Articles, Blog

2018 NHSN Training – Central Line-associated Bloodstream Infection (CLABSI)

August 14, 2019

>>So, good morning. I am LaTasha Powell. I am one of the subject matter
experts for the BSI event chapter, and the backup subject matter
expert for the late– upcoming late onset sepsis meningitis protocol. Welcome to our participants in person and via
webstream to our fourth day of NHSN training. You are almost there, light at
the end of the tunnel, right? So this morning we will discuss laboratory
confirmed bloodstream infection events or primary BSIs. My colleague, Kyle Puckett will discuss
secondary BSIs in a later session. So, I wanted to show you this picture. This is a picture of my husband in preparation for his student-teacher basketball
game [laughter]. I wanted to show you this picture to let you
know that you– this is a no judgment zone, OK? [Laughter] It is OK if you don’t know
all of the answers or understand all of the concepts that we’ll be going over today. And it’s also OK if you want to wear neon
socks and walking shoes for a basketball game. But we are in this together, so whether you
are and had been an infection preventionist for two years or 20 years, I hope that
you will learn something new today. So by the end of this presentation, we hope
that our participants and users will be able to locate the trainee resources
protocol and supporting materials, define key terms for device-associated
infections specifically for CLABSI, discuss device-associated infection
surveillance changes for 2018, describe the data collection
process for key NHSN locations, and then identify our case studies correctly. We’re going to have a pretty extensive
tabletop case study at the end, so it’s very important that
you take really good notes. So, this slide is a testament to what we
as infection preventionist already know and understand, that the awareness of data
drives our interventions in preventing CLABSIs and other health hospital associated infections. The publication on this data has led to an
awareness that has resulted in a 46% reduction in the occurrence of CLABSIs
between 2008 and 2013. These numbers come from the 2014 publication of the CDC’s national and
state HAI progress report. A 46% reduction is a really
huge accomplishment that has– corresponds with countless lives
saved and then estimated $36 million– to $40 million saved through cost avoidance. This is really amazing work but we
cannot stop until we get to zero. The current estimate suggests that about
30,000 CLABSIs still occur annually this year. When we collect sound data, we can make informed
decisions on how to improve patient care. Part of collecting sound data is
ensuring that we all stay abreast of the most recent resources
to identify infections. So, I’m going to make this
a little bit bigger for you. So, the protocol tab contains
Chapter 4, which is our protocol for bloodstream infection event surveillance
that we will discuss in great detail today, as well as Chapter 2, which
provides a foundation in how to identify healthcare associated infections. Under the Training tab, you’ll
find numerous training videos and the slides that go with them. These resources are kept current and new
content is added as it becomes available. Actually the sessions that have been conducted
this week will be available in late spring. The Frequently Asked Question
tab contains just that. The frequently asked questions about bloodstream
infection surveillance contains answers to some of the most frequent and most difficult concepts
related to bloodstream infection surveillance. It is in an HTML’s format sorted
by topic so you would just click on the appropriate question that you have. Under the supporting material section, you
will find important resources like Chapter 17, which is the site specific infection
definitions for secondary BSI determinations. In addition, you will also
find the NHSN Organism List that you will need for BSI surveillance. The Organism List is an Excel file
with individual tabs for all organisms, common commensals and MBI organisms. Make sure that you are referencing
the most recent correct list. So, let’s move on to some
key terms and definitions that you will be using in
identifying BSI events. The infection window period is a seven-day
period in which all BSI criteria must be met. It includes the collection data of the first
blood specimen that identifies the organism, the three calendar days before
and the three calendar days after. The date of event for laboratory-confirmed
BSI criterion 1 will always be the first date and element that is used to meet– I’m sorry,
will always be the date of the blood culture that identifies and recognize pathogen. The positive blood specimen with a
recognized pathogen is the only element that is needed to meet this criterion. The date of event for LCBI 2 or 3 will always
be the firs t date and element that is used to meet the LCBI 2 or LCBI 3 criterion that
occurs within the BSI infection window period. There are two elements needed
to meet these two criterion, a symptom and the two blood specimens
identifying matching common commensals. If the blood specimens are
collected on consecutive days, they are considered a single
element for meeting the criteria. So the date of the first one would
be used as the first date of the date of the first positive diagnostic test that’s
used to determine the infection window period. A laboratory confirmed bloodstream infection
is a primary BSI and there is an organism cultured from the blood that are not
related to an infection at another site. In other words, they are the
LCBI 1, 2, and 3 criteria. Primary BSIs do not have a
secondary BSI attribution period. Secondary BSIs are bloodstream infections that
are not reported as LCBI because it’s associated with the site-specific infection at another
site which has seeded the bloodstream. Secondary BSIs do not create a repeat infection
timeframe but rather the primary site of– site-specific source of the secondary
BSI creates an RIT and note no infections of that specific type will be reported. The SBAP is a new acronym
that we’re using this year. Secondary BSI attribution
period is not a new term. It’s the period in which a
blood specimen must be collected for a secondary BSI attributed
to a primary site of infection. The SBAP is made up of the infection window
period and repeat infection timeframe and is 14 to 7 days depending on the date of event. An eligible BSI organism is any organism
eligible to meet LCBI or MBI-LCBI criteria and it is not an excluded organism. Any organism not on the common commensal
list is considered a recognized pathogen for reporting primary LCBIs
with these exceptions. There are two organisms added to the list this
year of organisms excluded from LCBI criteria, enterohemorrhagic E. coli and Vibrio species. You may notice that al of these excluded
organisms are enteric organisms or gut bugs. These organisms are eligible for
use in secondary BSI determinations but will not be reported as
sole pathogens for primary BSIs. Organisms in the right column are
