APIC Questions with Answers. NHSN FAQ Webinar. Wednesday, September 9, :00-3:00 PM EST

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1 APIC Questions with Answers NHSN FAQ Webinar Wednesday, September 9, :00-3:00 PM EST General Questions We are an acute general hospital - psych, do we need to be reporting anything to NSHN? Yes, please see the operational guidance for reporting healthcare personnel influenza vaccination data at

2 BSI/ RIT Questions Once the 14 days have passed, can a patient have a new infection after that even if it is the same pathogen and same infection type? Does the RIT timeframe have to occur in that admission, not from before admit or from transfer from other HCF? How is the BSI span determined? What if more than 2 organisms are identified during the 14 day RIT? Only 2 can be entered, so do you ignore the others? We are an IRF. The closest acute facility frequently transfers patients on treatment for UTI without a C&S--having only a UA+-- -if we culture after the 2 days post admit but cannot match it to another pathogen (because they didn't do one) is this a repeat infection or our HAI? Yes. The patient is eligible to have another infection of the same type the day after the last day of the RIT, even if that pathogen is the same pathogen previously identified. The RIT is simply an objective time period developed for surveillance to avoid the subjectivity of determining whether a previous infection has unresolved. Yes. RITs do not carry over from one admission to another. However, if the date of infection occurs on one of the 2 days before the day of admission, i.e., during the Present on Admission timeframe, the date of event will be the day of admission, and that day will set an RIT. The Secondary BSI Attribution Period is the period in which a positive blood culture must be collected to be considered a secondary bloodstream infection to a primary site infection. This period includes the Infection Window Period combined with the Repeat Infection Timeframe (RIT). It is days in length depending upon the date of event. Please see examples of determining the secondary BSI attribution period on page 2-7 of the NHSN manual at 3 pathogens can be entered for BSI. Only 2 pathogens can be entered for UTIs, unless there is a secondary BSI, in which case 3 pathogens can be entered. In the case where additional pathogens identified during the RIT exceed the number of organisms that can be entered, simply do not enter the additional organisms. In these cases, if the patient meets the UTI criteria and the date of event is on day 3 or later for this admission, the UTI will be attributable to your facility. Only if the date of event is during the Transfer Rule time period (day of transfer or next day) may the infection be attributed to the transferring facility. Please note however, that repeat infection timeframes do NOT extend between admissions. This simply means that if a patient meets criteria for an infection in the acute care facility, and then is transferred to your facility, there will be no RIT for the infection.

3 Any infection that occurs within your facility and which has an event date of day 3 of admission or later will be attributed to your facility. Question related to NEC with secondary BSI. Can you have a secondary BSI since a BC is not part of the NEC definition? When there is documented Pneumatosis/pneumoperitoneum, it is common to get a positive BC also. If a patient has a BSI on admission and does not have a central line and then a central line is placed and another pathogen grows in the blood culture, is this a CLABSI? Or does the BSI without a central line start the RIT for the subsequent positive blood culture making this a BSI and not a CLABSI? If a patient has a BSI on admission- 13 days later the patient has repeat positive blood cultures- does this second BSI get reported, or is it an RIT, since the first one did not get reported initially because it was POA? Following the NEC criteria there is a Reporting Instruction that outlines how BSIs may be considered secondary to NEC. Please see that guidance. It is found on page 18 of this document A primary BSI on admission, sets a BSI RIT, regardless of whether or not the BSI was centralline related. Any positive blood cultures collected during that BSI RIT will not be reported as another BSI. So, no CLABSI will be reported for the subsequent BSI in your example. Please note that a BSI that is present on admission, but is secondary to another site of infection sets an RIT for the other site of infection but does NOT set a BSI RIT. This means that subsequent BSIs will need to be considered for any BSI surveillance being performed. A primary BSI on admission, sets a BSI RIT, even if it was present on admission (POA). Any positive blood cultures collected during that BSI RIT will not be reported as another BSI. Please note that a BSI that is present on admission, but is secondary to another site of infection sets an RIT for the other site of infection but does NOT set a BSI RIT. This means that subsequent BSIs will need to be considered for any BSI surveillance being performed.

