Using NH NHSN N for or Mul ultidrug ug Resistant O Orga gani - - PowerPoint PPT Presentation

Using NH NHSN N for

• r Mul

ultidrug ug Resistant O Orga gani nism an and Clo lostridium d diffic ifficile Infect ection (MDRO/CDI) Labor

• rator
• ry-Iden

entified ed (Lab abID) Even ent Re Reporting

National Center for E merging and Zoonotic Infectious Diseases Place Descriptor Here

Objec ectives es

• Review the structure of the Multidrug-Resistant Organism &

Clostridium difficile Infection (MDRO/CDI) Module within the Patient Safety Component of NHSN

• Describe the rationale for monitoring MDROs and CDI
• Review requirements for MRSA Bacteremia and CDI LabID

Event reporting to CMS through NHSN

• Describe the methodology, protocols, and definitions used in

data collection and reporting under the MDRO/CDI LabID Event Reporting in NHSN

• Review the correct method for entering MRSA Bacteremia and

CDI LabID Events into NHSN

• Apply knowledge through case studies

Patien ent S Saf afet ety C Component 5 M Modu dule les

Patient Safety Component

Device-associated Module Procedure- associated Module Antimicrobial Use and Resistance (AUR) Module MDRO & CDI Module Vaccination Module

Mul ultidrug ug-Resi sist stant Organism sm & & Clostrid idiu ium d diffic fficile ile Infection

• n Mod

Module (MDR DRO/CDI DI)

Inf nfection n Surveilla illance

MDRO RO CD CDI

Labor

• rator
• ry-

Iden entified ed (Lab abID) Even ent

MDRO RO CD CDI

Prevent ntion

• n

Process ss Meas easures es

Hand nd H Hygi giene ne Gown wns/Glo loves Adher eren ence t e to Act ctive e Survei eillan ance e Testing ng (AST) MRS RSA & V VRE RE only

Outco come Meas easures es

AST Preval alen ence/ e/ Inc ncidenc nce MRS RSA & & VRE RE o

• nly

Only in locations where AS T adherence done

Backg kground nd

Goal of t the MDRO and C d CDI M Modu dule le

• Monitoring of MDR

Os and C. difficile infection (CDI) helps to evaluate local trends and changes in the occurrence of these pathogens and related infections

• This module provides a mechanism for facilities to report

and analyze MDRO and CDI data, in order to inform infection control staff of the impact of targeted prevention efforts

Why C

• C. difficile

ile?

• Unlike many causes of healthcare associated infections (HAIs), C. difficile

diarrheal infections have increased, and are now at his istoric ic hi highs ghs

• C. difficile infections are linked to about 14,

14,000 d 000 deaths each year, with approximately 90% being among the elderly

• Antibiotic use and healthcare exposure are two of the greatest risk

factors

• Careful attention to surface cleaning, and wearing gowns and gloves

when treating those known to be infected, can reduce spread by 20%

• Renewed interest:

– Reporting to CMS via NHSN

• CDC. (2012). Vital signs: Preventing clostridium difficile infections, MMWR, 61.

http://www.cdc.gov/mmwr/pdf/wk/mm61e0306.pdf

S HE A/HICP AC Position Paper (October 2008):

R ecommendations for MDR O Metrics in Healthcare S ettings

• Define reasonable and practical metrics to best

measure impact of prevention

• Authors from APIC, CDC, SHEA, HICPAC
• Five Categories of MDRO Outcome Measures

1. Tracking Patients 2. Monitoring Susceptibility Patterns 3. Estimating Infection Burden 4. Estimating Exposure Burden 5. Quantifying Healthcare Acquisition (which includes Transmission)

Recommended metrics from the SHEA/HICPAC Position Paper were the basis for the new MDRO and CDI Module

Organism sms

1) Methicillin-R esistant S taphylococcus aureus (MRSA) [option w/ Methicillin-Sensitive S . aureus (MSSA)] 2) V ancomycin-Resistant E nterococcus spp. (VRE) 3) Cephalosporin-Resistant (CephR) Klebsiella spp. 4) Carbapenem-Resistant (CRE) Klebsiella spp. 5) Carbapenem-Resistant (CRE) E . coli spp. 6) Multidrug-Resistant (MDR) Acinetobacter spp. 7) Clostridium difficile