excluded from all NHSN definitions just as they were in the previous year. These infections are almost
always community acquired and tend to have really long incubation periods. And they could be incorrectly
identified as healthcare associated if this exclusion were not in place. And we still have an exclusion for
group B strep as a causative agent for CLABSI in the first six days of life. Group B strep often cause infections in
newborns as a result of vertical transmission or from a passage through the birth canal. These events like the intravenous drug
abuse exclusion are considered LCBIs and will create a BSI RIT but are
not associated with a central line. A central line is an intravascular catheter that
terminates at or close to the heart or in one of the great vessels, which
is used for infusion, withdrawal of blood or hemodynamic monitoring. Neither the type of the device or the
insertion site will be used to determine if a line qualifies for central line. Patients must have one or more qualifying
lines to be included in CLABSI surveillance. Infection surveillance for NHSN is not aimed at
a particular device but instead of identify– but instead, identify risk to the patient
as a result of general device use. This is a list of the great vessels for use
in making determinations about central lines for CLABSI reporting and device day counts. If a line has a lumen and terminates at or
close to the heart or one in of the vessel, great vessels and use for the purposes
listed above, it is a central line. Once it is deemed a central line, it continues
to be a central line until it’s discontinued, meaning physically removed from the body
or discharged, whichever one comes first. There has– There are situations in which a
line may migrate out of its original location. But once you have verified that that line is in
the correct location and it meets the criteria for a central line, it is included in CLABSI
surveillance and also device day counts. So for NHSN reporting purposes,
central lines will either be temporary, permanent and in neonates they
can be umbilical catheters. A temporary line is a non-tunneled,
non-implanted catheter. A permanent catheter is tunneled, a
tunneled catheter or an implanted port. Oftentimes you’ll see hemodialysis
patients with these lines. An umbilical catheter is inserted through
the umbilical artery or vein in a neonate. It is only necessary to distinguish between a
temporary and a permanent central line reporting for specialty care areas such as
oncology, hemodialysis or transplant units. In these locations, central lines are stratified
by a line type for monthly denominator reporting because these specialty care areas
serve high risk patients populations, and therefore are likely to use permanent lines
because they have a lower risk of infection when compared to use of temporary lines. Other than specialty care areas, it is likely
for patients to have more than one line. When multiple lines are present in the same
patient, report only one central line day. One– report only one central line. Going back to specialty care areas, if a patient
has a permanent line and a temporary line, you would only count the temporary line. So this is a list of devices that are
considers central lines for NHSN– that are not considered central
lines for NHSN reporting purposes. Another device was added this
year, Atrial catheters also known as transthoracic intra-cardiac catheters. An introducer is down here by its lonesome
because it may or may not be a central line but you must asses for the location
where the tip of the catheter terminates and assess the uses, the reasons
for which the device is being used. Access has been defined for
2018 as the performance of any of the following activities during
the current inpatient admission. Line placement, a needle into the port or any– or infusion withdrawal of blood or
uses for hemodynamic monitoring. An eligible central line is a central
line that has been in place greater than two consecutive calendar days following
their first access of the central line in an inpatient unit during
the current admission. They are eligible for CLABSI events
until the day after removal from the body or patient discharge, whichever one comes first. Dialysis patients who have a
central line that is only used by a dialysis personnel are
included in central line day counts for the location where they are housed. And the patient must be included in
CLABSI surveillance and also device or denominator counts must also be performed. Central line-associated BSIs or CLABSIs are
laboratory confirmed bloodstream infections where an eligible BSI organism is identified
and an eligible central line is present on the LCBI date of event or the day before. Table three on page 4-16 provides examples that
illustrate device association as determined by the presence of an eligible central line
on the BSI date of event or the day before. The CLABSI event eligibility, in addition,
it also shows CLABSI event eligibility based on the presence of an eligible central
line one or after central line day three. Patient A becomes eligible for a CLABSI on 4/4
because an access central line has been in place for some portion of greater than
two consecutive calendar days, make it in an eligible central line on 4/4. A central line remains eligible
for a CLABSI until it is removed or the patient is discharged,
whichever one comes first. Patient B is eligible for
CLABSI on 4/4 through 4/5. An access central line had been in place greater than two consecutive calendar days making
it an eligible central line on 4/4. A bloodstream infection date of event on
the day of or the day after device removal or patient discharge is considered
device associated or CLABSI. Patient C is eligible for a
CLABSI on 3/31 through 4/6 because an access central line had been in place
greater than two consecutive calendar days. A BSI date of event occurring on the
day of or the day after device removal or patient discharge is considered a
device– device associated infection. The patient remains eligible
for a CLABSI event through 4/6 because a full calendar day did not
elapse without a central line in place. The device days continue– device
day counts continue uninterrupted. Patient D is eligible for a
CLABSI on 3/31 through 4/3. An access central line had been in place
greater than two consecutive calendar days. However, a full calendar day passed
on 4/3 with no central line in place. Therefore, device day count start over on
day one when a new central line was placed. After 4/3 that the device– the patient will
not be eligible for a CLABSI again until 4/6 when a new central line becomes an
eligible central line on calendar day three. So let’s move on to some new changes
and/or revisions to 2018 protocol. So we get a lot of questions about
whether or not we can exclude a CLABSI. The intravenous drug abuse exclusion
is not necessarily a new exclusion but we just want to supervise
some clarification. So this exclusion is provided for observed or suspected patient injection
into his or her vascular access. Please note that this exclusion requires
