2019 NHSN LTCF Training – LTCF UTI Module Part 1


>>Good morning. So it looks like most
of you came back. That’s a good sign. Hope you brought
your umbrellas today. So this is a great
segue from the session that Nicola just
talked about. And I love the question about the variance
and the definitions. Great eye. So I’m going to talk
about the NHSN version of the urinary tract
infection definitions. I will have some polling
questions if you want to log in on the web or via your phone, and here is the poll everywhere
information if you need it. Then here is the web
information for poll everywhere. Okay. So our goals for the next
two hours are for you to be able to describe the benefits
of using NHSN for UTI surveillance
and reporting. To be able to describe the
NHSN methodology protocols and definitions used for UTI
surveillance and reporting, and then we’re going
to test your knowledge as you accurately
apply these definitions through case studies. So as Nicola just talked about UTI’s are prevalent
in the nursing homes. They are one of the most
common infections that we see in the nursing homes with symptomatic UTI’s
being the most common. So that’s your non-catheter
associated. So surveillance is pretty
important for these infections. Out of the room, how many of you are currently
performing UTI surveillance in your facilities? Impressive. And how many use
the NHSN criteria? Okay. So I’m going to talk
about today the NHSN criteria, but I’m also going to give
you an outline of where some of the variances are from NHSN
definitions versus the McGeer so that you have a
deeper understanding of the differences. And so we’re – we know
that UTI’s are one of the most common infections
in the nursing homes. They account for anywhere
from 50 or more percent of the antibiotic use. So I think it’s great
that most of you in here are including
UTI surveillance and with your surveillance
programs. As you’ve learned this
week just a quick review from yesterday surveillance
is important. Because we have to know what’s
going on in our facilities, before we can implement
change, right? So UTI prevention
begins with surveillance. We want to get that data in
front of those policy makers, in front of your administrators so that action can
take place, right? I thought this was interesting. I actually did a talk at APIC
and got really interested in the history of surveillance
and infection control. And so I did some digging on
how surveillance is defined and found these different
variations of how surveillance is
defined and it actually – if you look in the American
Heritage dictionary, surveillance goes
back to the 1800’s. And it was started by French – the French when they
were using surveillance as part of spying on people. And so no to bore you too
much, so these are just some of the different variations. But as Dr. – woop, I thought I
had a – so as Dr. Bell talked about yesterday for the purposes of public health we
really define surveillance as the collection, collation
analysis, interpretation and dissemination of data. And so again, you must have the
data to encourage change, right? Sometime else that you know,
I think is really important is in our country we take – can’t
take surveillance for granted. Because we have resources and
we have wealth in many areas. So, data is not always
required to get action. But if you look at some
of the other countries who do lack in resources. And who lack in the same wealth. Without surveillance,
without information, without data they lack the
resources that they need to get what they want for
communities and for programs. Surveillance is really important and goes much farther beyond
just infection control in the hospitals, if you
really think about it. There’s my square. So why do we perform
surveillance? Well we talked about
his yesterday, but for you guys it’s important to know what’s going
on in your facility. You want to know what
infections are most prevalent in your facility, what
organisms are most prevalent, what patient populations are
you seeing the most infections. You want to identify new
or increasing infections. I you have an outbreak
brewing, you want to know about it sooner rather
than later. And the only way you’re
going to know about that, is through surveillance. For example, do you
have a system in place where if an employee
your CNA’s call out sick, or your nurse’s call out sick where you can identify what
illness that employee has and compare that to what’s
going on in your facility? That is an example
of surveillance and that’s a great example of how you can prevent
a potential outbreak from occurring but just
being knowledgeable, knowing what’s going
on in your facility. And then also highlighting
opportunities for improvement. If you know that
you have a problem with catheter associated
UTI’s and you have the data, then hopefully your
administrators, your powers to be are going
to give you the resources, staff wise, financial wise to put prevention
processes in place. But you need that data. And then again, to
assess the impacted new prevention strategies. So if you implemented a new
hand hygiene program it’s going to be nice to know does the
data support improvement? Are you seeing a decrease
in infections related to – to poor hand hygiene? And then of course to comply
with regulatory expectations. So we know that surveillance can
directly measure what’s going on in a population, but again
it can also measure strategies that you’ve put into place,
and I am a true believer in what gets measured, gets
done or hopefully it gets done. But if you don’t measure it then
you don’t know what you don’t know, right? So you have to know so that you
can put processes into place. Resources and ideally
your resources are going to follow your data. And I think about this too
with our politicians, we get – you know I sometimes will go
through the healthcare bills on the table and just looking at what policies are the
politicians trying to put into place and it seems the
most informed politicians, the states that have good
data have good advocacy, have the best bills going into
place to improve patient safety, improve public awareness;
