Slide 1: Hello and welcome. Thank you for joining us. In this presentation, we are reviewing NHSN criteria for catheter associated urinary tract infections (or CAUTI).
Slide 2: The National Healthcare Safety Network (NHSN) is an electronic, integrated surveillance system used to collect comprehensive data about hospital acquired infections. The data then enables healthcare facilities to effectively identify problem areas and to focus efforts on process improvement and prevention. To ensure accurate and meaningful data, NHSN requires facilities to report events based on specific, clearly defined criteria. This presentation will provide definitions related to CAUTI criteria and reporting and will provide examples for application in adult acute care settings. This learning module is approximately 15 minutes in length and can be viewed as often as needed. As NHSN reporting is extensive, be sure to click on and review provided links and resources in your handout for more in-depth and nuanced definitions and application of criteria.
Slide 3: After viewing this learning module, the learner will be able to identify CAUTI events using the NHSN definitions and will understand reporting requirements. Please note, this presentation will address CAUTI events in any patient over one year of age. For non-catheter associated urinary tract infections and CAUTI in patients one year of age or less, please refer to the NHSN Patient Safety Component Manual as well as the NHSN website.
Slide 4: The first two documents on this slide cover all of what we are reviewing today. If possible, it would be beneficial to your learning and comprehension to have these two documents open and available as you continue this module. You may pause this video and click the links on the handout that accompanied the video to obtain these documents. The third document is the comprehensive NHSN organism list for reference when investigating a possible hospital acquired infection. Please note, this list is not exhaustive. For guidance and clarification regarding an organism not on the list, contact NHSN directly. Be sure to download and save all documents for future use.
Slide 5: These next two slides will review infection definitions that apply to CAUTI as well as other hospital acquired conditions. These definitions can be found in the comprehensive document “NHSN general key terms and definitions” on the link provided. We will put these concepts into practice through case studies later in this presentation. So again, if possible, it would be beneficial to your learning and comprehension to have this document open and available as we move through the module. Let’s quickly review the definitions on this slide:
Healthcare associated infection (HAI): This Criterion occurs on or after the third calendar day of admission to an inpatient location.
Present on admission (POA): The Criterion for CAUTI occurs during the admission time period, which includes the day of admission to the inpatient location, two calendar days before admission and one calendar day after admission.
Infection window period (IWP): The seven days during which all site-specific infection criteria must be met. Includes the collection date of the first positive diagnostic test, three calendar days before and three calendar days after that collection.
Date of event (DOE): This is the date the first element used to meet criteria occurs for the first time within the seven-day infection window period
Location of attribution (LOA): The inpatient location where the patient was assigned on the date of event (DOE).
Transfer rule: If the date of event is on the date of transfer or discharge, or the next calendar day, the infection is attributed to the transferring location.
• Repeat infection timeframe: This is the 14-day timeframe during which no new infection of the same type is reported. This is applied only to a single admission.
• Device days: This is a count of the number of patients with a specific device in a specific inpatient care location during a defined time period.
• Patient Days: This is a count of the number of patients in a specific patient care location during a defined time period.
• Calendar Day: is defined as midnight (00:00) to 11:59pm.
• Settings: Surveillance occurs in any inpatient location where the denominator data can be collected. This includes:
› Intensive care units
› Specialty care areas
› Step-down units
› Medical/surgical units
› Inpatient rehabilitation unit
One thing to note about surveillance settings -- if an observation patient is admitted to an inpatient location, the patient must be included in surveillance and included in patient and device day counts as the patient is being housed, monitored, and cared for in an inpatient location and therefore is at risk for acquisition of an infection.
Slide 7: Let’s review the background on CAUTIs. CAUTIs are the fifth most common type of healthcare associated infection, with virtually all of them caused by improper insertion and maintenance of catheters. The human and financial burden of CAUTIs is high. Studies show that with each day an indwelling catheter is in place, the patient has a 3-7% increased risk of acquiring infection. Additionally, it is estimated CAUTIs cost an average of $14,000. Additional cost is defined as the incremental costs to the hospital for the inpatient stay attributable with CAUTI based on results from 2015. The costs are limited to the hospital costs that would not have occurred had the CAUTI not occurred. Above all, it is estimated that there are still 13,000 deaths per year in the U.S. associated with CAUTI.