observed or suspected patient injection. Behavior such as picking or biting or sucking from the central line access is
not eligible for this exclusion. The documentation must indicate
that the observed or suspected injection occurred during
the IWP of the positive blood culture. The documentation cannot– has to be
extremely specific and it has to have dates. So, in some of the documentation
that we’ve received from– in emails and users, we’ve seen them
document things like we suspected that the patient injected into
their site during, during so that central line during the hospitalization. It has to be specific dates. And also, we have added an exclusion for
the presence of the ECMO or VAD device. So if the device has been in place
greater than two consecutive calendar days on the bloodstream infection date of event
and still in place on the date of event or the day before, an exclusion
will be provided. There is an optional fill located
on the BSI event form for 2018 but it will be a required fill in 2020. If the patient meets criteria for
either of the above exclusions, you would enter central line
equals no in the NHSN application. It would be an LCBI event and a
14-day BSI RIT would be created with day one being the date of event. And here is a screenshot of the two fills
for ECMO and VAD on the BSI event form. So, epidermolysis of bullosa is
a genetic connective tissue– skin disorder that makes
the skin extremely fragile. This disorder causes the
skin to blister and tear. EB patients tend to develop wounds
that are very heavily colonized with microorganisms placing them at an
increased risk for bloodstream infections. And additionally, it’s very
difficult to culture these individuals because the process is just too painful. An exclusion is provided for this condition if the clinician documents this disorder
during the current patient admission. Munchausen syndrome by proxy also
known as factitious disorder imposed on another is a mental illness condition in
which a caregiver makes up or causes injury on to a person under their care for
the purposes of personal attention. To meet criteria for this exclusion,
a clinician must document suspected or confirmed diagnosis during
the current patient admission. Both of these exclusions–
in both of these exclusions, you would enter central line
equals no in the NHSN application. It would be an LCBI event and a
14-day BSI RIT would be created with day one being the date of event. The fills for EB and Munchausen syndrome
by proxy are currently not on the BSI form. However, they will be an optional fill
in 2019 and required filled in 2020. So this is a hot bun topic, isn’t it? So for central lines, do we count
days of admission or days of access? Well, the simple answer to
this question is both. For device days for denominator
counts you will start on the first day the central line is
present on an inpatient admission. If the line is inserted during
the current admission, day one is the first day the central line
is present on an inpatient admission. If the central line was present– If the
patient came in with the central line, day one is the first day that the patient
is admitted to an inpatient unit regardless of whether that line has been accessed or not. This is different from the 2017 protocol
in that the line was not counted on– as in the denominator until
that line was accessed. The second count is for the central line days for device attribution or
counts for the numerator. And we’ve kind of reviewed that
a little bit in previous slides. But to attribute a central line to a BSI
event, you must count the days of access. A central line becomes an eligible central
line for CLABSI once the central line has been in place for greater than two
consecutive calendar days. So let’s look at a couple of tables
to further explain this concept. So this table is pretty straightforward in
that the device days for denominator counts and the central line days for device
attribution start on the same day. Patient A was directly admitted
to an inpatient unit on 8/5 and a central line was placed on this day. In comparison, this table speaks to
a patient who was admitted to the ED with a hemodialysis central line in place. So the patient was admitted on 12/31 and then
he was admitted to the medical ICU on 1/1 and his device for denominator
count start on this day. Because a central line was not accessed
until 1/3, his central line days for device attribution was start on 1/3. The patient would have an
eligible central line on 1/5. So I really don’t have to
go over this slide, do I? I had originally the title of this slide. Why do we have to keep explaining
this to clinicians? [Laughter] Well, we often
have to do it, don’t we? So every IP knows that there’s a difference between surveillance definitions
and clinical diagnosis. Surveillance definitions are intended
to identify trends in the population to guide prevention efforts
or for research and we try to keep those definitions
as objective as possible. Clinical diagnosis, identify disease and
treatment needs in individual patients. And clinical judgment and
subjectivity is highly valuable. But how many times have we marched in to a board
room or a nurse manager’s office or even spoke to a physician with our manuals in hand
and maybe eye of the tiger in their heads as they walk and try to explain
to them that there is a difference between a clinical diagnosis and surveillance. And perhaps I’m the only one with eye on the–
of the tiger in my head when I’m on my way to the boardroom but whatever works for you. So let’s move on to laboratory
confirmed criteria. So this is a hierarchy of laboratory
confirmed bloodstream infections. As mentioned earlier, all BSIs will either
be a primary source of infection or secondary to another site specific infection
like a UTI or an SSI, an ammonia or any of the Chapter 17 definitions. In other words, the criteria are– or a
LCBI 1, LCBI 2 and 3 because we all know that these are primary sources of infection. There are no site-specific
infections that are related to this bloodstream– these blood specimens. So this is a step by step process,
well, that will kind of walk you through how to make a BSI determination. CLABSI surveillance will always start
with a positive blood specimen, right? Never fails. So, whether there is culture based or
non-culture based in your head when you see that blood culture you know that there
is something that needs to be done. There are some intervention that needs
to be done and you need to figure out where you need to move on from there. So first you want to determine
the infection window period. Determine the elements present in the IWP. Consider the organism and
determine the date of event. Determine if it’s POA or HAI. And if it’s POA you can stop
because there’s nothing to report. However if it’s a healthcare
associated infection, you need to determine the device
association and location of attribution. Determine the repeat infection
timeframe and determine if another site specific
source of infection is present. If it is secondary, then you would
go on– go to reported it as a– There’s no LCBI to report,