so again the policies. It goes far beyond
just the hospital and the nursing home
environments. By now you all should be
familiar with this slide. We have three modules
within the NHSN component. And today we’re going to focus on the healthcare
associated infection module. And right now this module does
include urinary tract infections and that is both
catheter associated and non-catheter associated. As I said yesterday, we are
knee deep or actually thigh deep in this respiratory
tract infection module. And so we’re hoping in the
next two years at the most, we’re going to have this live. We’re going to be doing
some field testing, we’ve developed a form
and a draft protocol based on literature reviews and
studies that have been done. And so we’re going to have field
testing this next calendar year. And if all goes well
we hope to push it into NHSN soon after that. And we’re also working
on this skin and soft tissue infection
module; so we have great big things
coming and we look forward to getting your feedback. I know some of you in the
room have participated in some testing and with
our dashboard for us; we may contact you again if
you’re interested to help us with some testing of these
new modules coming out. So definitely if you’re
interested in doing any of that and getting involved and helping
us develop great protocols and – and forms, send us an email and we’ll definitely
put you on our list. I’d like to keep
this slide in here. I know, I feel like I’m drilling
this in about the benefits of surveillance, but I like
this slide because it allows you to put in your mind, to put in practice what you
can do with NHSN. By reporting your data into
NHSN using the NHSN definitions you’re able to retrieve
everything that you put into NHSN basically because the
application will calculate your UTI data for you. And it will be immediately
available. So you’re going to have
access to your UTI rates. You’re going to see the great
dashboard today for those of you who were not able to go to the
analysis sessions yesterday; you’re going to get a
preview – sneak preview today. So the NHSN will also give you
line lists, analysis options; there’s just all
kinds of things, NHSN that you can do data wise by reporting your
data into NHSN. There’s some antibiotic
stewardship features, built in based on the
summary data that you report and we’re going to talk about
that as we get into more into this presentation. But for example you’re able
to look at your antibiotic use in your facility
for the treatment of urinary tract infections. You’re able to look at your
urinary catheter utilization and so forth. Certified skilled nursing
facilities and nursing homes, as well as intermediate
chronic care facilities for the developmentally
disabled are eligible to report UTI event data. So what I’m going
to talk about as far as the surveillance definitions
for UTI’s this is going to be different from the
surveillance talk we talked about yesterday for lab
idea vent reporting. Because for UTI surveillance
you’re looking at a combination of the laboratory data
combined with the constitutional and localized signs
and symptoms, right? With the lab idea event
reporting we talked about yesterday we
were not looking down on that clinical level. We were really just looking at admission data
and laboratory data. So it’s different
for UTI surveillance. You’re going to incorporate
those resident signs and symptoms as well as
that urine culture data. And you have to have both in
order to meet one of the – the NHSN UTI criteria. We did adopt the UTI protocol from the revised McGeer
criteria; so you’re going to see is very, very similar. We have made changes
over the year, based on feedback
from our users. And some of the data that
we see coming in and really to improve the applicability
of using these data for surveillance purposes. So here’s a list of some of the
differences that you will see, and I’ll kind of talk through
these a little bit for you. So, the first one are
signs and symptoms. For NHSN the signs and symptoms
are considered non-specific. And what that means is that
they can be applied to more than one infection cause. Take fever being
the most common. If your resident has a fever, and your resident has a
positive urine culture, and you’re resident has dysuria
or another localized sign and symptom of a UTI that resident will
meet NHSN UTI criteria. Even if the resident has a cough or has an infiltrate
on the x-ray. Because the way that we
view fever as non-specific, meaning it can be applied to
more than one infection cause. Now when you compare
that to McGeer, McGeer says that you must
look for other sources of infection before using
fever, rigors or hypotension. So that is one difference
that you’re going to see. Another difference is the cam
criteria, are not required when applying new onset
confusion or functional decline to the NHSN UTI criteria. What you’re looking
for with NHSN as an acute change not
related to another cause, but acute change in that
mental status or confusion. Something is not right
with that resident. And compared to McGeer the
confusion assessment method or the cam method is required to assess mental status
or functional change. Now with the NHSN you’ll see as
we get deep into the protocol, you do have to have
to use mental status – acute mental status change. You do have to have accompany
leukocytosis as well. But we’ll talk more about that. And then as one of your
colleagues pointed out earlier, the urine culture requirements
are different between the two. And for NHSN it does not – your urine culture requirements
are not dependent on how that specimen was collected. Regardless if it was a straight
catch, a – a clean catch or however your urine
was collected. The – the colony count
requirements are the same compared to McGeer where the
urine culture requirements are dependent on how that
specimen was collected. For NHSN the urine culture
must have more than two species of micro-organisms with at least
100,000 colony forming units of bacterium. And again when you look – compare that to McGeer
you’ll see that if the specimen is
