1. 2015 NHSN Training Teresa Fox, CIC Quality Improvement Advisor

2. Objectives Discuss New Definitions and Modifications for 2015
Review of Reporting for LabID Events
Review of Reporting for CAUTI

3. HAI Surveillance in the Current U.S. Environment
Public Reporting
Pay for Reporting
Pay for Performance
Implications
Changes in NHSN’s purposes, infrastructure and operations
New scrutiny of HAI case criteria
Increasing attention to data quality
Pressure to HAI definitions and move to electronic HAI detection and reporting
In 2015, NHSN is primarily used for mandatory and public reporting
Vast majority of healthcare facilities enrolled had not participated in the legacy CDC system
Primary motivation is compliance with reporting requirements
Uncertainties about the quality and completeness of data submitted to CDC

4. Implications of Public Reporting and Pay for Performance
New scrutiny of HAI definitions and case studies
Updates of definitions and case criteria that reflect user’s concerns about misclassification of some events
Heightened emphasis on data validation
Assistance to states and CMS for validation
Pressure to simplify HAI definitions and data requirements and move to electronic HAI detection and reporting
Revise definitions and data requirements in ways to reduce complexity, maintain clinical relevance, and avoid potential case misclassification
Accelerate use of electronic healthcare data for event detection and reporting purposes

5. NHSN Plans for 2015 and Beyond
New baseline year for ALL HAIs
Implementation of new definitions and criteria changes for several HAIs concurrently and retaining those previously established
Allow data from single calendar year as the new baseline for SIRs
Provide baseline data for calculating SIRs for 2016 and the following years
Potential to recalculate 2015 SIRs from the 2015 baseline population
Future changes (3-5 years) will be driven by increasing healthcare data availability via electronic methods and increasing EHRs

6. 2015 CMS Reporting Requirements-Acute Hospitals
CLABSI
Adult, pediatric and neonatal ICUs
Adult and pediatric medical wards, surgical wards & med-surgical wards
CAUTI
Adult and pediatric ICUs
SSI
Inpatient colon and abdominal hysterectomy procedures

7. 2015 CMS Reporting Requirements-Acute Hospitals (cont’d)
MRSA Bacteremia and CDI LabID Events
Facility-wide inpatients
HCP Influenza Vaccination Summary
Inpatient and outpatient healthcare personnel
Medicare Beneficiary Number
All events (numerators) from Medicare patients
At this time, I want to remind you that NHSN will only submit data to CMS for those complete months in which the following are indicated on the monthly reporting plan. Facilities must enter a Monthly Reporting Plan for EACH month.

8. Major Definition Changes for Specific Types of Infections
BSI, Pneu, SSI, UTI, VAE
Removed from Chapter 17
Found in separate, dedicated chapters
Chapters cover both device-associated and non-device associated
BRON
Removed entirely from NHSN surveillance
UTI
Major changes to definitions-covered in UTI presentation
Secondary BSI Attribution
Major changes to definition for Secondary Bloodstream Infections
Reinforced in CLABSI presentation
Clostridium difficile infection

9. New Definitions and Modifications
Infection Window Period *+
Date of Event *
Present on Admission Infections (POAs) *+
If housed in ED prior to admission- date of Admission is date when moved to inpatient location
Healthcare Associated Infections (HAIs) *+
Repeat Infection Timeframe (RIT) *+
Secondary BSI Attribution Period *+
Pathogen assignment (part of RIT) *+
* Does not apply to VAE, or LabID Events
# Does not apply to SSI

10. 2015 Removed Criteria Gap Days to determine criterion met
Logical pathogens to determine secondary BSI
Date of Event- when last element of criteria is met
DELETE

11. Infection Window Period
A 7-day-period which all site-specific infection criterion must be met to determine an event includes:
Date of the first positive diagnostic test
3 calendar days before
3 calendar days after
If site-specific criterion does not include a diagnostic test, the first documented localized sign and symptom that is an element of the infection criterion will be used
-3 day
-2 day
Event Date
1 day
2 day
3 day
First positive diagnostic test
A 7-day period during which all site-specific infection criterion must be met. It includes the date of the first positive diagnostic test, that is an element of the site-specific criterion, 3 calendar days before and 3 calendar days after.
For site-specific criterion that do not include a diagnostic test, the first documented localizing test result is used. Example would be if you were trying to determine if you had a MBI-LCBI, you would use the blood culture instead of the absolute neutrophil count

