2017 NHSN Training – CAUTI Definition with Case Studies


>>Good morning everyone,
my name is Eileen Scalise and I am the subject matter
expert for UTI and CAUTI. I welcome you this morning here
in the room and on the web stream. So today we’re going to define our — the key — the CDC and NSHN key concepts and common
misconceptions of the NHSN UTI protocol and review how to correctly apply the protocol. We’ll identify the correct way to
count indwelling urinary catheter days to determine device association to a UTI. We’ll identify the data collection
form and table of instructions. And then, apply what we’ve
learned through case studies. Case studies that I’ve used
that are not real studies. However, I tweaked them from
actual questions people have asked. So the UTI burden, it is
the fourth most common HAI with over 93,000 UTIs in acute care hospitals. And it accounts for 12% of infections
reported by acute care hospitals. And approximately 12% to 16% of adult hospital
inpatients have a Foley sometime during their stay. And for each day that a catheter is in
place there is a 3% to 7% increase risk of acquiring a catheter-associated UTI. The complications include discomfort to the
patient as well as prolonged hospital stay, increased cost, and mortality, with over
13,000 estimated deaths per year for UTI. But having said all that, I
always like to put, you know, a face to these statistics,
and a real patient’s story. So I’m going to minimize and see
if I can figure out how to do this.>>Jerri Allen was a vibrant 72 year old, who was excited about getting her
hip replacement behind her and back out on the dance floor with her husband. Jerri had experienced hip pain for years and
had seen some pretty nice results in several of her friends who had undergone
the same procedure. She was looking forward to being pain
free, or at least having less pain. She had always been so active and had just
recently reached the point she could no longer function well. She and her husband were planning a cruise
to celebrate her recovery in three months. In no way was she prepared
for what happened next. Jerri’s surgery was a success. She was recovering well when on the third
day after surgery just as she was preparing to be transferred into the
rehabilitation unit, she spiked a fever. Tests ruled out pneumonia and a blood infection,
but she did have a urinary tract infection. Her surgeon told her it was from
having the bladder catheter in. She had kept the catheter in an extra
day because her son had requested it to spare her the extra pain of getting
out of bed to go to the bathroom. A few days and a few anti-biotic
doses her infection had cleared up, or so everyone thought. As she was preparing to leave rehabilitation and return home she began having
more pain in her hip area. Her surgeon reassured her
that it was most likely due to her increased activity as she progressed. Her incision looked good
and there was no drainage. Four days after getting home that all
changed; the incision became very inflamed and started draining a reddish yellow fluid. Her surgeon immediately readmitted
her to the hospital and took her to the operating room to open the hip incision. Jerri was diagnosed with a
deep surgical site infection. Cultures came back positive for the
same organism she had in her urine. Her surgeon said she had probably seeded the
hip infection from that urinary tract infection. The next several months were a nightmare. Hospital stays, going back and forth to
the operating room to clean out the wound, then finally to remove her new hip. Jerri was sent to a skilled
nursing facility to await the point when her wound would be clean
enough to have a new hip implanted. She became very depressed and refused
to participate in physical therapy. She lost weight and stopped eating;
a feeding tube had to be placed. Three months later when her surgeon
decided to go ahead and replace the hip, Jerri was not the same person she
was at the time of her first surgery. Financial problems were added on top of health
problems; Jerri’s care was not fully covered by Medicare or her supplemental insurance. And Mr. Allen, her husband, was
dipping into their modest savings to pay medical bills, now in excess of $200,000. The end was not in sight either. Who knew urinary tract infections
could be so devastating?>>This illustrates the work that you
do for prevention, how critical that is. So I thank you and applaud you for all
your prevention work you do with UTIs. And how devastating, what we think is
a simple infection can really become. And just, yes, thank you. Perfect. Okay. So now we’re going to move
onto NHSN CAUTI definitions. And I just want to refresh what Kathy
reviewed with you yesterday about chapter two. The infection window period, which I may
call it IWP or infection window period, if you don’t mind, is the — for UTI the urine
culture always sets this seven day window. So it’s always going to be the urine culture
with greater than or equal to 100,000. And then, it’s three days
before and three days after. The date of event is the first element that
occurs within that infection window period. The RIT, or repeat infection timeframe,
is set on the date of event — day one, is day one of the 14 day timeframe. And so, no new infections
will be reported of the same. No new SUTIs or ABUTIs, et cetera for UTI, and the secondary BSI attribution
period is set as well. And that includes the infection window period,
plus the RIT, and that could be 14 to 17 days in length depending on the date of the event. And I’ll be illustrating these later. So let’s look at the indwelling
urinary catheter. What is a indwelling urinary catheter? Because I get a lot of questions
about, you know, is this a catheter or should I use this urine? So it is a drainage tube that is
inserted into the urinary bladder, and this does include a neo-bladder. And the key here is that
it’s through the urethra. So if it goes through the urethra and
it’s left in place and is connected to a collection system then it should
be included in UTI surveillance. This catheter is also known
as a Foley catheter, often. What does not qualify is a straight
catheterization, or known as in and out catheterization, or
a condom, or Texas catheter. And the following do not qualify
unless there’s also a Foley in place. So suprapubic catheter, nephrostomy
tubes, urostomy, and ileal conduit, unless there’s a Foley in place,
those do not count as catheters. So there are two types of
urinary tract infections. There’s SUTI and ABUTI, which is asymptomatic
