Pennsylvania Department of Pennsylvania Department of Health - - PDF document
Pennsylvania Department of Pennsylvania Department of Health (PADOH) CLABSI, CLABSI, Health (PADOH) CAUTI, and SSI Audit CAUTI, and SSI Audit Mary Andrus, BA, RN, CIC Mary Andrus, BA, RN, CIC Infection Preventionist Consultant
A total of 120 records were reviewed
Auditors reviewed 23 patients that had been reported to NHSN
Bloodstream infections that were reported by hospitals and confirmed by auditors
Bloodstream infections that were reported by hospitals and not confirmed by auditors
Total number of positive blood cultures reviewed by audit.
Bloodstream infections that were identified as CLABSI by audit but were not reported to NHSN
Positive blood cultures that were not identified as CLABSI by audit and were not reported by the hospital to NHSN
– 3 cases were not reported because the hospital identified the BSI as secondary to another infection. In each case, the criteria for the primary infection were not met – 2 cases were missed by the hospital
– 2 cases were reported as a primary BSI (CLABSI) when criteria for an infection at another site with the same organism was identified by the auditor – 1 case was reported by the hospital, but it appears to be associated with a CLABSI on an earlier date – 1 case was reported as CLABSI, but no corresponding blood culture was identified by the auditor
Common commensal
Diphtheroids (Corynebacterium spp.) Bacillus spp. (not B.anthracis) Proprionibacterium spp. Coagulase-negative staphylococci (including
Viridans group streptococci Aerococcus spp. Micrococcus spp.
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commensals
Diphtheroids (Corynebacterium spp.) Bacillus spp. (not B.anthracis) Proprionibacterium spp. Coagulase-negative staphylococci (including
Viridans group streptococci Aerococcus spp. Micrococcus spp.
This chapter contains the CDC/NHSN surveillance definition of healthcare- associated infection (HAI) and criteria for all specific types of HAI. These criteria include those for the “Big Four” infection types (surgical site infection [SSI], pneumonia [PNEU], bloodstream infection [BSI] and urinary tract infection [UTI]),
specific event types that constitute organ/space SSIs (e.g., mediastinitis [MED] that may follow a coronary artery bypass graft, intra-abdominal abscess [IAB] after colon surgery). Additionally, it is necessary to refer to the criteria in this chapter when determining whether a positive blood culture represents a primary BSI or is secondary to a different type of HAI. A BSI that is identified as secondary to another site of infection must meet one of the criteria of HAI detailed in this chapter. Secondary BSIs are not reported as separate events in NHSN, nor can nor should they be associated with a central line.
Example: Mrs. Jones has a fever and grows E. coli in her urine (>100,000 col/cc) and in her blood. She has both a femoral central line and an indwelling urinary catheter. A CAUTI (SUTI) is reported with a secondary BSI. Example: Mr. Smith grows A. baumanii in his surgical wound which is resistant to amikacin and levofloxin but sensitive to other tested
susceptible to amikacin. The SSI is reported with a secondary BSI. W h e n d e t e r m i n i n g i f a b l
s t r e a m i n f e c t i
i s t h e p r i m a r y i n f e c t i
s i t e
s e c
d a r y t
n i n f e c t i
a t a n
h e r s i t e , t h e r e w i l l b e n
e q u i r e m e n t f
t h e a n t i b i
r a m s
t h e b l
c u l t u r e i s
a t e ( s ) a n d a n t i b i
r a m s
t h e i s
a t e ( s ) f r
t h e p r i m a r y i n f e c t i
s i t e c u l t u r e t
a t c h . T h e i s
a t e ( s ) m u s t
l y m a t c h a t t h e g e n u s / s p e c i e s l e v e l f
t h e b l
s t r e a m i n f e c t i
t
e c
s i d e r e d s e c
d a r y t
h e p r i m a r y i n f e c t i
s i t e .