12. Infection Window Period
Diagnostic tests
Laboratory specimen collection (If more than one diagnostic test, use most localized test result)
Imaging test
Procedure or exam
Physician diagnosis
Initiation of treatment
Localized S&S
Diarrhea
Site specific pain
Purulent drainage
For site-specific criterion that do not include a diagnostic test, the first documented localizing test result is used. Example would be if you were trying to determine if you had a MBI-LCBI, you would use the blood culture instead of the absolute neutrophil count. For UTIs and BSIs you would always use the culture collection date.

13. Date of Event 2014 2015 Last element of criterion met
First element of criterion met
The date the first element used to meet the CDC NHSN site-specific infection criterion occurs for the first time with the seven-day infection window period.
The element may have been present prior the infection window period.

14. Infection Window Period

15. Infection Window Period and Date of Event
Date of Event is Day 11

16. Infection Window Period and Date of Event
First positive Diagnostic Test

17. POA vs HAI
Present on Admission (POA)- date of event occurs on the day of admission or the day after admission to an inpatient location
POA time period includes day of admission, 2 days before and the day after admission
Healthcare-Associated Infection (HAI)- the date of event occurs on or after the 3rd calendar day of admission
If first element occurs prior to inpatient admission, the date of event will be the admission date. Also, if the patient is housed in the ED prior to admission to an inpatient location, date of event will be the admission date to the inpatient location

18. Determining New vs. Continuation of Infections
2014
2015
Continuation of symptoms or treatment at time of next infection
Subjective
Undocumented treatment target
Repeat Infection Timeframe (RIT)
Objective
No interpretation of treatment purposes
Reduces IP labor resources

19. Repeat Infection Timeframe (RIT)
Uses date of event to determine a 14-day timeframe during which no new infections of the SAME type are reported
The date of the event is DAY 1 of the 14-day timeframe for the RIT
If date of event for subsequent potential infection is within the 14-day RIT
Do not report new infection
Add additional pathogens to the original event

20. Repeat Infection Timeframe (RIT)
UC >100,000
Proteus Fever F

21. Repeat Infection Timeframe (RIT)
RIT applies at the level of specific type of infection with the exception of BSIs, UTIs and PNEUs where the RIT applies at the major type of infection
Patient will have no more than one BRST (specific type of major type SST)
VS.
Patient will have no more than one BSI
Patient will have no more than one UTI
Patient will have no more than one PNEU

22. Pathogen Assignment
Additional eligible pathogens identified within the RIT are added to the event
Pathogen exclusions for specific infection definitions also apply to secondary BSI pathogen assignment
UTI- yeast
Pneu- yeast, coag. negative Staph, Enterococcus unless isolated from lung tissue or pleural fluid; yeast is included for PNU3 (immunocomprised patients)
Fungal pathogens
Excluded pathogens must be attributed to another site infection to be reported as a secondary BSI or it is identified as a primary BSI

23. RIT Skin and Soft Tissue Infection BRST Burn Circ Decu Skin UTI SUTI
MAJOR TYPE
SPECIFIC TYPE
Skin and Soft Tissue Infection
BRST
Burn
Circ
Decu
Skin
UTI
SUTI
ABUTI
May have more than one
in RIT OR

24. Secondary BSI Attribution Period
Hospital Day
SUTI Criterion 9 10
Fever F 11 12
Fever F 13
UC > 100,000 E.coli 14 15 16 17 18 19 20 21 22 23 24 25
Date of Event
14 days
Secondary BSI Attribution Period =
Infection Window Period + RIT

25. Secondary BSI Attribution Period
Hospital Day
SUTI Criterion 9 10 11 12 13
UC > 100,000 E.coli; costovertebral angle pain 14
Fever F 15 16 17 18 19 20 21 22 23 24 25 26
Date of Event
17 days

26. Temperature Changes for 2015
No longer require core temperatures
Used documented temperature for all surveillance
Do not convert based on site