Defin init itio ions

 MR

S A: S . aureus testing oxacillin, cefoxitin, or methicillin resistant;

• r positive from molecular testing for mecA and PBP2a

 MSSA: S

. aureus testing oxacillin, cefoxitin, or methicillin intermediate or susceptible; or negative from molecular testing for mecA and PBP2a

 VRE: Any Enterococcus spp. testing resistant to vancomycin  CephR-Klebsiella: Klebsiella spp. testing intermediate or resistant to

ceftazidime, ceftriaxone, cefotaxime, or cefepime

 CRE-Klebsiella: Klebsiella spp. testing intermediate or resistant to

imipenem, meropenem, or doripenem

 CRE-E

. coli: E . Coli spp. testing intermediate or resistant to imipenem, meropenem, or doripenem

Defin init itio ions (2 (2)

 MDR-Acinetobacter: Acinetobacter spp. testing intermediate or resistant

to at least one drug within at least 3 antimicrobial classes of 6, including: β-lactam/β-lactamase inhibitor combo (PIP, PIPT AZ) cephalosporins (CEFEP, CEFT AZ) carbapenems (IMI, MERO, DORI) aminoglycosides (AMK , GENT , TOBRA) fluoroquinolones (CIPRO, LEVO) sulbactam (AMPSUL)

 C. difficile: C. difficile is identified as the associated pathogen for LabID

Event or HAI reporting [Gastrointestinal System Infection (GI)

• Gastroenteritis (GE) or Gastrointestinal Tract (GIT)]

Active e par articipan ants must c choose e mai ain r rep eporting met ethod Infection S urveillance LabID E vent R eporting ad additional al options t then en b bec ecome e avai ailab able Prevention Process Measures:

• Adherence to Hand Hygiene
• Adherence to Gown and Glove Use
• Adherence to Active S

urveillance T esting (for MR

S A /VR E Only)

Outcome Measures:

• AS

T Prevalence / Incidence (for MR

S A/VR E Only)

Rep eporting R Req equirem emen ents an and Options

CMS Rep eporting R Req equirem emen ents

LabID E Even ent f for Fac acWideIN

Heal ealthcar are e Fac acility HAI Rep eporting to CMS via a NHSN – Curren ent an and Proposed ed Req equirem emen ents

DR AFT (11/ 1/23/ 23/2011 2011)

CMS 201 013 MRSA Bac acter eremia LabID E Event

Organism: Methicillin-R esistant S taphylococcus aureus (MRSA) Data Collection: CDC NHSN - MDRO/CDI Module Required Locations: All inpatient locations (=FacWideIN) for LabID Events Required Data: Communi unity-On Onset ( (CO) O) and Heal ealthcar are-On Onset ( (HO) O) Event MRSA blood specimens at the facility-wide inpatient level

CMS 2 2013 13 C. dif iffic icile le La LabID Event

• Orga

gani nism: Clostridium difficile (C. diff )

• Dat

ata Colle llectio ion: : CDC NHSN - MDRO/CDI Module (LabID Event)

• Req

equired ed Loc

• cation
• ns:

: All inpatient locations at Facility-wide Inpatient level (FacWideIN) minus NICU, SCN, or other Well Baby locations (e.g. Nurseries, babies in LDRP)

• Req

equired ed Dat ata: – Communi unity-On Onset (CO) O) and Heal ealthcar are-On Onset (HO) O) Events – All ll C. difficile LabID Events on unformed stool specimens at the facility-wide Inpatient level

F acility-wide Inpatient FacWideIN

Inclu ludes all ll in inpatie ient lo locatio ions, inc nclud uding o ng observation n patients ho hous used i in a n an n inp npatient location

CMS 2 2013 13 What Data Will N ill NHSN R Report t to CMS?

