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NHSN Catheter-associated Urinary Tract

NHSN Catheter associated Urinary Tract

Infection Surveillance in 2015

Laura Gillim, RN, BSN, CIC

Infection Preventionist

Kentucky Webinar Series – 2015 Updates to Measures and Analysis for The National Healthcare Safety Network Users

June 12, 2015

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Objectives

• Define 2015 CDC/NHSN CAUTI and key concepts used for CAUTI surveillance

• Identify the correct way to count indwelling urinary catheter days to determine infection association

• Identify the correct way to distinguish between a single UTI with sequential positive urine cultures and separate UTIs

UTIs

Objectives 2

• Describe how to collect indwelling urinary catheter and patient day data

p y

• Identify data collection form and Table of Instructions for UTI surveillance

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Agenda

• CAUTI epidemiology and trends • Changes to CAUTI definitions • 2015 CAUTI Definitions

• Denominator collection

• Resources for CAUTI surveillance

Healthcare Facility CAUTI Reporting Requirements to CMS via NHSN-- Current or Proposed Requirements

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CAUTI? Who Cares?

• Urinary tract infection is tied with pneumonia as the second most common type of healthcare-associated infection, second only to SSIs1

• Majority of UTIs associated with indwelling catheters

• Secondary BSI in 5.7% of ICU and 7.4% non-ICU CAUTIs2_in

2013

• Each year, more than 13,000 deaths are associated with UTIs3

• One-third of asymptomatic bacteriuria treated with

antimicrobials although in conflict with published guidelines4

• May be a proxy for quality of care

1Magill SS, Hellinger W, et al. Prevalence of healthcare-associated infections in acute care facilities. Infect Control Hosp Epidemiol. 2012;33(3):283-91.

2Unpublished NHSN data

3Klevens RM, Edward JR, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports 2007;122:160-166

4Cope M, Cavellos ME, et. al. Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.Clin Infect Dis. 2009; 48(9):1182-8.

Things to Consider for CAUTI Surveillance

• All CAUTIs require a positive urine culture.

 Start there.

 Routinely generated report?

• Know your laboratory’s urine culture reporting policies:

– What are the ranges of CFU reported?

– What minimal CFU are reported i.e. 10,000-100,000 CFU/ml-can the laboratory tell you this is at least 100,000 CFU/ml – Are positive urine cultures reported for the unit on which theyp p y

were collected or where the patient is housed at the time of report? Consider the Transfer Rule.

• Account for positive cultures from the ED which may represent recently discharged patients

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A Caution

_!

Spinal cord injury patients:

R t f F l th t di ti d ith t d t

• Reports of Foley catheters discontinued without adequate alternative bladder emptying method

• SCI patients may appear to be voiding voluntarily but actually retaining huge volumes

• Potentially serious adverse effects include bladder

d l d t i d fl i d th t

damage, renal damage, autonomic dysreflexia, death, etc. • Use of Foley should be clinical decision providing

appropriate alternatives/care

Sample Worksheet to Help With Chart Review

CDC form 57.114

Sample W orksheet

Your facility may create its own data collection form and collect additional data so long as the required NHSN data are captured.

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Urinary Tract Infection Definitions

There are two specific types of UTI: • Symptomatic UTI (SUTI)

• Asymptomatic Bacteremic UTI (ABUTI)

Urinary Tract Infection Definitions

There are two specific types of UTI: • Symptomatic UTI (SUTI)

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UTI Overview

Any Age

SUTI 1

Infant

≤ 1 yr

SUTI 2

Any Age

ABUTI

SUTI 1

A: Catheter-associated

SUTI 2

Catheter-associated

ABUTI

Catheter-associated B: Non-catheter associated Non- catheter-associated Non- Catheter-associated

The Logic Behind SUTI Definitions

Symptoms of true UTI will vary depending on whether or not a device (i.e. Foley) is in

Infants will exhibit infection differently from patients of other ages

not a device (i.e. Foley) is in place.

