Cohort 3 Stop CAUTI Collaborative Measurement: Outcome Data Application of NHSN CAUTI Definitions & Surveillance for CAUTI – Deep Dive into the mechanics of surveillance Russell Olmsted, MPH, CIC – Director, Infection Prevention & Control Services, SJMHS, Ann Arbor, MI Shelby Lassiter, RN, BSN, CPHQ, CIC - Performance Improvement Specialist, NC Center for Hospital Quality and Patient Safety, Cary, NC

Why CAUTI? According to Rodney…”these just don’t get any respect!” Increased morbidity, mortality (attributable mortality = 2.3%), hospital cost, and length of stay. 15% - 25% of hospitalized patients may receive short-term indwelling urinary catheters. CAUTI is the most common site of HAI 17% to 69% of CAUTI may be preventable with recommended infection prevention measures Up to 380,000 infections and 9000 deaths related to CAUTI per year could be prevented Gould CV, et al. Guideline for prevention of CAUTIs, 2009

Building the Business Case for Prevention of CAUTIs: Reservoirs of Resistance 3

NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) - Planning year; 2012 / full implementation; 2013

Getting Paid for Reporting: CMS Incentives – Current & Coming Attractions for 2012 HAI Event Facility Type Reporting Start Date CLABSI Acute Care Hospitals Adult, Peds, and Neonatal ICUs January 2011 CAUTI Adult and Pediatric ICUs January 2012 SSI Colon and abdominal hysterectomy Long Term Care Hospitals * October 2012 Inpatient Rehabilitation Facilities * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN CMS 2012 IPPS final rule released; August 18 2011 Federal Register 76 (no. 160) 5 5

Healthcare Personnel Safety Surveillance of HAIs Patient Safety Healthcare Personnel Safety Biovigilance* Research & Development 6

What is the National Healthcare Safety Network (NHSN)? Voluntary, secure, web-based database Implemented by the CDC in 2006 Integrates patient and healthcare personnel safety surveillance systems Managed by the Division of Healthcare Quality Promotion (DHQP) at CDC Expanded in 2008 to include most types of healthcare settings in addition to acute care. http://www.cdc.gov/nhsn/

State-specific NHSN Patient Safety Component, 26 States and DC 2007 2008 2009 2010 2011 2006 Central line-associated bloodstream infections (CLABSIs) AL, AR, CA, CO, CT, DC, DE, HI, IL, MA, MD, NC, NH, NJ, NV, NY, OK, OR, PA, SC, TN,TX, VA, VT, WA, WV Surgical site infections (SSIs) AL, CA, CO, DE, HI, IL, MA, MD, NH, NJ, NV, NY, OR, PA, SC, TN, TX, VT, WA Multidrug-resistant organisms and Clostridium difficile infections CA, DC, ME, NJ, NV, NY, PA, TN and other states considering its use Ventilator-associated pneumonias (VAPs) OK, PA, WA Catheter-associated urinary tract infections (CAUTIs) AL, NJ, PA Central line insertion practices (CLIP) CA, NH Dialysis events CO 2012 SC NY TN OK VA PA VT WA CT DE MD MA CA NJ WV IL OR NH NV TX AL DC AR ME HI NC CO 8 8

Background on NHSN NHSN HAI site criteria are intended for population-based, epidemiologic surveillance – not for clinical care of an individual patient NHSN criteria have been validated and are reproducible. Consistency in application of criteria by infection preventionists for HAI sites is vital. NHSN CAUTI data collection tool will assist in data collection at point of care. For purposes of this collaborative, only Symptomatic Catheter-associated Urinary Tract Infection (SUTI) will be tracked. NHSN criteria are designed to look at a population at risk. It is critical to identify patients meeting the criteria and consistently apply them. This ensures comparability of the data. Criteria are not perfect. Valid clinical arguments may be made against the criteria, but as the NHSN manual states, “The definitions used in this manual are the only criteria that should be used when identifying and reporting NHSN events. While all participants may not agree with all the criteria, it is important that NHSN participants consistently use them for reporting infections, so that rates between hospitals can be appropriately compared.” This may take some getting used to…but is necessary comparable data. Keep in mind that these are surveillance case definitions, not clinical case definitions.

