APIC Questions with Answers

14 Pages·2015·1.03 MB·English

APIC Questions with Answers

NHSN Webinar Monday, April 27th 1:00-2:00pm EDT
Miscellaneous Questions
1. How do I determine if an infection is present on admission or healthcare-
associated?

A: There is a logical sequence of considerations to distinguish between an infection
that is present on admission according to NHSN protocols, and a healthcare-
associated infection. To make a proper determination in 2015, proceed in this
order:
1. Determine the date of the diagnostic test that is an element of the NHSN site-
specific infection criterion, for example, when considering a possible UTI, the urine
culture.
2. Determine the infection window period (3 days before the diagnostic test, the day
of the test and 3 days after for a total of 7 days).
3. Determine if all of the elements of the criterion are met during the infection
window period. If they are, there is an infection event. If they are not, there is no
event.
4. Determine the date of event, i.e., the date that the first element used to meet the
infection criterion occurs for the first time within the infection window period.
5. Determine if the date of event is in the POA time period (i.e. during the 2 days
before admission, the day of admission or the next day)? If it is, the infection is POA,
if not, it is an HAI. Please note, when assigning a Repeat Infection Timeframe for a
POA event, if the date of event is determined to be either of the two days prior to
inpatient admission, then the date of event will be hospital day 1.

In the rare case that a diagnostic test is not used to meet the criterion, use the first
sign or symptom that is an element of the infection criterion in place of the
diagnostic test.
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2. What is the meaning of “evidence of infection on gross anatomical exam”
found in several of the NHSN infection criteria?
A: This phrase refers to documentation of infection that is made following physical
examination of the patient with or without invasive procedure. Gross anatomical
exams include physical examination of a patient during admission or subsequent
assessments of the patient, including those that occur during a medical procedure.
The location of the infection as well as the NHSN infection criterion will determine if
the exam must involve an invasive procedure. For example, gross anatomical exam
of an intraabdominal abscess will require an invasive procedure to actually visualize
the abscess. However, criteria for a Urinary System Infection (USI) include “Patient
has an abscess or other evidence of infection on gross anatomical exam, during
invasive procedure, or on histopathologic exam.” Since urethra is one of the specific
locations included in USI, identification of pus from the urethra would be an
example of evidence of infection made on gross anatomic exam without an invasive
procedure.

3. My patient had a Foley catheter placed on admission and in place until day 4.
On the 4th day, the Foley was removed and then reinserted the next day. The
patient subsequently developed an NHSN UTI with date of event on day 6. Is
this UTI catheter-associated, or since the second catheter had not been in
place for greater than 2 days, is this a non-catheter associated UTI for NHSN
purposes?

A: If a device is present for any part of a calendar day, then that day contributes to
the minimum day requirement for the device-associated infection. In this example,
because a Foley was present for some part of day 4 (i.e., before it was removed), and
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also some part of day 5 (i.e., after it was inserted) the indwelling catheter day count
will continue for this patient. Since the UTI occurred after more than 2 days of
catheter use and the catheter was in on the date of infection, in this case, this is a
CAUTI for NHSN purposes. Another way to think of it is that if a full calendar day
passes without device presence, then the day count begins anew for device days.
An example would be the removal of a device on Monday, without reinsertion until
Wednesday or later. The catheter day count for that patient would start anew on
the date of insertion. Remember, NHSN is assessing the risk of catheter use in
general and not the risk of an individual catheter.

The same guidance applies to central line use in central line-associated bloodstream
infection surveillance.

4. The CAUTI modifications shared in the March 2015 NHSN Newsletter go into
effect April 1st, and the SSI modifications on January 1st. When do the other
changes take effect?

A: The other modifications to the definitions in chapter 17, CDC/NHSN Surveillance
Definitions for Specific Types of Infections, should be applied to surveillance for
events occurring on or after April 1, 2015.

CAUTI Questions

5. If a patient is identified with an NHSN UTI at Facility A and during the Repeat
Infection Timeframe (RIT) of that UTI is transferred to Facility B, how are
positive urine cultures collected at the new facility handled? Can positive
urine cultures at Facility B that occur in what would have been the UTI RIT at
Facility A be considered a part of the previously identified UTI and therefore
not considered in Facility B’s UTI surveillance?