collected via straight catch or straight in/out catheter, you can have 100 colony
forming units versus 100,000 if it’s a urinary catheter
specimen or a voided urine. And then lastly NHSN does not
consider yeast an attributor to a UTI. So yeast is not considered
an acceptable UTI pathogen when yeast alone
is in the urine. If you have yeast plus
a bacterium then it – you can use that culture. But if you only have
yeast it does not qualify as a positive urine
culture for NHSN versus McGeer there
are no exclusions for yeast only urine cultures. If I could give you
two pieces of advice for your surveillance program; I would say set your
expectations wisely when you’re thinking about
a surveillance program. So you’re sitting
here this week, and I know that there are
many of you who are new and this is overwhelming. Especially yesterday when we
talked about all those NDRO’s and C-diffocele and now today
I’m throwing UTI’s on you. It’s overwhelming and there is
no expectation that you’re going to leave here and go back
to your facility and put all of this in your monthly
reporting plan, right? You need to decide what is
important to your facility, what are the risk and the
benefits in your facility? And the best way for you to
set those expectations is look at your risk assessment. What is your patient population? What are the organisms that are
most prevalent in your facility? Do you have an issue with UTI’s? Because if you don’t
then maybe you don’t need to add UTI surveillance. Maybe your issue is
you have a lot of MRSA in your facility or
wound infections. So really set your
expectations wisely and don’t over extend yourself
beyond your resources. So look at your risk assessment
and look at your resources to determine what surveillance
options you’re going to put into place. And the second thing
that I would tell you is to institute consistent
surveillance definitions. Save yourself the headache
of wondering oh gosh, did I remember to do this? Did I remember to do that? Or if you’re transitioning
to a new facility, you want to make
sure that no matter who is doing the
surveillance in your facility, they are applying the
definitions exactly the same. So have in place consistent
definitions for how you’re going to identify infections
in your facility. And then once you have that,
you’ll – it will make it easier for you to more consistently
apply the criteria, and it’s going to make
your data more comparable. You want to be able to stand
in front of your administrators and be confident when they say
“Are you sure our rate was 3.5 in 2018 and now it’s
9.7 in 2019?” You want to be able to stand
in front of that administrator and say “Yes I am sure we
use the same definitions. We apply the definitions
consistently and this is what it is.” We have a problem. Here are some considerations. If you are going to adopt
NHSN UTI surveillance criteria or really any surveillance
criteria for that matter, when you’re looking
at a resident you want to identify are the symptoms
new or acutely worse? So did the resident come into our facility
with this infecting? Because there is that
two day I’m not going to report what’s considered
present on admission? Or what about the resident
who has a UTI, got better and then has – is
symptomatic again? So you want to ask yourself
is this new or worse? Does a resident have an in dwelling urinary
device in place? And this is important because
the criteria are different depending that a dwelling
catheter is in place. So the in dwelling
catheter is not in place, there are certain criteria that
can’t be used to meet the UTI. For example, if there’s no in dwelling catheter a
fever alone is not going to meet NHSN criteria versus if
there is a catheter then there’s a higher chance that maybe
that fever is related to a UTI. And then evidence
of an infection that you must always have
a positive urine culture to meet NHSN criteria. Are there localizing
signs and symptoms? So for example a resident
without an in dwelling catheter and without localizing signs of
infection to that urinary tract, chances are it may not be
a urinary tract infection or at least may not
meet the criteria, the definition for a UTI. And then does a clinical
presentation meet the NHSN criteria? Again, that goes back
to the – to the signs of infection, the
localized signs. And Nicollete talked about this,
there’s a clinical disagreement. You’re going to have clinical
disagreements, that is – that is almost a guarantee. Because when you’re looking
at – when you’re looking at surveillance definitions versus clinical treatment
guidelines surveillance definitions are looking at
a population based, right? They’re not looking at
individual residents. So the surveillance
definitions do not take into account the individual
history of that resident or that individuals
– the circumstances of that individual resident. So for example we get questions
sometimes about residents who are – who may be
non-verbal or confused. And how do you identify a UTI
in those residents and why – why don’t our criteria
accommodate those? Well again, because the criteria
for surveillance are designed to look at a population. So we’re not able to –
to add each and every one of those specific
nuances that may occur. So there does have to be some
clinical judgment involved when you’re looking at the
UTI criteria and when we get into the case studies, I think
that’s going to help you. So just know that
surveillance and treatment, clinical treatment are –
serve two different purposes and we never want you to treat
or not treat a resident based on the surveillance findings. That’s very, very important and
we get those questions sometimes where the IP’s or the
DON will send us an email and say “Well my medical
director is treating based on the NHSN criteria or the McGeer criteria”
and we’re like no. Because they’re not meant
to be treatment guidelines. We – if you kind
of cause a resident and you’re not quite sure
and there’s some nuances with that resident, but you feel like the resident still does
meet UTI criteria for example, had non-verbal resident who you
know, twitches or closes his or her eyes during a
lower abdominal exam. And you may feel that’s –