Comparison of Surveillance vs. Clinical Case Definitions Surveillance definitions establish uniform criteria to be used to report a disease to better ensure usefulness in aggregating and analyzing population-based data affecting policy change and public health actions. These types of definitions should not be used as the sole criteria for establishing clinical diagnoses or for determining the standard of care necessary for a particular patient. (aka “analytical epidemiology”) Clinical definitions are specific to a patient and can manifest progressively during an illness. The use of additional clinical, epidemiological, and lab data may enable a provider to diagnose a disease even when the formal surveillance definition may not be met. Failure to meet the surveillance criteria of the formal case definition should never impede or override clinical judgment during the diagnosis, management or treatment of patients. (aka, “clinical epidemiology”) Surveillance definitions can include clinical, laboratory, and epidemiological criteria to define cases. For example, a patient with diarrhea and suspected C. diff may have a negative EIA for C. diff and not meet the surveillance LabID definition but is clinically assessed to have C. diff and is treated accordingly. The whole idea is that while surveillance definitions will not capture all actual infections, they will capture adequate numbers so as to allow decisions to be made for policy related to the population whereas individual patient decisions should be made using specific patient information. Surveillance case definitions and clinical diagnoses. Paediatric Child Health 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805969/?log$=activity

On the CUSP: Stop CAUTI Data Both Outcome and Process data are collected Data is collected according to a cohort-specific schedule Today’s presentation will focus on Outcome (CAUTI Rate & Device Utilization Ratio) data For a detailed data collection calendar, visit the On the CUSP Website: http://www.onthecuspstophai.org/wp-content/uploads/2011/04/CAUTI-Data-Collection-for-Cohort-3.pdf 11

Cohort 3:Surveillance for CAUTI What Do We Need to Collect? For the entire month (not just M-F) each enrolled unit must collect: Total # of patient days for unit / month - denominator Total # of indwelling urinary catheter days for unit/month - denominator Total # of Symptomatic CAUTIs (SUTIs) for that month; NHSN - numerator Outcome Metrics: CAUTI Rate; device utilization ratio (DUR) - prevalence of use of indwelling urinary catheters in the unit(s) under surveillance

Definition: Indwelling Urinary Catheter (aka “Foley” catheter) Drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system Does NOT include: Intermittent (straight) cath. External (condom) cath. Suprapubic cath. (surgically placed) Gould CV, et al. Guideline for Prevention of CAUTIs, 2009. Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html

Cohort 3: Outcome Data When & Where do we enter? Collect monthly for 5 months and quarterly thereafter (first 3 months are considered baseline) Where: Manual data entry into Care Counts Automatic data transfer from NHSN (note: must convey rights in NHSN to your state collaborative leads for this option)

Outcome Data Expectations: NHSN Complete entry of all CAUTIs + denominators (patient and urinary catheter days) by the end of the month following the one under surveillance; e.g. for Nov. 2011 data – complete entry by 12/31/2011. MHA Care counts Submit aggregate data (numerator (CAUTIs), denominators (pt. Days and urinary cath. days) by the end of the month following the one under surveillance

NHSN Training Resources http://www.cdc.gov/nhsn/training.html If you have not already gone through available training with the CDC resources, it is strongly recommended prior to collecting outcome data for this collaborative.

Surveillance Methods Concurrent, lab-based surveillance Use retrospective model only when absolutely necessary Non-IPs can screen cultures but trained IP should make final call Non-IPs can collect denominator data but IP needs to review Patient days and catheter days should be collected at the same time daily Need to ensure device days do not exceed patient days It is not required to monitor for CAUTI infections after the patient is discharged from the facility, however, if discovered, they should be reported. No additional indwelling catheter days are reported.

Important Notes NHSN has definitions for other types of UTIs e.g. as asymptomatic bacteremic UTI [ABUTI] but this IS NOT included in this collaborative. Reporting to CMS also is limited to symptomatic CAUTIs. ABUTI typically is infrequent event but has been documented by facilities reporting data to NHSN.