A: RITs do not extend across admissions but the Transfer Rule does. (Transfer Rule:
If the date of event is on the date of transfer or discharge, or the next day, the
infection is attributed to the transferring/discharging location). This means that in
the example provided, if a UTI is identified at Facility B on the day of transfer or the
next day, the infection would be attributed to Facility A. Facility B should inform
Facility A, who will consider the transfer rule and record any additional organisms
as needed according to the NHSN protocol. For Facility B, a new RIT is established
on day 1 of the admission to account for an infection present on admission….albeit
attributed to the previous admission. If the date of event for a UTI is identified on
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day 3 or later of admission to Facility B, that UTI will be considered a healthcare-
associated UTI for Facility B, regardless of events reported at Facility A.

6. Please clarify the following scenario. A patient presents with an E. coli UTI
with date of event on the day of admission and is treated with antibiotics. On
day 8 a urine culture that is collected is negative for growth. On day 21
(beyond the 14 day repeat infection timeframe [or RIT]) another positive
urine culture that is collected is positive for E coli > 100K colony forming
units/ml. Would this be considered an extension of the UTI from day 1 despite
the negative urine on day 8 if an infectious disease doctor says it could be an
extension of the existing UTI from admission?
A: No. For NHSN surveillance, the urine culture collected outside of the RIT should
be evaluated for another UTI and should not be considered an extension of the UTI
from day 1. It is acknowledged that these surveillance criteria will not always match
the clinical opinion of whether an infection was present; however, the need for
objective and reliable surveillance definitions and criteria is paramount when data
are being used for public reporting purposes. The RIT states that an infection with a
date of event identified outside of the RIT must be reported as an infection in any in-
plan reporting that is occurring.
7. Please clarify the role of fever and age in the UTI definitions. How does fever
and age > 65 years affect the CAUTI criteria?

A: The exclusion of fever as a symptom of symptomatic UTI in patients greater than
65 years of age applies only to SUTI criterion 1b, for non-catheter-associated UTI.
Because fever is a non-specific symptom for UTI in the elderly, non-catheterized
patient, it is not used for non-catheterized SUTI identification in NHSN. Therefore
one of the other localizing signs or symptoms of UTI must be present to meet the
NHSN SUTI 1b criteria in this patient population to avoid over-reporting UTIs.

BSI Event Questions

8. How do I determine if a bloodstream infection (BSI) is primary in nature or
secondary to another site and therefore not reported as a central line-
associated BSI (CLABSI)?

A: If you believe that there is a non-blood source of infection to which a BSI may be
secondary, you must first fully meet one of the NHSN site specific infection
definitions. These are outlined in Chapter 17 [CDC/NHSN Surveillance Definitions
for Specific Types of Infections], as well as the PNEU, UTI, SSI and VAE protocols. If
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the patient does not meet any of the infection criteria in Chapter 17, PNEU, UTI , SSI
or VAE then the LCBI must be reported as a primary LCBI and as a CLABSI if central
line-association requirements are met.
IF you have identified that a site specific definition has been met to which you
believe the BSI may be secondary, apply guidelines located in Appendix 1,
Secondary BSI Guide, found at the end of Chapter 4 (Bloodstream Infection Event
[Central Line-Associated Bloodstream Infection and Non-central line-associated
Bloodstream Infection]) in the NHSN manual. In order for the BSI to be secondary
to the other site of infection, the blood culture must either be an element used to
meet the site-specific criterion OR blood and site-specific specimen cultures (used to
meet the infection criterion) must match for at least one organism. You may find it
helpful to use the Secondary BSI flow diagrams located on page 4-26 and 4-27 of the
BSI chapter.
The rules for infection window period and secondary BSI attribution period must
be followed as well. More guidance about these rules may be found in Chapter 2
(Identifying HAIs in NHSN). Note however, that in the case of VAE, the guidance for
assigning a secondary BSI to VAE, as outlined in the VAE protocol, must be adhered
to.

In an effort to assist users, a table of criteria that has blood as an element to meet
criteria was published in the March NHSN newsletter. This table may also be found
on the FAQ document posted on the BSI webpage.

9. When will mucosal-barrier injury- laboratory-confirmed bloodstream
infection (or MBI-LCBI) data be removed from the CLABSI data that is
submitted to CMS?

A: NHSN does not plan to remove the requirement for hospitals to include MBI-
LCBIs as a part of in-plan CLABSI reporting. Facilities will still be required to report
these events to NHSN if the location's monthly reporting plan includes CLABSI
surveillance. Instead, NHSN will be removing the MBI-LCBI counts from the main
LCBI tracking metrics and will create a separate report for MBI-LCBI tracking. This
means that the MBI-LCBIs will not be included in any of the CLABSI metrics used for
national reporting or for files that are shared with CMS. They will only be used in
specific MBI-LCBI reports. CDC intends to use the 2015 NHSN data as the new
baseline for all of the HAI standardized infection ratios (SIR) calculated for
subsequent years. Therefore, it is in the 2016 SIR data, which will use 2015 as the
baseline, that users will see the MBI-LCBIs removed from their CLABSI counts
reported to CMS. We believe that the continued collection and tracking of MBI-LCBI
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data is important because these infections cause significant morbidity and mortality
for patients, and through their identification and measurement exists the potential
to identify new prevention efforts.