MRSA B Blood

• od a

and C

• C. diffic

ifficil ile Heal ealthcar are e Facilit ility-Onset (HO) La LabID E Events

CD CDI: Al

All n non-dupl duplicate, n non

• n-rec

ecurren ent L LabID E E ven ent s spec ecimen ens c collected > 3 3 d days s af after ad admission to

• the facili

ility

MRSA B Blood

• od: Al

All n non-du dupl plicate, L Lab abID E E vent s specimens c col

• llected >

d >3 day ays af after admis issio ion to the facili ility

Get etting R Read eady for Rep eporting

Creating ng a Monthl hly Reporting P ng Plan

Mo Monthly R y Reporting Plan

• C. diff and MR

S A LabID (blood specimens only) Events must be included in Monthly Reporting Plan each month for data to be reported on behalf of the facility to CMS

All specimens are not required for CMS, but if state mandates, require facility to report all specimens, then it is okay and

• nly bloods will be counted for

CMS reporting

Location Reporting Op Options

Facilit ility-Wid ide I Inpatie ient or Facilit ility-Wide O e Outpat atient:

• Options currently available only for LabID E

vent reporting

• R

eport from throughout all of a facility’s inpatient or outpatient locations

• Numerator (MDR

O/CDI E vents)- report separately for each location in facility

• S

ingle denominators for entire facility:

• FacWideIN – patient days and admissions
• Separate counts for MDR

O and CDI

• Minus baby locations for CDI
• FacWideOUT – encounters

Lo Loca cation S Speci cific:

• Select only a few locations or every location for full facility coverage
• R

eport separately from each selected location in the facility

• Separate denominators for each location:
• Patient days and admissions for inpatient locations
• E

ncounters for outpatient locations

CMS S Req equirem emen ent

Location R Reporting Op Options

Overall Facility-wide Inpatient (FacWideIN) and/or Outpatient (FacWideOUT)

Selected Locations All Locations

Location Specific

Adding L ng Locations ns

Why do do I N Need d to Add L dd Locatio ions?

 E

ach LabID E vent (numerator) is reported according to the patient’s location when the specimen is collected

 This means that any inpatient unit could potentially house a

patient who has a MR S A blood specimen or C. difficile stool specimen LabID Event

 To ensure that a location is available for reporting when a

LabID Event is identified:

• Add all inpatient locations before reporting begins in

2013

PS H Home e Page: F Facilit ility > Locatio ions

Loc

• cation
• ns P

Page: Spe pecif ify L Locatio ion I Info

Fin ind L d Locatio ions: All o ll or S r Specif ific ic Search

LabID E Even ent R Reporting Introduction

R eporting of prox

• xy infection measures of MDR

O and C. difficile heal ealthcar are e acquis isit itio ion, expo posure bu burde den, and inf nfection n bur urden n by using primarily laboratory data. Laboratory testing results can be used without clinical evaluation of the patient, allowing for a much less labor-intensive means to track MDROs and CDI

Ov Overview

MRSA B Bac acter eremia La LabID Event R Reporting in N NHSN

Defin init itio ion MRSA P Posit itiv ive B Blo lood d Isola late

Any blood specimen obtained for clinical decision making for MR S A

Excludes tests related to active surveillance testing

Defin init itio ion MRSA B Bac acter eremia LabID E Even ent

MR S A positive blood specimen for a patient in a location with no prior MR S A positive blood specimen result collected within 14 14 days for the patient an and location Also referred to as all non-duplicate LabID E vents

Defin init itio ion Duplicate MRSA B Bac acter erem emia LabID E Even ent

Any MR S A blood isolate from the same patient and same location, following a previous positive MR S A blood laboratory result within the past 14 14 days

Summary: MRSA B Bac acter eremia

Purpose: T

• calculate proxy measures of MR

S A bloodstream infections, exposures burdens, and healthcare acquisitions through monitoring and reporting data from positive clinical cultures LabID E vent: A laboratory-identified event. MR S A positive blood specimen for a patient in a location with no prior MR S A positive blood specimen reported within 14 14 days f for t the pat atien ent an and loc

• cation
• n. It must be a specimen that is collected for

diagnosis/treatment (NO surveillance cultures). A patient in a location in a month can then have additional MR S A blood specimens reported as LabID E vents after a full 14-day interval with no positive MR S A blood specimen for the same patient and same location identified by the lab

 LabID Events (numerators) are reported by specific location where

the specimen was collected

 Monthly Monitoring Summary Data (denominators) for T

• tal Patient

Days and T

• tal Admissions are reported for the overall inpatient

facility (FacWideIN)

Add dd Event - Patient nt I Infor

• rmation
• n

Add Event nt Infor

• rmation
• n

Auto-filled Patient Location when S pecimen Collected E ntries for Blood LabID E vents

01/14/2013 01/09/2013 01/09/2013

NHSN w will C ill Categoriz rize y your MRSA B Blood Spec ecimen en L Lab abID Events as CO o