Cannotuse the following

symptoms to identify UTI in catheterized patients for NHSN:

F

other ages.

For infants the following additional symptoms may indicate UTI: • Apnea • Bradycardia • Frequency • Urgency • Dysuria y • Lethargy • Vomiting • Hypothermia <36.0°C

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SUTI Definitions

No more than 2 species of microorganisms

• Urine cultures with > 2 organisms are routinely regarded as contaminated cultures and not used for clinical care nor NHSN CAUTI surveillance.

• Urine culture including “mixed flora” or equivalent cannot be used • Organisms of same genus but different species = 2 organisms.

Example: Pseudomonas aeruginosa and Pseudomonas stutzeri • The same organism with different antimicrobial susceptibilities = 1 g p

organism.Example: MRSA and MSSA

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UTI Overview

Any Age

SUTI 1

A: Catheter-associated B: Non-catheter associated

SUTI 1a (catheter in place)

Patient must meet 1, 2, and 3 below:

1 P ti t h i d lli i th t i l f th ti d th

1. Patient has an indwelling urinary catheter in place for the entire day on the

date of event and such catheter had been in place for >2 calendar days, on

that date (day of device placement = Day 1)

2. Patient has at least one of the following signs or symptoms:

• fever (>38.0°C)

• suprapubic tenderness*

• costovertebral angle pain or tenderness*

3. Patient has a urine culture with no more than two species of organisms,at least one of which is a bacteria of ≥105_CFU/ml_{. All elements of the UTI} criterion must occur during the Infection Window Period.

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With No Other Recognized Cause

*With no other recognized cause

Note: Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI

determination because they are clinically deemed due to another recognized cause.

SUTI 1a (catheter recently removed)

1. Patient has an indwelling urinary catheter in place for greater than 2 days which was removed on the day of or the day before the date of event which was removed on the day of or the day before the date of event 2. Patient has at least one of the following signs or symptoms:

• fever (>38.0°C)

• suprapubic tenderness*

• costovertebral angle pain or tenderness*

• urinary urgency*

i f *

• urinary frequency*

• dysuria*

3. Patient has a urine culture with no more than two species of organisms,at least one of which is a bacteria of ≥105_CFU/ml_{. All elements of the UTI} criterion must occur during the Infection Window Period.

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Criterion Rationale- SUTI 1a

Catheter removed

UTIs with event date on the day of device discontinuation or the following calendar day are considered device-associated UTIs if the device had been in place already for >2 calendar days

place already for >2 calendar days.

For this criterion urgency, frequency and dysuria are symptoms.

Day 1 Day 2 Day 3 Day 4 CAUTI?

Foley placed Foley in place Foley in place for part of day only

then removed

Date of Event Yes

Criterion Rationale- SUTI 1a

Catheter removed

Foley placed Foley in place Foley in place for part of day only then

removed

Date of Event Yes

Foley placed Foley in place for part of day

No Foley Date of Event No for part of day

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Criterion Rationale- SUTI 1a

Catheter removed

Foley placed Foley in place Foley in place for part of day only then

removed

Date of Event Yes

Foley placed Foley in place for

part of day then No Foley Date of Event No part of day then

removed

Foley placed Foley in place for part of day then removed

Date of Event No

SUTI 1b (Non catheter-associated)

Patient must meet 1, 2, and 3 below: 1. One of the following is true:

• Patient has/had an indwelling urinary catheter but it has/had not been in place >2 calendar days,

OR OR

• Patient did not have a urinary catheter in place on the date of event nor the day before the date of event

1. Patient has at least one of the following signs or symptoms: • fever (>38°C) in a patient that is ≤ 65 years of age • suprapubic tenderness*