10. A patient has a blood culture collected on hospital day 4 that meets LCBI
criteria. No central line is in place and a BSI event is identified. On hospital day
5 a central line is inserted. Another blood culture is collected on hospital day
8, that is positive for a pathogen, and the patient meets CLABSI criteria. Should
the primary non-central-line-associated event be changed to a CLABSI within
NHSN?

A: No. Do not change the device-association determination during the RIT. If a
primary BSI is identified that begins the RIT, do not "upgrade" the event if a patient
later meets CLABSI criteria during the RIT of the BSI. The second positive culture is
considered an extension of the first non-central-line associated BSI.

LabID Event Questions for APIC

11. If I have an inpatient psychiatric facility (IPF) located within my acute care
hospital and it has a different CCN, do I have to map and report separately for
this IPF location for LabID Event reporting?
A: Since there are no Centers for Medicare and Medicaid reporting mandates for the
IPFs at this time, facilities are not required to report to NHSN separately for these
locations. Instead, for FacWideIN, facilities can continue to include and report LabID
events from the IPF location just like they’ve been doing, and NHSN will remove the
counts prior to sending FacWideIN data to CMS. Remember, if the IPF does have a
different CCN number than the ACH, the patient day and admission counts for the
IPF location must be removed from those denominator counts for MDRO and CDI
reporting. Additional information is available in the March 2015 NHSN newsletter
found here: http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN-NL-
March_2015.pdf
12. Question. Should patients in “swing beds” be included with inpatient counts
for LabID Event reporting?
A: The answer to this question depends on the location of the beds. If these beds
reside in an inpatient location, then, yes, patients staying in the swing beds must be
included in all NHSN surveillance being performed in that location. This includes all
event data and all denominator data for the inpatient location.
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13. Am I required to add FacWideOUT to my NHSN Monthly Reporting Plan since
acute care hospitals (ACH) are required to include 24-hour observation and
emergency department locations when reporting in-plan FacWideIN LabID
Events?
A: No. FacWideOUT is not required for participating in facility-wide inpatient
reporting for LabID Events. However, if facilities are reporting FacWideIN LabID
event data for participation in the CMS Inpatient Quality Reporting Program, they
must add each outpatient emergency department location and each 24-hour
observation location to their monthly reporting plan. If these locations are already
set-up in the NHSN application, the monthly reporting plan will auto-populate these
additional outpatient locations when FacWideIN is selected.
14. LabID reporting is so time consuming because it requires everything to be
entered manually. Is there a way to upload all of the required denominators
and events?
A: Currently the application will not accept downloads of this information.
However, the good news is that NHSN is working on a process to make downloads
possible. More information will be shared with users as it becomes available.
SSI Q&As
15. Can a patient develop a surgical site infection per NHSN definitions following a
dirty/infected surgical procedure or would such an infection be considered
present or incubating on admission or at the time of surgery? If yes, does this
SSI need to be reported to NHSN?

A: Patients who have an NHSN operative procedure coded as dirty/infected can
develop a subsequent SSI, including an organ space SSI. If the patient subsequently
meets SSI definition during the surveillance time period. This SSI should be reported
if this procedure is in your monthly reporting plan.
The present on admission definition does not apply to SSIs.
SSIs that occur after surgeries where an infection was present at the time of surgery
may meet the new PATOS - Infection Present at Time of Surgery criteria.
When entering an SSI that meets criteria for PATOS the PATOS field on the SSI event
form should be marked as YES. When investigating an SSI look back at the operative
procedure notes to determine if the patient had an infection at the same level as the
SSI being investigated. SSIs that meet PATOS criteria are NOT excluded from SSI
reporting. The SSI should still be entered into NHSN if it has occurred following a
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procedure for which SSI surveillance is performed and reflected in your facility’s
monthly reporting plan. Complete details for the new PATOS field are found in the
SSI protocol on the NHSN Website.
16. If a patient is felt to have an organ/space SSI, but doesn’t meet a site-specific
infection criteria, can a deep incisional SSI be reported instead?
A: No, SSIs should only be reported for levels at which they actually meet criterion.
For example if a patient had a hip arthroplasty, an HPRO procedure, and they were
readmitted with a possible SSI, if they did not meet the organ space PJI
(Periprosthetic Joint Infection) criteria, do not simply downgrade and call the
infection a deep incisional SSI. It should only be reported as a deep incisional SSI if it
met the definition for deep incisional SSI.
17. When we the new mappings for the upcoming transition to ICD-10-CM codes
be available from NHSN?
A: NHSN is keeping NHSN users and vendors updated regarding the transition via
NHSN Newsletters and emails.

