Frequently Asked Questions Last updated: 17/11/10 Completion of the Surveillance Form: For which patients in ICU should I complete a surveillance form? Fill out a form for all patients in your ICU that are (i) (ii) (iii) aged 18 years or older, present in the ICU for more than two days between 1/11/2010 and 31/01/2011, and have a temporary central venous catheters (CVC) inserted. Only lines that were inserted after the 1/11/2010 are to be included. Therefore, at the beginning of the project, if there is a patient in the ICU that meets all of the inclusion criteria but had a line inserted before 1/11/2010, this line is not to be included in the surveillance. However, if the same patient gets a new CVC line inserted, this line can be included. What is the patient ID number? This is the record number that you use to identify the patient in your hospital; such as the medical record number, admission episode number. How do I calculate duration of ICU admission? For duration of ICU admission, if ICU date of discharge minus ICU date of admission plus 1 is greater than two days, then the patient is included. Example 1: Minnie Mouse is admitted to ICU on 3/11/2010 and discharged on 7/11/2010. (Date of Discharge Date of admission) + 1 (7/11/2010 3/11/2010) + 1 = 4 + 1 = 3 1
Minnie Mouse is included! Example 2: Donald Duck is admitted to ICU on 9/11/2010 and discharged on 10/11/2010. (10/11/2010 9/11/2010) + 1 = 1 + 1 = 2 Donald duck is NOT included! Should I work out the hours that the patient has spent in ICU when deciding their length of stay? For example, my patient was admitted at 4pm on 2/11/10 and discharged at 10pm on 4/11/10. Therefore, my patient was admitted for more than 48 hours. To avoid confusion and difficult calculations, it is advised to stick to the formula described in the previous question. The formula refers to DATE of admission and is easier to calculate than trying to figure out what hour the patient was admitted or discharged. (Date of discharge Date of admission) + 1 = (4/11/10 2/11/10) + 1 = 3 days. Therefore, your patient is included. At what time should I start counting a new day in the surveillance protocol? Midnight is the time point at which a new day begins. Therefore, if a patient was admitted to ICU before midnight that day (e.g. at 10pm), the patient would be 1 day in ICU at midnight. Example: Mickey Mouse (20yrs old) was admitted to the ICU on 3/11/2010 at 10pm. A temporary CVC was inserted into the right Jugular on the 4/11/2010. He was discharged on the 5/11/2010 at 3pm. (5/11/2010 3/11/2010) + 1 = 2 + 1 = 3 Mickey Mouse would be included in the surveillance as he was present in the ICU for 3 days with a CVC in situ. 2
What is the date of hospital admission if the patient is transferred from another hospital? Date of hospital admission is the date admitted to YOUR hospital, and not the date admitted to another hospital. What if a patient came into the ICU from theatre with a line in situ? If the patient was 18, present in the ICU for 3 days and had a line in situ (no matter where it was inserted!) then this patient would be included. In Section 2 on the surveillance form, there is place to record the location of insertion of the CVC. In this case, theatre would be ticked. A patient was transferred to this ICU from the ICU of another hospital and had a line inserted in the ICU of the referring hospital. For location of insertion, can I place an X in the box ICU and/or other hospital? No. Place an X in the box other hospital only. Do not fill out X for ICU. If the CVC has been inserted in another hospital, then you are not required to find out the location in the other hospital that the line was inserted. One of my patients has already had 3 different CVCs and still has the 4 th CVC in situ. When filling out the form, I am finding it difficult to follow which CVC number I m working on. It is important to consistently keep to the same corresponding CVC number throughout all sections of the surveillance form. If the patient has more than one CVC, then you might find it useful to use a different colour of highlighter marker for each CVC number throughout the form to help you keep track. It is important to ensure that all of the information recorded on the form is legible for the data manager. What do I enter if the Date of CVC Insertion is not known? It should always be possible to identify the Date of CVC Insertion if the patient had a CVC inserted in your hospital. However, if a patient was transferred from another hospital with a CVC in situ and the information on date of CVC insertion was not found on the transfer letter then record Unknown in this field (Section 2). This information will be useful to 3