Example: 6 days postoperatively, Miss Green has an abdominal abscess, confirmed by CT scan. On the same day, her blood is drawn and grows Bacteroides fragilis. The infection is reported as an SSI-GIT (organ space SSI) with a secondary BSI. The organism is reported as B. fragilis
Positive blood culture Does patient meet the criteria for HAI at another site? (If infection is CA, or if NHSN criteria for the specific site HAI has not been met, answer “No”.)
No Yes
CA or HA Is blood isolate a common pathogen for this site?
HA CA
This CA infection with secondary BSI is not reported through NHSN nor is the BSI. Primary BSI
No Yes
Site infection with secondary BSI Primary BSI
Total number of records reviewed
Auditors reviewed a total of 38 patients that were reported to NHSN by the hospitals as CAUTI
CAUTIs that were reported by hospitals and confirmed by auditors
CAUTIs that were reported by hospitals and not confirmed by
Total number of unreported positive urine cultures reviewed by audit
Urine cultures that were identified as CAUTI by auditors. This is an under- reported case.
Positive urine cultures that were not identified as CAUTI by audit and were not reported by the hospital
– 4 patients were reported as CAUTI when no indwelling catheter was in place – 4 patients were reported as CAUTI, but patients were asymptomatic – 1 patient was asymptomatic and there was no culture on the date CAUTI reported – 2 patients had no urine culture on the target date – UTI on this date is not a new UTI, but an extension of a previous CAUTI
Patient with or without an indwelling urinary catheter
Patient of any age None of the following:
tenderness Patient ≤ 1 year of age None of the following:
A positive urine culture of ≥105 CFU/ml with no more than 2 species of microorganism A positive blood culture with at least 1 matching uropathogen microorganism to the urine culture
Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)
*
A total of 240 records were reviewed
70 patients were reported as having SSI by the hospital
* 60 of the SSI cases reported by hospitals were also identified as SSI by the audit
10 of the SSI cases reported by hospitals did not meet SSI criteria during the audit
When the Specific SSI Event was evaluated, only 42/70 matched
*
28/70 records reviewed were either over-reported
incorrect Specific SSI Event
170 operative procedures were reviewed in cases where an SSI was not reported
4/170 were identified as SSI by the auditor (under-reported)
166/170 were not identified as SSI and were correctly not reported to NHSN
– 1 not reported because case was infected at the time of surgery – 3 cases were missed (undetermined)
– 1 reported case should have been associated with a different surgery date – 8 cases were reported to NHSN where event criteria for SSI were not met – 1 case reported as DIP was actually SIP, but it was >30 days so should not have been counted
Hospital Determination Auditor Determination Number of Cases SIP DIP 4 SIP Organ/Space 1 SIP DIS 1 SIS DIS 1 DIP Organ/Space 5 DIP DIS 1 Organ/Space SIP 1 Organ/Space DIP 1 Organ/Space Organ/Space (different O/S) 2
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13(10):606-8.
Deep incisional primary (DIP) A deep incisional SSI that is identified in the primary incision in a patient that has had an operation with
(e.g., C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB]) Deep incisional primary (DIP) A deep incisional SSI that is identified in the primary incision in a patient that has had an operation with
(e.g., C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB]) Deep incisional secondary (DIS) A deep incisional SSI that is identified in the secondary incision in a patient that has had an
site [leg] incision for coronary artery bypass graft with a donor site [CBGB]) Deep incisional secondary (DIS) A deep incisional SSI that is identified in the secondary incision in a patient that has had an
site [leg] incision for coronary artery bypass graft with a donor site [CBGB])
Specific event types that must be used to differentiate
BONE Osteomyelitis JNT Joint or bursa BRST Breast abscess/mastitis LUNG Other infections of respiratory tract CARD Myocarditis/ pericarditis MED Mediastinitis DISC Disc space ORAL Oral cavity EAR Ear, mastoid OREP Other respiratory EMET Endometritis OUTI Other urinary ENDO Endocarditis SA Spinal abscess EYE Eye, other than conjunctivitis SINU Sinusitis GIT GI tract UR Upper respiratory IAB Intraabdominal, NOS VASC Arterial or venous IC Intracranial VCUF Vaginal cuff
C = Clean CC = Clean Contaminated CO = Contaminated D = Dirty U = Unknown Wound class is an assessment of the likelihood and degree of contamination
time of the operation
Clean
Uninfected wound with no inflammation Respiratory, alimentary, genital or uninfected urinary tract are not entered Primarily closed Closed drainage, if needed
Clean-Contaminated
Respiratory, alimentary, genital, or urinary tracts entered under controlled conditions and without unusual contamination Include operations on biliary tract, appendix, vagina, oropharynx if no evidence of infection or major break in technique
Contaminated
Open, fresh, accidental wounds Major breaks in sterile technique or gross spillage from the GI tract Includes incisions into acute, nonpurulent inflamed tissues
Dirty
Old traumatic wounds with retained devitalized tissue Wounds involving existing clinical infection or perforated viscera
Duration: Record the hours and minutes between the skin incision and skin closure. Do not record anesthesia time! Duration: Record the hours and minutes between the skin incision and skin closure. Do not record anesthesia time!
