C. difficile Infection and C. difficile Lab ID Reporting in NHSN

C. difficile Infection and C. difficile Lab ID Reporting in NHSN MARY ANDRUS, BA, RN, CIC Infection Preventionist Consultant Learning Objectives Review the structure and of the MDRO/CDAD Module within the Patient Safety Component of NHSN Describe the rationale for monitoring MDRO/CDAD Identify the methodology, protocols and definitions used in the data collection of MDRO/CDAD

Goal of CDAD (CDI) Module Monitoring C. difficile infection (CDI) will help to evaluate local trends and changes in the occurrence of these pathogens and related infections Provide a mechanism for facilities to report and analyze CDI data Note: The term CDI is replacing CDAD. Both terms represent the same illness and are used interchangeably. Introduction C. difficile infection has increased in prevalence in U.S. hospitals over the last 30 years C. difficile has important implications for patient safety Options for treating patients with C. difficile are often extremely limited C. difficile infections are associated with increased lengths of stay, costs and mortality If you choose to monitor C. difficile, you must select at least one of these two reporting options! Adherence to Hand Hygiene Adherence to gown/glove use

CDI Infection Surveillance An HAI is a localized/systemic condition resulting from an adverse reaction to the presence of an infectious agent or its toxin. There must be no evidence that the infection was present or incubating at the time of the hospital admission. C. difficile infections must meet NHSN-defined criteria for gastroenteritis or gastrointestinal tract infection Reporting Requirements CDI Infection Surveillance JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Reporting Method CDI Infection Surveillance For Infection Surveillance, use either: A Facility-wide by location B- Selected locations in the facility NICU locations are not included in CDI surveillance!

Forms Reporting Infections: Facility-wide by location CDI Infection Surveillance + + + + Medical Report separately from every location in the facility Reporting Infections: Facility-wide by location CDI Infection Surveillance

Reporting Infections: Selected Locations Only CDI Infection Surveillance Medical Report separately for one or more specific locations of a facility Reporting Infections: Selected Locations Only CDI Infection Surveillance Definitions http://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf

NHSN Reportable Infections for C.difficile GI GE: Gastrointestinal System Infection Gastroenteritis GI GIT: Gastrointestinal System Infection Gastrointestinal Tract If the patient develops both GI-GE and GI-GIT, report only GI-GIT, using the date of onset as that of GI-GE C. difficile infection. Option #1 CDI Infection Surveillance GI-GE (Gastroenteritis) must meet at least one of the following criteria: 1.Patient has an acute onset of diarrhea (liquid stools for more than 12 hours) with or without vomiting or fever (>38 C) and no li kely noninfectious cause (e.g., diagnostic tests, therapeutic regimen other than antimicrobial agents, acute exacerbation of a chronic condition, or psychological stress) 2.Patient has at least two of the following signs or symptoms with no other recognized cause: nausea, vomiting, abdominal pain, fever (>38 C), or headache and at least one of the following: a. an enteric pathogen is cultured from stool or rectal swab b. an enteric pathogen is detected by routine or electron microscopy c. an enteric pathogen is detected by antigen or antibody assay on blood or feces d. evidence of an enteric pathogen is detected by cytopathic changes in tissue culture (toxin assay) e. diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for pathogen Option #2 CDI Infection Surveillance GI-GIT (Gastrointestinal tract) infection excluding gastroentereitis and appendicitis, must meet at least one of the following criteria: 1.Patient has an abscess or other evidence of infection seen during a surgical operation or histopathologic examination 2.Patient has at least 2 of the following signs or symptoms with no other recognized cause and compatible with infection of the organ or tissue involved: fever (>38 C), nausea, vomiting, abdominal pain, or tenderness and at least one of the following: a. organisms cultured from drainage or tissue obtained during a surgical operation or endoscopy or from a surgically placed drain b. organisms seen on Gram s or KOH stain or multinucleated giant cells seen on microscopic examination of drainage or tissue obtained during a surgical operation or endoscopy or from a surgically placed drain c. organisms cultured from blood d. evidence of pathologic findings on radiographic examination e. evidence of pathologic findings on endoscopic examination (e.g., Candida esophagitis or proctitis).