bacteremic UTI and SUTI is symptomatic UTI. And both types, if they’re
catheter-associated, must be reported as part of any CMS CAUTI reporting requirements. And the two types of UTIs can be
categorized by the age of eligible patients and their association with
indwelling urinary catheters. So patients of any age can use SUTI-1 and
ABUTI, but only infants less than one year — less than or equal to one year,
are eligible to use SUTI-2 and we’ll see different symptoms
in the next slide I believe. Each type of UTI, SUTI-1, SUTI-2, and
ABUTI can either be catheter-associated or non-catheter-associated. It is only the catheter-associated SUTIs
and ABUTIs that are reportable as part of CMS quality reporting program for CAUTIs. So we’ll start with the criteria,
and we’ll get to SUTI-2 criteria, but we’ll start with SUTI-1,
which is catheter-associated. The patient must meet one, two,
and three, of the following. The patient had an indwelling urinary catheter
that had been in place for greater than two days on the date of event, and that device
date — placement equals day one. And was either still present for any portion
of the calendar day, on the date of event, or removed the day before the date of event. And I highlighted any portion of the
calendar day because I get questions about — well it was removed on that
day, so it wasn’t in place. But it was in place for part of
that day, so that still counts. And the following signs or symptoms,
the patient has at least one; fever greater than 38 degrees Celsius,
so not 38 degrees Celsius, greater than. Okay. So that’s a lot of questions as well. So suprapubic tenderness and
costovertebral angle pain or tenderness, if they have no other recognized
physiological cause for these symptoms. And then, urinary urgency,
urinary frequency, and dysuria. And keep in mind that these symptoms cannot be
in place or used when the catheter’s in place. Now, later on, I’ll show you this but if a
catheter is removed and the symptom occurs and then it’s reinserted on the
same day you can use that symptom as long it occurred when
the Foley was not in place. Okay. We’ll look at some examples later. Patient has a urine culture with no more than
two species of organism and at least one of which is the bacterium of
greater than or equal to 10 to the fifth colony forming units per ml. So let’s look at some urine culture
clarifications, questions that come in, I’d like to provide clarification. So Candida species or yeast, or other
non-bacterium such as fungi, or mold, and parasites, are excluded as
organisms in the UTI definition. So keep in mind that blood with these
organisms cannot be secondary to UTI. A urine culture with yeast can be included
as long as there is at least one bacterium with the appropriate colony count
of greater than or equal to 10 to the fifth, and no more than two organisms. So for example, you could have 10 to the
fifth colony-forming units of E. coli and 10 to the fifth of Candida
albicans, and you could use that one. Urine cultures with greater than two organisms
are routinely regarded as contaminated cultures and not used for NHSN CAUTI surveillance. So an example would be E. coli at 10 to
the fifth, greater than 10 to the fifth, you have Staph aureus in the
urine, and also Candida albicans. That’s three organisms, so you
would not use that culture, that would be considered contaminated. And then, also urine cultures
including mixed flora or its equivalent. Your organization calls it different things,
perineal flora, vagina flora, normal flora, these are different questions I’ve
received, they cannot be used. So even if you have 10 to the fifth of E. coli but you have perineal flora
that’s a contaminated specimen. Organisms of the same genus but
different species equals two organisms. So in this example, Pseudomonas aeruginosa
and Pseudomonas stutzeri are two organisms. The same organism with different
antimicrobial susceptibilities. We don’t look at — even though we ask for
that you enter it, it’s the same organism, it’s staph aureus, so that’s one organism. One resistant, one sensitive,
but it’s one organism. And of course with CAUTI you always set the IWP
on the date of the urine specimen collection that is eligible and not
the date of specimen result. And do not add multiple urine cultures together. For example, on February 1, a urine was positive
for 10 to the fifth of Klebsiella pneumoniae and Citrobacter freundii, I
said that wrong, and February 2, urine is positive for Klebsiella oxytoca. This does not meet three organisms. Okay. And again, I guess we can’t say
this enough, but all elements must occur within the seven day infection window period. And I like to use this, this is
when I get questions in my mail box, this is the flow that I use and so,
I thought I would share it with you. I just start with the diagnostic
test, the first one that’s eligible. I set the — I set the IWP three
days before, three days after. Then I determine, do I have
an element in that window? And then, I determine what occurred
first, the urine culture or element, the symptom, and determine the date of event. And is it in the POA time period? If it is then we’re done. Except it does set an RIT,
but if not it is an HAI. So then you would look at on the date of event,
was the catheter in greater than two days? Then of course, you would use
the transfer rule if applicable. The location — we’ll talk about location
of attribution a little bit later. But let’s look at a SUTI-1A example. The patient’s admitted to an acute care hospital
for a CVA stroke, Foley catheter is inserted on day of admission, January 25th. And the Foley remains in
place on the 26th, 27th, and on 28th it’s discontinued early morning, and at noon the patient complains
of urinary frequency. On the next day, 1/29, there’s no
fever but urinary frequency continues. The 30th, there are elevated WBCs. And on the 31st there’s a positive urine
culture with 10 to the fifth of E. coli. So do we have clickers on the table? Okay. Good. The patient’s complaint of
urinary frequency on 1/28, after the Foley catheter was
removed — do we have — oh yeah. Polling’s open. Good — can be used to meet SUTI-1A. And I’m getting some responses in. Good. Is that A, true, or B, false? We’re going to get 100% right. Right? Okay. It looks like its slowing
down, I’ll close the poll. Oh, 88%. Okay. Well that’s good, it is true. The urinary frequency can be
used to meet the SUTI-1A criteria because the symptom occurred while the Foley was