SUTI: The Numerator Symptomatic urinary tract infection (SUTI) associated with use of an indwelling urinary catheter Plus (for hospitals using NHSN) Asymptomatic Bacteremic UTI (ABUTI)

CAUTI Surveillance Criteria Decision Flow Chart; SUTI with urinary cath. If fever is present in Signs & Symptoms continue down flow chart – nonspecific symptom and do not try to distinguish other possible causes

CAUTI Surveillance Criteria Decision Flow Chart; SUTI without urinary catheter If fever is present in Signs & Symptoms continue down flow chart – nonspecific symptom and do not try to distinguish other possible causes

ABUTI Surveillance Criteria Decision Flow Chart; +/- urinary catheter + Urine Culture of >105 CFU/mL with no more than 2 spp ABUTI Surveillance Criteria Decision Flow Chart; +/- urinary catheter

Steps For Identifying Cases of SUTI [CAUTI] Start with review/sort of final, positive urine cultures – e.g. daily report of all from your facility’s microbiology lab Data Traffic Tip: Pull out positive urine cultures from the unit(s) under surveillance Important: the unit on the lab result is location at the time of specimen collection – may not reflect recent transfers to or from the unit(s) under surveillance Can remove cultures taken on day of admission or other units not included in this project do not need to be reviewed.

Automated Laboratory Information System (LIS) Caveat Verify with your facility’s information technology personnel that reporting rules applied to the LIS do not preclude your receipt of certain positive cultures; Example: some custom facility-specific reporting rules or data mining systems remove results where colony counts are < 105. impact – removes possible cases of CAUTI from detection during review, e.g. criterion 2a

Automated Device Denominator Collection Have you validated accuracy of urinary catheter Days collated automatically if this is available via Your facility’s electronic medical record (EMR)? Rule of thumb: urinary catheter days from EMR Need to be within 5% of those identified from Manual collation method, e.g. monthly device log. There are successful examples of use of EMR for device days: Burns AC, et al. Accuracy of a urinary catheter surveillance protocol. AJIC 2011 (in press) Choudhuri JA, et al. An Electronic Catheter-Associated Urinary Tract Infection Surveillance Tool. ICHE 2011;32:757-62. *Wright MO, et al. The electronic medical record as a tool for infection surveillance: successful automation of device-days. AJIC 2009; 37(5):364-70

Steps For Identifying Cases of SUTI [CAUTI] For positive culture, review patient’s medical record; Did patient have urinary catheter at time of specimen collection or during 48 hours prior to specimen collection? Yes – continue review No – stop; no need to continue review Does this patient have at least one of the following signs/symptoms with no other recognized cause ?: fever >380C (1004F), or suprapubic tenderness, or costovertebral angle pain* or tenderness AND 4) Urine culture of ≥105 CFU/ml [< 2 different species]? If yes ; this is a SUTI; NHSN criterion 1a – enter into NHSN UTI form or your HAI data collection system * area of the back overlying the kidney producing pain in people with an infection around the kidney

Steps For Identifying Cases of ABUTI Patient with or without an indwelling urinary catheter has no signs or symptoms of UTI: i.e., for any age patient, NO fever (>38°C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, and a positive urine culture of >105 CFU/ml with no more than 2 species of uropathogen microorganisms* a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture Uropathogens: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae,and Corynebacterium (urease positive).

SUTI Data Collection Form, NHSN

Collecting Denominator Data 1. 2. Make sure CAUTI is included in your monthly reporting plan for the unit(s) included in this OntheCUSP collaborative Engage personnel in unit(s) identified in your surveillance plan to collect urinary catheter Days; same time, each day of the month

Calculation of Catheter-associated SUTI (CAUTI) Rates Data elements required to calculate: Numerator: # of Catheter-associated symptomatic Urinary Tract Infections (SUTI) / month Denominator: # of indwelling urinary catheter days per month CAUTI Rate = # of SUTIs in unit in month of surv. X 1000 # Catheter Days in unit in month of surv.