• r HO

NHS N Application Categorizes* LabID E vents As:

• Communi

unity-Onse set (CO CO): : LabID Event specimen collected as an inpatient ≤ 3 days after admission to the facility (i.e., days 1 (admission), 2, or 3)

• Heal

ealthcar are F e Fac acility-On Onset (HO) O): : LabID Event specimen collected > 3 d > 3 days after admission to the facility (i.e., on or after day 4)

*Based on Inpatient Admission & Specimen Collection Dates

Ov Overview

CDI LabID E Even ent Reporting in NHSN SN

Defin init itio ion CDI P Positive Laboratory Assay

• A positive laboratory test

result for C. difficile toxin A and/or B ** OR OR

• A toxin-producing C. difficile
• rganism detected by culture
• r other laboratory means

performed on a stool sample

Remember..

• C. difficile testing
• nly on

unformed stool samples (should conform to shape of container)

**P

• sitive PCR

result for toxin producing gene is equal to a positive C. diff test result

Defin init itio ion CDI L Lab abID Even ent

A toxin-positive C. difficile stool specimen for a patient in a location with no prior C. difficile specimen result reported within 14 d 14 days for the patient an and location Also referred to as all non-duplicate LabID E vents

Defin init itio ion Duplic licate C

• C. dif

iffic icil ile Positive T Test

Any C. difficile toxin-positive laboratory result from the same patient and same location, following a previous C. difficile toxin-positive laboratory result within the past 14 14 days

Ide dentif ifyin ing a a C. d difficile ile La LabID Event

(+) C. difficile toxin test result

Figure 2. C. difficile T est Results Algorithm for LabID Events http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO CDADcurrent.pdf page 12-23

Facilit ility-wide ide I Inpatie ient (FacWide ideIN) R Reportin ing f for r CDI

Summa mmary: C

• C. dif

iffic icil ile

Pu Purpose: T

• calculate proxy measures of C. difficile infections, exposures burdens, and

healthcare acquisitions through monitoring and reporting data from positive clinical cultures (unformed stool only) La LabID Ev Event: A laboratory-identified event. A toxin-positive / toxin-producing C. difficile stool specimen for a patient in a location with no prior C. difficile specimen reported within 14 days for the patient and location, and having a full 14-day interval with no toxin-positive C. difficile stool specimen identified by the lab since the prior reported C. difficile LabID Event. Also referred to as non-duplicate C. difficile toxin- positive laboratory result



LabID Events (numerators) are reported by specific location where the specimen was collected



Monthly Monitoring Summary Data (denominators) for Patient Days and Admissions (minus all NICU, S CN, and Well Baby locations, including LDR P baby counts) are reported for the overall inpatient facility (FacWideIN)

LabID E Even ent R Report Form

Add dd Patient Infor

• rmation
• n

 The top section of data collection form is used to collect patient

• demographics. Required fields have an asterisk (*).

 There are 4 required fields:  Facility ID  Patient ID  Gender  Date of Birth

Add Event nt Infor

• rmation
• n

Auto-filled when LabID and CDIF selected Auto-filled Patient Location when S pecimen Collected

01/ 01/13/ 13/2013 01/ 01/11/ 11/2013 01/ 01/11/ 11/2013 12/ 12/19/ 19/2012

NHSN w will C ill Categoriz ize CDI La LabID Ev Events Base sed o

• n Inpatient Admissi

ssion & & Spec ecimen en Collec ection D Dates es

• Heal

ealthcar are e Facilit ility-On Onset (HO) O): LabID Event specimen collected > 3 days after admission to the facility (i.e., on or after day 4).

• Communi

unity-Onse set (CO CO): : LabID Event specimen collected as an inpatient ≤ 3 days after admission to the facility (i.e., days 1 (admission), 2, or 3).

• Communi

unity-Onset et Heal ealthcar are F e Fac acility-Asso ssociated ( (CO-HCFA FA): : CO LabID Event collected from a patient who was discharged from the facility ≤ 4 weeks prior to the date current stool specimen was collected.