that’s maybe super pubic pain. And you feel that, then
that is your decision, this is not NHSN
decision to make that; that is your decision. This is your facility. But what you – what I
may suggest and this is for really you’re internal, not
for us because we don’t look at your notes, but make
yourself some notes when you submit an event. You have a comment section and that is really
for the next person. So say a new IP comes
in behinds you and they’re validating your
events that you reported. Just so that he or
she can kind of know where you’re coming from. Don’t be afraid to
use the comments because that box is
meant for the facilities. Also we encourage you, if you
have a case that is interesting and you’re just not quite sure
how to apply the definitions, send us an email with the
case and we will help you. We will give you our opinion,
if we feel like it meets or not. But again, ultimately it’s
your decision how you want to handle that. But we will give you our opinion
and we’ll give you a background of why we came to our opinion. So feel free to email us at
[email protected] for that kind of feedback and we actually
enjoy reading those cases because it keeps us
abreast of the front line, what you guys are going
through on the front lines. So please don’t hesitate
to reach out to us. Okay so now we’re
going to get kind of into the nitty gritty
with NHSN reporting. If you’re participating in urinary tract
infection surveillance. So we have the UTI monthly
participation requirements, remember this. So the NHSN monthly reporting
plan must be completed. Again for each calendar month in which a facility
plans to enter data. If you’re planning on
submitting UTI events for the calendar month you’re
going to want to make sure that you’re doing surveillance
for both catheter associated and non-catheter associated and
you’re looking at facility wide. So, all resident care
locations in your facility. At the end of that
month you’re going to submit your summary data and remember the summary
data must be completed even if you did not report any UTI;
so if you perform surveillance and found zero UTI’s
in your facility, you still must complete
that summary data. And then lastly,
you’re going to want to make sure you resolve
those alerts each month so that your data are complete
and included in your analysis. We talked about this a
lot I feel like yesterday but that monthly reporting
plan is important because first of all you have to have it on file before the
application will allow you to enter any events. But it just lets NHSN know
what your intentions are so that we know and
we can trigger – so it will trigger alerts for
you to remind you of things that need to happen so that your
data are complete each month. Just quickly, to enter your
monthly reporting plan you’re going to log in, remember
your navigation bar here. You go to your reporting plan,
you’re going to click add and this is what’s
going to populate. You’re going to enter
your month and year, the very first section is going
to be the HAI module and that is where you’re going
to find your UTI. And right now when you
go to the HAI module, UTI is your only choice, but
when we add the RTI and the skin and soft tissue the drop down
will include those sections as well; so for now
you have the UTI. And then this is the only
surveillance module you’re going to follow for the month, you just put a check
mark and you click save. Of course, if you’re going to add additional modules then
you would make those selections on that same page. Again the UTI surveillance
must occur for all resident care
locations in the facility and it must occur
for residents with and without urinary devices. Sometimes we get this question, especially when a facility
has an incomplete UTI event. And what we find is that some
facilities are entering UTI events even if the resident
does not meet NHSN criteria. And if you do that
then you’re going to constantly be getting alerts
from NHSN, so it’s important that you’re only
entering UTI events that meet NHSN definition. And I’m going to show you – I
have some screen shots in some – on slides further down that
will show you how to identify if your event actually
meets the NHSN criteria. So one thing I do want to point
out because this is different from the lab idea metrics. Is that you’re looking at
residents with UTI signs and symptoms presenting
more than two calendar days after your current
admission; so if you look here if your resident is admitted
on June 4, you’re looking at day one, day two,
don’t count. So you’re looking for
the onset of signs or symptoms on day three on. So if the resident comes in and
complains of dysuria on day one, but the urine culture is not
collected until day three, what are you going to do? Count it or not count it? Not count it, because the
onset actually occurred – so you’re looking at the onset,
so the onset is identified as either the first sign or
symptom or the collection of that positive urine culture. Which residents are
excluded from NHSN reporting? This actually is very similar
to the lab ID event metric that we talked about yesterday. You’re only including residents
receiving inpatient care in your facility. If they’re receiving care in another facility you
do not report those UTI’s. Again, only residents fully
meeting the NHSN UTI criteria should be included and
that includes the positive culture requirement. And then we just talked about
residents presenting with signs or symptoms on day
one or day two of current admission are not
included in your reporting. Now the resident is
transferred to your facility from another facility and
presents with signs and symptoms on day one or day two. It would be best practice
to contact that facility, the IP in that facility
and let he or she know hey, we just received a
patient from your facility and the patient presented
with UTI symptoms. That facility does have
reporting requirements that have to be met. We have this nice form
that you are able to use for your UTI data collection. If you are new I do recommend
that you have these forms to get you started until
you really get used to the data elements