4 Would you please review how the "7-day window" is defined for an event? If a positive culture is not a criteria to meet a site-specific criteria - i.e. EPIS and a patient has the same pathogen in a blood culture and purulent drainage from the episiotomy - can this be called a secondary BSI? Do we need to contact a nursing home to ask about sign and symptoms if they were brought in EMS from NH? The UMB-oomphalitis definition does have 1b. Organisms cultured from blood. Doesn't this mean that it meets part 2 "The blood culture must be an element used to meet the site specific infection criterion."? I review all cases with our Infectious disease specialist. At times his decision (and mine) does not agree with NHSN as to whether it is a HAI or a line related BSI just because the patient has a line present... etc. Do we go by NHSN definitions vs ID specialist decision? The Infection Window Period is defined and examples provided on page 2-2 of the NHSN manual. Please visit and review that information and let us know if you have further questions at NHSN@cdc.gov No. There are only 2 ways in which a BSI may be attributed as secondary to another site of infection. Those are, 1) having an organism in the blood which matches at least one organism in a site-specific culture that is used to meet the site-specific infection criteria, or 2) using the positive blood culture as an element of the site-specific infection criteria. Neither of these are possible for EPIS, so a BSI cannot be secondary to EPIS. The rationale for this is that these infections are considered to rarely cause a BSI. You may use information supplied by the EMS to make infection determinations. However, if you believe you have not received all pertinent information necessary to make a determination, it may be helpful for you to contact the nursing home. Good question. This patient actually may meet 2 means of attributing the BSI as secondary to UMB. The patient meets UMB criterion 1a using the site specific culture and that site culture matches a blood culture organism collected within the secondary BSI attribution period. However, the patient may also meet UMB criterion 1b, using the blood culture as an element of that criterion provided there is still erythema or serous drainage present in the 3 days before or 3 days after the blood culture. If neither of those symptoms are present during that time period (the infection window period) the UMB criterion 1b will not be met and the BSI could not be considered secondary for this reason. In-plan data reported to NHSN is used to determine benchmarking data, which is in turn used to calculate Standardized Infection Ratios (SIR). SIRs are used to determine some Centers for Medicare and Medicaid Services reimbursements. Consistency of data reporting is necessary for these reasons. Therefore, any reporting that is made to NHSN for data that is included in your monthly reporting plan, MUST adhere to the NHSN criteria and protocols. This includes reporting all events that meet criteria. Physician adjudication and exclusion of events from data reported to NHSN due to clinical disagreement represents a breach of the NHSN Agreement to Participate which all enrolling facilities sign. This breech could result in facility exclusion from NHSN, and may in turn affect federal reimbursement.

5 Bloodstream infection RIT question: if positive blood cultures with the same organism begin within the 14 day RIT time period and continue past the 14 day window, will this be a new bloodstream infection? Is the date of event for blood cultures the day it was drawn or the date the results came back, when looking at RIT? If you have MRSA positive blood cultures on admission and central line inserted on same day; then 6 days later have VRE growing in blood culture and still have Central line, do you not count the second set of cultures due to POA criteria? Do you use elements occurring in the POA period to meet criteria? If it is not a Primary BSI/CLABSI, do you report it to NHSN (do not report secondary BSI etc.)? Is there access to a blank work sheet that is used by you in the presentation for CAUTI/CLABSI case examples? Yes. Any BSIs with date of event on the first day following the BSI RIT, will be eligible for BSI attribution, even if the patient had a positive blood culture with the same organism, during the RIT. The RIT is a simply an objective time period developed for surveillance to avoid the subjectivity of determining whether a previous infection is unresolved. The date of culture collection is used for NHSN surveillance, not the date culture results are reported. For LCBI 1, the date that the blood culture is collected is the date of event. For LCBI 2, the date of event is the date the first LCBI 2 element occurred during the LCBI RIT. This may be the date of a symptom, e.g., fever, chills, hypotension or the date of the positive blood culture collection, whichever comes first. If the MRSA BSI is primary in nature, it will set a BSI RIT. If another blood culture with the same or different organisms is collected during that BSI RIT, it will not be considered a new BSI for NHSN reporting purposes. Please note if the MRSA BSI that is present on admission is secondary to another site of infection that will set an RIT for the other site of infection but will NOT set a BSI RIT. Subsequent blood cultures will need to be included in all BSI surveillance being performed and, if primary in nature, included in BSI data. Yes, elements occurring in the POA time period may be used to meet infection criteria. Only primary BSIs are reported for CLABSI surveillance. A blank worksheet is available at this location listed under Supporting Materials NHNS is developing an electronic worksheet generator which will be available on line and will assist in determining and documenting the Infection Window Period, Repeat Infection