you would go to secondary BSI. If it is not secondary, then you
need to determine if it meets LCBI 1, 2 or 3 based on the organism and
the symptom if it is required. All blood specimens, regardless of
the collection site or the reason for which they were collected must
be included in CLABSI surveillance. So even if for whatever reason, the blood
culture is collected without an order or for whatever reason all blood cultures and positive specimens are
eligible for CLABSI surveillance. So LCBI 1 is identified in a patient of any
age that has a recognized pathogen from one or more blood specimens by a culture or
non-culture based microbiologic testing method. The organisms identified in the blood are
not related to an infection at another site. If it is secondary to a primary
source of infection, it will not be reported to
NHSN as an LCBI or a CLABSI. The primary source may be reported
depending on your monthly plan or state mandates but the
secondary BSI will not. Primary BSIs are identified by ruling out
a site– secondary or site specific source. A bloodstream infection cannot have– cannot
be secondary to a bloodstream infection, therefore primary BSI will never have
a secondary BSI attribution period. And, again, Kyle Puckett will be discussing
secondary BSIs in another session. So let’s see if you– I’m going to
read a scenario and I want you all to get your clickers ready, but we’re
going to look at a scenario here. So, Mr. Rhoades was admitted on June
3rd to CCU after having a heart-attack. A central line was placed on June 4th in CCU. On June 7th, Mr. Rhoades started to
become confused and complained of chills. The blood culture was collected and resulted
as Serratia marcescens, a recognized pathogen. And no other source of infection was identified. So the question is, is it an LCBI? I’m going to ask for you to hold
your responses for a few seconds and now you may make your determination. Few more seconds. OK, I’m going to close the poll. Let’s see how you did. All right. So, Mr. Rhoades did meet
criteria for an :LCBI 1. So let’s talk about why. Mr. Rhoades had a positive blood
specimen for Serratia marcescens on 6/7. The blood culture is the only
element used to meet LCBI– what LCBI 1, so for that reason
it is also the date of event. A 6/4 to 6/7 infection window period is
created based upon the 6/7 blood culture. It is a central line-associated event
because the central line was in place on four calendar days on the date of event
and an RIT is established of 6/7 to 6/20. LCBI 2 and 3 definitions are the same with the
exception of the symptoms that are eligible for meeting the criteria
because they are based on age. LCBI 2 can be used in a patient of any age and those symptoms would include
fever, chills or hypotension. LCBI 3 provide symptoms that are more likely to
be present in children and therefore can be used in children less than or equal to one year
of age and they might show symptoms one of– show symptoms of one of the following,
fever, apnea, hypothermia or bradycardia. In addition to the age and symptom differences,
the infection identified is not related to an infection at another site and the
common commensals drawn on separate– are drawn on separate occasions on the same
or consecutive days and they are matching. Only genus and species are used to
determine the sameness of organisms. If one organism is less definitively
identified than the other, the identifications must be complementary. So for example, if you have a blood
culture growing coag-negative staph and another blood culture growing Staphylococcus
epidermidis, they are considered a match because Staph epidermidis
is coag-negative staph. However, if you have a blood
culture with coag-negative staph and another one growing Staphylococcus,
they are not considered matching, because Staphylococcus can be
coagulase-negative or coagulase-positive staph. This bottom table can be found on page 418
of the protocol and can help answer questions about reporting differing lab results. You always report the highest
level of identification. So for example, if you have one culture
that identifies d coagulase-positive staph and Staph aureus blood culture that
is found in the companion culture, you would always report Staph aureus. Or for example you have enterococcus species
in one culture and the complementary culture or the companion culture reports E.
faecium, you will report E. faecium. So let’s look at another patient, Ms. Lead. So on August 18th, Ms. Lead was
admitted to the oncology ward and a central line was placed
for parenteral nutrition. On 8/19 she developed a fever
of 102 degrees Fahrenheit. On 8/21 she had two positive
blood cultures that were collected that grew coagulase-negative staph. On 8/22 there were repeat blood cultures
collected that also grew coag-negative staph. No other source of infection was identified. So what is the date of event? I’m going to wait for the poll to open,
and now you can make your determination. What is the date of event? Is it 8/21, 8/19 or 8/22? Give you a few more seconds. And I’m going to close the poll. See how you did. OK. You guys did pretty well. So that is correct, the date of event was 8/19. So I have another question as well
for you to make a determination. I’m going to wait for the polls to open. Is this a POA or HAI event? You can make your response
now, A for POA or B for HAI. I’m going to give you a few more seconds. OK, let’s see how you did. OK, so you all did well. You’re correct, 85% of you
got present on admission. So let’s explain the rationale. So, Ms. Lead had two positive blood specimens
for coagulase-negative staph on 8/21. The 8/21 positive specimens create an
8/18 to 8/24 infection window period. On 8/19, the patient developed fever, and
this is identified as the date of event because it’s just the first element
in the IWP used to meet the criterion. And you will also notice that the date
of event occurs during the POA timeframe, which is usually the date of admission,
the two days before and the day after. So for that reason, the patient
met criteria for POA LCBI 2. So let’s look at another scenario,
and this is to determine whether or not the patient would meet criteria for an
LCBI 2 or 3 using fever for the LCBI 2 criterion or 3– or bradycardia with the LCBI 3 criterion. Just going to read the scenario and I
want you to just tell me the answer. March 1st, the four-month-old
Baby Michelle was admitted, was afebrile with no symptoms of infection. On March 2nd, the patient developed
a fever and periods of bradycardia. Two cultures were collected but
only one specimen grew diphtheroids. Does this meet LCBI 2 or 3? The answer would be no. Sorry. Because to meet LCBI 2 or 3 you must
have at least two matching common commensals and in this case you only had one
positive specimen for diphtheroids. So let’s look at Baby Boy
Pearson and an LCBI 3 scenario. And again, you will just tell me what
your answer is once I read the scenario. So 7/5, Baby Boy Pearson was admitted to
NICU after being born one month premature. On 7/8, the baby had new onset of
apnea and a central line was placed. On 7/9, he developed a low grade fever
