NHSN CASE STUDIES or… Russ’s title NHSN Jeopardy Allison Gibson Murad, MPH aka Allie...
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NHSN CASE STUDIES or… Russ’s title NHSN Jeopardy Allison Gibson Murad, MPH aka Allie “Trebek” NHSN Epidemiologist Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit Michigan Department of Community Health [email protected]& Russ Olmsted – MSIPC Fundamentals Faculty
NHSN CASE STUDIES or… Russ’s title NHSN Jeopardy Allison Gibson Murad, MPH aka Allie “Trebek” NHSN Epidemiologist Surveillance for Healthcare-Associated
NHSN CASE STUDIES or Russs title NHSN Jeopardy Allison Gibson
Murad, MPH aka Allie Trebek NHSN Epidemiologist Surveillance for
Healthcare-Associated and Resistant Pathogens (SHARP) Unit Michigan
Department of Community Health [email protected] & Russ
Olmsted MSIPC Fundamentals Faculty
Slide 2
NHSN: Not Just for Acute Care www.cdc.gov/nhsn
Slide 3
2011 CAUTI Acute Care ICUs (except NICUs) (Jan.) CAUTI LTCH,
IRF, Cancer Hospitals (Oct) SSI Colon Surgeries and Abdominal Hyst.
Acute Care (Jan) Dialysis Events ESRD (Jan) CLABSI LTCH, Cancer
Hospitals (Oct) 2012 2013 HCP Influenza Vaccination ASCs (Oct.) SSI
Cancer Hospitals (Jan.) HCP Influenza Vaccination IRF (Oct.) 2014
CLABSI Acute Care ICUs (Jan.) C. Diff LabID Events Acute Care
(Jan.) MRSA Bacteremia LabID Events Acute Care (Jan.) HCP Influenza
Vaccination Acute Care (Jan.) HCP Influenza Vaccination LTCH (Jan.)
2015 Federal HAI Reporting To NHSN Under Inpt. Quality Reporting:
Past/present & Future CLABSI Acute Care Med, Surg, Med/Surg
Units (Jan.) CAUTI Acute Care Med, Surg, Med/Surg Units (Jan.) MRSA
Bacteremia LabID Events LTCH (Jan.) C. Diff LabID Events LTCH
(Jan.) APIC. Federal HAI Reporting to NHSN resource update.
www.apic.org 9/17/13
Slide 4
All case studies and responses are derived from slides
developed by CDC or are approved by CDC NHSN staff.
Slide 5
CAUTI Module (1) 84 year old patient is hospitalized with a GI
bleed. Day 3: Patient has an indwelling urinary catheter in place
but has no signs or symptoms of infection. Day 9: Patient becomes
unresponsive, is intubated and CBC shows WBC count of 15,000. Temp
is 38.0 C. Patient is pan-cultured. Blood culture and urine both
grow Streptococcus pyogenes. Urine culture shows > 100,000
CFU/ml.
Slide 6
CAUTI Module (1 part A) Is this a UTI? A CAUTI? If so, what
type? A.No UTI because the blood seeded the urine. B.Yes, this is
an ABUTI [asymtomatic, bacteremic UTI]. C. Yes, this is a SUTI
[symptomatic UTI] NHSN Criterion 1a with a secondary BSI.
Slide 7
CAUTI Module (1- Part B) What if the organism in both cultures
had been a Micrococcus? Would it be a UTI? Would it still be an
ABUTI?
Slide 8
CLABSI Module (1 ) 5/15: 79 year old male, admitted with
gastric cancer. Central line placed day of admission for total
parenteral nutrition. 5/16: Partial gastrectomy performed. 5/21: Pt
progressing well until fever spike of 101.3 F (38.5 C) Blood
cultures sent. 5/22: Increasing abd pain. CT scan of abd shows
small fluid collection posterior to stomach. Fluid collection fully
drained by ultrasound-guided needle aspiration, & fluid sent
for culture. Blood cultures repeated.