evaluate the quality of the information on CVCs when patients are transferred between hospitals. What if a patient has a PICC line and a temporary CVC in situ? This patient can be included if he/she meets the other inclusion criteria but only the temporary CVC would be included. Permanent and semi permanent CVCs (tunnelled CVCs, portacaths, PICC lines) arterial lines and peripheral venous catheters are excluded from this surveillance study. What happens if my patient has a Swan Ganz introducer inserted and not a Swan Ganz catheter? For the purposes of the surveillance form, further differentiation of catheter versus introducer is not being considered. Regardless of which is used, if it fits with Swan Ganz, place an X in the box. My patient had a Swan Ganz catheter inserted through an introducer. The catheter was removed but the introducer remains in situ. Do I count these as two different lines? No. Regard the introducer as the line and ignore the catheter. Therefore, the insertion details relate to the date and site of insertion of the introducer and the removal details relate to the date and reason for removal of the introducer. What if a patient has a suspected CVC related infection and blood cultures are taken from the temporary NT CVC and from an arterial line. Where should the blood culture results for the arterial line be recorded if positive? The results should be recorded in Section 4 under the box BC Other site Pos. Should I record on the form that cultures have been sent even if they are not positive? No. You should only record information in section 4 of the form, if culture results are positive. The positive culture results are key to deciding if the patient meets the HELICs definitions. 4
What if two blood cultures were taken from the temporary CVC and both were positive. Where should the second result be recorded as there is only one box for BC Line Pos? The second result could be recorded in the box BC Other Site Pos. Similarly, if two samples were taken from the peripheral site and were positive, the second result could be recorded in the box BC Other Site Pos. My patient has two temporary CVCs in situ. My patient has symptoms and signs suggestive of infection. It is not clear which of the two CVCs is the source of the infection. What cultures should I send for a patient with >1 temporary CVC in situ? It is advised that you send a blood culture from each of the two temporary CVCs in situ and in addition to these, you should also send a blood culture from a site peripheral to the two temporary CVCs. Should I record the condition of the exit site at line removal and the nearest recorded temp and WCC to that time and the same information at 48 hours later, even if the CVC was removed for reasons other than suspected infection? Yes. It is recommended that section 3 is completed in full when the CVC is removed, regardless of the indication for CVC removal. In some ICUs it is the policy to routinely send every CVC tip for culture, regardless of whether the CVC was removed for infection or not. It is not uncommon that 72hours later, a positive microbiology report is received, with significant growth of a significant organism. If you have already recorded the state of the exit site at the time of CVC removal and at 48 hours later and there was no evidence of exit site infection, then it will be easy to decide that the patient cannot be assigned as CRI 1 and only as CRI 2 if there were signs of systemic infection at CVC removal which improved within 48 hours of CVC removal. Getting into the habit of always completing section 3 will greatly facilitate the MDT decision process. 5
The patient had an exit site which was red at the time of CVC removal and was less red 48 hours later. How do I record this? Place Y in the box red/inflamed exit site at CVC removal and place Y in the box red/inflamed exit site at 48 hours. The site is still red so it s fine to record it as such. What is significant growth? As blood should always be sterile, any positive growth in a blood culture should always be considered to be significant, unless there are clear signs that it reflects contamination with skin flora. Any positive blood culture in a patient with a temporary CVC should be brought to the attention of the MDT for discussion. Depending on the microbiology laboratory, the quantification of the organisms isolated from the CVC tip may vary. Some labs use a cut off of 15 colony forming units (cfu) as significant growth from a tip( >15cfu = significant growth). Each participating CRI Audit Nurse is advised to check with the local microbiology laboratory regarding their definition of significant growth from a CVC tip. Positive growth from an exit site swab is only relevant where the definitions CRI 3 or CRI 4 are being considered. The patient must have a positive blood culture and the same organism isolated from the exit site should be isolated from the blood culture. The microbiology laboratory may quantify the growth from the exit site swab as; light, moderate or heavy growth. As the exit site swab result must be accompanied by a positive blood culture, the key point is that the same organism is isolated from the CVC tip and the blood culture. The quantity of growth on the exit site swab is of secondary importance. What happens if a patient is discharged from ICU and then readmitted? In the event that a patient is discharged from the ICU and subsequently readmitted, then a new surveillance form should be completed for the readmission and the second form must be completed in full as per the protocol. Please write at the top right of the form to indicate to the data manager that this is a second form for this patient (e.g., FORM 2 of 2). 6