27. Secondary Bloodstream Infection (BSI)
2014
2015
No objective time period for associating BSI to another infection
Secondary BSI Attribution Period

28. Secondary BSI Attribution Period
Period in which a positive blood culture must be collected to be considered as a secondary bloodstream infection to infection at another primary site
Period includes the Infection Window Period combined with the Repeat Time Timeframe (RIT)
Period is days in length depending on the date of event
Primary BSIs do not have a Secondary BSI Attribution Period

29. Device-Associated Denominator Sampling
Beginning January 2015, hospitals can begin to use an alternative method of collecting CLABSI and CAUTI denominator data in eligible ICU and Ward locations
Reduces staff time in manual collection
Requires data collection on the number of patient days, central lines and/or catheter days on a SINGLE DAY once per week
Requires the number of patient days for every day of month
Entry of monthly sampling of device days and NHSN will automatically calculate and use the estimated CLABSI and CAUTI denominator
DO NOT use weekends. Use week days, not weekend days.

30. Denominator Sampling
Estimate denominator data, only for non-oncology ICUs and wards with ≥ 75 device days/month
Review each location’s prior year (12 months) to help determine which units or wards are eligible for sampling
More information available in the 2015 NHSN Manual

32. Updated Protocols and Clarifications
Protocols and outline of recent clarifications and UTI and SSI protocol modifications were posted to CDC/NHSN website in early April, 2015
Footers for each updated protocol will have a revision date of April 2015
UTI and SSI Surveillance will be impacted by revisions
SSI modification should be used beginning January 1, 2015
2015 changes to the Inpatient and Outpatient OR procedure definition
UTI modification should be used beginning April 1, 2015
No requirement to edit CAUTI data for 1st quarter, 2015

33. Food for Thought
What admission and discharge date should be entered when the patient is admitted into a separately licensed CMS inpatient rehab facility (IRF) that is located inside of my acute hospital?
For NHSN purposes, if the IRF is set up as a patient care location within
Hospital, movement between the acute care hospital and the IRF location
should not be counted as a separate facility discharge and admission.
Movements should be considered location transfers and counted as one
Admission and one discharge from the acute care hospital.

34. Summary 2015 Surveillance definitions for specific infection types
BRON no longer an NHSN infection
New CDI Infection
Other important changes
Temperatures are as documented in the chart
New alternative device day count option- weekly
Available for certain locations
Minimal average device days must be ≥ 75/month in prior year

35. Summary 2015 (cont’d) GAP DAY concept no longer used
Date of Event- first date of element during infection window period
POA vs. HAI definition unchanged
Secondary BSI Attribution Period
Time-limited
Secondary BSI Rules
Simplified- blood culture matching site or part of infection definition
Pathogen assignment
Add on if in RIT and not an excluded organism
Organism may be added to more than one event

36. LabID Event Reporting

37. MRSA Bacteremia & C. difficile Reporting
MRSA: S. aureus testing oxacillin, cefoxition, or methicillin resistant; or positive from molecular testing for mecA and PBP2a
C. difficile: positive result for laboratory test for C. difficile toxin A and/or B or toxin-producing C. difficile detected in stool specimen by culture or by nucleic acid amplification testing by polymerase-chain reaction or PCR
Testing should be performed ONLY on unformed stool specimens
Enzyme immunoassay or EIA.

38. MRSA Bacteremia & Clostridium difficile Reporting for 2015
Participating in CMS Inpatient Quality Reporting (IQR) Program
Acute Hospitals must report MRSA Bacteremia
and C. difficile LABID Events at Facility-Wide
Inpatient Level (FacWideIN)
If reporting to CMS only the Incidence Case will be reported on behalf of the facility by NHSN.
In participating CMS Long-Term Care Hospitals----Facility-wide inpatient (FACWIDEIN) MRSA bacteremia and C. difficile is required beginning January 1, 2015.
In participating Inpatient Rehab Facility, reporting for MRSA bacteremia and C. difficile LabID event reporting also become mandatory on January 1, 2015 for free-standing IRF facility-wide and for IRF units within an acute care or critical care access hospital by specific location.