• costovertebral angle pain or tenderness* • urinary frequency*

• urinary urgency* • dysuria*

2. Patient has a urine culture with no more than two species of organisms,at

least one of which is a bacteria of ≥105_CFU/ml._{All elements of the SUTI}

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UTI Overview

Infant

≤ 1 yr

SUTI 2

Catheter-associated Non- catheter-associated

SUTI 2 (≤ 1-year-old)

1. Patient is ≤1 year of age (with‡_{or without an indwelling urinary catheter )} 2 Patient has at least one of the following signs or symptoms:

2. Patient has at least one of the following signs or symptoms:

• fever (>38.0°C) • hypothermia (<36.0°C) • apnea* • bradycardia* • lethargy* • vomiting* • suprapubic tenderness*

3. Patient has a urine culture with no more than two species of organisms,at least one of which is a bacteria of≥105_CFU/ml. _{All elements of the SUTI} criterion must occur during the Infection Window Period (See Definition Chapter 2 Identifying HAIs in NHSN).

‡ If patient had an indwelling urinary catheter in place for >2 calendar days, and catheter was in place on the date of event or

the previous day the CAUTI criterion is met. If no such indwelling urinary catheter was in place, UTI (non catheter associated) criterion is met.

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UTI Overview

Any Age

ABUTI

Catheter-associated Non- Catheter-associated

Asymptomatic Bacteremic UTI (ABUTI)

1. Patient with* or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age

 N t P ti t > 65 f ith th t i t d ABUTI

 Note: Patients > 65 years of age with a non-catheter-associated ABUTI may have a fever and still meet the ABUTI criterion

2. Patient has a urine culture with no more than two species of organisms,at least one of which is a bacteria of≥105_CFU/ml

3. Patient has a positive blood culturewith at least one matching bacteria to the urine culture, or meets LCBI criterion 2 (without fever) and matching ( ) g common commensal(s) in the urine. All elements of the ABUTI criterion must occur during all elements of the SUTI criterion must occur during the Infection Window Period

* Patient had an indwelling urinary catheter in place for >2 calendar days, with day of device placement being Day 1, and catheter was in place on the date of event or the day before.

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ABUTI

NOTE: Only events with catheters in place for >2 calendar days prior to date of event are catheter-associated.

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Key Terms

Healthcare-associated infection (HAI):

~Not to be used in the SSI, VAE, or LabID Event protocols

An infection is considered an HAI if all elements of a CDC/NHSN site An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were not present during the POA time period and date of event occurred on or after the 3rd calendar day of

admission to the facility (the day of admission to an inpatient unit is calendar day 1)

Date of Event:

~Not to be used in the VAE, or LabID Event protocols

The date the first element used to meet the CDC NHSN site-specific infection criterion occurs for the first time within the seven day infection window period

Key Term:

Present on Admission (POA)

An infection is considered Present on Admission (POA) if the date of event of the NHSN site specific infection criterion date of event of the NHSN site-specific infection criterion occurs during the POA time period, which is defined as

• the day of admission to an inpatient location (calendar day 1)y )

• the 2 days before admission

• the calendar day after admission

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Key Term:

UTI Repeat Infection Timeframe

• 14-day timeframe

• No new UTIs are reported

• No new UTIs are reported.

• Date of event = Day 1

• Additional pathogens recovered

during the RIT from urine cultures

are added to the event.

• Patients will have no more than

Patients will have no more than

one UTI in an RIT

• The RIT applies during a patient’s

single admission, including the day

of discharge and the day after

Key Term:

Indwelling Catheter

A drainage tube that is inserted into the urinary bladder through the urethra is left in place and is urethra, is left in place, and is connected to a collection system. This includes a collection system that is used for irrigation of any type or duration (e.g., intermittent,

continuous).

•Also called a Foley catheter •Does not include (among others):

•Straight in and out catheters •Suprapubic catheters

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Key Term:

Indwelling Catheter

A drainage tube that is inserted into the urinary bladder through the urethra is left in place and is urethra, is left in place, and is connected to a collection system. This includes a collection system that is used for irrigation of any type or duration (e.g., intermittent,

continuous).

