Slide 1: Hello and welcome. Thank you for joining us. In this presentation, we are reviewing NHSN criteria for multidrug-resistant organisms, MDRO, and Clostridioides difficile, C. difficile.
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 and considerations related to MDRO and C. difficile infections, CDI, criteria and reporting in adult acute care inpatient settings. This learning module is approximately 15 minutes in length and can be viewed as needed. As NHSN reporting is complex and extensive, be sure to click on and review provided links and resources 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 MDRO and CDI events per NHSN definitions and will understand reporting requirements. Please note, this presentation will primarily address MRDO and CDI LabID events in the adult patient population. For additional reporting options, please refer to the NHSN Patient Safety Component Manual as well as the NHSN website.
Slide 4: The two documents on this slide cover all of what we are reviewing today. We will focus on the first document -- chapter 12 of the NHSN Patient Safety Component Manual covering MDRO and C. difficile infections. The second document is the NHSN Patient Safety Component Manual in its entirety. 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 the video and download the documents using the link in your handout. And be sure to download and save all documents for future use and reference.
Slide 5: MDROs are bacteria organisms that have become resistant to certain antibiotics, meaning those antibiotics can no longer be used to effectively control or kill the bacteria. Organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are found primarily in hospitals and long-term care facilities, and have steadily increased in prevalence in the U.S. over the past few decades. There is growing concern in healthcare as treatment options for these infections are often extremely limited and are associated with poor patient outcomes such as increased length of stay and increased mortality.
Slide 6: C. difficile is a bacterium that causes infection and inflammation of the large intestine (colon) and is associated with sustained watery diarrhea. C. difficile most often occurs during or shortly after the use of antibiotics. It can spread rapidly in hospitals and long-term care facilities, with older adults at increased risk of infection. It is estimated that C. difficile toxins cause about half a million infections in the U.S. each year and is linked to around 14,000 deaths. 90% of those deaths are people 65 years and older. However, thanks to the incredible work of healthcare providers and improved prevention and early detection measures, these numbers are lower than in previous years. C. Difficile infections are estimated to cost at least $1 billion in additional health care costs annually. Work still needs to be done to continue to decrease the physical and financial burdens of C. difficile and MDROs.
Slide 7: The next three slides will review definitions specific to MDRO and CDI. For accurate and meaningful reporting and data, it is important to understand these definitions and follow strict adherence to definitions and reporting instructions.
Methicillin-Resistant Staphylococcus aureus (MRSA) includes S. aureus cultured from any specimen that tests oxacillin-resistant, cefoxitin-resistant, or methicillin-resistant by standard susceptibility testing methods, or any laboratory finding of MRSA, including PCR and other molecular based detection methods.
Vancomycin-Resistant Enterococcus (VRE) includes Enterococcus faecalis, Enterococcus faecium, or Enterococcus species unspecified (for those not identified at the species level) that is resistant to vancomycin, by standard susceptibility testing methods or a laboratory finding of VRE, including PCR and other molecular-based detection methods.
Clostridioides difficile is defined as a positive result for a laboratory test for C. difficile toxin A and/or B (for example, enzyme immunoassay, or EIA test), OR a toxin-producing C. difficile organism detected in the unformed stool specimen by culture or other laboratory means (for example, nucleic acid amplification testing by polymerase-chain reaction, or PCR).
Slide 8: LabID is a non-duplicate MDRO isolate from any specimen source and/or unique blood source MDRO isolate. Please note, positive MDRO results on active surveillance testing (AST) are not LabID events and should not be entered into NHSN. LabID is also a non-duplicate C. difficile positive laboratory assay.
An MDRO isolate is any specimen obtained for clinical decision making and testing positive for an MDRO.
A unique blood source is an MDRO isolate from blood in a patient with no prior positive blood culture for same MDRO in less than or equal to two weeks.