Slide 9
CLABSI Module (1- Part A) 5/23: Blood cultures from 5/21: 1 of
2 positive for Staph epidermidis. Abd fluid growing gram positive
cocci. Antibiotics begun. 5/24: Abd culture: Enterobacter cloacae.
Blood cultures from 5/22: 2 of 2 positive for coagulase- neg.
staphylococcus. Does this pt have an infection? If yes, is it an
HAI?
Slide 10
CLABSI Module (1- Part B) Does this patient have a CLABSI?
Options: A.Yes, the patient has a CLABSI with S. epidermidis. B.No,
the BSI is secondary to the abdominal infection. C. Not sure.
Slide 11
SSI Module (1) 4/12: Pt is admitted to hospital for elective
surgery and an active MRSA screening test is positive. On same day,
pt undergoes total abd hysterectomy. 4/16: Post-operative course is
unremarkable. Pt is discharged to home. 4/29: Pt is readmitted with
complaints of acute incisional pain since day before. Surgeon opens
wound into the fascial level and sends drainage specimen for
culture & sensitivity. 5/1: Culture results are positive for
MRSA.
Slide 12
SSI Module (1 Part A) Does this patient have an HAI? Options:
1. Yes. If yes, then what type of infection should be reported to
NHSN? SSI-SIP? SSI-SIS? SSI-DIP? SSI-DIS? Or SSI-IAB? 2. No
HAI.
Slide 13
SSI Module (1 Part B) What is the date of the event (SSI)?
Options: A.4/12 B.4/16 C.4/29 D.5/1
Slide 14
MDRO/CDI Module (1) 3/1: 55 year old patient with end stage
pancreatic cancer with liver & bone metastasis is admitted to
inpt unit 3E from hospice facility. The pt has no previous history
of inpt admission to this facility. Upon admission to 3E, pt is
noted to have foul loose stools. After three episodes of loose
stools over the course of 24 hours, an unformed specimen is
collected and test positive for C. difficile toxin.
Slide 15
MDRO/CDI Module (1 Part A) For FacWideIN LabID reporting,
should this be entered into NHSN as a LabID event? Options: A.Yes.
Specimen was collected from 3E inpatient location. B.No. This
infection belongs to the hospice facility. C.No. This is not a HAI,
therefore it should not be reported into NHSN.
Slide 16
MDRO/CDI Module (1 Part B) How will NHSN categorize the CDI
event? A.Community-Onset (CO) B.Healthcare Facility-Onset (HO)
C.Community-Onset Healthcare Facility-Associated (CO-HCFA) D.NHSN
will not categorize the event; the user will need to make the
decision.
Slide 17
MDRO/CDI Module (1 Part B) Correct Response: A. Community-Onset
(CO) Rationale: The patient has no previous history of admission to
this facility and the stool specimen was collected as an inpatient
less than 4 days after admission to the facility. Note:
Community-Onset Healthcare Facility- Associated (CO-HCFA) is based
on previous discharge from index facility. Also.(next slide)
Slide 18
MDRO/CDI Module (2 Part A) January 1 st, 10:30am: 75-year old
male presents to the ED from a LTAC with the chief complaints of
shortness of breath, abdominal cramping, and a three day history of
multiple episodes of diarrhea. Medical history: myocardial
infarction and a three vessel coronary artery bypass grafting
procedure performed on Dec. 2 at this hospital, which was
complicated by a prolonged post- operative stay in the ICU.
Slide 19
During the stay, he was treated for a UTI with Levofloxacin. He
was discharged to undergo rehabilitation at the LTAC on Dec. 23
where he had his onset of diarrhea While in the ED on Jan. 1, a
chest X-ray reveals bilateral pleural effusions and pulmonary
edema. Before being admitted to an inpatient location, aggressive
diuresis is initiated and a diarrheal stool specimen is collected
and sent to the lab for C.diff toxin testing. MDRO/CDI Module (2
Part A)
Slide 20
Test result indicates positive C.diff toxin A/B. Patient is
admitted to 2N telemetry at 3:45pm on Jan. 1. Jan. 2: during the
night, patient has respiratory deterioration requiring mechanical
ventilation, and is subsequently transferred to the ICU. Continues
to have abdominal cramping and multiple episodes of diarrhea.