•Also called a Foley catheter •Does not include (among others):

•Straight in and out catheters •Suprapubic catheters

•Nephrostomy tubes NOTE: If a patient has a Foley and a suprapubic catheter or nephrostomy tube they meet the criteria for having a Foley.

Key Term:

CAUTI Device-associated Infection

Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement being Day 1,

-and-an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for >2 calendar days and then removed, the date of event for the UTI criteria must be the day of discontinuation or the next day.

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Discontinuation and Reinsertion

If a Foley catheter is discontinued, and a full calendar day passes before a Foley is reinserted, then the day count for determining catheter-associated UTI begins anew. Otherwise

th d t ti f th i th t

the day count continues from the previous catheter.

March 31

(Hospital day 3) April 1 April 2 April 3 April 4 April 5 April 6

Foley Foley

Example A Foley Day 3 Foley Day 4 removed replaced Foley Day 7 Foley Day 8 Foley Day 9 (Foley Day 5) (Foley Day 6)

Example B

Discontinuation and Reinsertion

If a Foley catheter is discontinued, and a full calendar day passes before a Foley is reinserted, then the day count for determining catheter-associated UTI begins anew. Otherwise

th d t ti f th i th t

the day count continues from the previous catheter.

March 31

(Hospital day 3) April 1 April 2 April 3 April 4 April 5 April 6

Foley Foley

Example A Foley Day 3 Foley Day 4 removed replaced Foley Day 7 Foley Day 8 Foley Day 9 (Foley Day 5) (Foley Day 6)

Foley Foley

Example B Foley Day 3 Foley Day 4 removed No Foley replaced Foley Day 2 Foley Day 3

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Location of Attribution

The location where the patient was

assigned on the date of the UTI event,

which is further defined as the date that

th fi t l

t

d t

t th UTI

the first element used to meet the UTI

infection criterion occurred for the first

time in the infection window period.

Exception to Location of Attribution

Transfer Rule: If the date of event for the UTI is

the day of transfer or the next day, the UTI is

attributed to the transferring location or facility.

Likewise, if the date of event is the day of

discharge or the next day, the infection is

attributed to the discharging location

attributed to the discharging location.

Receiving facilities should share information about such HAIs with the transferring location or facility to enable reporting

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Transfer Rule – Examples

Admit Day

Key Terms Day Day Day Day Day Day Day

1 2 3 4 5 6 7

Transfer

Rule ICU ICU ICU-5W Date of event5W for an HAI 5W HAI is attributable to the ICU Transfer Rule Transfer Rule Multi

* Page 7-4 of January 2015 NHSN manual

transfer Rule

Transfer Rule – Examples

Admit Day

1 2 3 4 5 6 7

Transfer

Rule ICU ICU

ICU-5W Date of event for 5W an HAI

5W HAI is attributable

to the ICU Transfer

Rule ICU ICU

ICU-5W 5W Date of event5W for an HAI HAI is attributable to the 5W Transfer Rule Multi

transfer Rule

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Transfer Rule – Examples

Admit Day

1 2 3 4 5 6 7

Transfer

Rule ICU ICU ICU-5W Date of event for 5W an HAI

Rule ICU ICU ICU-5W 5W Date of event for 5W

an HAI HAI is attributable to the 5W Transfer Rule 5W 5W 5W Discharge 5W-d Home Admit to ED meeting infection criterion Attributable to 5W

Multi transfer Rule

Transfer Rule – Examples

Admit Day

1 2 3 4 5 6 7

Transfer

Rule ICU ICU

ICU-5W Date of event for 5W an HAI

Rule ICU ICU

ICU-5W 5W Date of event for 5W

an HAI HAI is attributable to the 5W Transfer Rule 5W 5W 5W Discharged 5W-Home Admit to ED meeting infection criterion Attributable to 5W