not in place, and it occurred during the IWP. Does this patient have an NHSN CAUTI? A for true or B for false. Okay. Let’s take a look, we’ll close the poll. Oh. Okay. So we have 72% who
say it is, and they’re correct, but we have 28% who say it isn’t. Well let’s look at why. So the 1/31 positive urine culture sets the
window, which is I guess yellow in this picture. So 1/28 to 2/3. The 1/28 urine frequency is the first element
to occur within the IWP, therefore is the date of event and the Foley was in place
greater than two days on the date of event. So even though it was removed that day
it was in place for part of the day. So when you want it — when you
enter this in NHSN you’re going to choose the risk factor urinary catheter in
place, even though it was removed that day, it was in place for part of the day. You’re going to choose frequency,
and you’ll get this alert. And this alert will just remind you that, you
know, to choose urgency, frequency, or dysuria, you can only choose that if the symptom
occurred when the Foley was not place. Okay. So we’ll look at SUTI-1B, non-CAUTI. And I know a lot of people don’t have this
in their reporting plan but it is really good to hook a secondary bloodstream infection
to or set a POA — I’m sorry, an RIT. So we’ll talk about SUTI-1B is. Patient must meet one, two, and three below. One of the following is true. The patient has or had an indwelling catheter
but it has not been in place for greater than two calendar days or the patient
did have a urinary catheter in place on the date of event — did not, sorry. Did not have a urinary catheter
in place on the date of event, nor the day before the date of event. So all of the symptoms are the same, except
that fever in a patient that is greater than 65 cannot use a fever in a
SUTI-1B, so the fever is only allowed in a patient less than or equal to 65. And the reason this is, is in the elderly
non-catheterized patient who has a fever but no other localizing signs and symptoms,
so if you can’t find suprapubic tenderness or costovertebral angle pain, there’s a
cause other than UTI in 90% of the cases. Therefore, one of the other UTI
signs or symptoms must be present to meet the NHSN UTI criteria in this
population to over avoid calling UTIs. And again, the same symptoms, suprapubic
and CVA pain with no other recognized cause and the other symptoms, frequency,
urgency, and dysuria, when catheter is in place you
do not use these symptoms. And the reason is the mere presence of
the Foley sometimes causes these symptoms, they feel like they have to
go when they have a Foley in. So, okay. And then, third, the patient has the
same urine culture, no more than two species of organism, at least one of which is a
bacterium, of greater than or equal to 10 to the fifth colony forming units per ml. And again, all the elements of the SUTI criteria
much occur during the infection window period. So let’s look at an example. On February 11th, this patient age 47 was
admitted with a fever of 101.7 and a history of pseudomonas aeruginosa in the wound
on a previous admission a month earlier. On 2/13 a urine culture is 50,000 CFUs per Ml. of pseudomonas aeruginosa and 100,000
of candida albicans, no fever. On February 15th the patient
spikes a fever of 101.3 Fahrenheit and a urine culture is collected, which results
in 100,000 of pseudomonas aeruginosa and greater than 100,000 of candida albicans. Okay. Clicker time. The first urine culture with
50,000 CFUs of pseudomonas and 100,000 candida albicans
is used to set the IWP. Okay. Good. Most people said false, and that’s good. The urine culture is not eligible because there
is not at least one bacterium with greater than 10 to the fifth colony forming units. Yeast is an excluded pathogen,
so we don’t count that 100,000. So this patient meets SUTI-1B
non-catheter-associated UTI. A for true or B for false. Okay. Let’s see what we have. Okay. So 82% of you — we’re
still having mixed reviews here. But okay, 82% are true — say
true, and that is correct. Let’s look at why. So we have a urine culture
that is eligible on 2/15, it sets the infection window period
here in yellow, 2/12 to 2/18. And within that window we
have a positive — a fever. Okay. And so, that’s the date of event. Both elements occur on the same
day, so that’s the date of event. And there was no Foley in place,
so this meets SUTI-1B non-CAUTI. This patient’s aged 47. Okay. I submitted the rationale for
you in your notes, so you have this. I just wanted to also just point out that
the 2/11 fever on admission cannot be used because it does not fall within the
IWP of the 2/15 positive urine culture. And again, the 2/13 urine culture
was not — is not eligible. Okay. So here are the little
different symptoms for SUTI-2. And I want to keep in mind that
you can use — you only need one. But for somebody under one or a one year old
you can use SUTI-1 criteria and two as well. So you can use SUTI-1 if they have
those symptoms or you could use these. And the difference is the hypothermia, these
children, babies, manifest different symptoms; apnea, bradycardia, lethargy, and vomiting. And you notice the asterisks there are if
there’s no other recognized cause for those. And the urine culture count is the same,
patient has a urine culture with no more than two species, at least one of which is
a bacterium of greater than or equal to 10 to the fifth colony forming units per ml. So let’s look at an example. On 12/23 we have a two month old admitted for
diarrhea and a Foley catheter is inserted. On 12/27, a few days later
the patient vomits twice. And on 12/28 there’s a positive urine
culture, E. coli greater than 10 to the fifth. So I gave you this answer, the patient
does meet a catheter-associated SUTI-2, they’re less than one year old, and using
the vomiting and the date of event is 12/27, which is the first element to occur. Okay. So we’re going to move on to asymptomatic
bacteremic UTI, also known as ABUTI. Here the patient must also
meet one, two, and three below. One is the patient is with or without an
indwelling urinary catheter, has no signs or symptoms of SUTI-1 or 2 according to age. And again, that’s greater than 65 years of age with a non-catheter-associated ABUTI may
have a fever, because it doesn’t count, because it’s non-catheter,
it’s not used as an element. And they could still meet the ABUTI criterion. And two, the patient has a urine culture
with no more than two species of organisms, at least one of which is a bacterium of
greater than or equal to 10 to the fifth. Additionally, number three, the