of 100 degrees Fahrenheit and two sets of blood cultures that were drawn separately
and both of those are growing Strep viridans and no other source of infection was identified. So did this patient meet LCBI 3 criteria? The answer is actually, yes. So let’s looked at why. So the Strep viridans blood cultures on 7/8
create a 7/6 to 7/12 infection window period. And during that infection window period, the
patient develops apnea, which becomes the date of event, because that’s the first element
within the BSI infection window period. This is an HAI event because the event occurred
on– date of event occurred on day four. So let’s move on to MBI-LCBI criterion
or mucosal barrier injury-LCBIs. They are a subset of LCBIs. So before you can determine whether a
patient meets MBI-LCBI you must meet LCBI criteria first. The MBI-LCBI criteria enable NHSN to identify
bloodstream infections that are believed to be the result of gastrointestinal
translocation due to a patient’s weakened immune
system or altered gut. They are considered primary BSIs because there
is no identifiable infection at another site, while with the gut it’s believed
to be the seeding source of the bloodstream infection
with colonizing organisms. MBIs are reported into NHSN but
since 2015 with the rebaseline, they are removed from the data shared
with CMS for reimbursement determinations. So this is our MBI-LCBI table that can
be found on page 4-10 in your protocol. It was created by my colleague
Kyle Puckett that condenses all of the criteria for MBI-LCBI into one table. So MBI-LCBI criterion 1 can be identified in
a patient of any age that meets criteria first by LCBI 1 with at least one blood
specimen identified by culture or non-culture based microbiologic testing, with only intestinal organisms
from the MBI Organism List. Please realize that not all intestinal
organisms are on the MBI Organism List and not all MBI organisms that you’ll find
on that list are intestinal organisms. A partial list is available
on page 4-26 in your protocol or you can review the MBI organism
tab on the NHSN organism list. So in addition to having a blood specimen
being positive with an intestinal organism from the MBI Organism List, the patient
must have at least one of the following. They must be an allogeneic hematopoietic stem
cell transplant recipient within the past year with one of the following documented during the
same hospitalization as positive blood culture. Grade III or grade IV gastrointestinal graft
versus host disease or greater than or equal to 1 liter of diarrhea in a 24 hour period
or in patients less than 18 years of age, they must have greater than or
equal to 20 cc’s per kilo in weight. The onset must be within seven days
before the date of the positive culture. Or they could meet element 2 for
neutropenia, which is defined at least– as at least two separate days with
values of absolute neutrophil count or total white blood cell count less
than 500 cells within a seven day period which includes the day of the positive culture
or specimen, the three calendar days before and the three calendar days after. So this is a table that better explains
and it provides a nice visual as how– as to how you can meet the
neutropenia criteria for MBI-LCBI. So when you look at this, this
particular table, the ANC or WBC– WBC values are eligible for use but they
must occur within a seven day period which includes the day of the positive
culture three calendar days before and three calendar days after. This timeframe kind of does look like
an infection window period, doesn’t it? But you must remember that the infection
window period and also the date of event for MBI-LCBIs was already
determined by the LCBI. For the purposes of meeting MBI-LCBI
criteria, low ANC or WBC levels are indicators or risk of infection and not
necessarily symptoms of infection. Therefore they are not considered
elements when meeting this criterion. This table in the protocol provides guidance
on how to correctly identify or determine ANC or WBC values that are eligible for
use when using MBI-LCBI criteria. So, on the first example, you have an
individual who meets LCBI 1 criteria with a Candida positive specimen. In addition to that, within a seven-day
period, they also have a WBC level of 320 on negative one and on day one a level of 400. So this patient would meet MBI-LCBI criterion 1. I wanted to show you this, so this
kind of gives you a calculation on how to calculate absolute neutrophil count. Well, please know that if your
laboratory already provides a formula, you do not need to use this particular formula. This is just for you to use if your
hospital laboratory does not provide one. So let’s look at another patient, Ms. LaBell. So on July 13th, Ms. LaBell had a
central line inserted on admission. On July 16th she had an ANC level of 400 cells. On July 17th, two positive blood cultures
were drawn for Enterococcus faecalis. On July 19th, the WBC level of 210 cells and
no other source of infection was identified. So, did this patient meet
criteria for an MBI-LCBI 1? I see a lot of head nods, yes. And that would be correct. So the patient initially met criteria for LCBI
1 on 7/17 and that is also the date of event. But during this seven-day period,
the patient had both an ANC and a WBC level that were less than 500 cells. And please note that you can use either two
WBC levels, two ANC levels or a combination of the two to meet the neutropenia
element for MBI-LCBI criteria. So we’ve already discussed LCBI
2 and 3 and the differences in the symptoms that are used based on age. MBI-LCBI 2 and 3 require only viridans
group strep and Rothia species. Both viridans group strep and Rothia are
both common commensals and MBI organisms. You may also notice that Rothia was
not– Is currently not in your protocol. This is an oversight on our part but please
note in your handouts and also on your protocol that Rothia can also be used
to meet MBI-LCBI 2 or 3. In addition to these organism requirements,
you must meet one of the following, the first element being an allogeneic stem cell
transplant with transplant patient with graft versus host disease, sorry,
or qualifying diarrhea. Please note that no other symptoms as mentioned
in this criterion, when it mentions that, so if you have a common–
A single common commensal, please note that that will not change
your determination for an MBI-LCBI. However, when a blood specimen that is
positive for an organism that is not included on the NHSN organism list is collected
during the BSI RIT of an MBI-LCBI, the initial MBI-LCBI event would–
must be added to an LCBI criteria. Is everyone tracking that? OK. So this is just an example of how to meet
MBI-LCBI 2 using the neutropenia element. So we have an individual who
tested positive for a group– strep group viridans group
times 2 and also had a fever. So they met LCBI 2 criteria. So then we can look at their
WBC or ANC levels to determine if they meet the neutropenia criteria. And in this case, the patient have more
than two of the required ANC or WBC– ANC levels less than 500 to meet this criteria. So for this reason, this