NHSN w will F ill Further Categoriz ize CD CDI La LabID Even ents b bas ased ed on Spec ecimen en Colle llectio ion Date & & P Prio ior Specim imen Collec ection Date o e of a a Previous CDI Lab abID Even ent (that w was as en enter ered ed into N NHSN)

• Incident CDI A

Assa ssay: Any CDI LabID Event from a specimen

• btained > 8

8 week eeks after the most recent CDI LabID Event (or with no previous CDI LabID Event documented) for that patient.

• Recurrent C

CDI A Assa ssay: : Any CDI LabID Event from a specimen obtained > 2 w week eeks and ≤ 8 weeks after the most recent CDI LabID Event for that patient.

Provision to L Lab abID Even ent R Reporting for CDI a and MRSA Bac acter eremia

A LabID E vent for an inpatient location can include specimens collected during an emergency department or

• ther outpatient clinic visit, if collected same calendar day as

patient admission. **Location will be assigned to the admitting inpatient location (for F acWideIN). ***If participating in both inpatient and outpatient LabID reporting, report the LabID E vent in both locations as two separate E vents, E D and admitting location.

Rule les for E r Enterin ring M MRSA Blo lood d and d

• C. diff L

Lab abID E Even ents Fac acWideI eIN

• C. diff toxin-positive and MR

S A blood specimens MUS T be monitored throughout all inpatient locations within a facility

• E

xception for C. diff: NICUs, SCN, Well Baby Nurseries, and babies in LDRP units excluded

• LabID Event(s) MUST be entered whether community-onset (CO)
• r healthcare facility-onset (HO)
• A specimen (C. diff stool and/or MRSA blood) qualifies as a LabID

Event if there has not been a previous positive laboratory result for the patient and location within the previous 14 days

• LabID Events never include results from Active Surveillance

Testing

Ent ntry of

• f

Mont

• nthly Denom
• minator
• r D

Data for r FacWide deIN LabID E Even ent Reporting

Summary D Data – FacWide ideIN L Locatio ion

• E

ach monthly S ummary Data (denominator) is reported at the inpatient facility-wide level = “FacWideIN”

• FacWideIN is a ‘virtual’ location within NHS

N, which means the user does not define it like other specific units/locations

MD MDRO/CDI S Summary y For

• rm

(Denom

• minator
• rs)

Choose S e Summar ary D Data a an and Add Sel elect ect S Summar ary D Data a Type e > Continue

Enter L r Locatio ion Code de = = F FacWide ideIN plus Month an and Y Y ear ar

2013

Enter A All ll Requir ired Facilit ility-Wi Wide Inpatient nt C Cou

• unt

nts

2013

Auto-filled MRS RSA Bac acter erem emia

C.

• C. diffic

icile ile

Res esources es

Resources for N NHSN

http://www.cdc.gov/nhsn/index.html

Resources es for M MDRO/CDI Lab abID Even ent R Reporting

• NHS

N Patient S afety Component Manual

– Ch 12: MDR O and CDI Module (January 2012); pages 18-21

http://www.cdc.go gov/nhs nhsn/ n/PDFs/pscManua nual/12pscMDRO_CDADcur urrent.pdf

– Ch 14: T ables of Instructions, T able 19, 21

http://www.cdc.go gov/nhs nhsn/ n/PDFs/pscManua nual/14pscForm_Ins nstructions

• ns_current.pdf
• Determining Patient Days for S

ummary Data Collection: Observation vs. Inpatients

http:/ ://www.cdc.go gov/nhs nhsn/ n/PDFs/PatientDay_Sum umData_Gui uide.pdf http://www.cdc.gov/nhsn/TOC_PS CManual.html

Resources es for M MDRO/CDI Lab abID

• NHS

N Forms (January 2012)

– 57.106: Monthly R eporting Plan – 57.128: LabID MDR O or CDI E vent Form (numerator) – 57.127: MDR O and CDI Prevention Process and Outcomes Measures Monthly R eporting (denominator) http://www.cdc.gov/nhsn/forms/Patient-S

afety-forms.html#mdro

Availa ilable le T Train inin ing

• C. difficile Guidelines for Clinicians

– http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_clinicians.html

• Training

– Lectoras (coming soon)

• NHS

N Training Website: http://www.cdc.gov/nhsn/training/ – Currently updating site with updated LabID E vent R eporting presentations

Emai ail hel elp d des esk: nhs nhsn@ n@ cdc.go gov NHSN w web ebsite: e: http://www.cdc.go gov/ v/nhs nhsn/ n/