that you are collecting. This form has all of the data
elements that are required and it comes with a table
of instructions and the form like our other forms
is also customizable. If you wanted to add additional
data elements to the form so that it meets the
needs of your facility. Here is the web page for
surveillance for UTI’s and on this page you’ll have
access to the training protocols and forms and instructions,
analysis resources and so forth. So next I want to talk about a
few of the important key terms and definitions you’re
going to need to be aware of when you’re performing
UTI surveillance using NHSN. So first is the date of event. The date of event is
defined as the date when the first clinical
evidence, so those signs or symptoms of the UTI appeared or the date the urine
specimen was collected, whichever comes first. And in-dwelling urinary catheter
is defined as a drainage tube that has been inserted
into the urinary bladder through the urethra
and is left in place and is connected
to a drainage bag. Also referred to as
a Foley catheter. This does also include
your leg bags. What we do not consider as an in dwelling urinary catheter
are those straight catheters, the in and out catheters that
are used to collect specimens or to relieve bladder
distention. Nor are super-pubic
catheters considered, or condom catheters
or nephrostomy tubes. Now if you have a
resident with one of these devices they can
still meet NHSN UTI criteria, but they would need to meet
the NHSN SUTI criteria, not the catheter associated. And we’re going to get to that,
those definitions as well. There are two specific
types of UTI. For NHSN you’ve got those
symptomatic UTI’s are the SUTI’s, so those are the
non-catheter associated. And then or the catheter
associated, then you got the asymptomatic
bacteremia UTI’s or ABUTI’s. So again both of these will
include your residents with and without an in
dwelling urinary device. So let’s talk about the
symptomatic UTI first. So this is your resident who
demonstrates signs and symptoms that localize that infection
to that urinary tract. These events, again can occur
with your residents with or without in dwelling devices
or other types of advices. And then we do occasionally
have those residents with a symptomatic
bacteremia UTI’s or ABUTI’s. And those are the residents
who do not display signs and symptoms localized
to the urinary tract. But they have a positive
urine culture as well as a positive blood culture. That’s important. You have to have
that blood culture and at least one organism and
those two cultures matches, so that tells you
something is going on, right? Even though the resident is
not showing localized signs and symptoms, there’s
an organism brewing in that body somewhere. Okay, so let’s start with
a symptomatic UTI infection and this is going to be the
non-catheter associated. And we kind of went
over this earlier but for these residents you’re
going to evaluate the resident. You’re going to identify the
resident does not have an in dwelling device in place
and has not had one in place in the previous two days, right? The resident does have
a positive urine culture and this is where many IP’s
will start the surveillance. They’ll start by getting
that positive urine culture. You get that positive urine
culture and then you go digging to figure out what
the heck is going on. Does the resident have one or more localized
signs or symptoms? When you’re looking at infection
related to not related to an in dwelling device, you really
want to hone in and look for those localized signs
and symptoms to make sure that whatever is going
on with the resident and that positive urine
culture is not colonization or something else. You want to make sure that it’s
linking you to a possible UTI and not – not something else. So here are the NHSN criteria
for what we call a SUTI without an in dwelling catheter. So criteria one, these are your
localized signs and symptoms. So if the resident has acute
dysuria or acute pain, swelling or tenderness of the
testes, epididymis or prostate automatically
meets NHSN criteria. So they can have one of those
because those are localized. If the resident has
some non-localized also, maybe that fever or
leukocytosis that’s fine, but the resident must
also have at least one of these signs and symptoms. So the resident must have fever or leukocytosis plus a
costovertebral ankle pain or tenderness. If you see that then likely
the resident is very sick and has more than
just a lower UTI. But it’s possible that you will
see that those residents may be on their way out
to the hospital. You may use fever
or leukocytosis if the resident has
a super-pubic pain or tenderness on examination. If there’s visible
blood in the urine, if the resident has
a new incontinence. Now this incontinence
doesn’t count if the resident is an
incontinent resident. This is a new thing
for the resident and you’re like what’s going on? Then it very well
could be a UTI. And then a new urgency
or frequency. And then criteria three here if the resident doesn’t
have a fever or leukocytosis they can meet
by having two of the criteria that I just mentioned. And what I recommend, I don’t
think I have a screen shot in the slides, but in the
protocol you have these nice figures if you guys
can see this, but I recommend having
these figures accessible, because it makes it really
easy to follow the criteria. To me this is a little
bit confusing because it’s blocked out, but if you use the algorithm
it makes it much easier. And that is in your booklet,
in your booklet that you have, but it’s also in our protocol. And then again you must have
that positive urine culture and regardless of how
the specimen is collected that urine culture has to
have no more than two species of microorganisms, at least one
of which must be a bacterium of at last 100,000
colony forming units or 10 to the five is how you may
see it on your lab report. So let’s talk about
fever a little bit. We defined fever in
a resident as greater than 100 degrees
Fahrenheit or greater than 99 degrees Fahrenheit
on repeated occasions. And so what that means