patient would meet MBI-LCBI 2. You’ll also note that the patient also
had two ANC levels less than 500 cells that were out of that seven-day period. Please note that they cannot
be used to meet this criteria. It must be within that seven-day window. So let’s move on to some
tips for data collection. The accuracy of NHSN data
is dependent on the accuracy of surveillance determinations,
data collection and data entry. It’s very important that we get accurate
numerator numbers by strict adherence to the definitions and reporting instructions
and that we also get accurate denominator data by mapping our locations correctly
and collecting device days and patient days accurately
depending on the location type because they can have specific requirements. So I wanted to show you the BSI Event
Collection Form and this can be found under the data collection tab in the
BSI event section of the NHSN manual. And also, this is what it would
look like in the NHSN application. So this slide or table basically provides the
denominator requirements by location and device, and we’ll kind of go into
more detail in later slides. So basically all locations would collect
central line days and our specialty care areas like oncology and dialysis, they
would collect central line days, both permanent and temporary lines. However if they have– individual has
both a permanent and a temporary line, they would only count the temporary line,
and they would also count patient days. In NICU, they would count both central
line and patient days by birth weight. As you can see here, if the central
line denominator data is incorrect, they can impact your SIR. This was very important that we’re ensuring that
we’re counting our central line days correctly and then ensuring that we have validated our
electronic data against the manual method. So this is just examples of the collect–
the data collection forms both on paper, because I love paper, and then
also the NHSN application. So for all locations, for ICUs
and wards for all locations, you would count at the same time each
day the number of patients on the unit and the number of patients with a central line. And then for our specialty care areas, you
would count the number of patients on the unit, the number of patients with
a permanent central line, the number of patients with a temporary line. However, if they have both a
permanent and temporary line, you would count the temporary line. And these are the denominator
forms for our NICU population. And you would count the number of
patients on the unit by birth weight, as well as the patients with the
central line by birth weight. The electronic collection of summary data
is fine but you must collect three months of concurrent data with both
electronic and manual counting, and the differences must
be within plus or minus 5%. The once weekly denominator collection
reduces NHSN data collection burden. But for eligible ICU and ward location
types, you may use this method if you have 75 or more central line days per month. Patient days would be collected daily. Central line days would be collected on a single
day once a week, and this is just an example of birth to– as of Tuesday
is used as the example. And this is an– just an application of
entering your summary data into the ICU wards. So I wanted to briefly go over
the NHSN BSI protocol changes. We had a new acronym, although not new– the
term was not new but the acronym was SBAP which stands for secondary
BSI attribution period. We had two definitions, new
definitions, eligible– eligible organisms and eligible central line. Devices that are not considered central lines, we added to the list this
year, atrial catheters. And then we discussed the CLABSI exclusions
for ECMO, VAD, epidermolysis bullosa and Munchausen syndrome by proxy. And then we clarified how to
count central line counts, so we know that there’s two ways to count. There are device days for denominator counts and then there are central line
days for device attribution. So in summary, CLABSIs result
in a significant morbidity, mortality and United– in
the United States Hospitals. But must– much progress has been made but the
journeys still continues until we get to zero. Clinical and surveillance definitions
will sometimes different– differ. The intention is the same but
the methods are quite different. Surveillance definitions must be
adhered to strictly and consistently. We’ve located the protocol and training
materials on– the NHSN website. We reviewed some key terms and
definitions specifically to CLABSI. We reviewed the 2018 protocol with
changes, and we briefly went over the forms and data collection tools for BSI events. And now we’re going to move on into– and then
we’ll eventually move on into our case study. These are your resources for BSI reporting. And if you ever get an opportunity,
please try to– well, please use the NHSN case study studies. There’s a good way to kind of test your
knowledge and to just see where you are with infection prevention protocol. And now we’re going to move
in to our case study. Yey. We’re now through that. So what we’re going to do is the case
study is a progressive case study. So what we’ll do is tables 1
through 10, we’ll have an answer– we’ll have to answer case study level 1. And we will have– you’ll have to select one
spokesperson to answer four of the questions for the case study and we’ll go over
the scenario and also the questions. Tables 11 through 20 will
have level 2 questions, so you will have to select
a spokesperson to come up to the mic and answer those four questions. And tables 21 through 28 will
answer the level 3 questions. And you will have four questions with that. For the individuals that are answering the level
3 questions, there are two calendars there. There’s a February calendar for both
central lines for device day attribution and also your denominator counts, and there’s
also a March calendar for denominator counts and also central line days
for device attribution. And I’m going to give you about five
minutes to answer the first questions for the level 1, for just level 1. You should have– you should
have copies of the handout. Oh, I’m sorry, I forgot table 30. I’m sorry. So you would go with both– between 21 and
30 would answer level 3 questions, level 3. So we’re going to go over
level 1, just a scenario, and the four questions that we’re going to ask. Lever 3, you have a little bit more
time to answer the questions, OK? So our scenario involves Mr. Beau Blue. On 2/11, the 55-year-old male was
admitted to the ED with rectal bleeding. The peripheral IV line was placed. The patient has a past medical history
of end stage renal disease and diabetes. He has a right internal jugular
permanent HD catheter in place and his last HD was performed on 2/10. On 2/12 he was admitted to the renal floor. On 2/13 the patient refused hemodialysis. On 2/14 he consented to HD,
and HD was performed. On 2/16 his WBC level dropped to 0.4. On 2/17 he had a WBC level of 0.3. He had a fever of 102 degrees Fahrenheit and