CDAD Complications Additional details if the following are identified: Severe CDI in patient within 30 days after CDI symptom onset and at least one of the following: Admission to ICU for CDAD complications Surgery for CDAD complications Death caused by CDAD within 30 days after symptom onset and during the hospital admission Monthly Reporting Plan Our Infection Prevention Team at Community Memorial Hospital, initiated an infection surveillance program for C. difficile infection in MEDICU and 3 West in June 2011. Because they are performing surveillance in 2 areas of her facility, the reporting method they have chosen is: B. Selected locations The next slide shows an example of how the Monthly Reporting Plan was completed. Monthly Reporting Plan

Completing the CDI Infection Event Form Event Form (cont.) Enter the Event Type here (will always be GI) Enter the date the first clinical symptoms of infection or the date the first positive specimen was collected, whichever came first. Event Form (cont.) Circle Yes if the infection occurred after an NHSN-defined procedure, but before discharge from the hospital Enter Yes if C.difficile infection is being followed for infection surveillance in that location in the Monthly Reporting Plan

Event Form (cont.) Event Form (cont.) Enter date patient admitted to facility Enter the Nursing care area where the patient was assigned when the C. difficile infection was acquired. If the CDI developed in a patient within 48 hours of discharge from another inpatient location, indicate the discharging location. Event Form (cont.) Indicate the specific CDCdefined infection event type Using the criteria in Chapter 17 (CDC HAI Definitions), check all signs and symptoms used to confirm the diagnosis of this infection event for this patient.

CDI Flow Diagram Event Form (cont.) Circle Yes to indicate admission to ICU for complications of C.difficile (e.g., shock that requires vasopressor therapy) Event Form (cont.) Circle Yes to indicate surgery for C. difficile complications. Surgery might include colectomy for toxic megacolon, perforation of refractory colitis, etc.

Event Form (cont.) If there is a cultureconfirmed BSI during this admission secondary to this C. difficile infection, circle Yes Circle yes only if the patient died within 30 days after C.difficile infection Circle Yes if the symptoms onset and during patient died during the current hospitalization this hospitalization Event Form (cont.) Optional field. Enter the date the patient was discharged from the facility. If the patient died, the date of death is entered here Enter Yes if pathogen is identified If the pathogen is C. difficile, enter it on the back under Other Organisms but do not include antibiogram Form used to report denominator. Form used to report denominator. Total Total patient patient days days for for the the location location

Example, cont. During the monitoring month the IP Team identified a patient in MEDICU with gastroenteritis due to C. difficile that had not been present when the patient was admitted to the hospital. The next slides show how the IP completed the NHSN form. The patient was identified as meeting Criterion #1 for GI-GE because he had liquid stools for 17 hours and a temp of 100.8 F

At the end of the month, the IP Team completed the Prevention Process and Outcome Measures Monthly Monitoring form that includes denominators. A separate form for each of the 2 units that were monitored were completed. Because they are performing infection surveillance the denominator is patient days. Even though they did not identify any C. difficile infections on 3 West, a denominator form for that location was also completed

CDAD Infection Incidence Rate If you choose to monitor C. difficile, you must select at least one of these two reporting options! Allows laboratory testing data to be used without clinical evaluation of the patient, allowing for a much less labor intensive method to track C. difficile.

Definitions Laboratory-Identified (LabID) Event: Any nonduplicate CDI-positive lab assay. CDI-positive Lab Assay: Positive lab assay for C. difficile toxin A and/or B, or toxin-producing organism detected from stool culture or other lab means Duplicate C. difficile-positive test: CDI-positive assay from same patient within 2 weeks of previous positive assay. Required Minimum Reporting All non-duplicate CDI-positive lab assays per patient per month At least three consecutive months in a calendar year JAN FEB MAR APR MAY JUN JUL AUG C. difficile testing performed routinely in lab, only on unformed (conforming to the shape of the container) stool samples SEP OCT NOV DEC Test on unformed stool sample Positive for C. difficile Prior C. difficile positive in 2 weeks Yes Duplicate Test Not C. difficile No Not a LabID Event Not a LabID Event

Reporting Method CDI LabID Event Reporting For CDI LabID Event reporting, use either: A Facility-wide by location B -- Selected locations in the facility C Facility-wide Settings: 1) Inpatient locations 2) Outpatient locations where care provided to patients post-discharge OR prior to admission No Newborn locations No outpatient dialysis centers 31 Forms for LabID Data Collection Reporting Location Options LabID Events You can collect C. difficile Lab ID Event data: Facility-wide by location: Report every location in the facility separately Patient days Admissions CDAD data Selected locations You choose the specific locations in your facility Patient days Admissions CDAD data Overall / Facility-wide Report all locations together Patient days Admissions CDAD data

Reporting Infections: Facility-wide by location CDI LabID Reporting + + + + Medical Report separately from every location in the facility CDI LabID Reporting Reporting Infections: Selected Locations Only CDI LabID Reporting Medical Report separately for one or more specific locations of a facility

CDI LabID Reporting Reporting Infections: Facility-wide CDI LabID Reporting + + + + Medical Report data for entire facility together.

If you would like to monitor a specific location in addition to the entire facility, you may do so. CDI LabID Event Form CDI LabID Event Form Select yes if the LabID Event is being reported from an outpatient location where there are no admissions (e.g., emergency department, wound care, etc.) If the patient was an outpatient, Date Admitted to Facility and Date Admitted to Location are not required.