6 Timeframe and Secondary BSI Attribution Periods for infections. Please watch your for announcements. CAUTI Questions Can we use "flank pain as costovertebral pain? A patient has a Foley inserted in surgery and was discharged with the catheter to allow for the bladder healing. The patient spikes a fever of 101 on day 7 post op in the clinic. A culture was done and was > 100,000cfu of enterococcus. Is this a CAUTI-HAI- even though the patient was discharged? I am confused on what to do with infections if the patient is discharge. In the presentation for CAUTI, Case #1, why would the second urine culture be considered HAC when the exact same organism was cultured in the POA time period? Please reference question # 17 in the April 2015 UTI FAQ document. Yes, left or right lower back or flank pain is acceptable for Costovertebral angle (CVA) pain or tenderness. It is not required to monitor for CAUTIs after the patient is discharged from the facility. However, if discovered, any CAUTI with the date of event on the day of discharge or the next day should be reported to NHSN. Please reference the Transfer Rule: If the date of event for a CAUTI is on the date of transfer or discharge, or the next day, the infection is attributed to the transferring/discharging location. IF there are no applicable UTI symptoms or matching blood culture to the urine organism within the Infection Window Period (IWP) of the POA 4/16 urine culture (IWP is 4/13 4/19), then NHSN UTI criteria is not met and this is not considered an infection present on admission according to the NHSN surveillance definition. Therefore, no Repeat Infection Timeframe (RIT) is set. The 4/16 asymptomatic bacteriuria which does not meet NHSN UTI criteria may be considered colonization of the bladder. A Foley catheter that remains in place puts the patient at greater risk for this to develop into a symptomatic UTI, which is what occurred during the Healthcare-associated infection (HAI) timeframe in this case example.

7 VAE Questions Would a VAE apply for intermittent mechanical ventilation or a patient that requires vent support at night only? VAE surveillance was meant to be done electronically, how are we supposed to capture an H&P that states the patient has been ventilated for 3 months? Long Term Acute Care Hospital - can I use the date of MV Initiation date from outside transferring hospital? Or do I use date of admit? Any patient that is ventilated for some portion of each calendar day is eligible for inclusion in VAE surveillance in locations where in plan VAE surveillance is conducted. You would select the daily minimum PEEP and daily minimum FiO2 values that used for making VAC determinations using those ventilator settings that are documented while the patient is receiving ventilator support (in this case at night). VAE is a potentially automatable event. The capture of an event attributable to your facility will not necessarily be missed if the date of initiation of mechanical ventilation is inaccurately stated. If the date represents a date prior to admission to your facility and is not an able to be captured electronically AND the MV initiation date is defaulted to the facility admission date, the event will not be missed. The point of accuracy (as best as possible) is to attribute the event to the correct location and also to allow for the correct application of the VAE window period. The latter will ensure correct specific event determination (VAC, IVAC, PVAP). A VAC will be detected if the VAC definition is met even if in lieu of a MV initiation date an admission date is used. It may however require that you manually review captured events (which hopefully will not be a large number and therefore not burdensome) to assure the MV initiation date has been assigned as accurately as possible. MV initiation date is to represent the actual or proxy date in which the patient was originally ventilated for the current episode of mechanical ventilation. If MV initiation occurred at a facility other than your own or if it occurred in the field by EMS, the date of that occurrence is the date you are to use. Date of admit is only to be defaulted to in situations where it is not possible to obtain the actual date of MV initiation or not possible to estimate a date such that you can provide a proxy date of MV initiation.