Multi ICU ICU ICU- CCU CCU HAI is

transfer Rule 5W-CCU Date of event for an HAI attributable to the ICU

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Entering CAUTI Events into

NHSN (Numerator)

Risk Factors

CAUTI

Required Field: Three options:

INPLACE- If catheter was in place >2 calendar days for the entire day on the date of event

REMOVE – If Foley catheter was in place >2 calendar days but was removed day of or day before the date of event but was removed day of or day before the date of event NEITHER – if no urinary catheter was in place on the day of or the day before the date of event OR not in place >2 calendar days on the date of event

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Risk Factors

CAUTI

Optional: Patient location where indwelling urinary catheter inserted.

Risk Factors

CAUTI

Optional: Date indwelling urinary catheter inserted.

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Collecting Summary

Denominator Data

-Manual

Collection-For all locations, count at the same time each day ▪ Number of patients on the unit

▪ Number of patients with an indwelling urinary catheter

Collecting Summary Denominator Data

Optional alternatives

● Electronically collected

▪ For any location, when denominator data are available from electronic sources (e.g., urinary catheter days from electronic charting)

▪ Following validation of the electronic method against the manual method

 The validation of electronic counts should be performed for each location separately ▪ 3 months concurrent data collection with both

methods

 Difference between methods must be within +/- 5% of each other

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Documenting Summary Data

or No Events

Collecting Summary Denominator Data

Optional alternatives:

● Weekly Sampling

● To reduce time spent collecting surveillance ● To reduce time spent collecting surveillance

data, once weekly sampling of denominator data to generate estimated urinary catheter days may be used as an alternative to daily collection in non-oncology ICUs and wards

● The number of patients in the location

(patient-days)and the number of patients with an indwelling urinary catheter (urinary with an indwelling urinary catheter (urinary catheter days) is collected on a designated day each week (e.g., every Tuesday), at the same time during the month

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Denominator Sampling

Summed sampling data for month

Alert Screen

Report No Events

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Also Worth Considering in Your Facility

• Culturing practices

– Change long-dwelling catheters before collecting

urine? exclude colonization

urine?- exclude colonization

– Reflex urine cultures?- send U/A along with culture

and only perform culture if U/A is positive

– Indications for urine cultures?

– Improving diagnostic practices can:

• improve patient safety

• improve patient safety • improve CAUTI rates • increase staff moral

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Resources for Surveillance

NHSN Forms

• 57 106: Monthly Reporting Plan

57.106: Monthly Reporting Plan

• 57.114: Urinary Tract Infection

• 57.118: Denominators for Intensive Care Unit

(ICU)/Other locations (not NICU or SCA)

Available Resources and Training

• Resource

– CDC/HICPAC Guideline for Prevention of Catheter-CDC/HICPAC Guideline for Prevention of Catheter

associated Urinary Tract Infections1

• Training

– Device-Associated Module – Pre-recorded Webinars

L t (i t ti ith k l d h k )

– Lectoras (interactive with knowledge checks)

http://www.cdc.gov/nhsn/training

1_{Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated}

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Available Training

• NHSN Enrollment & Facility Set-up

• Overview of the Patient Safety Component, Device-associated y module

• Data Entry, Surveillance, Analysis, Import, and Customization • Introduction to the Device-associated Module (Training Course

with quiz)

• Catheter-associated Urinary Tract Infection (CAUTI) (TrainingCatheter associated Urinary Tract Infection (CAUTI) (Training Course with quiz)

• http://www.cdc.gov/nhsn/training/

NHSN Catheter-associated Urinary Tract

NHSN Catheter associated Urinary Tract

Infection Surveillance in 2015

Thank you to the author of these slides ~ Katherine Allen-Bridson, BSN, RN, MScPH, CIC

Nurse Consultant NHSN Training 2015

February 17, 2015

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