39. FacWideIN Reporting Facility-wide Inpatient FacWideIN
Includes inpatient locations
Includes observation patients housed in an inpatient location
All specimens or blood specimens only from each outpatient emergency department and 24-hour observation location
Facility-wide by location. Report for each location separately and cover all locations in
a facility. This reporting method requires the most effort, but provides the most detail for local and national statistical data.
B: Selected locations within the facility (1 or more). Report separately from one or
more specific locations within a facility. This includes reporting individual Events and denominator data for each of the selected locations. This reporting method is ideal for use during targeted prevention programs. Note: Some select locations can be monitored for MDRO blood specimens only (i.e., IRF, ED, 24-hour Observation).To ensure accurate categorizations of LabID events (Incident, Recurrent and Healthcare facility-onset) , report events from ALL inpatient locations in the facility, including those locations with different CMS Certification Numbers (CCN)
Different CCN locations will be removed prior to sending to CMS
Different CCN include inpatient rehabilitation facility (IRF) and inpatient psychiatric facility (IPF)
PLUS Specimens collected in the ED and 24-hour observation locations must be entered and assigned to the outpatient location where the specimen was collected, regardless whether patient is admitted or not.
Incident, recurrent, healthcare facility-onset)
Accurate categorization of LabID events depends on all inpatient locations reporting including locations with different CMS Certification Number (CCN), however these data will be removed prior to submitting to CMS for IQR.
Different CCN include inpatient rehab facilities and inpatient psychiatric facilities
Specimens collected from other affiliated outpatient locations (excluding ED and 24- hour Obs) can be reported for the inpatient admitting location if collected on the same calendar day as inpatient admission
This means LabID specimens collected in the ED and 24-hour observation location must be entered in the NHSN application and assigned to the appropriate outpatient location based on the location where the specimen was collected, regardless of whether the patient is admitted or not.
EXAMPLE: If monitoring blood specimens for FacWideIN (which requires surveillance in the emergency department and each 24-hour observation location), a patient has a positive MRSA laboratory isolate while in the emergency department. This specimen represents an MRSA LabID Event and should be entered for the outpatient emergency department. The next calendar day, the same patient is admitted to ICU and three days later, has a second positive MRSA blood specimen. This specimen also represents a unique LabID Event, because it is the first positive blood specimen in this location (ICU). Note that while this patient has two LabID Events, the second specimen that was taken from the ICU will be removed from most analysis reports.
If facility is reporting all specimens, only Blood
Specimen data will be shared with CMS

40. FacWideIN Surveillance
Beginning in 2015 for FacWideIN surveillance, facilities will be required to enter denominators for all locations physically located in the hospital, as well as denominators for all locations minus inpatient rehabilitation facility and inpatient psychiatric facility locations with a separate CCN. The totals should not include other facility types within the hospital that are enrolled and reporting separately (e.g., LTAC).
C. difficile LabID Event reporting can occur in any location: inpatient or outpatient. Surveillance will NOT be performed in NICU, SCN, babies in LDRP, well-baby nurseries, or well-baby clinics. If LDRP locations are being monitored, baby counts must be removed.Step 1: Map every inpatient location
• Reporting of MRSA bacteremia and C. difficile LabID events must be done for all inpatient locations in your facility – each of these inpatient locations must be mapped as a unique location in NHSN. Free-standing IRFs have two types of locations within NHSN that can be used for location mapping: ‘Rehabilitation Ward’ or ‘Rehabilitation Pediatric Ward’.
• To view, add, or edit the locations that you have mapped in your facility, click on Facility > Locations in the NHSN navigation bar on the left side of the screen to access the Location Manager.
• For more information and instructions on how to map your inpatient locations, refer to the location mapping guidance at
Step 2: Include facility-wide reporting of MRSA bacteremia and C. difficile LabID events in your monthly reporting plans
• At the beginning of each month, add facility-wide reporting or MRSA bacteremia and C. difficile LabID events to your monthly reporting plan (MRP) using the “FACWIDEIN” location. The MDRO/CDI Module section of the plan must contain the two rows shown in the screenshot below in order for your facility’s data to be sent to CMS. Use the “Add Rows” button to add an additional row to the MRP.If your facility chooses to report LabID events for all MRSA specimens (and indicates this on your monthly reporting plan), only the MRSA LabID events from blood specimens will be included in the data sent to CMS.
Step 3: Identify and enter all MRSA bacteremia and