patient has a positive blood culture with at least one matching bacterium to
the urine culture, or they meet LCBI-2, criterion two, without the fever, and
we’ll talk about that in a minute, with a matching common commensals in the urine. All the elements must occur within
the infection window period. The other thing I want to highlight
about this is, the urine — the blood culture must match the urine
culture that has greater than or equal to 10 to the fifth bacterium, not — you know, if
there’s one with 10 to the fifth then one without — it has to meet
the one with 10 to the fifth. So only events with catheters in place
greater than two calendar days on the date of event are catheter-associated and reportable
if they’re in the monthly reporting plan, and this includes catheter-associated ABUTI. So let’s look at an example, on February 20th, a
patient’s admitted for an MI, Foley is inserted. On 2/21 through the 23rd there
are no UTI signs or symptoms. On 2/24 there are elevated WBCs, no UTI signs
or symptoms, a positive blood with staph aureus, and a positive urine culture
with greater than 10 to the fifth colony forming
units per ml of staph aureus. And then, 2/25 through 2/27
no UTI signs or symptoms. On 2/18 the Foley is removed and
the patient’s discharged to home. So let’s take a look at this. We have a positive urine culture with 10 to the
fifth of staph aureus, so that sets the IWP, 2/21 through 2/27 here in yellow. So we look in the window for UTI
signs or symptoms, we don’t see any. However, we find a blood culture that
matches the urine organism that has 10 to the fifth of colony forming units. So we can call that an ABUTI. And the date of event, because
they both occurred on the 24th of February, is the date of event. And then, you check, is the Foley in place
greater than two days on the date of event? And yes, it was inserted back on February 20th. So we went over the UTI repeat infection
timeframe during the nuts and bolts yesterday, but I do like to reiterate it a little bit. It is a 14 day timeframe, date of event
is day one, no new UTIs are reported. For example, you wouldn’t report a SUTI or an
ABUTI if you a non-catheter-associated SUTI. Additional eligible pathogens
from urine cultures that occur within the RIT are just added to the event. And you do not change the device
association during the RIT, so we’ll get to that in a minute. And non-catheter-associated SUTI or
ABUTI, or catheter-associated SUTI or ABUTI POA sets a UTI RIT and a
secondary BSI attribution period. Catheter-associated is, again, UTI where an
indwelling urinary catheter was in place greater than two days on the date of the event. Starting to get a theme, date of
event is really critical that’s — because it sets a lot of things, decides a
lot of the RIT, you know, device association. So we got to get that date of event right. And device — day of device placement being day
one and indwelling urinary catheter was in place on the date of the event or the day before. If an indwelling catheter was in place
greater than two calendar days and then, removed the date of the event for
the UTI criteria must be the day of discontinuation or the next day. Okay. So device association and UTI key concept. Here’s a patient admitted
with a fever the next day — they’re admitted on January 5th with a fever and the next day they have a positive
urine culture, so they meet POA. He’s age 48. There’s no Foley yet. So he meets a non-catheter-associated,
present on admission. It sets the RIT in the lighter blue. Date of event being 1/5,
and that’s the first day. But you notice the secondary BSI
attribution period goes back up two days to the top of the infection window period. So the infection window period
starts the BSI secondary. Later on in the RIT the patient has another
positive urine culture, they also have a fever. So that’s the date of event, 1/10. And now, it’s day four of the Foley. So it was a SUTI-1B. This changes to a SUTI-1A CAUTI, true or false? False. How come I can’t get 100%? Okay. False. 68% say false. And you are correct, and let’s look at why. The 1/10 date of event occurs
within the RIT of the POA event, therefore it’s considered an
extension of the POA event, and it does not become catheter-associated
during the RIT. That’s what we mean by, do not change
device association during an RIT. There’s only one SUTI whether its non-catheter
or catheter-associated is one through the RIT. So we’re going to talk a little bit
about discontinuation and reinsertion, just so we’re clear on this little bit. If a Foley catheter is discontinued and a full calendar day passes before the
Foley is reinserted, then the day count for determining catheter-associated
UTI begins again. Otherwise, the day count continues
from the previous catheter. So if you look at example A, the patient
has Foley day three on March 31st. Then on April 2nd it’s removed
then on April 3rd it’s replaced. So that count continues you see, when it’s
replaced we call it Foley day six. So it’s removed on Foley day five but Foley
day six is April 3rd, seven, eight, et cetera. For B you have a Foley on
March 31st, Foley day three. It’s removed on April 2nd on Foley day five. There’s no reinsertion on the third, there’s
no Foley, but it’s replaced on the fourth. Now, the Foley count starts
again, Foley day one. Okay. So let’s look at a reinsertion example. This patient on — age 59, admitted
to the ICU on 3/1 with Foley — they had a Foley inserted on that day. On 3/4 removed, 3/5 there’s
no Foley, they’re asymptomatic. On 3/6 the Foley is reinserted and there’s a
fever of 100.5, 3/7 there’s a fever of 100.5, and a positive urine culture of
100,000 of E. faecium bacterium. And then, later on at 3/10 they’re
discharged to home with the Foley. This patient has a CAUTI, true or false? I think I have the wrong fever, but — Okay. Okay. Good. More people said the correct answer. But this is a little difficult but it’s false. Let’s look at why. So they have a urine culture
on 3/7, that’s eligible, sets the infection window period, 3/4 to 3/10. There’s a fever on 3/6, that’s
the date of event. So now we look at the Foley. So the Foley was removed on 3/4, there’s
a full calendar day without a Foley, and then it was reinserted on 3/6. So this now becomes non-catheter-associated,
SUTI-1B. And this is the rationale I just explained. Okay. We’re going to move on to data
collection form and table of instructions. Again, on our website under the
catheter-associated urinary tract infections, you’ll find training, links,