is more than once. It doesn’t have to
be five times, 10 times; just more than once. If you see greater than 99, if you see 99.4 documented
two different times, the resident meets
that repeated occasion. Or, an increase of more than two
degrees Fahrenheit over baseline and your baseline should
really be based on when that resident was not sick,
so maybe the intake form when the resident initially
comes in, what was the – and was not ill or
any medications that impact the temperature. Maybe you used that
as the baseline. NHSN does not require a
specific route of measurement; so we don’t say oh it must
be rectal or tympanic. It’s whatever route of temperature measurement
your facility implements. And the temperature documents in the residents medical
record is what you use. No conversion based on the
route of collection we – we don’t ask facilities to do
that because it gets confusing and then it’s not easily to
compare between facilities; so use the temperature
that’s documented in the medical record, regardless of how
it was collected. And just remember fever is
considered for NHSN reporting and non-specific
sign that can be used to meet more than one criteria. So if there’s possibly
two infections going on in this resident fever
can be used to meet UTI. Leukocytosis, so this is
defined by NHSN as an elevation in the number of white blood
cells in the blood on more than 14,000 cells per millimeter
or left shift of greater than 6% or 1,500 bands. It is identified through
a complete blood count and a differential blood test
and you may see neutrophilia or left shift documented
in the medical record. And that may be a clue for you. So let’s look at an
example of a SUTI without an in dwelling catheter. Mrs. Stevens is a resident
of the nursing home. On March 1 she develops new
or increased incontinence and new supra pubic pain. The following day on March 2 a
voided urine specimen was sent to the lab and subsequently
tested positive for greater than 100,000 colony
forming units of E-coli. Mrs. Stevens does meet criteria for non-catheter
associated UTI, right? So she has the new
increased and incontinence, new supra pubic pain and she has
the qualifying urine culture. Here we’re going to switch
gears a little bit now and move on to catheter associated
urinary tract infection. So this is CASUTI. Here’s the figure again, so
again you’re going to assess if the resident had that
in dwelling urinary device and if so, or if not
was there one in place in the previous two
calendar days. And then you’re going
to make sure you have that qualifying urine
culture, right? And then you’re going to look
at your signs and symptoms to – and with – when the resident
has an in dwelling device in place the signs and
symptoms requirements are not as rigorous, so you can see here
the resident can have any one of these signs and
symptoms of an in dwelling device is in place. Okay, so the resident
may simply have a fever and a positive urine
culture, a rigors or a new onset hypotension that
is not related to a medication or a non-infectious cause. So for example if the resident
has a cardiac condition and a positive urine culture, you have to ask yourself is
the hypotension really related to the cardiac condition or is
it related to the infection? So you’re looking for
a new change that is around the same time as
that positive urine culture. Is there a new onset confusion
or functional decline? With no alternative diagnosis, if your patient has dementia you
cannot use new onset confusion because it’s not new, right? But if this is a resident or
a patient who has been alert and cognitive and
following commands and all of a sudden stops, then there’s
a reason – there’s reason for you to do a further
assessment, to kind of figure
out what is going on. Now I do want to point out
if you’re going to use, this is the only criteria where you must have
two for this CASUTI. So if you are going
to use confusion or acute functional decline, there must also be
leukocytosis present. So these two must be together
in order to use either one of these criteria
for your CASUTI. And new onset or acute
functional decline does not – is not included in the criteria
for non-catheter associated. So this is just specific
to those – those residents who have those in
dwelling devices in place. Your resident can have
a new or marked increase in super pubic pain or that
costovertebral ankle pain or tenderness or have a
new acute pain or swelling or tenderness of the testes,
epididymis or prostate or purulent discharge from
around that catheter site. So for these to meet
CASUTI you only have to have one of these categories. Again, the urine culture
requirements are exactly the same regardless of how
the specimen is collected so you’re looking for no more than two species
of micro-organisms. And at least one
bacterium present; so if that resident has
candida and E-coli is that a qualifying urine culture? Yes. If the urine
culture has candida only, is that a qualifying
urine culture? No. Okay. Good job. I’m going to talk a little
bit about hypotension. We get these questions
occasionally. Defining hypotension
is put back on you all. You want to use the vital signs
parameter per your facility policy and practices
for clinical practice. So what – however you
define hypotension in your facility is how you’re
going to apply that definition for your UTI criteria. Again, it is considered a
non-specific sign of infection, so if you have a resident who potentially has
another infection source, hypotension can be used to
meet – can continue to be used to meet he UTI criteria. However if there is a
non-infection source related to that hypotension like
cardiac or new medication, then you will not want
to use the hypotension to meet the UTI criteria, right? Because chances are it’s related to some non-infectious
cause for that resident. And then we talked about
the new onset confusion. You’re looking for new – something is different
with Mr. Smith. Something he’s not
following commands and he has been following
commands and he’s all of a sudden incontinent and
he is stumbling when he walks. You’re looking for
something acutely new. But you do not have to