Slide 8: And back to definitions! We will review definitions specific to CAUTI before we discuss reporting requirements and work through examples. If needed, refer to slides six and seven for common infection definitions or the NHSN General Key Terms document as we move through this section. The accompanying resource on this slide is Chapter 7 of the NHSN patient safety component manual. Again, for accurate and meaningful reporting and data, it is important to understand these definitions and follow strict adherence to definitions and reporting instructions. An indwelling urinary catheter or IUC, is a drainage tube that is inserted into the urinary bladder through the urethra, left in place, and connected to a drainage bag. These devices are also often called Foley catheters. Note, IUCs that are used for intermittent or continuous irrigation are also included in CAUTI surveillance. Condom or straight in-and-out catheters are not included nor are nephrostomy tubes, ileoconduits, or suprapubic catheters. A CAUTI is determined if an IUC was in place for more than two consecutive days, with the day of device placement being day one, in an inpatient location on the date of event, AND an IUC catheter was in place on the date of event or the day before. CAUTIs can be symptomatic or asymptomatic. Additionally, it is important to understand that a UTI is a primary site of infection; it is never considered secondary to another site of infection.
Slide 9: This table defines the criteria for symptomatic CAUTIs and can be found in chapter 7 of the NHSN patient safety component manual. The patient must meet ALL three criteria -- Patient had an indwelling urinary catheter in place for more than 2 consecutive days in an inpatient location on the date of event and was either present for any portion of the calendar day on the date of event or removed the day before the date of event; the patient has at least one of the listed symptoms, AND the patient has a urine culture with no more than two NHSN recognized species of organism identified with at least one being a bacterium greater than or equal to 100,00CFU/ml. All of these elements must occur during the infection window period. Again, you will need to review this criteria and accompanying notes in depth so keeping this table readily accessible is highly suggested.
Slide 10: This table defines the criteria for asymptomatic CAUTIs. Again, the table can be found in chapter 7 of the NHSN patient safety competent manual. Patient must meet all three criteria – the patient has an indwelling urinary catheter with no signs or symptoms of symptomatic UTI, and patient has a urine culture with no more than two species of organism identified with at least one being a bacterium greater than or equal to 100, 00 CFU/mL, and patient has organism identified from blood specimen with at least one matching bacterium to the bacterium at greater than or equal to 100,000CFU/ml.
Slide 11: CAUTI events should be reported at a minimum every quarter for the prior three months of surveillance periods. If no CAUTIs are identified during the surveillance periods, the “Report No Events” box must be checked. If CAUTIs are identified, the numerator reported will be the actual number of events confirmed during the surveillance period. Included on this slide is an investigative tool to help identify CAUTIs as well as the instructions for tool completion.
Slide 12: The denominator consists of two data points – device days and patient days. For CAUTI, device days are the number of patients on a specific inpatient location with an IUC device, collected daily at the same time each day. Patient days is the number of patients on a specific inpatient location, collected daily at the same time each day. Each of these data points should be collected separately for each inpatient location surveilled. Daily counts are summed and only the total for the month should be reported to NHSN. Included on this slide is a denominator tracking form. And remember, if your organization is pulling counts electronically, you first must validate the electronic method against the manual method. This is done by collecting three months concurrent data using both methods. The electronically calculated data must be within 5% (+/-) of the manually collected data.
Slide 13: Let’s look at the steps for investigating a possible CAUTI. This is pulled directly from the NHSN training. We will use these steps as we work through CAUTI examples on the following slides.
• Consider the organism and amount and determine the date of the urine culture collection.
• From the date of the urine culture, determine the 7-day IWP (This is three days before the urine culture, the day of urine culture, and three days after the urine culture).
• Determine if all the elements of the UTI are met during the IWP. If “YES,” there is an infection event. If “NO,” there is no event.
• Determine the Date Of Event or DOE. This is the date the first element occurs for the first time within the IWP.