CAUTI Surveillance Tips CAUTI-Catheter-associated urinary tract infection which occurs in a patient who had an indwelling urethral catheter in place within 48 hours prior to specimen collection. There is no minimum period of time that the catheter must be in place for the UTI to be considered catheter-associated. HAI rule: there must be no evidence that the infection was present or incubating at the time of admission to the care setting

CAUTI Surveillance Tips Transfer rule –if the CAUTI develops within 48 hours of transfer from an inpatient location, indicate the transferring location as the location of the CAUTI. Example: A patient with a Foley is transferred from SICU to the step-down unit on Friday [11/04/11]. Saturday [11/05/11] afternoon, fever of 38.5 C is observed, urine culture is obtained which finds >105 K. pneumoniae cfu/ml. CAUTI identified; the location should be listed as the SICU. Note: There is no requirement to monitor for CAUTI after discharge. However, if discovered, it should be reported. No additional catheter days are recorded. NHSN inpatient: when the admission date is different from the discharge date NHSN OP: when admit and discharge date are the same

Special Considerations for CAUTI Surveillance Infections associated with complications or extensions of infections already present on admission (POA) are NOT considered healthcare-associated unless associated with a previous admission. If the patient has a UTI POA, then has a change in the uropathogen or symptoms strongly suggest the acquisition of a new infection, this should be considered as an HAI. Colonization of the urine (asymptomatic bacteriuria) is NOT considered an infection, even if an MD diagnoses a UTI.

Assigning to a Unit Assign the CAUTI to the location where the patient was located on the date of onset of the SUTI event. Exception: The Transfer Rule If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility, the infection is attributed to the transferring location. Examples for assigning CAUTI: EXAMPLE: Patient has a Foley catheter inserted in the Emergency Department and then is admitted to the MICU. Within 24 hours of admission to the MICU, patient meets criteria for UTI. This is reported to the NHSN as a CAUTI for the MICU, because the Emergency Department is not an inpatient location and no denominator data are collected there.   EXAMPLE: Patient on an inpatient unit of Hospital A had a Foley catheter removed and is discharged home a few hours later. The IP from Hospital B calls the next day to report that this patient has been admitted to Hospital B with a UTI. This CAUTI should be attributed to the inpatient unit for Hospital A.

Determination of Infection Date Date of infection = the date when the first clinical evidence of the HAI infection appeared or the date the specimen used to make or confirm the diagnosis was collected, whichever comes first.

Catheter-associated SUTI Criteria SUTI Criterion #1a, Patient had an indwelling urinary catheter (UC) removed within the 48 hours prior to specimen collection or onset of signs and symptoms And At least one of the following signs/symptoms with no other recognized cause: fever >380C urgency frequency dysuria suprapubic tenderness costovertebral angle pain or tenderness A positive urine culture of ≥105 CFUs/ml with ≤ 2 species of microorganisms. Mrs. Johnson was admitted 4 days ago following a motor vehicle accident in which she sustained multiple fractures. This morning she has been requesting assistance to get up and use the bathroom several times an hour and states that she has a burning feeling when she urinates, the little bit she is able. Her Foley was removed 36 hours earlier. She is afebrile and her lungs are clear. A urine specimen is obtained for culture which is later reported to have > 105   CFU/ml Acinetobacter lwoffi. She meets the criteria for 1a SUTI. Her catheter was removed in the previous 48 hours, and she has urinary frequency and dysuria as well as a urine culture positive for the required number of colony forming units of not more than 2 species of organism.

Catheter-associated SUTI Criteria SUTI Criterion #2a Pt had an indwelling urinary catheter at the time of specimen collection or onset of signs or symptoms And at least 1 of the following signs/symptoms w/no other recognized cause:fever >38°C, suprapubic tenderness, or costovertebral angle pain/tenderness + urinalysis demonstrated by at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with >10 white blood cells [WBC]/mm3 of unspun urine or >3 WBC/high power field of spun urine) c. microorganisms seen on Gram stain of unspun urine a + urine culture of >103 and <105 CFU/ml with ≤ 2 species of microorganisms  

Catheter-associated SUTI Criteria SUTI Criterion #2a, continued Pt had indwelling urinary catheter removed w/in the 48 hours prior to specimen collection or onset of signs or symptoms And at least 1 of the following signs/symptoms w/no other recognized cause:fever >38°C, suprapubic tenderness, or costovertebral angle pain/ tenderness a + urinalysis demonstrated by at least 1 of the following findings: + dipstick for leukocyte esterase and/or nitrite pyuria (urine specimen with >10 white blood cells [WBC]/mm3 of unspun urine or > 3 WBC/high power field of unspun urine) microorganisms seen on Gram stain of unspun urine + urine culture of >103 and <105 CFU/ml with ≤ 2 species of microorganisms.