and protocols, and our FAQs. I really recommend you look at the frequently
asked questions, which will be updated soon, but they’re still relevant,
the ones that are on there. And we’re going to draw attention
to the data collection forms. The form 57.114, we like to
call it, is the UTI form. And then, the table of instructions
that accompany that. So here is the UTI form that your
facility can use, or we have it in a Word and you can tweak it as long
as you use the requirements. You know, there are not optional
fields that you have to use. So anyway, for each of these fields, the table of instructions
instructs you how to fill these out. I get a lot of questions about risk factors
so I’m going to talk about that in a minute. But I wanted to bring you to
page three because I also — there are needs clarification
I think for this form. On page three people ask, well what do
I do if they didn’t run a susceptibility or what’s the key for the antibiotics. And that’s all right here, so I just
wanted to make everybody aware of that. And yes, if it’s not tested you use N. Okay. And so, we’re going to talk about the risk
factors in place or removed, or neither. I think the more questions
I get are location and date. Well more location, so I’ll tell you about that. So here’s the table of instructions
that goes with that. So in place is if the urinary catheter had been
placed greater than two days and was present for any portion of the calendar day on the date
of event, which we talked about — removed. If a urinary catheter had been
in place greater than two days and was removed the day before the date of event
neither is, patient had an indwelling catheter or didn’t but has not been in place
greater than two days on the date of event or never had a urinary catheter in place. And I just also want to draw
your attention the notes, date of insertion is day one, and — oh sorry. Urinary system infection
cannot be catheter-associated, therefore USI as we call it, will
only present a specific event type if urinary catheter status is marked neither. And if you have an USI and you
have a UTI you report only the UTI. Okay. Location of device insertion,
this is an optional field. And so, is date of device insertion. The other ones are required. So I’m going to just take
you to this instruction page. And I tell users to use the custom fields
and comment fields if they want to track if a Foley was inserted in an outside facility. And this is the direction on page four
of the instructions, how to do that. However, there’s also a way when we enter
— I’ll get to that in — on this page. Here are the requirements, you see the
asterisks, so it’s in place, remove, or neither. But this optional field you
can set up your reporting plan to include location outside
facilities so that you — I’m sorry. Not your reporting plan. You can include your locations. There’s a drop down to choose this. And then, you could have this available to you. And then, you could put in comment
fields where they came from. So just so you know that’s there. And then, date of device
insertion also is optional. So — because a lot of people don’t know
when it was inserted so that’s why they ask that they don’t have to fill that out. Unless you’re doing some internal tracking. Okay. And the summary data, denominator
data, the manual collection, there’s a form. And you need to fill it out, the
count for all locations that are — that you’re tracking in your reporting plan. At the same time each day you look at
the number of patients on the unit, and the number of patients with an indwelling
catheter, and this form is available to you. And in this example on this
medical unit there were 13 patients on this date and eight had urinary catheters. There’s an alternative to reduce staff time
spent collecting surveillance data once weekly. We could do sampling of denominated data to
generate estimated urinary catheter days. It may be used as an alternative to the daily
collection in non-oncology ICUs and wards. To ensure the accuracy of estimated denominator
data obtained by sampling only the ICU and ward location types with an average of 75 or more urinary catheter days per
month are eligible to use this method. And a review of each of these locations tells
us that Saturdays are not a good day to sample, Saturdays and Sundays, that during
the week it’s better to sample. And then, you would — let me
just go to the next slide here. So what you would do is you would put the number
of patients in the location, the patient days, the number of indwelling catheters. And again, at the same time, each
— the same time during the month. And the following must be collected. The monthly total patient days based on collection
daily, and the sample total patient days, and the sample total urinary catheter days. Okay. Common misconceptions. UTI as a secondary infection. Positive culture on admission
automatically equals POA. Not accurate. UTI signs or symptoms such as fever
on admission automatically equal POA. That’s not accurate. And the RIT continues during a readmission. So let’s look at each of these. UTI is a secondary infection. It’s a primary site of infection
and cannot be considered secondary to another site of infection. So when a patient meets a CAUTI
and the same organism is identified in a burn wound culture — burn. These are considered two sites of infection. So they’re not — the CAUTI
is not secondary to a burn. When a patient meets a PNEU event,
a CAUTI cannot be classified as a secondary infection even though
the same organism is identified. So the patient can actually
have two sites of infection. Positive on — a positive culture on
admission automatically means POA. So in this example we have
a patient admitted on 1/1. And on 1/2, which in the POA time period,
they have a positive urine culture, E. coli. And it’s in the POA time period, but when you set the infection window
period there are no UTI signs or symptoms, and no positive blood, so there’s no event. Later on in the stay there’s
a positive urine culture, sets the infection window
period, and there’s a fever. So now, we have an event on 1/9. And the Foley was in place greater
than two days because inserted on admission, therefore it’s CAUTI. So the positive urine culture during
the POA timeframe, without UTI signs or symptoms nor matching
blood organism in the IWP of that urine culture is not an
event; therefore it does not meet POA. And, you know, people like to
say, well the CAUTI relates back to the positive urine culture