blood cultures were collected for Pseudomonas– tested positive for Pseudomonas times 1. On 2/18, he had a WBC level of 0.2 and
a hemodialysis central line was removed. A new HD central line was placed
in the right internal jugular. And no site-specific infection was identified. So question one is, what
criteria did Mr. Blue meet? Did he meet A, LCBI 2; B, MBI-LCBI 1; C, LCBI
1; D, the patient did not meet any criteria. The second question is, is this a POA event? Question three is, is this central line,
this event central line associated? And question four, what is the date of event? One more thing, that if you cannot find
your information on your resource manual, in your handouts or your notes,
feel free to use your manual and also any of the resources online. OK, are our level 1 people ready? Do we have a brave soul that
wants to answer the questions? Please come up to the mic.>>I got it.>>OK.>>We have it, if we mess this one up we are in trouble.>>OK. So for the first question,
what criterion did Mr. Blue meet?>>C, the LCBI 1.>>Absolutely. Good job. All right, the next one?>>HAI, B.>>Good job.>>Question three, is it this
event central line associated?>>Yes.>>Yes, it is. Question four, what is the date of event?>>2/17.>>Good job. What– What table are you, what table are you
sitting, where are you sitting [applause]? What table are you sitting at? Let’s give table 9 a hand. [ Cheering and Applause ] OK. So let’s look at why Mr. Blue
met criteria for LCBI 1 on 2/17. So Pseudomonas for first is not an MBI
organism, it is a recognized pathogen. And because there’s only one element
to meet LCBI one which is the date of the positive specimen,
the date of event is 2/17. It also creates an infection window period
of 2/14 to 2/20, and then RIT as well. It is a central line associated event because
the hemodialysis central line was accessed on an in patient unit greater than two calendar days. Excellent job table 9. Is level– are level 2 folks ready? Do we have a volunteer to come up to
the mic and answer the four questions? So before you start I’m going to go
ahead and read the scenario for 2. So Mr. Blue is still with us on 3/5. He develops a fever of 103 degrees
Fahrenheit, has a WBC level of 0.3 cells. On 3/6, the blood culture collected is
positive for Streptococcus mitis times 2 and they were collected in separate occasions. On 3/7 he had a fever of 101 degrees Fahrenheit. He had an ANC level of– on 3/8 of 0.4 cells. On 3/9 he had a fever of 101 degrees
Fahrenheit and also WBC level of 0.4 cells. The hemodialysis central line was still in place
and no site-specific infection was identified. So what criteria did Mr. Blue meet?>>We agreed, B.>>Actually the–>>Or C. [ Laughter ]>>So the patient actually met MBI-LCBI
2 because Streptococcus mitis is part of the viridans group strep group, and
we’ll talk a little bit more about that. So let’s move on to question two. What is the date of event?>>So, 3/5.>>Very good. Question three?>>Yes.>>Very good. And then question four, guess
I’m giving that away, but how would you enter this
event in the NHSN application?>>As a mucosal barrier injury, LCBI 2.>>You would enter central line equals yes.>>Yes.>>And then what would you select under
the underlined conditions for MBI-LCBI?>>So we’ll select fever. We’ll select A and C neutropenia.>>Very good. And then you would enter the
organisms under pathogen one.>>Correct.>>OK, very good. What table are you– Where are you sitting?>>Fifteen, the only one.>>Fifteen?>>Yes.>>Good job. [ Applause ] So let’s look at Mr. Blue’s rationale. So Mr. Blue met criteria
4 and MBI-LCBI 2 on 3/5. He had two positive blood cultures
that were collected separately for Streptococcus mitis on March 6. And then the patient also developed, because this is a common commensal,
you have to meet LCBI 2 first. The patient also had a fever during the
infection window period on March 5th. The patient also had two levels or two findings
of WBC or ANC levels less than 500 cells on March 5th and also March 8th, and
you would enter central line equals yes on the NHSN application. Good job. So I’m going to
go ahead and read level 3. And again, it’s a progressive case
so it builds upon the previous level. So on 3/18, Mr. Blue is still with us. He has a positive fever– has
a fever and two blood cultures for coagulase-negative staph times 2. These blood cultures were
collected on separate occasions. On 3/19, the WBC finding was 0.3 cells. The patient had a new HD central line. The central line HD was removed and
a new central line was placed on 3/21 and there are no site-specific
infections identified. So these were the questions. What criterion did Mr. Blue meet? What is the date of event? What were the denominator counts for
this HD catheter on the date of event? And keep in mind that February had 28 days. And what were the device days for central
line attribution on the date of event? OK. So, who would like to
answer the level 3 questions? OK, let’s give her a hand
as she comes to the mic. [ Applause ]>>OK, question one is A. B?>>It’s actually B.>>How is it B?>>I’ll show you in just a few minutes.>>OK, good, because we’re confused by that.>>What was the date of event?>>I have no answer to that since you just
changed my answer [laughter], 3– A. No.>>No actually–>>We had A.>>3/5.>>We got that right. Yey.>>How many days are included in the
denominator counts on the date of event?>>Twenty-two.>>Absolutely, good job.>>And–>>OK. And so, the number of calendar days
between February 12 and February 28 was 17 days, and you had 5 calendar days between March
1st and March 5th, which made a total of 22 denominator days on
3/5, the date of event. So what were the device days for central
line attribution on the date of event?>>That would be C, 20.>>Very good. So let’s talk about– We
just back up one second. So the HD central line was accessed on
February 14th and there were 15 calendar days between February 14th and February
28th, and between March 1st and March 5th there were five calendar
days making a total of 20 central line days for device attribution on the date of event. So let’s go back to question one and
why we met the criteria that we met? So remember when we discussed
in the presentation that when a blood specimen that’s positive
for an organism that is not included in the NHSN MBI organism list and is
collected during the BSI RIT of that MBI-LCBI, the initial MBI-LCBI event would be edited
from an L– edited to an LCBI event. Does that make sense? OK. And this can be found on page 4-15. So let’s explain why. So remember initially when we met
MBI-LCBI on 3/5 with the fever and the positive blood culture,
and the event date was 3/5. But because coagulase-negative
staph is not an MBI organism and because it occurs during the RIT of
that MBI-LCBI event, that event would have to be changed from an MBI to an LCBI event. Why were we told that we did not have to change it from a MBI-LCBI to a LCBI? I’m going to have to phone
our friend on that one. [ Laughter ]>>So this– It is a unique situation. All right. And the rationale for it is that when the MBI
criteria were developed, the intention was never to forgo calling another infection that
