HAI and Device-Associated Infection

Healthcare-associated Infection (HAI):
◦ Localized or systemic condition resulting from an adverse reaction to the
presence of an infectious agent(s) or its toxin(s) that was not present on
admission.
◦ All elements of a CDC/NHSN site-specific infection criterion first present
together on or after the 3rd hospital day (day of hospital admission is day 1).
◦ An element of the infection criterion may be present during the first 2
hospital days as long as it is also present on or after day 3.
◦ All elements used to meet the infection criterion must occur within a
timeframe that does not exceed a gap of 1 calendar day between elements.

Device-associated Infection:
◦ Device was in place for >2 calendar days when all elements of a
CDC/NHSN site-specific infection criterion were first present together.
◦ HAIs occurring on the day of device discontinuation or the following
calendar day are considered device-associated HAIs if the device had been in
place already for >2 calendar days.
Transfer Rule
If all elements of an HAI were present within 2
calendar days of transfer from one inpatient
location to another in the same facility (i.e., on
the day of transfer or the next day), the HAI is
attributed to the transferring location.
 If all elements of an HAI were present within 2
calendar days of transfer from one inpatient
facility to another, the HAI is attributed to the
transferring facility.
 Receiving facilities should share information about
such HAIs with the transferring facility to enable
reporting.
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Transfer Rule: Question from the Field
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Q: Patient is seen in the ED, central line is placed, and
patient is moved to the medical ICU. She receives IV
medications and line care. On day 3, fever and chills are
present. Two sets of blood cultures are collected and sent
to the lab. On day 5, cultures come back positive for
S. epidermidis. Insertion site is clean and free from
inflammation and no other documented signs of infection.
Where do we attribute the infection?
A: This patient meets the definition for labconfirmed bloodstream infection 2. Infections
cannot be attributed to a location where patients
are not housed overnight (like an OR or ED).The
infection should be attributed to the next inpatient
location; in this case the MICU.
Date of Event
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Also known as infection date, date of infection
For HAIs [excluding Ventilator-Associated Events
(VAE)]: the date when the last element used to meet the
CDC/NHSN site-specific infection criterion occurred.
For VAE: the date of onset of worsening oxygenation
(i.e., the first calendar day in which the daily minimum
worsening oxygenation threshold value occurs).
Ex. CAUTI
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Seen in ED 2/11/13
Admitted to medical ICU; urinary catheter inserted 2/12/13
Develops fever 2/14/13
Urine specimen collected 2/15/13 (positive for E. coli, 105 organisms)
What is date of event?
 2/15/13
Vital Signs and Fever

If a specific value for a vital sign is not stated in a
CDC/NHSN HAI definition criterion, the facility should
use the vital sign parameters as stated in its policies and
procedures for clinical documentation.
◦ For example, if a facility has a policy to adjust temperature readings
to reflect core temperatures, then the adjusted temperature value
used for clinical decision making should be used for its HAI
surveillance as well.

When assessing infection criteria (ex. for CAUTI and
VAP), “with no other recognized cause” phrase removed
for fever/hypothermia.
o
Fever/hypothermia are non-specific findings and can be caused by
more than one infectious/non-infectious process.
Central Line-Associated Bloodstream
Infection (CLABSI) Changes

Mucosal barrier injury laboratory-confirmed BSI
◦ Pertains to patients who are post allogeneic
hematopoietic stem cell transplant or severely
neutropenic
 CLABSI rates in this population inflated by misclassification of BSI
resulting from translocation of intestinal organisms
 These BSIs not impacted by CLABSI prevention measures and not
associated with the central line
◦ Will not be removed from CLABSI case counts for CMS
purposes in 2013

Updated secondary bloodstream infection guide
(see Appendix 1 of CLABSI protocol)
◦ Note: this guide is not applicable to VAE
CLABSI: MBI-LCBI Definitions
Intestinal organism (see list in protocol)
or viridans group strep identified, with no
other organisms identified AND
 At least one of the following:

◦ Allogeneic hematopoietic stem cell transplant
recipient with one of two documented clinical
symptoms/manifestations
◦ Neutropenia

Slight modification of definition for infants
(MBI-LCBI Criterion 3)
CLABSI: Question from the Field
Q: I have a patient who was admitted to
the medical/surgical ICU with an implanted
port-a-cath. On day 4, criteria were met for
a LCBI. What do I consider the first day for
the line since it was in place on admission?
 A: If admitted or transferred to a
facility with a central line in place
(e.g., tunneled or implanted central
line), the day of first access is day 1.

