Welcome to the 2016 National Healthcare Safety Network, or NHSN,
Quick Learn series. These CDC presentations are an educational resource
for facilities working to prevent Healthcare Associated Infections, or H-A-Is.
This session will review frequently asked questions related to catheter-associated
urinary tract infections. In this program, we assess Urinary Tract Infection,
or U-T-I, events and apply a variety of rules. We will also review
how to apply NHSN protocol, according to U-T-I signs and symptoms.
An infection is considered Present on Admission, or P-O-A,
if the date of event of the NHSN site-specific infection criterion
occurs during the POA time period, which is defined as the day
of admission to an inpatient location, calendar day 1, the 2 days before
admission, and the calendar day after admission. For purposes
of NHSN surveillance and determination of the Repeat Infection Timeframe,
if the date of event is determined to be either of the two days prior to
inpatient admission, then the date of event will be hospital day 1.
Let’s review case one. On April 15th a patient,
aged 73, is admitted for pneumonia with a fever of 101 degrees Fahrenheit.
A foley catheter is inserted. On day two,
the patient’s urine tests positive for E. Coli greater than
100,000 colony forming units, or C-F-Us, per milliliter.
On days three through five, there are no U-T-I symptoms.
On the sixth day in the hospital, the patient complains of supra-pubic tenderness.
Since the patient tested positive on day two for E. Coli, would this
infection be considered as present on admission? (PAUSE for animation) The answer is no.
The patient had no symptoms of U-T-I during the infection window period.
This can’t be considered an H-A-I either. The symptom of fever alone cannot be
used in a patient greater than 65 years of age when a foley catheter has
been in place for less than two days. The patient remains in the hospital.
On April 20th, a second urine culture is collected and is positive again for E.coli.
Would that make this a healthcare associated infection? (Pause)
The answer is yes. The e-coli positive urine culture on April 20th
sets the infection window period, which is April 17th
through 23rd. The catheter was first inserted on the 15th.
The U-T-I symptom of supra-pubic tenderness on April 20th meets the
SUTI 1-A CAUTI definition. The date of event, April 20th,
is in the infection window period. The R-I-T is April 20th
through May 3rd. This patient has an H-A-I that would be categorized
as a SUTI 1-A CAUTI. For the first urine culture to be considered
an H-A-I or P-O-A, several requirements were not met.
First, there were no U-T-I symptoms or matching blood culture to the
urine organism within the infection window period. The
asymptomatic bacteriuria taken on April 16th does not meet NHSN criteria
and is considered colonization of the bladder. As the foley catheter
remains in place, it puts the patient at greater risk for symptomatic
U-T-I. After the second urine culture tests positive and
the patient develops symptoms within the infection window period, the case
becomes an H-A-I. Now let’s review the NHSN definition of
the repeat infection timeframe. The repeat infection timeframe,
or R-I-T, is a 14-day timeframe during which no new infections
of the same type are reported. The date of event
is day one. Additional pathogens recovered during the R-I-T from the same
type of infection are added to the event. Let’s look at an example.
A patient complaining of chest pain is transferred from a nursing home to
the emergency room on May 5th. The nursing home documents dysuria
on May 5th. The patient is admitted on May 6th and a foley catheter
is inserted. On May 7th the urine tests positive
for more than 100,000 C-F-U’s per milliliter of E. Coli.
On May 12th the urine tests positive for more than 100,000 C-F-U’s
per milliliter of Acinetobacter baumannii.
For this case, what is the U-T-I determination?
For this case, what is the U-T-I determination? (PAUSE) This is a
SUTI 1b: non-CAUTI Is the May 12th positive urine culture a second
infection? (PAUSE) No. Here’s why.
The May 7th urine culture sets the infection window period which is
May 4th through May 10th, shown here in green.
The U-T-I symptom of dysuria during the P-O-A time period can be used because
the symptom occurred when the foley catheter was not in place. If the date of event
is either of the two days prior to in-patient admission, then the date of event
will be hospital day one. The Foley catheter was not in place greater than
2 days on the date of event therefore this is a non-CAUTI.
The date of event of the non-CAUTI is May 6th, the admission date.
The R-I-T is May 6th through May 19th.
The May 12th positive urine culture occurs in the R-I-T
so this is added to the P-O-A event. Note,
the P-O-A is not reported. Here’s another case study.
A 77 year-old female is admitted on July 1st for heart failure. She is placed
on Lasix and a foley catheter is inserted. On July 2,
the patient complains of dysuria. On July 4th, a urine culture tests
positive for E. Coli greater than 100,000 C-F-U’s per milliliter.
On July 5th, the patient has a fever 101 degrees Fahrenheit.
What is the U-T-I determination for this case? (PAUSE)
This is an H-A-I. This case meets SUTI 1a: CAUTI.
Here’s why. The July 4th urine culture sets the
infection window period, which is July 1st through July 7th.
The U-T-I symptoms of dysuria on July 2nd cannot be used
because the patient complained of the symptom while the foley catheter was in place.
The presence of the foley catheter can cause this symptom. The next
U-T-I symptom in the infection window period is a fever on July 5th.
July 4th is the date of event because the urine culture is the first element
used to meet the UTI infection criterion and occurs for
the first time within the seven-day infection window period. The R-I-T is
July 4th through July 17th and the secondary B-S-I attribution period
is July 1st through July 17th. Let’s review the transfer rule definition.
The transfer rule states, if the date of event for a CAUTI is on the
date of transfer or discharge, or the next day, the infection is attributed
to the transferring or discharging location. Let’s look at a case study.
A patient has a foley catheter removed July 25th which is catheter day five.
The patient is discharged the same day from the hospital’s surgery ward.
On July 26th, the patient is re-admitted to the hospital’s medical ward.
The in-dwelling foley catheter is not in place and the patient experiences
urinary frequency on admission. On July 26th, a urine culture
tests positive for E. Coli more than 100,000 C-F-U’s per milliliter.
The infection window period is July 24th – July 29th.
For a positive urine culture upon admission that meets NHSN
criterion, the Infection Window Period includes the 2 days before admission,
day of admission and 3 days after admission.
Urinary frequency on July 26th is the first element used to meet the
SUTI definition, therefore this is the date of event.
Because the July 26th date of event is the day after transfer,
this H-A-I CAUTI should be reported to NHSN for the previous admission and
attributed to the surgery ward.The CAUTI is P-O-A for the July 26 re-admission
and an R-I-T is set for July 26th through August 8th.
The secondary B-S-I attribution period is July 24th through August 8th.
P-O-A is not reportable. This concludes the
NHSN Quick Learn focusing on H-A-I’s and catheter-associated
urinary tract infections. For additional questions, please contact
NHSN user support at NHSN@c-d-c-dot-gov.