41. FacWideIN Surveillance
Step 3: Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location
• Each month, facilities should use the MDRO/CDI Module protocol to identify MRSA bacteremia and C. difficile LabID events.
• All identified LabID events must be entered into NHSN using the specific inpatient location where the patient was assigned at the time of specimen collection, as shown in the screenshot below. You will not be able to use the FACWIDEIN location when reporting individual LabID events.
Step 4: Enter monthly summary data for the entire facility
• At the end of the month, enter an MDRO/CDI Module summary data record for the FACWIDEIN location.

42. FacWideIN Surveillance
Patient day and admission counts should be the same for all three required “Tiers” because IRFs should not have units that need to be excluded from Tier 2 or Tier 3 counts. For more information about how to collect and report the information required for Tier 1, Tier 2, and Tier 3, refer to the MDRO/CDI Module protocol.
• If you have identified and reported both MRSA bacteremia and C. difficile LabID events during the month, you are finished with your reporting for the month. If not, proceed to Step 5 (reporting no events).
Step 5:
Reporting no events for MRSA bacteremia and C. difficile LabID events
• If you have not identified any LabID events for MRSA bacteremia or C. difficile at the end of a month, you must indicate this on the summary data record in order for your data to be sent to CMS.

43. What facility admission date should be used?
Acute Care Hospitals and CMS-IRF
The admission date should reflect the date the patient was physically admitted to the inpatient unit in the hospital

44. LabID Events Checklist
Review location options and map locations in NHSN
Review Monthly Reporting Plan and update as needed
Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by LOCATION using the MDRO/CDI LabID Event protocol
Enter denominator data for each month under surveillance
Resolve ”ALERTS”

45. LabID Events Summary
Must be reported and monitored throughout all inpatient locations within the facility (except for locations traditionally house predominantly newborns)
Location specific reporting is required for CMS-IRF
Specimens and LabID Events collected from ED and 24-hour observation must be reported for outpatient locations regardless of whether patient is later admitted or not
Denominator counts are reported separately for each outpatient location
Specimens collected from other affiliated outpatient locations may be entered for FacWideIN ONLY if specimen collection date and admission date are the same
Important to select the correct CDI test for future risk adjustment
If one selects “other” when a more appropriate choice is available, your facility’s data will not be appropriately risk-adjusted.

46. CAUTI Reporting

47. Consider for CAUTI Surveillance
All CAUTIs require a positive urine culture.
Know you laboratory’s urine culture policies:
Ranges for CFU reported
Positive urine cultures are reported for the unit where they were collected
Minimal CFUs are reported

48. CMS Hospital Inpatient Quality Reporting Program 2015
Acute Care Hospitals
Unless a “Hospital IQR Program Healthcare-Associated Infection (HAI) Exception Form” is submitted
2015 added adult and pediatric medical, surgical and medical/surgical wards to all ICUs except NICUs

49. Urinary Tract Infection Definitions
Two Types of UTIs
Symptomatic UTI- SUTI
Asymptomatic Bacteremic UTI-ABUTI
Both types, if catheter associated, must be reported
as part of the CMS CAUTI required reporting

50. UTI Overview SUTI 1 SUTI 2 ABUTI Any Age Infant ≥ 1 year Any Age A
Catheter-Associated B
Non-catheter-Associated
Non-Catheter-Associated
SUTI 2
ABUTI
Non-catheter- Associated
CMS
Reporting

51. SUTI Definition
Symptoms of a true UTI will vary depending on whether or not a device is present
CANNOT use the following symptoms to determine an UTI in a catheterized patient for NHSN:
Frequency
Urgency
Dysuria
Infants will exhibit symptoms differently from other ages
For infants the following additional symptoms may be used
Apnea
Bradycardia
Lethargy
Vomiting
Hypothermia < 36.0 C

52. UTI Infection Window Period3
3 Days Before 2 1
Date of Urine Culture Collection
1st Positive Diagnostic Test
3 Days After