C. difficile-positive laboratory assay is a positive laboratory test for C. difficile toxin A and/or B tested on an unformed stool specimen OR a toxin-producing C. difficile organism detected by culture or other laboratory means performed on an unformed stool sample. It is important to note that stool specimens used for C. difficile testing must be liquid and conform to the container. Additionally, there is no single test or standard format to identify C. difficile. It is up to individual facilities to determine which test they will use to identify and document LabID C. difficile events.
Slide 9: Multi-step CDI testing is a multi-step/multi-test testing algorithm for CDI on the same unformed stool specimen. The finding of the last test performed on the specimen will determine if the CDI positive laboratory assay definition is met. Facilities should note that if every step and/or test is listed on their lab reports used for documentation in patient records, they must have clear indication of which test was used to confirm C. difficile.
Duplicate C. difficile-positive test is any C. difficile toxin-positive laboratory result from the same patient and same location following a previous C. difficile toxin-positive laboratory result within the past 14 days, even across calendar months and readmissions to the same facility.
Slide 10: There are two methods for collecting MDRO and CDI event data – LabID and infection surveillance. The table shown here outlines the differences and can be found in chapter 12, page 52. This presentation will focus on LabID as it is the most commonly used collection method. ALL LabID events, along with required data, are to be entered into NHSN, and from there the system will delineate hospital-acquired or community acquired. For the infection surveillance method, users must follow the protocols of chapter 12 AND chapter 17 -- CDC/NHSN Surveillance Definitions for Specific Types of Infections – of the Patient Safety Component Manual. Only hospital-acquired infections are to be entered into NHSN.
Slide 11: Once facilities choose a data collection method, they can also choose to monitor infection prevention process and outcome measures such as care provider adherence to hand hygiene or Active Surveillance Testing (AST) prevalence and incident. These additional metrics are optional and will not be discussed in this presentation. Definitions and instructions for supplemental reporting can be found in chapter 12, section 2, page 29.
Slide 12: Let’s discuss MDRO and CDI patient settings for data collection. For MDROs, patient settings include inpatient locations where infections can be identified and where denominator data can be collected. This may include critical and intensive care units, specialty care areas, neonatal units, step-down units, medical-surgical units, chronic care units, and Labor, Delivery, Recovery, & Post-partum locations. CDI patient settings include areas where denominator data can be collected – critical and intensive care units, specialty care areas, step-down units, medical-surgical units, and chronic care units. Please note – CDI surveillance will NOT be performed in neonatal intensive care units, specialty care nurseries, babies in labor, delivery, recovery, and post-partum, or well-baby nurseries. If LDRP locations are being monitored, baby counts must be removed for reporting. A patient housed in an inpatient location is included in the location denominator count regardless of status designation. Facility specific status designations such as “observation,” “swing bed,” and “short stay” are not recognized or used for NHSN reporting. And just a quick reminder about denominators -- when denominator data for NHSN measures is used from electronic databases, the accuracy of the database will have to have been validated to be within 5% (+/-) of the manually collected once a day counts.
Slide 13: CDI patient settings include areas where denominator data can be collected – critical and intensive care units, specialty care areas, step-down units, medical-surgical units, and chronic care units. Please note – CDI surveillance will NOT be performed in neonatal intensive care units, specialty care nurseries, babies in labor, delivery, recovery, and post-partum, or well-baby nurseries. If LDRP locations are being monitored, baby counts must be removed for reporting.
A patient housed in an inpatient location is included in the location denominator count regardless of status designation. Facility specific status designations such as “observation,” “swing bed,” and “short stay” are not recognized or used for NHSN reporting. And just a quick reminder about denominators -- when denominator data for NHSN measures is used from electronic databases, the accuracy of the database will have to have been validated to be within 5% (+/-) of the manually collected once a day counts.
Slide 14: Why do facilities choose LabID event tracking? LabID does not include clinical evaluation of the patient and is therefore less labor intensive for tracking MDRO and CDIs. Additionally, facilities can choose to track one or more MDROs (MRSA, VRE, etc.,) based on facility needs and resources. Because clinical evaluation of the patient is not included in data collection, LabID events only have two healthcare associated infection surveillance rules that apply -- location and event date. LabID events are attributed to the location where the patient is assigned and physically located at the time of specimen collection. The event date will always be the date of specimen collection. The first lab positive finding in a specific inpatient location qualifies as the LabID event; no other LabID events are to be reported to NHSN for that inpatient location until greater than 14 days.