What if a patient has more than four CVC lines in situ during their ICU stay? If a patient has more than 4 temporary CVCs during the surveillance period (01/11/2010 31/01/2011), then a second form maybe commenced. How do I calculate how many days a CVC has been in situ or how many days it has been since a CVC was removed? For consistency, always use 00:00 as the time for changing number of days a CVC is in situ. A temporary NT CVC is inserted at 22:30 on 02/11/10 = Day 0. At 00:00 03/11/10 = Day 1. A temporary NT Vascath is inserted at 00:25 on 29/12/10 = Day 0. At 23:30 29/12/10 = Day 0. At 00:00 30/12/10 = Day 1. A temporary NT CVC is inserted at 02:30 on 15/01/11 and removed at 23:50 25/01/11 (CVC has been in situ x 11 days). Blood cultures taken at 04:00 26/01/11 are positive for S. aureus (BC taken within 48 hours of removal of CVC). Therefore, that blood culture result should be discussed at the MDT meeting to ascertain whether or not it related to the recently removed CVC? If the result of a blood culture shows mixed growth, should the details of this be recorded for the MDT, for example if both S. aureus and S. epidermidis are present? In the event that there are positive microbiology results with mixed growth or organisms, it is advised that the code for mixed growth (19) is entered in the organism code box. As there is a positive microbiology result, this form will need to be discussed at the MDT meeting, therefore, it is suggested that the CRI Audit Nurse keep a record of the organisms isolated from the mixed culture (e.g., Peripheral blood culture was positive for E. coli and Candida albicans) as this will facilitate the MDT meeting. When should the MDT sign off on surveillance forms? The MDT should sign off on all forms for which an infection related to a temporary CVC was suspected or confirmed. In the event that a temporary CVC is removed from a patient with 7
no clinical suspicion for infection and there are no positive relevant microbiology results corresponding with that temporary CVC, then there is no need for the local MDT to sign off on that CVC. If there is any doubt about whether or not an infection was possible for that patient, then the form should always be brought to the attention of the MDT for discussion. Who should be involved in the MDT? In the larger ICUs, it is commonplace for intensivists and microbiologists to cover the ICU on a rota. Therefore, there may be a large number of personnel who could potentially be involved in the MDT. For the purposes of this three month study, it is recommended that the MDT membership should be consistent and that there is always at least one MDT team member, in addition to the CRI Audit Nurse, who is very familiar with the HELICS definitions of CRI. As the study progresses from week to week, more personnel can get involved with the MDT. The more experience that the MDT members have with the HELICS definitions, the easier it gets to apply those definitions. The key here is that the definitions are strictly adhered to and applied in a consistent way. We would recommend retaining patient charts in ICU if the patient has died or been transferred to another hospital. If the case is to be discussed at the MDT meeting, the chart be easily accessed at the MDT and the CRI can be signed off in a timely fashion. What happens if the patient has >1 CVC during the ICU admission. There is only enough space on the form for one set of signatures? As space on the form is very limited, it is suggested, that if a patient has >1 CVC, fill out the signature part of the form as demonstrated in the picture below. Tracking the signatures to the CVC number, will assist you in deciding which CVC number requires sign off and which CVCs have already been discussed at your MDT 8
What happens if a patient is discharged from ICU with a temporary CVC in situ? Should I continue to collect information on this patient? No. Once the patient is discharged from ICU, even if he/she still has a CVC in situ, surveillance on this patient stops. The form is completed with the ICU discharge date and status recorded and returned to the central data manager. What happens if a patient is discharged from ICU with a temporary CVC still in situ? If there are any earlier CVCs recorded on the surveillance form, which have already been removed, then those CVCs should be signed off. If a temporary CVC was still in situ at the time of ICU discharge, leave the corresponding row number in section 3 CVC removal blank as there is no information available relating to when the line was removed. Section 6 of the form ICU discharge details should be completed, and if relevant for previous CVCs, Section 7 MDT Sign off should also be completed and the form returned to the Data Manager. 9
What happens if we subsequently receive a positive blood culture result from a patient who has already left the ICU with a temporary CVC in situ? As the patient has been discharged from the ICU with the CVC in situ, you are not following the patient or the CVC beyond the ICU for the purposes of this study. Therefore, the positive result is not included in the surveillance. What happens if a patient is discharged from ICU before a suspected line infection was signed off by the MDT? Should information on this infection be included in the surveillance? If the CVC has been removed prior to discharge or death, then that patient s form should still be brought to the MDT meeting if there is any concern regarding possible infection related to that line (patient had symptoms or signs consistent with CVC infection or positive microbiology results were obtained within 48 hours before or after line removal). If the patient was discharged from the ICU on the day of CVC removal, information regarding the clinical condition 48 hours after CVC removal will not have been recorded in the form. Depending on the microbiology results, it may be possible to assign a CRI status to that patient CVC, even if the patient is no longer in the ICU. Again, the MDT meeting is important in reaching a conclusion. If a temporary CVC was still in situ when the patient was discharged/died and it is unknown if the patient had a CRI, leave the corresponding row number in section 3 CVC removal blank as there is no information available relating to when the line was removed. Section 6 of the form ICU discharge details should be completed, and if relevant for previous CVCs, Section 7 MDT Sign off should also be completed. If there are any earlier CVCs recorded on the surveillance form, which have already been removed, then those CVCs should be signed off and the form returned to the Data Manager. 10