SSI Changes
No more information collected on implants
 New post-discharge surveillance time
periods for deep incisional and organ/space
SSIs

◦ 30-day: AAA, AMP, APPY, AVSD, BILI, CEA, CHOL, COLO,
CSEC, GAST, HTP, HYST, KTP, LAM, LTP, NECK, NEPH,
OVRY, PRST, REC, SB, SPLE, THOR, THYR,VHYS, XLAP
◦ 90-day: BRST, CARD, CBGB, CBGC, CRAN, FUSN, FX,
HER, HPRO, KPRO, PACE, PVBY, RFUSN,VSHN
SSI Changes: Primary Closure
•
•
Closure of all tissue levels, regardless of the
presence of wires, wicks, drains, or other
devices or objects extruding through the
incision.
If there is nothing extruding from the incision
but the skin edges are not fully
reapproximated for the entire length of the
incision (e.g., is loosely closed with gaps
between suture/staple points), the incision is
not considered primarily closed and therefore
the procedure would not be considered an
operation.
SSI: Question from the Field
Q: Patient had a colectomy and the skin
was closed with sutures in the operating
room. A penrose drain was woven inbetween the suture line. Is this considered a
primary closure?
 A: Yes. In this instance, all tissue levels
were closed.The presence of the drain
does not affect whether it is a primary
closure.

New VAE Protocol
Replaces prior VAP event definitions (PNEU)
– those are now for patients <18 yrs
 VAE protocol for adult patients in acute care,
long-term acute care, or inpatient rehab
 Three tiers of VAE definitions - hierarchical

◦ Ventilator-Associated Condition (VAC)
◦ Infection-related Ventilator-Associated
Complications (IVAC)
◦ Possible and Probable Ventilator-Associated
Pneumonia (VAP)
IVAC: Infection-related VentilatorAssociated Complication

Patient meets criteria for VAC and
on or after calendar day 3 of mechanical
ventilation and within 2 calendar days
before or after the onset of worsening
oxygenation, the patient meets both of the
following criteria:
◦ Temperature >38°C or <36°C OR white blood
cell count ≥12,000 cells/mm3 or ≤ 4,000
cells/mm3 and
◦ A new antimicrobial agent is started and
continued for ≥ 4 calendar days
VAE Calculator
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No patient identifiers required
Does not store any data that you enter
Does not report any data that you enter or any
VAE determinations to NHSN
Cannot export data entered into the calculator,
although you can print screen shots if that is
helpful to you
http://www.cdc.gov/nhsn/VAEcalculator/index.html
Overview of LabID Reporting

Reporting of proxy infection measures of MDRO and
C. difficile healthcare acquisition, exposure burden,
and infection burden by using primarily laboratory data
◦ Never include results from active surveillance testing
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
Less labor-intensive means to track MDROs & CDI
NHSN application classifies whether an event is communityonset (CO) or healthcare-onset (HO) based on inpatient
admission date and specimen collection date
◦ NHSN will report HO events to CMS, excluding duplicates and
recurrent CDI events (collected >2 weeks and ≤8 weeks after the
most recent CDI labID event for that patient)

For C. diff, community-onset healthcare facility-associated
(CO-HCFA) events are from patients who are discharged
from the facility ≤4 weeks prior to the stool specimen
collection date
Pre-populated
Auto-populated
MDRO Module Notes

SIR reports available for MRSA bacteremia and
C. difficile (acute care hospitals only)
◦ Baseline: 2010-2011 FacWideIn labID data
◦ Calculated for 2012 data and forward
◦ SIRs specific to CMS IPPS reporting available for 2013
and forward (limited to in-plan)
◦ Adjusts for medical school affiliation, facility bedsize,
community-onset prevalence rate, & test type (CDI only)

A note about denominators – facility-wide
inpatient reporting is required for CMS
◦ Report single denominators for entire facility, not by unit
 Separate counts for MRSA and CDI
 Minus baby locations for CDI (NICU, specialty care nursing, well
baby locations)
Reporting No Events
If your facility has no events for the month,
indicate this on the summary data record
 If LabID events have already reported, the
“Report No Events” box will be disabled,
preventing it from being checked.

MRSA Bacteremia LabID event
CLABSI Identified with MRSA as a Pathogen
Data entry
New reports
Demo of NHSN
Resources
NHSN protocols and resources for hospital users
o http://www.cdc.gov/nhsn/acute-care-hospital/index.html
 ***NHSN training – Oct 2012 slides***
o http://www.cdc.gov/nhsn/training/ (see New Training box on
right side of page)
 North Carolina-Virginia Hospital Engagement Network VAE webinar
o http://www.ncqualitycenter.org/nocva/vap.lasso (see Webinar
box on the right side of the page – January 16, 2013)
 VAE calculator
o http://www.cdc.gov/nhsn/VAE-calculator/index.html
 Patient Safety analysis resources
o http://www.cdc.gov/nhsn/PS-Analysis-resources/index.html
• CMS requirements
o http://www.cdc.gov/nhsn/cms/index.html

Contact Us!
Andrea Alvarez – Program Coordinator
[email protected]
Carol Jamerson – Nurse Epidemiologist
[email protected]
◦ For Andrea or Carol – 804-864-8141
April Achter – new HAI Epi!
[email protected]
757-683-2479
www.vdh.virginia.gov/epidemiology/surveillance/hai