apply the CAM criteria. Let’s look at an
example with Mrs. Ross. So Mrs. Ross is a
resident in your facility. She has an in dwelling urinary – urinary catheter
inserted on March 1. And then on March 5 the
nurse practitioner documented that she complained
of supra pubic pain. The following day on March
6 a specimen is collected from that Foley catheter
and was sent to the lab, which subsequently
tested positive for more than 100,000 colony
forming units of E-coli and then 100,000 colony
forming units of candida aureus. Mrs. Ross does meet the NHSN
criteria for CASUTI on March 5 since she has that in dwelling
device in place, right? And she had at least one
documented sign or symptom and she had the positive
urine culture. So we had that in
dwelling urinary catheter, the super pubic pain and
then there is your qualifying urine culture. I want to spend a
little bit of time on the asymptomatic bacteremia
urinary tract infection event. It’s very simple. As you can see from my slide. I don’t even think you need
to print this it’s so simple. So basically these
are your residents who have no localized
signs or symptoms. But, they – you have this
positive urine culture and a positive blood culture
with matching organisms. And that case you would
have an ABUTI to report. And with that ABUTI when
you report that you’re going to report the positive
urine culture as well as that positive blood culture. And an ABUTI applies
to both catheter and non-catheter
associated infections. Now I don’t want to leave you
confused between the bacteria versus the bacteria because
we’re definitely not advocating that you treat asymptomatic
bacteriuria or ASB because those are not included
in NHSN surveillance and what that is if you have a positive
urine culture, no signs and symptoms, nothing else. Would you report that? No. We do not consider ASB
as meaningful infections, a lot of times it
is colonization and you will often see this –
these positive urine cultures in your chronically ill
residents or your residents who have been chronically
catherized. So we do not advocate
treating these residents. We do know from literature
that these residents are often over treated with antibiotics
and which puts them at risk for adverse drug reactions and what else does it
put them at risk for? C-diffocele. So very important that
– that you understand that this is not what
we’re advocating. We’re only advocating
for the ABUTI, so that positive urine culture with a positive blood
culture that it’s matching. Okay. So now I want to talk about how do we submit
a UTI event to NHSN? So you have your – your
monthly reporting plan in place and you’ve been out on the floor and you’ve identified
your very first event. And you’re ready to
submit it to NHSN. So when you log on you
go to your home page, your left navigation
event and add. Let’s say that you have
two IP’s in your facility because you have a wealth of
resources and you’re not sure if the other IP already
entered this event. What could you do
really quickly to see? Find, you would click find and
then when you get to the page – I don’t think – I should
have put a screen shot. But when you get to the page where you enter the resident
information just go straight to the bottom and
click find again. And it’s going to give you
that line list of everything, not just UTI’s, but
everything that’s been submitted so that you’ll have an idea of
what’s already been submitted. So once you click add, this is
the page you’re going to see. The resident information
section is exactly the same as what we talked
about yesterday. And let’s say that you’ve
already entered a CDI for this resident,
then all you have to do is enter the resident ID and everything else
will populate that you’ve already entered. You’re going to come
down to resident type and select short
stay or long stay. Again this is based on the
date of specimen collection and the date of first
admission is – if it’s more than 100 days it
will be long stay. If it’s less than 100 days
it will be short stay. And then you’re going to enter
the date of first admission to the facility,
so that’s the date when that resident first
came into your facility and it does not change unless
the resident left your facility for more than 30
consecutive days. And then your date of current
admission will be the same as your date of first admission
unless the resident has left your facility more
than two days. If the resident has been
out for more than two days for an admission it’s very
important that you update that current admission. Because remember your
– your infections and your categorizations
are all based on that current admission date. And then you come down
to your event information and you’re going to select UTI. And then the date of event. And remember the date of
event is the date of onset of the clinical signs
or symptoms or the date the specimen
was collected, whichever comes first. The resident care location, you
want to document the location of that resident at
the time of onset. Okay? Let’s do a
knowledge check if you want to get your phones ready. This is going to test if you guys were
listening to me yesterday. I am entering a UTI event for
a resident in my facility. That when I try to select her
resident care location the drop down box is blank. What is wrong? So A, the resident
doesn’t really have a UTI. B, the resident is
not really a resident in your facility,
you’re delusional. Or C, the resident care
locations have not been set up for your facility and
you must do this before submitting events. You guys do not even need
to be here; you’re so smart. I think we should let
them out early today. Good job. So those resident
care locations must be mapped; so that’s the first thing you
want to do when you get back to your offices this week. If you don’t have
those locations set up, go ahead and do that. If you have any problems
setting them up, let us know and we will help you
get those things set up. Once you select the
location then you’re going to select the primary resident
service type, which corresponds to the location that
you selected. And then here’s that
same question, has that resident