A patient has a CVC tip culture positive for coagulase negative staphylococcus in a significant quantity and the CVC exit site is noted to be red. There are no systemic signs of infection. Can I call that a CRI 1? No. CRI 1 only relates to positive tip culture with an organism which is considered to be a significant pathogen, such as; S. aureus, Enterococcus sp, Beta Haemolytic Streptococci or any of the Gram negative organisms or Candida sp. (See the back of the surveillance form under the organism code list for differentiation of significant vs. non significant pathogens). A patient has a CVC tip culture positive for S. aureus in significant quantity and the CVC exit site is noted to be red. The patient is febrile and has a high WCC. Can I call that a CRI 1? No. Whilst you do have significant growth of a significant pathogen from the CVC tip and you also have a red exit site, note that the patient also has systemic signs of infection (pyrexia, elevated WCC). Therefore, the patient meets the CRI 2 definition, provided that the systemic signs of infection improve within 48 hours of removal. Redness at the exit site is not considered to be a systemic sign of infection, more of a local sign of infection. For the diagnosis of CRI 4, can the single positive blood culture be a peripheral blood culture or from a site OTHER than from the suspected CVC infection? No, for the diagnosis of CRI 4, the single positive blood culture must be from the suspected infected CVC. What is the difference between CRI 1 and CRI 2? CRI 1 refers to local infection only CRI 2 refers to systemic infection with clinical signs of infection improving within 48 hours after removal of temporary CVC. See below. 11
What does Clinical signs of infection improve within 48 hours after removal of temporary CVC in CRI 2 mean? This refers to the resolution of systemic signs of sepsis (WCC and temperature) and not to the improvement in the degree of redness at CVC insertion site When is the form complete? The surveillance form is complete as soon as a patient is discharged from ICU (or dies), or no longer has a temporary CVC in situ. How do I send off forms to the central data manager? Once surveillance forms are completed they should be photocopied and the copy retained locally. The original should be stored securely and, using the schedule below, be posted using registered mail to the HPSC at: Margaret Foley. CRI Project Data Manager Health Protection Surveillance Center 15 27 Middle Gardiner St Dublin 1 The schedule for returning forms is: Completed patient surveillance forms and monthly denominator data forms should be returned to HPSC using the following schedule: - At 2 weeks (completed forms only) - At 4 weeks (completed forms and November denominator data form) - At 8 weeks (completed forms and December denominator data form) - At 12 weeks (completed forms and January denominator data form) It is critical that every surveillance form is completed in full at the local ICU level. The data quality depends on completed data being provided. It will not be possible to go back to the local ICU and clarify missing data once the forms are returned. 12
As the project progresses, we are finding that we often have to discuss individual lines and microbiology results at more than one MDT meeting. For example, a patient may have positive cultures that flag up on the day of the MDT meeting and the final results are not available. Is there any way to keep track of the discussion from week to week? For bigger ICUs where a lot of patients and CVCs and microbiology results are being tracked over time, it may be useful for the CRI Audit Nurse to keep minutes of the cases discussed at each MDT meeting and to highlight those cases which need to be brought forward to the following week s meeting and the reason that they need to be discussed again. In the event that the patient has been discharged from the ICU in the intervening period, having the details in the minutes will make it easier to remember and follow at the following week s MDT. This is particularly helpful if the personnel who attend the MDT change from week to week. In my hospital, there is more than one ICU participating in the study. As the study progresses, our MDT meeting is getting longer. Is there any way to minimise the time that our nursing staff spend at the MDT? It is advised that the patients to be discussed at the MDT are grouped according to their ICU of origin. If you have >1 ICU participating in the study, why not discuss the cases from one ICU first and then move onto the other ICU. That way, nursing staff from each unit only have to be at the MDT meeting for the cases relating to their own ICU. 13