53. SUTI 1a (catheter in place)
Patient must meet 1, 2 and 3 below
Patient has an indwelling urinary catheter in place for the entire day on the date of event and such catheter has been in place >2 calendar days, on the that date
Patient has at least one of the following signs or symptoms
Fever (> 38.0˚C) or
Suprapubic tenderness
Costovertebral angle pain or tenderness
Patient has a UC with no more than two species of organisms, and at least one of which has a colony count of ≥105 CFU/ml and all elements of UTI criterion occurs during the Infection Window Period
An indwelling urinary catheter in place would constitute “other recognized cause” for patient complaints of “frequency” “urgency” or “dysuria” and therefore these cannot be used as symptoms when catheter is in place.
Back pain- no
Yes to right or left lower back or pelvic pain

54. SUTI 1a (catheter recently removed)
Patient must meet 1, 2 and 3 below:
Patient has indwelling urinary catheter in place for greater than 2 days which was removed on the day of or day before date of event
Patient has a least one of the following signs or symptoms
Fever (>38.˚C) Urinary urgency
Suprapubic tenderness Urinary frequency
Costovertebral angle pain or tenderness Dysuria
Patient has a UC with no more than two species of organisms, and at least one of which has a colony count of ≥105 CFU/ml and all elements of UTI criterion occurs during the Infection Window Period

55. Criterion SUTI 1a Catheter Removed
UTIs with event date on the day of device removal and the
following calendar day are considered device-associated UTIs,
if the device has been in place already > 2 calendar days
For this criterion urgency, frequency and dysuria are symptoms
Day 1
Day 2
Day 3
Day 4
CAUTI?
Foley placed
Foley in place
Foley in place for part of day, then removed
Date of Event
Yes
No Foley No

56. SUTI 1 b (Non-catheter-associated)
Patient must meet 1, 2, and 3 below:
One of the following is true:
Patient has/had an indwelling catheter but it has/had not been in place> 2 calendar days OR
Patient did not have a urinary catheter in place on the date of event or the day before the date of event
Patient has at least ONE of the following S&S
Fever (>38.˚C) Urinary urgency
Suprapubic tenderness Urinary frequency
Costovertebral angle pain or tenderness Dysuria
3. Patient has a UC with no more than two species of organisms, and at least one of which has a colony count of ≥105 CFU/ml and all elements of UTI criterion occurs during the Infection Window Period

57. SUTI 2 (≤ 1-year-old) Patient must meet 1, 2 and 3 below:
Patient is ≤ 1-year-old (with or without an indwelling urinary catheter)
Patient has at least one of the following signs or symptoms:
Fever (>38.˚C) Lethargy
Hypothermia (<36.0˚ C) Vomiting
Apnea Suprapubic tenderness
Bradycardia
3. Patient has a UC with no more than two species of organisms, and at least one of which has a colony count of ≥105 CFU/ml and all elements of SUTI criterion occurs during the Infection Window Period

58. No more than 2 Species of Bacteria
UC with >2 organisms are not used for NHSN definition
“Mixed Flora” or equivalent cannot be used to meet definition
Organisms of the same genus but different species = 2 organisms
Same organism with different antimicrobial susceptibilities = 1 organism Ex. MRSA = MSSA

59. Asymptomatic Bacteremic UTI (ABUTI)
Patient must meet 1, 3 and 3 below:
Patient with or without indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age (Note: Patients > 65 years of age with a non-catheter-associated UTI may have a fever and still meet the ABUTI criterion)
Patient has urine culture with no more than 2 species of organisms and at least one which has a colony count of ≥ 105 CFU/ml
Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meet LCBI criterion 2 (without fever) and matching common commensal(s) in the urine. All elements of ABUTI criterion must occur during Infection Window Period

60. Identifying SUTI and ABUTI Flowchart

61. No other Recognized Cause
Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination because they are clinically deemed due to another recognized cause.