been transferred from an acute care facility
in the past four weeks? If you say yes, then you’re
going to get another box that asks you to be specific
about the date of transfer. And then you’re going to be
asked did the resident have an in dwelling catheter at the time
of transfer to your facility? Yes or no? And then actually it’s
not – yeah, so yes or no. And if you say yes, it’s
going to be in place – or no. It’s not yes or no. It’s in place, neither
or removed in the last two calendar days. And the reason these questions
are in here is this allows you when you’re looking at
your data and looking at your UTI data it
really allows you to get an assessment – especially if you have
a large skilled facility at any residence that are
coming in with catheters already in place, maybe UTI brewing,
it just gives you an idea of what’s coming
into your facility and these residents
coming in with devices, not placed in your facility. So if you select the resident
came in with the device in place or removed in the last two days. Then you’re going to have
a question that says site where the catheter was
inserted and that’s going to be your place or
the acute care facility and then it asked you a
date but that is optional. If you don’t know the date, you
don’t have to enter the date. But if you know it and that’s – that’s data that
you are interested in collecting then
certainly enter that. If you select not in place,
there’s no in dwelling device in place, it’s going to ask you if there was another
type of device in place. And so if you select yes
to that, then it’s going to give you the option
of was there supra pubic or an intermittent
straight cath. So you can answer, and
again this just allows you to further analyze you
know maybe you’re – if you’re interested in
looking at your UTI’s associated with your super pubic
caths or your residents who are chronically
straight cath. It allows you to
look at that data. Then you’re going to scroll down
and this is the next section. So you’re going to specify
the criteria that you use to meet the NHSN definitions. Now what I want to point out
is this is blank, but down here in the little corner, you see
where it says specific event. Notice that’s blank because this
little section is auto populated by NHSN, we will
identify the type of UTI your resident has based on how you -on your
selections up here. All right, so it’s going
to be really important that your selections
before you enter up here already meet
NHSN criteria. So let’s say that the resident
has a positive urine culture that meets, so we checked that. And we found documented that
there was purulent drainage around the catheter site, right? And we already documented
previously that the resident had an in
dwelling catheter in place. So once I make those
two selections and that meets CASUTI,
this will populate it as this resident has a CASUTI. If you enter the criteria
and this doesn’t populate, that means the criteria
that you entered do not meet NHSN criteria. So either you have to go back
to the documentation to see if there are other
criteria that do meet or you should delete
the event altogether because if you save this
without this being populated the application will
allow you to save it. But guess what you’re
going to come – run into when you log back in? Those alerts. And you’re going to –
what did I do wrong? And it’s going to force
you to either update this or just delete the
event altogether because it doesn’t
meet criteria. Once you select that
it’s going to ask if the resident had a secondary
blood stream infection and what that means is was there
a matching blood culture. So if this is an ABUTI
you’re going to say yes; otherwise it’s probably
going to be no. But if you do know of a
positive blood culture with a matching organism,
select yes and then was that resident transferred to an acute care facility
within seven days? Yes or no and then
optionally did the resident die within seven days of the
event for any reason? It doesn’t have to be related to
the UTI, but again you’ll notice that there’s no red
asterisk here, and that’s an optional question. And then you come down to
selecting the pathogens that were identified. So remember you can only select
up to two because any more than two in a urine culture
will not meet criteria. So you select your pathogen
and then it will populate the – the antibiogram section
for you to select. And I just want to point out
here so S is for susceptible. I is for intermediate, so you see here R is
resistant and N is non-tested. Here, so this little box on the
form if you run into you know, forgetting what these
mean, just look on the form and you’ll see the box with
the little key for you. If you have an organism,
let’s say a protease because we do know that – or we’ve actually been seeing
protease in the urine cultures in long term care residents. And we – this was not
common when NHSN – when we – the antibiogram were
originally built. And so when you put in
protease what’s going to populate here
is pretty blank. I think maybe one drug comes up. But what we ask you to do is that when you have your
urine culture report, if there’s drug susceptibility
results on drugs that are not in our list, we ask you
to add that drug for us. And this is good for you as well
as for us because it allows us to assess what are the
prevalent organisms that we’re seeing in a field. And actually Nicola’s team
found from the prevalent survey that protease was one of
them, and we’re in the process of making updates in our
application but any type of update like that is
a pretty big update, so it’s going to be a process. But in the meantime if
you see an organism that – that the drugs don’t match
or there’s additional drugs that your laboratory
tested, you just click add and it will be a box
and you can type it in and accept the susceptibilities. Here the custom fields again, just like on the
lab ID event forms. You have the option to
build in custom fields for your urinary tract infection
forms, and then you have the – the free text comments and then
just be sure to select save.

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