and that’s not a consideration. You only use what’s in the IWP. Okay. Number three, UTI signs and symptoms. This is similar to the urine, in that when they
get admitted you just automatically say its POA. They must be accompanied by a
urine culture and they must occur within the infection window
period of that urine culture. And the date of event must occur
within the POA time period. So we’ll look at example here. We have a patient admitted with a fever
on 3/1 and a Foley catheter was in place. But the UTI criteria has not met POA because
there’s not a positive urine culture. Later on in the stay on 3/11, there’s a
positive urine culture, which sets its IWP. Fever on 3/10, so that’s the date
of event, and it’s now a CAUTI. Well it’s a CAUTI because they came with
a fever — a Foley and it stayed in. The Foley’s been in greater than two days. You cannot you the 3/1 fever, even though
it’s greater than 38 degrees Celsius because it does not occur within the IWP. The fourth misconception is the
RIT continues during readmission. And actually it applies during a
single — a patient’s single admission, including the day of discharge and the day
after in keeping with the transfer rule. So we’ll talk about that. First, I want to say the location of attribution
is where the patient was assigned on the date of the UTI event, that’s the date of the
first element to meet the UTI criterion. So that’s the location of attribution. But there’s an exception to the
location and that’s the transfer rule. If the date of event for the UTI is on the
day of transfer or discharge, or the next day, the UTI is
attributed to the transferring or discharging location or facility. And it is advised that receiving facilities
should share this information about such HAIs so that they can enable reporting
at that transferring facility, or if it’s your own you’ll be aware. So let’s look at how the
transfer rule and the RIT work. So on November 23rd a patient is discharged from an inpatient care facility
with an indwelling catheter. And on the 24th they’re readmitted
to the same in patient care facility with a positive urine culture,
Klebsiella pneumoniae greater than 100,000, and the Foley remains intact. On the 25th they have a fever of 38.7. And then, on the 26th a second
positive urine culture klebsiella, again, the same colony count. The first question for you is does
the RIT continue with readmission? And I want 100% on this. All right. Okay. Well, don’t have 100%. Are people sleeping? Okay. It’s false. You do not — an RIT does not
continue with a readmission. But, does this meet the transfer rule? That’s another question for you. A is true and B is false. Okay. I think we’ll see what we have here. Oh. Not 100% but we’re getting there. Yes it does, 85% say yes. Let’s look at why. So the patient’s discharged
on 11/23, they’re readmitted on 11/24 with a positive urine culture. They have a fever within
the infection window period that was set by that positive urine culture. So we have a POA event for the readmission. That sets an RIT as you see here in blue and a
secondary BSI as you see here in lighter blue. The CAUTI day of event is the
day after transfer; therefore, it’s attributed to the previous admission. So it did not — the RIT did not cross
admissions, but using the transfer rule and having it POA it sets another RIT. And then, the second urine culture
falls within the RIT of the SUTI. And so, that’s just added —
well it’s the same pathogen. Okay. We’ll do case studies. When you submit questions for case review
this is kind of a list of the elements that would be required so that I could help. So the date of — you can read through this. It’s important — I don’t
like to know their birthdays. That’s personal identifiable
information, I call PII. Don’t send me any of that, just tell me if
over 65 or under 65, or 65, that’s fine too. Yeah. And then, people forget
to put the colony count so I really need the colony count
and all of this information. So — and also, if you would include
what you think it is because that will me to understand your understanding and then,
I could focus on that education piece. Okay. So let’s look at case one. Patient on 3/2 is 57 years old, admitted
with — and gets a Foley inserted. On 3/3, fever of 100.9 and 3/4 a fever of 100.2. The urine culture on 3/5 is pos — is eligible. It has coag-negative Staph, 100,000. Okay. Get your clickers. The day two fever can be used as
an element in this age patient. True is A and B is false. That’s a nice fast response. Good. Okay. Eighty-seven percent have
the correct answer it is true. Anybody who answered false to that
maybe you could talk to me later. Okay. So let’s look at the rationale. The urine culture on 3/5 sets
the infection window period in — I guess it’s a light blue
now or gray, 3/2 to 3/8. The first element to occur is the fever on
Foley day two, but this patient is less than 65. So that’s used and so, that’s the date of event. The Foley catheter was only inserted
for one day on the date of event. So day two is not greater than day two. So it is non-catheter-associated UTI. Right? And it is POA, but it also sets a
secondary BSI attribution period and an RIT. So it meets the SUTI-1B non-catheter. But let’s look at the same
case and the patient’s 67. So it’s the same thing, Foley’s inserted on
the day of admission, there’s a temperature of 100.9 on 3/3, on 3/4 it’s 100.2. On 3/5 there’s an eligible urine
culture with coag-negative staph. Okay. The day two fever can be
used as an element in this patient. True or false? People are a little more hesitant. I’m sorry. Okay. Let’s see. So false is the correct answer. Let’s look at why. Well actually before we do
that if you would poll, what is the correct determination in this case. Did they meet A, SUTI-1B, non-CAUTI? Does this patient meet B, SUTI-1A CAUTI? C, the patient has a non-catheter-associated
ABUTI. Or D, this patient does not meet a UTI event. Okay. We’ll close the poll. All right. Well good, most of you got the correct answer. They do not meet an event. Okay. So let’s look at why. So we have a urine culture that sets —
again, we start with the urine culture, sets the infection window period, 3/2 to 3/8. Cannot use that fever on day two of the
Foley because the patient is greater than 65, so we look at the next fever and we
can’t use it because it’s not eligible. It’s not greater than 38 degrees Celsius. There are no other UTI elements, nor
matching blood organism within the IWP. Therefore this does not meet a UTI event. No RIT is set. Okay. We just have two more cases I think. Okay. So the patient is admitted on