Another diarrheal stool specimen is collected and sent form the ICU
for C.diff toxin testing. Result is positive for C.diff toxin A/B.
Flagyl is started. MDRO/CDI Module (2 Part A)
Slide 21
Would you identify the Jan. 1 st C.diff toxin positive assay as
a CDI LabID Event for facility-wide inpatient (FacWideIn)
reporting? A. No. The patient was admitted with diarrhea form the
LTAC and the transfer rule applies. B. Yes. The result would be
identified as a CDI LabID Event for 2N. C. Yes. The result would be
identified as a CDI LabID Event for the ED. D. No. Since the
patient presented to the ED with diarrhea suggestive of CDI, this
is considered community-onset, and therefore should not be
considered a CDI LabID Event for FacWideIn reporting. MDRO/CDI
Module (2 Part A)
Slide 22
Would you identify the Jan 2 nd positive C.diff toxin result as
a CDI LabID Event for FacWideIn Reporting? A. No. His symptoms
started
Slide 23
If the Jan 1 st positive C.diff toxin result is a CDI LabID
Event, how will the event be categorized by the NHSN application?
A. Community-Onset (CO) B. Healthcare- Facility-Onset (HO) C.
Community-Onset Healthcare Facility-Associated (CO-HCFA) D. The
NHSN application will not categorize the event. MDRO/CDI Module (2
Part C)
Slide 24
The patient remains in the ICU until Jan 14 th when he is
transferred back to 2N telemetry. He has completed a course of
Flagyl, has no abdominal complaints and his stools are formed with
no further C.diff toxin testing having been performed. Jan. 16 th :
he has an episode of diarrhea after eating breakfast and another
episode of diarrhea in the afternoon. A sample is sent for C.diff
toxin testing and the result is positive for C.diff toxin A/B.
MDRO/CDI Module (2 Part D)
Slide 25
Would you identify the Jan 16 th positive C.diff toxin result
as a CDI LabID Event for FacWideIn reporting? A. Yes. The result
would be identified as a CDI LabID Event for 2N since the specimen
was collected in a location with no prior C. difficile specimen
reported within 14 days for the patient and location. B. No. The
result would be considered a duplicate episode of C. difficile and
would not be reported as a separate CDI LabID Event for FacWideIN
reporting. C. Yes. The result would be identified as a CDI LabID
Event for the ICU since the specimen was collected 14 days after
the last positive specimen for the ICU and the patient was in that
location within the previous 48 hours and the transfer rule applies
MDRO/CDI Module (2 Part D)
Slide 26
CLABSI Module (2 Part A) 8/14: 41 year old female presents to
ER in diabetic coma and with anemia. She has a subclavian catheter
inserted in the ER. The next day, in the ICU she has a midline
catheter inserted and receives a blood transfusion. 8/17: Pt
develops fever of 39 C and shaking chills. Two sets of blood
cultures sent to lab. 8/19: Blood cultures positive for Pseudomonas
aeruginosa. Neither insertion site shows inflammation and there is
no other documented infection.
Slide 27
CLABSI Module (2 Part A) Does Ms. E have a Laboratory-Confirmed
Bloodstream Infection (LCBI)? Options: A.No, the pt does not have
an LCBI. B.Yes, the pt has an LCBI with P. aeruginosa. C.Not
sure.
Slide 28
CLABSI Module (2 Part B) If Ms. E has an LCBI, which criterion
of LCBI applies? Options: A.LCBI criterion 1 recognized pathogen
cultured from 1 or more blood cultures. B.LCBI criterion 2 pt has
fever, chills and 2 or more positive blood cultures.
Slide 29
CLABSI Module (2 Part C) What unit should be indicated for the
location of the device insertion? Options: A.The ED should be
recorded as the location of device insertion. B.The ICU should be
recorded as the location of device insertion. C.Neither location.
D.Not sure.