Example: Mr. Jones goes to the OR and has a coronary artery bypass graft with a [leg] donor site (CBGB) and also a mitral valve replacement (CARD). The time from the first incision until skin closure is 5 hours. A Denominator for Procedure record is completed for the CBGB and another for the CARD. The duration for each is recorded as 5 hours and 0 minutes. Example: Mr. Jones goes to the OR and has a coronary artery bypass graft with a [leg] donor site (CBGB) and also a mitral valve replacement (CARD). The time from the first incision until skin closure is 5 hours. A Denominator for Procedure record is completed for the CBGB and another for the CARD. The duration for each is recorded as 5 hours and 0 minutes. March 11-12, 2009
Example: Fred Smith had a small bowel resection (SB) done on Tuesday morning which had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to the OR where an exploratory laparotomy was done through the same incision to repair a leaking anastamosis. The cut time for this surgery was 1 hour and 10 minutes. Report only one procedure – SB combining the two durations. The duration reported is 4 hours and 20 minutes Example: Fred Smith had a small bowel resection (SB) done on Tuesday morning which had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to the OR where an exploratory laparotomy was done through the same incision to repair a leaking anastamosis. The cut time for this surgery was 1 hour and 10 minutes. Report only one procedure – SB combining the two durations. The duration reported is 4 hours and 20 minutes
March 11-12, 2009
ASA Class: An assessment score by the anesthesiologist of the patient’s preoperative physical condition using the American Society of Anesthesiologists Classification
ASA Class: An assessment score by the anesthesiologist of the patient’s preoperative physical condition using the American Society of Anesthesiologists Classification
that is not incapacitating
disease that is a constant threat to life
to survive for 24 hours with or without
that is not incapacitating
disease that is a constant threat to life
to survive for 24 hours with or without
March 11-12, 2009
SSI Rates have been moved to the “advanced” section of the
will only be able to obtain your facility’s SSI rates Comparison to the previously-published NHSN pooled means will no longer be available
NHSN Operative Procedure Risk Factor(s) – All SSIs
AAA Duration CBGB/C Age, ASA, duration, gender, number of beds* COLO Age, anesthesia, ASA, duration, endoscope, medical school affiliation*, number of beds*, wound class FUSN Approach, ASA, diabetes, duration, medical school affiliation*, spinal level, trauma, wound class HPRO Age, anesthesia, ASA, duration, HPRO type, number of beds* trauma HYST Age, anesthesia, ASA, duration, endoscope, number of beds* KPRO Age, anesthesia, ASA, duration, gender, KPRO type, number of beds*, trauma
LAM Anesthesia, ASA, duration, endoscope PVBY Age, ASA, duration, gender, medical school affiliation* RFUSN Approach, diabetes, duration VSHN Age, medical school affiliation*,number of beds*, wound class
13 SSIs identified.
were expected.
during this time period our facility identified 94% more SSIs than expected.
number of observed SSIs is significantly higher than the number of expected SSIs.