January 6th with a Foley inserted — Oh. I’m sorry. Admitted, Foley was inserted temperature
of 100.3 degrees Fahrenheit, 1/7, a temperature of 100.7 degrees Fahrenheit,
1/8 a temperature of 100.8 degrees Fahrenheit. On 1/9 the Foley is discontinued
with a temperature max of 100 degrees Fahrenheit,
1/10 99.6 degrees Fahrenheit. And on 1/11 the urine culture is positive
for greater than 100,000 of proteus mirabilis and 50,000 E. coli, temperature max
of 99.6, 1/12 temperature max 99.6 and then, 1/13 discharged to rehab. So this patient does not meet CAUTI criteria. Kind of a backwards question
but is it A true or B false? Okay. We’ll close the poll. Thank you for your responses. Okay. I guess we needed this training, huh. Okay. So we have 59% with the correct
answer, 41% on a learning curve. Okay. Let’s look at the rationale here. So the 1/11 urine culture sets the infection
window period depicted here in yellow. It’s yellow. The first element to occur within the window
is the fever, 100.8, that’s the date of event. And the Foley was in place greater than
two days because it was inserted on 1/6. So it meets SUTI-1A, CAUTI, date of event 1/8. So — and this is tricky, I get
a lot of questions about this. Even though the positive urine
culture occurred two days after the Foley catheter was removed the
1/8 fever was the first element to occur in the seven-day infection window
period, therefore it’s the date of event. Again, that date of event is
critical to get that correct. On the date of event the Foley
catheter was in place greater than two days and that’s why it meets CAUTI. And the only pathogen here is the proteus
mirabilis, you wouldn’t report the E. coli because it doesn’t have the
correct colony count. All right. Case four. Patient’s admitted with a
chronic Foley, so long term Foley. They have 40.1 degrees Celsius. And a positive urine culture that’s
eligible, klebsiella pneumoniae. On 3/2 they have a fever of 41.1 Celsius, and all the way later they 3/14 they
have a fever on 3/14, 39.9 Celsius. And then, 3/15 a positive urine culture with an eligible pathogen greater
than 100,000, Enterococcus. So let’s look at this one. So basically we have a POA. Because we — the patient came in with a chronic
Foley, it doesn’t matter what age they are because you can use the fever
because the Foley’s been in greater than two days for that patient. There’s a positive urine culture on the
date of event, sets the window period. And I think — I want to say
this is not a leap year, 2/28 — we go back just two days instead of three when the positive urine culture
is on day of admission. Because that’s, like, your POA time period. That’s as far back as you
can go for an admission. So it’s two days, you know, back, and
then, three days after the urine culture. Okay. So we have a POA event, sets
an RIT in the light blue, and then, the secondary BSI attribution
period in the dark. But later on here we have
a positive urine culture. But oops, it falls out of the RIT. However, there’s a fever in the
RIT, so that’s the date of event. And you can say that positive urine
culture is part of that POA event. Now, if you didn’t have a fever and you just
had the urine culture you would set a window and then, see if there are any
symptoms after the window — I mean three days after the urine culture. That might be a new event. Okay. So this is the rationale. Again, it’s not a leap year so. I wanted to illustrate the
two days before when the date of the urine culture’s on the day of admission. And when you use the HAI generator
it figures that out for you as well. So if your urine culture is on the day of admission it gives you the
two days before admission date. And you can use symptoms. Kathy mentioned this yesterday. You can use symptoms if they’re
documented in the current medical record, you can use UTI symptoms if eligible. In Chapter Two we describe some examples there. As we said, the 3/15 sets an IWP 3/12
to 3/18, which overlaps the other RIT. And so, that fever fell within the RIT. So you can — it’s not a new UTI event. Last case. This poor patient has been in the
hospital a long time for colon mass. And several weeks into the stay
they had a Foley placed on 1/30 and two weeks later they still have it in. They do have a positive wound
culture, with Staphylococcus species and Enterococcus faecalis on 2/11. On 2/14 they have Staphylococcus
epidermidis greater than 10 to the fifth and blood culture Staph epidermidis in two of
two culture bottles drawn on separate occasions. On 2/15 they have hypotension. Then on 2/11 through 17 there’s no fever greater than 38 degrees Celsius and
no UTI signs or symptoms. So hopefully you can read that. What is the correct determination in this case? A, the patient meets SUTI-1A CAUTI. B, the patient meets catheter-associated ABUTI. C, the patient does not meet a UTI event. Or D, this patient meets primary LCBI-2 BSI. Oh. Okay. We’ll close the poll. Okay. So most people got
the correct answer, yay. This meets catheter-associated ABUTI. It’s interesting that 25%
thought it was a primary BSI. You don’t want to give yourself
a primary BSI if you don’t need to. Okay. Let’s look at why. So in order to meet ABUTI criteria using a
matching blood common commensals the patient must meet LCBI-2 with either
chills or hypotension. Not fever. Does anybody know why? Because if they has a fever
it would be a SUTI then. Right? And then, the blood may be
considered secondary, but it would be a SUTI. Okay. So let’s look at this case. So we have a positive urine
culture set in the IWP. And there are no UTI signs
or symptoms within the IWP. However there’s a positive
matching common commensals from two separate draws,
and there’s hypotension. So they’re meeting LCBI-2. So now it can — and the date of event
is the date of the urine culture. And so, this meets — well
it meets catheter-associated because the Foley is in place on admission. And it’s ABUTI with the matching
common commensals as secondary. And reportable if it’s in your reporting
plan, because it’s catheter-associated. So in summary we review the key concepts and
common misconceptions of the NHSN UTI protocol. We looked at indwelling urinary catheters
in place, inserted through the urethra. Inserted through the urethra and left in place. Do not change device association
during the UTI RIT. RIT does not cross over admissions
in keeping with the transfer rule. Positive urine culture or UTI signs or symptoms