The latest March NHSN Newsletter had an update in the SSI section of the
newsletter regarding this transition.

NHSN has received the ICD- 10-CM and CPT mappings and is working feverishly to
validate this data for all of the NHSN operative procedure categories for SSI
surveillance. These mappings are anticipated to be available sometime this Spring.

At this point ICD-10-CM codes will replace ICD-9-CM codes on October 1, 2015
however NHSN will not have the ability to receive these codes until the January
2016 release.
The NHSN guidance for entry of surgical denominator data for the last quarter of
2015 data is to enter the NHSN Procedure Code (e.g. COLO or HYST) but do not
enter any ICD-10-CM codes associated with the procedure.

Because the amount of work involved in mapping the new codes to the NHSN
Operative Procedure Categories is substantial, NHSN had to consider the practicality
of including the mapping work to the current NHSN operative procedure code
category “OTH-Other”. “OTH – Other” is a catch-all category for NHSN operative
procedures for which NHSN does not perform any in-plan SSI surveillance nor
provide any benchmarking data. The NHSN Category “OTH” will not be mapped to
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ICD-10-CM and CPT codes and the procedures in that group will not be considered
an NHSN operative procedure.
VAE & PNEU/VAP
18. What lower respiratory tract event surveillance can be done “in-plan” for
NHSN reporting?

1) Ventilator-associated event (VAE) surveillance is the ONLY in-plan respiratory
event surveillance for mechanically ventilated adult inpatients housed in adult
locations (regardless of the age of the patient). Pediatric and neonatal units are
excluded from VAE surveillance (even in circumstances where a pediatric unit
may occasionally care for adult patients).

2) Pediatric ventilator-associated pneumonia (VAP) surveillance using pneumonia
(PNEU) definitions is the ONLY in-plan respiratory event surveillance for
mechanically ventilated inpatients in pediatric locations (regardless of the age of
the patient). In-plan surveillance for ventilator-associated PNEU is no longer
available for patients in neonatal locations.

NOTE: The PNEU definition (PNU2 & PNU3) is available for use as a site specific
infection to which a bloodstream infection can be assigned as a secondary BSI for all
patients to include adults, children, neonates, ventilated or non-ventilated.

19. Why am I required to report an Infection-related ventilator associated
complication (IVAC) when the qualifying antimicrobial day parameter is met
based on antimicrobial agents that were not administered to treat a
respiratory infection?

A: The IVAC definition, is not intended to specifically identify infectious events
arising from the respiratory tract—it is meant to identify events that may be
infectious in nature and associated with a period of respiratory deterioration
(whether arising from the lungs or elsewhere). Therefore, the list of eligible
antimicrobial agents that is included in the VAE protocol is quite broad, and some
agents are drugs that are rarely used to treat respiratory infections. There is no
requirement to determine the reason for the administration of the antimicrobial.

It may be helpful to consider that having an IVAC is not necessarily “worse” than
having a VAC. The VAE algorithm is progressive in terms of criteria to be met but
this is not to imply that each subsequent tier is more clinically significant than the
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one before. The fundamental definition within the algorithm is the VAC definition so
even in those circumstances where an IVAC is detected that event still met the VAC
definition. In the case of the IVAC, there is simply some additional evidence that the
event may be infectious in nature, as opposed to non-infectious. This is what the
IVAC definition is intended to detect.

20. Can you explain baseline period of stability or improvement and the period of
worsening oxygenation that is required to meet the VAC definition?

A: By definition the baseline period of stability or improvement on the ventilator is
defined as the 2 calendar days immediately preceding the first day of increased daily
minimum PEEP or FiO2, and must be characterized by ≥ 2 calendar days of stable or
decreasing daily minimum FiO2 or PEEP values
After a period of stability or improvement on the ventilator, there must be at least
one of the following indicators of worsening oxygenation:

1. An increase in daily minimum FiO2 of ≥ 0.20 (20 points) over the daily minimum
FiO2 in the baseline period, sustained for ≥ 2 calendar days.
OR
2. An increase in daily minimum PEEP values of ≥ 3 cmH2O over the daily minimum
PEEP in the baseline period, sustained for ≥ 2 calendar days.
For a better understanding, let’s look at a few examples.

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