62. UTI Repeat Infection Timeframe (RIT)
14- day timeframe
No new UTIs are reported
Date of Event = Day 1
Additional pathogens from urine culture are added to the event
If POA do not report based on Infection Window Period

63. Applying CAUTI RIT
Patient is admitted to 5W on 1/15/2015 with a positive UC >100,000 of E. coli. No S&S present. Foley is inserted on admission. 7 days later (1/22/15), patient has fever (38.5˚C) and is culture positive from E. coli, >100,000.
Is this a POA?
No, did not meet criteria of POA on admission
Is this an HAI?
Yes, what type?
CAUTI, Event Date of 1/22/15

64. Discontinuation and Reinsertion
If Foley catheter is discontinued, and a full calendar day passes before a Foley is reinserted, then the day count for determining catheter-associated UTI begins anew. Otherwise the day count continues from the previous catheter.
Mar 31 (hospital Day 3
April 1
April 2
April 3
April 4
April 5
April 6
Patient A
Foley Day 3
Foley Day 4
Foley Day 5; Foley removed
Foley Replaced; Foley Day 6
Foley Day 7
Foley Day 8
Foley Day 9
Patient B
No Foley
Foley Replaced; Foley Day 1
Foley Day 2

65. Location of Attribution
The location where the patient was assigned on the date of the UTI Event, which is further defined as the date that the first element used to meet the UTI infection criterion occurred for the first time in the Infection Window Period
Exception - Transfer Rule
If the date of the UTI event is the day of transfer or the next day, the UTI is attributed to transferring location or facility. Likewise, if the date of event is the day of discharge or the next day, the infection is attributed to the discharging location
Receiving facility should share information about HAIs with the transferring location or facility to enable complete reporting

66. UTI Case Study 1
Day 1: 58 year old male patient is admitted via ED with GI bleed and indwelling catheter is inserted
Day 2: Patient spikes temp of 38.6˚ C. Indwelling catheter remains in place
Day 3: UC collected
Day 4: Culture report is 100,000 CFU/ml of Pseudomonas aeruginosa. Antibiotics started
Day 5: Patient is asymptomatic and afebrile
Is this an HAI? If so, what type?
Yes, HAI- UTI but not CAUTI, catheter had not been in place > 2 days
No, it is a UTI that is POA
Yes, CAUTI, SUTI Criterion 1a

67. CAUTI Case Study 1 (cont’d)
Day 15: Foley remains in place. Patient completed treatment for UTI on hospital day 11 and has been afebrile since. Hospitalization has been complicated by development of DVT. Temp today is 38.1˚C. Cough is productive of yellow phlegm. Rhonchi present.
Day 16: Urine cloudy. Fever 37.9˚C, continued cough. Sputum collected
Day 17: Urine Culture collected
Day 18: Urine and sputum cultures are both positive for S. aureus, > 100,000 CFU/ml
Should another CAUTI be reported?

68. UTI Case Study 1 RIT If the first UTI had been an HAI, then
Day 1
Foley inserted
Day 2
Foley in place; fever
Day 3
UC collected
Day 4
100,000 Ps. aeruginosa; Antibiotics started
Day 5
no S&S
Day 6
Foley in place
Day 7
Day 8
Day 9
Day 10
Day 11
Antibiotics completed
Day 12
abrile
Day 13
Day 14
Day 15
fever; productive cough and rhonchi
Day 16
Urine cloudy; fever 37.9; cough continues; SPT collected
Day 17
Day 18
UC and Spt Cultures positive for S. aureus; >100,000 in urine
No, the date of event for a UTI related
to this culture occurs during the RIT
of previous UTI
What is the date of event?
Day 15, which is in the RIT for the POA
From Day 2
RIT
Rationale:
Unlike CLABSI, CAUTIs may NOT
be excluded as secondary to another
Site-specific infection
If the first UTI had been an HAI, then
the S. aureus would have been added to
that event

69. CAUTI Summary All CAUTIs require a positive urine culture
Minimal CFU/ml > 100,000 of no more than 2 species
Account for positive UC from the ED which may represent recently discharged patients
Infection Window Period is a 7-day period (3 days before positive diagnostic test and 3 day after)
RIT period uses the date of event to determine a 14-day timeframe during which no new infections of the same type are reported. Date of event is Day 1 of the timeframe.
If date of event of subsequent infection is within the 14 day period, additional organisms are added to the original event.

70. Thank You
Slides and information adapted from CDC/NHSN Training slides and materials