CDI LabID Event Form CDI LabID Event Form If the LabID Event was reported from an outpatient location, leave this blank Enter the patient care area where the patient was assigned when the LabID specimen was collected Note: the Transfer Rule does not apply to LabID Events CDI LabID Event Form Note: Because of existing business rules for edit checks in NHSN, the date of specimen collection must be the same date or later than the admission date.

CDI LabID Event Form Circle Yes if the patient has been an inpatient and discharged from your facility in the past 3 months CDI LabID Event Form If the patient was discharged from your facility in the past 3 months, enter the most recent date of discharge. CDI LabID Data Entry Screen Non-editable field. Will be auto-filled by the system only, depending on whether there is prior LabID Event entered for the same organism and same patient. If there is a previous LabID Event for this organism entered in NHSN in a prior month, the system will autopopulate with Yes.

Denominator Data (LabID) If you are using Method A or B, complete a Denominator Record for each location Denominator Data (LabID) If this is a single inpatient location, enter the total number of patient days for the month. If this is a single inpatient location, enter the total number of admissions for this location for the month Denominator Collection (LabID) Check C.difficile as the organism that will be monitored in this location

FacWideIN Denominators This number would be the total number of patient days for the entire facility for the month minus any patient days for NICU or Well Baby Nurseries This number would be the total number of admissions for the entire facility for the month minus any admissions to NICUs or Well Baby Nurseries Denominators Outpatient Location FacWideOUT Denominators If LabID C. difficile Events are being monitored at the FacWideOUT level, then Total Encounters minus any encounters for Well Baby Clinics must be entered here

CDI Metrics Note! The following categories and prevalence and incidence calculations are built into the analysis capabilities of NHSN. Incidence vs. Prevalence Incidence Rate: measures the occurrences of new cases or events in a specific population during a given time period Prevalence Rate: measures the occurrence of existing (old and new) cases in a specific population during a given time period

Categories of CDI LabID Events Community Onset (CO): LabID Event collected as an outpatient or an inpatient 3 days after admission to the facility (i.e., days 1, 2, or 3) Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from the facility 4 weeks prior to current date of stool specimen collection Healthcare Facility-Onset (HO): LabID Event collected >3 days after admission to the facility (i.e., on or after day 4) CDI Prevalence Rates Admission Prevalence Rate By facility # non-duplicate CDI LabID Events per patient per month identified 3 days after admission to the facility # patient admissions to the facility X 100 By single location # non-duplicate CDI LabID Events per patient per month identified 3 days after admission to the specific location X 100 # patient admissions to the same location Location Percent Admission Prevalence that is CO # Admission Prevalent LabID Events to a location that are CO Total # Admission Prevalent LabID Events X 100 Note: the numerator in this formula does not include Admission Prevalent LabID Events that are CO-HFCA

Location Percent Admission Prevalence that is CO-HFCA # Admission Prevalent LabID Events to a location that are CO- HFCA Total # Admission Prevalent LabID Events X 100 Location Percent Admission Prevalence that is HO # Admission Prevalent LabID Events to a location that are HO Total # Admission Prevalent LabID Events X 100 Overall Patient Prevalence Rate Number of 1 st CDI LabID Events per patient per month for the location*, regardless of time spent in that location* Number of patient admissions to the location* * or facility

Outpatient Reporting By specific location: Facility-wide (FacWideOUT) # all non-duplicate CDI LabID Events per patient for the location # of patient encounters for the location X 100 # all non-duplicate CDI LabID Events per patient for the facility # of patient encounters for the location X 100 CDI Incidence Rates Location CDI Incidence Rate # of Incident CDI LabID Events per month identified >3 days after admission to the location # of patient days for the location X 10,000 Facility CDI Healthcare Facility- Onset Incidence Rate # of all Incident HO CDI LabID Events per month in the facility # of patient days for the facility X 10,000 Note: this calculation is only accurate for Overall Facility-Wide Inpatient reporting

Facility CDI Combined Incidence Rate # of all Incident HO and CO-HCFA CDI LabID Events per month in the facility Number of patient days for the facility X 10,000 Note: this calculation is only accurate for Overall Facility-Wide Inpatient reporting Metrics Summary CDI LabID Events Question I don t have a strong statistics background and I m not sure I have time to separate out the Healthcare Onset (HO) from the Community Onset (CO) MDROs. What should I do? No problem. The NHSN analysis tool automatically calculates the rates No problem. based on the The information NHSN analysis you tool provide automatically using the calculates reporting the plan, rates event, based and on denominator the information information. you provide using the reporting plan, event, and denominator information.

If you choose to monitor C. difficile, you must select at least one of these two reporting options! Adherence to Hand Hygiene Adherence to gown/glove use