8 ICD-10-PCS Questions For ICD 10 OTH-other can they still be used for SSI denominator counts for rates of other things? October 1 is in a "couple of weeks"...how are we supposed to have time to get our electronic surveillance mechanisms in place when we are still waiting on decisions/directions/guidance from CDC? We have been preparing for ICD-10 for years, so I am not sure I understand why NHSN is not ready with the application. Is there anything that we need to do on our end in reference to the ICD-10 mapping? The OTH-other was not mapped and does not have NHSN operative procedure groups associated with it. But if the patient develops an infection after a non-nhsn operative procedure you can still review to see if the infection meets HAI criteria, for example a HAI skin or soft tissue infection. It just won t be an SSI. The ICD-10 codes are available on the SSI website now. The Diabetes diagnosis codes and the codes for history of prior infection at hip or knee will be uploaded shortly and NHSN users will be notified via an to all NHSN users. The applications releases are performed in January to align with the new protocols. NHSN was not able to do an October release. The ICD-10 codes are optional fields and NHSN has released guidance for denominator data for the last quarter of 2015 in the NHSN Newsletters and NHSN s regarding the transition. You should work with your IT department to see if they will need the new codes for any reports they run for you. If you use a vendor for your surveillance system ensure they are very aware of the transition.

9 SSI Questions Are SSI PATOS reported to CMS? In 2014 and 2015 procedures that were selected as closure other than primary are not factored into your SIR and for COLO and HYST these procedures and any SSI attributable to them are not being sent to CMS. This is stated in the Analysis section of the SSI protocol. Additional Notes about SSI SIRS: 1. Primary closure: All of the SSI SIRs that use the SSI baseline data will include only those procedures that were reported with a primary closure method.3 2. Infection present at time of surgery (PATOS): All of the SSI SIRs that use the SSI baseline will include SSIs that are reported as present at time of surgery. Point #2 above is true if the procedure was a primary closure. In 2016 SSI events that are PATOS = Yes will not be factored into your SIR analysis and for COLO and HYST the PATOS cases will not be reported. You will still enter you PATOS = YES SSI events and have them available for internal analysis.

10 MDRO/CDI Questions Does the transfer rule apply to MDRO reporting? Does a swing bed program for skilled care get taken out of the numbers for patient admissions and patient days? This can be IV therapy, physical therapy, or anything requiring skilled care that is not acute care. We are a CAH with no ICU or OB. Was the MDRO information as presented in the webinar to have been entered for first quarter 2015? No, the transfer rule does NOT apply to MDRO reporting. If the swing bed program is on a dedicated unit (only swing bed patients are housed on this unit), these patients are not included in total facility days or total facility admission counts. If the swing bed program uses beds on an inpatient unit, the swing bed patient counts for patient days, admissions and device counts for the inpatient location where they are housed and cared for. Yes the information presented covered reporting effective January 2015.

11 LTC Questions When working in a LTC facility, are all the infections subsequent to the second day of admission to the LTC facility considered HAI? If your facility is participating in the NHSN LTCF Component, then you have the option to report healthcare associated UTI events and/or multi-drug resistant and/or C. difficile LabID Events. LTCFs should use the current surveillance definitions and reporting protocols specific for long-term care facilities, which are located on the NHSN LTC website For the purpose of LTCF HAI surveillance, available for UTI, the protocol does not have a specific time-period for identifying an HAI, some clinical judgment has to be used. For example, a UTI should be attributed to a LTCF onset if there is no evidence of an incubating infection at the time of admission to the facility (on the basis of clinical documentation and laboratory screening, if applicable), and if the onset of clinical manifestations occurs more than two calendar days after admission to the LTCF. Of course, the symptoms associated with the UTI must be new or acutely worse (e.g., change from the baseline). Other considerations may include ongoing signs and symptoms as well as continuation of antimicrobial therapy. Since the NHSN LTCF definitions are based on recommendations from the Society for Healthcare Epidemiology of America (SHEA), you may be interested in the SHEA/CDC position paper, which discusses in more detail the LTCF surveillance definitions and rationale (revised McGeer definitions). This paper can be accessed on the CDC-LTCF Resource Page for Clinicians - I have a question about reporting. I had a patient get admitted to the Med/Surg from Long Term Care. She was diagnosed with C-Diff. Do I report the C-Diff in the Acute Care or LTC? For LabID Event reporting, specimens collected while the patient is housed in your facility should be reported for your facility.

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