• Is the DOE in the Present on Admission (or POA) time period? This is day of admission to an inpatient location, the two days before admissions, and the calendar day after admission. If “YES,” the infection is POA. If “NO,” the infection is an HAI.
• If appropriate, determine if the HAI is device-associated. If the DOE occurred on or after day three of device use in an inpatient location, and the device was in place on that day or the day before, the HAI is device-associated (REMEMBER: a CAUTI event that needs to be reported to NHSN).
Slide 14: This slide includes a useful flowchart from the CDC to identify symptomatic and asymptomatic UTIs. The link on your handout will open a PDF of this flowchart. This flowchart may be very helpful to have available to the nursing staff.
Slide 15: Ok, let’s run through two examples of reporting CAUTIs in NHSN. In the first example, the patient was admitted to the hospital on unit A on August 1st with heart failure. An indwelling urinary catheter was placed on the day of admission. On hospital day three, August 3rd, the patient had a fever of 100.9 Fahrenheit and complained of suprapubic tenderness. The catheter was removed on hospital day four, August 4th and a urine culture is collected. The culture was positive for NHSN recognized bacterium at greater than 100,000 CFU/mL. Step 1: Determine the date of urine culture collection: Urine culture collected on August 4th. Step 2: Determine the infection window period: Urine collection date is August 4th, making the infection window period August 1st – August 7th. Step 3: Determine if all the elements of urinary tract infection are met during infection window period. Yes – fever documented on August 3rd, catheter in place, and identified bacterium was greater than 100,000 CFU/mL. Step 4: Determine the date of the event: The first identified criteria was fever and suprapubic tenderness on hospital day three, making the date of the event August 3rd. Step 5: Determine if present on admission or a hospital acquired infection. The date of event, August 3rd, falls outside the present on admission timeframe of July 30 – August 2, making this event hospital acquired. Step 6: Determine if the hospital acquired infection is device associated: we see the date of event is August 3rd, meaning it occurred on day three of the device and the device was present on the date of event as well as two days prior. This is a device associated hospital acquired infection. Criteria is met for symptomatic CAUTI, attributed to hospital unit A.
Slide 16: In example two the patient was admitted to the hospital on unit B on March 5th with bowel obstruction. An indwelling urinary catheter was placed on hospital day 2, March 6th. On hospital day 6, March 10th, a urine culture is collected with the results positive for NHSN recognized bacterium at greater than 100,000 CFU/mL. On hospital day 7, March 11th, blood cultures were collected and identified to match bacterium in urine. Step 1: Determine the date of urine culture collection. Urine culture collected on March 10th. Step 2: Determine the infection window period. Urine culture was collected on March 10th, making the infection window period March 7th – March 13th. Step 3: Determine if all the elements of a urinary tract infection were met during the infection window period. In this case the answer is Yes –the patient had an indwelling urinary catheter in place, a positive urine culture with bacterium greater than 100,000 CFU/mL, and a positive blood culture matching bacterium in urine. Step 4: Determine date of event. As there are no s/s in this example, date of event is the day the urine culture was collected, which is March 10th. Step 5: Determine if the infection was present on admission or a hospital acquired infection. Date of event, March 10th, falls outside of the present on admission timeframe of March 3 – March 6, making this event hospital acquired. Step 6: Determine if the hospital acquired infection is device associated. The Date of event is March 10th, meaning it occurred on device day 5 and the device was present on date of event as well as the two days prior. This is a device associated hospital acquired infection. Criteria is met for asymptomatic CAUTI, attributed to hospital unit B.
Slide 17: Explore these additional resources for further and more in-depth instruction on NHSN CAUTI criteria and reporting. The hyperlinks on your handout will direct you to the resources.
Slide 18: So, what to do with your data? Although NHSN requires organizations submit data quarterly, getting into the consistent habit of internally tracking and reviewing data monthly allows organizations to promptly identify, drill down, and respond to areas for improvement. Additionally, routine analyzing and interpreting of data helps support an organization’s ability to make meaningful operational decisions to improve patient care and outcomes. And be sure to share organizational and department progress and celebrate the wins!
Slide 19: Thank you for viewing this video. Remember, you can contact NHSN anytime with questions and clarifications at email@example.com. Let’s get to work!