is actually probably central line related. So if we don’t do this, what could potentially
actually really be a CLABSI and not do to the MBI would be, would be over. You know, you wouldn’t be calling
it, so that’s the reason for it. But you’re right, if what
we had said was you do– you wouldn’t go back and change the
central line attrib- attribution or a catheter attribution, you
wouldn’t go back and change that. That’s what we referred to.>>OK. Do we have any other questions?>>I have a question.>>Yes?>>How do you use Munchausen by proxy–
use Munchausen syndrome as an exclusion?>>Because there is an increased likelihood
that that individual that is providing care to that patient could be injecting
into the line placed in that patient at risk for a bloodstream infection.>>[Inaudible] Munchausen syndrome as opposed to
Munchausen by proxy, which would be more typical in the outpatient settings, unless
of course you do have a nurse or a parent who is injecting into that line.>>OK.>>So the difference is, there’s
already an exclusion for that. That would be a patient that
is injecting into their line. So you would be able to exclude that patient
based on the fact if there is documentation that they were suspected or
observed injecting into their line. So that’s the reason.>>Are there any other questions?>>I have a question.>>Yes.>>If you have a patient that came back
with two blood cultures of staph epi but the physician calls it a pseudobacteremia, would that still be considered a
central or a bloodstream infection?>>Well, I would definitely
assess that patient for an LCBI 2 because again all blood cultures
regardless of the reason that they were collected must be
included in CLABSI surveillance. So I would, despite the physician
saying that it’s not a BSI, I would still evaluate that
patient for an LCBI 2.>>OK, thank you.>>You’re welcome. Yes.>>Hi. So I work at a hospital that has a very
high rate of IV drug abusers that we treat, and I would like some clarification around
what constitutes a sufficient evidence of line injection. So, exactly what needs to be documented? Is the phrase suspicious for line
injection documented within the infection when they’re period sufficient by
itself or do you need more context clues or like a description of the event in
addition to suspicious or, you know, observed line infect– injection.>>That’s a good question. I think that if the clinician documents, I
suspect that this patient documented will– I suspect that this patient
injected into their line between these days is sufficient
documentation to meet the IV drug use. I think that’s actually perfect.>>OK, great. I only asked because in the September
2017 newsletter that examples provided–>>OK.>>There was a lot of context, so we
were kind of confused as to whether that was necessary to exclude a patient. We didn’t want to be excluding patients
that we should be calling CLABSIs on.>>Absolutely.>>Thank you so much.>>But, yeah, actually that’s perfect.>>Great. Thank you.>>Back to the Munchausen syndrome by proxy. We do have a patient who has Munchausen
syndrome, and he is not injecting in his line but he is contaminated in his line
in every way possible that he can. He smears feces on it. He takes the dressing off. You know, it is documented in his chart,
you know, that he has Munchausen syndrome but every time he comes in, he has one
bloodstream infection after another. And so when you say just by proxy
that excludes those patients who actually are diagnosed
themselves and are self-harming not by injecting but by manipulation of the line.>>And unfortunately the exclusion is
only provided for those who are observed or suspected injection into the line. So those individuals who are diagnosed
with Munchausen syndrome will be covered under that IV drug abuse exclusion only
if they are injecting into the line.>>Well, could you think about adding somebody
who is like a patient who deliberately tries to contaminate their line is going to get a
bloodstream, and there is nothing we can do about that except put a sitter in
the room with them continuously. So if we can– If they were
diagnosed with Munchausen syndrome, could it be Munchausen syndrome and Munchausen
by proxy because the outcome is the same, the line is manipulated by either
themselves or by their caregiver. Just put that in for next year.>>We have discussed it.>>OK.>>And you know, a lot of those things
that you mentioned should be taken care of by decontaminating the site that
you draw blood culture through. Well, it’s a slippery slope.>>Yes.>>We have a saying, give a mouse a cookie.>>Yes [laughter] thank you.>>You know, so we have discussed it.>>I have a similar question. We have a patient who has severe ADHD and
severe behavioral problems, has a central line. Constantly chewing on the line, just will snap,
all of a sudden grab the line and get out. Again, same question, can there be something
that’s added, he needs to have a sitter with him 24/7, and we’re still not able
to keep him from getting at this line. Is there something in the future that they can
add to kind of exclude this type of patients because we keep getting dinged for
the same patient over and over?>>That’s certainly something that,
unfortunately, at this time still with the IV drug use abuse exclusion. It specifically does say injecting or
suspected or observed injection practices. So right now we can’t afford or to provide
an exclusion in that particular case, which is unfortunate and it does become very
challenging for the nurses and also for the IP as well, because you are
doing everything you can. But I would venture to say that
these are very unique circumstances and unfortunately we can’t make
exclusions for very unique circumstances.>>OK.>>But if you want to– You ever have
a question you’re not quite sure, you can always send a question to NHSN
and we’ll be happy to reply to you.>>We have a couple questions from the web.>>OK.>>Can you go back to the
Pearson case just to clarify that?>>Absolutely.>>So we have a couple of people from the
web that have asked about the Pearson case and they thought that the attribution
was that it was a CLABSI but I think that that’s not what you said, that
it was just healthcare associated.>>Yeah, I said that it was a
healthcare associated LCBI 3.>>But not central line.>>Because a line was not in place greater
than two calendar days on the date of event. So if I said CLABSI, I apologize,
but it is an HAI LCBI 3. Right, I think we have time
for one more question.>>Yeah, I just wanted to find out with
the IV drug abusers, what if it’s a friend or a family member that’s
injecting into the line?>>It’s a good question. I’m wondering if– if you could send us that
specific example, I’d like to give you– I don’t want to speak, give a blanket reply but I can give you some guidance
if you send it to NHSN.>>OK. Thank you.>>And we’ll review it and
then we will send you a reply.>>OK, thank you.>>Thank you all so much. If you have any other questions
later, you can grab me. I’ll be happy to answer any
questions you might have. [ Applause ]

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