Application of SUTI Criteria, Case #1 Mrs. J, a 62-yo female was transferred from CCU 4 days ago after admission for a MI. Her Foley was removed at midnight on the day of her transfer to unit 4 East. Today,on unit 4 East, she spiked a temp to 100.6 F (38.1 C). A UA and UC were sent. UA showed 5 WBCs from an unspun sample. The UC came back growing 102 CFU/ml of E. coli. Does this case meet the criteria for a catheter-associated SUTI? * Participant response requested Answer: No. Foley was discontinued >48 hours before temp, UA WBC count too low to meet criteria, CFUs too low to meet criteria.

Application of SUTI Criteria, Case #2 Frank, 86, is a stroke patient in your MICU. He has had a Foley in place since admission. On hospital day 11, he c/o of pain just above his pubic area upon examination. A UA showed >10 WBCs/mm3 of unspun urine and UC grew 10,000 CFU/ml Pseudomonas aeruginosa. Is this a catheter-related SUTI? Why or why not? Frank meets SUTI Criterion 2a. He has suprapubic tenderness, a positive urinalysis and 104 CFU/ml Pseudomonas aeruginosa.

Urine Specimen Collection Urinary catheter tips SHOULD NOT be cultured and are not acceptable for a diagnosis of a UTI. Urine cultures must be obtained using appropriate technique, such as clean catch urine or aseptic catheterization. Specimens from indwelling catheters should be obtained by aspiration from the disinfected sampling port(s). Urine specimens should be processed ASAP, within 1-2 hours. If cannot be processed in this time, should be refrigerated or inoculated into primary isolation medium prior to transport or transported in an appropriate transport preservative. Refrigerated specimens should be cultured within 24 hours.

Catheter Prevalence, also known as Urinary catheter utilization ratio Data elements required to calculate: 1. Catheter days 2. Patient days Equation: DUR = # Catheter Days # Patient Days Unit(s) should preferably collect pt days and cath days at same time of day consistently, recognizing that it will not be a perfect count. (If pt days are taken from admin reports, those reports may capture # of patients at a certain time of day, e.g. MN or 12 noon, etc. Device days should try to be captured as close to that same time in the attempt to ensure a relationship between them. Otherwise, if pt days are recorded at 12 noon and cath days at MN, for example, there is the potential for a significant discrepancy in the number of patients on the unit, thus no true relationship between these two numbers. This can result in inaccurate DUR assessment.) CT ICU: Pt days recorded at 12 noon in one hospital by accounting. Due to the type of patients in this type of unit, the patients having surgery the day before have been tx out and the census at 12 noon is 3 patients. However, pts begin to arrive from OR around 1 to 2 p.m. and by MN, their census is 12 cases, all with Foleys. Therefore, their patient days are recorded as 3 and device days as 12…

(50 Catheter days ÷ 100 Patient days = 0.50) What does it mean? Provides ratio of time in which patients are at risk of developing complications such as infection from an indwelling urinary catheter. For example, MICU’s Catheter Utilization Ratio is 0.50 (50 Catheter days ÷ 100 Patient days = 0.50) That means that 50% of MICU’s patient days are days in which patients are at risk of device-related complications. Must be analyzed in conjunction with rates. No magic number to determine where it should be. If rates are acceptable, DUR is most likely OK. If rates are not good, DUR should be assessed to determine if utilization is too high. This is where comparative data can help along with a good understanding of the patient population in your unit. Under-utlization can result in other untoward outcomes so balance must be assessed. Assessment of compliance to appropriate insertion/necessity criteria should be included when DUR data are analyzed, along with quality of these criteria. (E.g. if compliance to criteria is high but DURs and/or rates are high, the criteria should be assessed to ensure they are not overly liberal.) Compare to NHSN and eventually NC CAUTI Collaborative. Expect to come down with insertion criteria and daily assessments for necessity in most cases. NOTE: CAUTI rate may go up if device days go down. Therefore, important to report raw numbers along with rates to key stakeholders.

Reporting CAUTI Annotated run chart/control chart to show change over time Days/weeks since last CAUTI Each case reported to CAUTI Project Team Lead as soon as IP identifies it to facilitate defect analysis as close in time to event as possible.

Resources Days/weeks since last CAUTI http://www.timeanddate.com/date/duration.html

Questions?