Slide 15: There are several options facilities can choose from to report MDRO and CDI LabID events. This slide outlines the options for MDRO. One. Facility-wide by location. This option requires facilities to map each inpatient location in NHSN and report LabID events for all specimens (blood, wound, etc.) with individual location numerators and denominators. Two. Selected locations. Facilities can choose to only monitor and report selected inpatient locations. Again, this option requires reporting of LabID events for all specimens with individual location numerators and denominators. Three. Overall facility-wide all specimens. Facilities are to report all LabID events from all inpatient locations under one combined numerator and denominator. Four. Overall facility-wide inpatient blood specimen only. In this option, facilities choose to monitor and track LabID events from only blood specimens. Facilities are to report blood specimen LabID events from all inpatient locations under one combined numerator and denominator. Please note, there are detailed and nuanced directions for calculating denominators if using the overall facility-wide reporting options. Be sure to thoroughly consult chapter 12 as well as this table.
Slide 16: Here are the reporting options for CDIs. One. Facility-wide by location. This option requires facilities to map each inpatient location in NHSN and report LabID events with individual location numerators and denominators. Two. Selected locations. Facilities can choose to only monitor and report on selected inpatient locations. Again, this option requires reporting of LabID events with individual location numerators and denominators. Three. Overall facility-wide inpatient. Facilities are to report all LabID events from all inpatient locations under one combined numerator and denominator. Reminder, there are detailed and nuanced directions for calculating denominators if using the overall facility-wide inpatient so be sure to thoroughly consult chapter 12 and this table.
Slide 17: MDRO and CDI LabID events should be reported to NHSN at the minimum every quarter for the prior three months surveillance periods. If no events are identified during the surveillance periods, the “report no events” box must be checked. If events 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 MDRO and CDI LabID events as well as the instructions for tool completion. The denominator is patient days and admissions. Also included on this slide is a tool to assist in collecting denominator data.
Slide 18: This is the NHSN algorithm for LabID determination of an MDRO result for all specimens such as blood culture or wound culture swap. It can be found on page 9 in chapter 12 of the NHSN Patient Safety Component Manual.
Slide 19: This is the NHSN algorithm for LabID determination of an MDRO result for blood specimens only. This algorithm should be used if facilities choose to only monitor and report blood specimen LabID events. It is found on page 10 of the same document.
Slide 21: While this presentation does not cover the infection surveillance method, here are the resources for tracking and reporting hospital-acquired MDRO and CDI events should facilities consider this option.
Slide 22: So, what to do with your data? All event and summary data for MDROs and CDIs entered in NHSN can be analyzed through the platform. Specific analysis reports can be created from user-generated datasets and can be displayed and visualized in various ways to assist facilities with identifying opportunities for improvement. Although NHSN requires organizations to submit data quarterly, it is important that facilities get into the consistent habit of internally tracking and trending data monthly as well as a daily review of lab reports. This allows for prompt response to identification and opportunities for invention of concerns, such as a cluster outbreak. 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 23: Don’t forget your protocols! To identify and report appropriate MDRO and CDI events, order sets and patient care algorithms must accurately reflect evidence-based criteria in their triggering mechanisms. Additionally, internal protocols and policies should be in place to stop or cancel inappropriate orders or “reject” inappropriate specimens, such as formed stool.
Slide 24: Explore these additional resources for further and more in-depth instruction on NHSN MDRO and CDI criteria and reporting. The calculator is a web-based tool that is designed to help users learn how to accurately apply the MDRO & CDI LabID event algorithms and assist users in making the correct MDRO & CDI LabID event determinations.
Slide 25: Thank you for viewing this video. Remember, you can contact NHSN anytime with questions and clarifications at nhsn@cdc.gov. Let’s get to work!