on admission does not automatically meet POA, and the same holds true for — oh. Signs and symptoms, I said that. Okay. And then, UTI is a primary site of
infection and is not considered secondary. Again, a calendar — a catheter — urinary
catheter days determine device association. So you want to get those counts correct
when there’s a removal and a replacement. We looked at the data collection
form and table of instructions. And yes, the form has been updated
for the 2017 UTI definitions. There weren’t changes to the
definitions, just clarifications. We made correct determinations. Well I wish it was all correct. But maybe there will be some questions
about why you’re struggling with this. We looked at the transfer rule, the IWP, the UTI
RIT, and those three symptoms; dysuria, urgency, and frequency that can’t be used in the
presence of an indwelling urinary catheter. We reviewed fever, age, and device association,
and we made determinations based on cases. So great job. I just want direct you for more
information and available training. Again, I showed you the training on the website. And I think Henrietta will be
reviewing that this afternoon. Which is not required to
go to but at lunch time. And then, as Kathy stated, again, to really — you know, even today it tells you that not
everybody’s answering the question the same way. So it’s — this is a really good tool to work
with your staff to get inter-rater reliability and see how everybody answers
these case studies. So now, we’re at questions. Any questions from online?>>Yes. We do a few questions
from the web stream audience. The first one is how should Foley’s
inserted in the OR or the ED be entered?>>Okay. How should they be entered? So, so, the device day count
for the denominator occurs — starts with the day they’re admitted
to the inpatient location. So if they have a Foley inserted in the
OR on 2/1 and then they don’t get admitted until 2/2 the device day count begins there. Same for the ED. I think that is the question. Oh yes. And I talked about the
insertion field that you — the Foley insertion field is optional. And you can use other location — if
you put that in your locations — well actually outside the facility,
which ED is, because it’s an outpatient. And then, you could just put
that in the comments section. Anything else? Okay. There’s one there.>>I’m Lisa from Toledo, Ohio.>>Hi Lisa.>>Can we use a urine culture
before the date of admission?>>If it — a couple things. Yes. If it occurs — well first of all
if its eligible, meet’s the criterion. If it occurs within the first two days of
admission, and — wait, just blanking out — and it’s documented in the medical record, it has to be documented in
the current medical record.>>So if they come over from a
nursing home or a doctor’s office with that urine culture done
from the day before –>>Right.>>– to our ED or whatever, and are
admitted, and then they have the temperature, et cetera, we can use that urine? We don’t have to get another urine ourselves?>>That’s correct. You can use that urine. Keep in mind if they’re coming — you know,
their age and fever and device associations. So when it’s fever you’re going to
have to think about those things. So you might want to encourage, you
know, some assessment, documented suprapubic tenderness or flank pain, not
just fever, because that’s more localizing, so it would really identify a POA for you. Okay.>>Thank you.>>Next? Thank you.>>Hi. This is actually just to clarify. While ED — time spent in the
ED or the OR doesn’t count for device days it still counts as catheter day.>>Correct. That’s a really good question. So yes. You don’t count denominator days,
device days, until they get admitted. However, if they’ve had the Foley in for two
days in the ED then that is a device day. So you could actually have
a CAUTI POA, you know. Even though they weren’t in your
place greater than two days, that Foley was in greater than two days. I hope that didn’t confuse
you more, but — okay. Another question from the web stream. Go ahead.>>So this question is, why does UTI
criteria use a cut off of 65 years of age and how is this concluded?>>Yes. So as I stated, in 90%
of the elderly with a fever alone and no other localizing symptom
the — there are — 90% of the causes are for
something else in this population. And so, we don’t want to over call UTIs. And what the second part? Oh, and the justification. There was research done and we have the paper. I don’t have the paper, but there
was research done on this population. And also, if you look at
McGeer definitions as well. When there’s not a non-catheter-associated — if there’s a non-Foley in the patient
they have to have localizing symptoms. So it’s this population. Got another question here?>>Hi. Could I clarify Lisa’s question? So where is Lisa? Lisa asked if we can count urinary
culture that’s taken before admission.>>Within the first two days of
admission, in that POA time period. Oh. And then, the date of event becomes — to set the RIT et cetera becomes the day of admission even though the
urine was the day before. You know, I’ll put that in my examples. That’s a good question.>>Oh. We can count it if it occurs when?>>Within the two days of
admission, in that POA time period. If you go to Chapter Two it —
and Kathy showed it yesterday, that POA time period is two days
before admission, day of admission. But it has to be documented
in the current medical record.>>Okay. Thank you.>>Think of validation.>>That makes sense now. Thank you.>>Okay. Good. You know, that’s a good question and I think
I’ll add that kind of example in my training. Anything else? Oh you get five minutes extra for — oh wait. One more question, sorry. Go ahead.>>You have one more from the web stream. This question is, the patient is admitted
from the nursing home with a chronic Foley and the Foley was not changed by the —
by us — by the new admitting facility. Three days later the patient has a
fever and a positive urine culture. Does it count as a CAUTI for the facility?>>You know, that’s a case question. And I — so okay. So perhaps I could answer this. There’s a fever and positive
urine culture three days later? And the fever’s three days later? So yeah. That’s in the HAI time periods. So yeah. That’s a CAUTI attributed
to your hospital. Right? I mean everybody here knows that I guess. Okay. Yeah. Thank you for the question. Yes. Okay. I guess that’s it. So thank you very much. Have a good morning — rest of your morning. Thank you [applause].

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