2019 NHSN Training – Catheter-associated Urinary Tract Infection (CAUTI)

2019 NHSN Training – Catheter-associated Urinary Tract Infection (CAUTI)


>>Good morning. I’m Bonnie Norrick, the subject
matter expert for CAUTI and we’re going to
get going with that. I know I’m between you
and lunch, but please stay with me for the next hour. And we will discuss the
UTI protocol for 2019. We will also look at fever,
age and device association, collection data forms and table
of instructions, summary data and device day count,
key concepts and pitfalls and apply the UTI protocol
with some case studies. The burden of UTI. That’s the reason
why you’re here. But first I’d like to thank
you for all that you’re doing to prevent infections. After some early lack of progress there have been
study declines in CAUTI over the past few years. The gains have been most
marked in non-ICU locations. But recent years we’ve seen
progress in ICU as well. Even with the removal
of yeast as a pathogen from the urinary site we are
still seeing decreases in CAUTI. In fact, from 2014 to 2017
we had a 5% decrease in UTI. Give yourself a hand. [ Applause ] The average cost of CAUTI in
the hospital can be anywhere between $5,000 and
$14,000 per admission, dependent on the drug being
used and the length of stay. And UTI continues to be
ranked number four HAI in the United States. This is the website link for
the UTI surveillance page. Most of the material we
discuss today can be found here. We will visit a few of
these sections today, but I strongly recommend
that you set aside some time when you get back
to work, 15 minutes. Close the door to your office,
put the phone on silent, get your favorite
beverage and stress snack. While enjoying some
decompression time pull up the website page
and open each heading and take note of its contents. Take useful notes as you know where to look the next time
you need the information. Definitely take a look at
the CMS supporting materials. And do this for the web page, for the surveillance
you are performing at your surveillance
at your facility. So now we’ll look
at some updates. There have been no changes
to the protocol definitions, but we have added some
language for clarification and enhancement for
understanding. Greater than two calendar days
has been replaced with more than two consecutive days
in an inpatient location. Under SUTI1a, catheter
associated urinary tract infection in any age
patient has been clarified. Under this statement the
patient has at least one of the following
signs or symptoms. We have a reminder
here for fever. To use fever in a patient
greater than 65 years of age, the IUC needs to be in place for
more than two consecutive days in inpatient location
on the date of event. And is either still in place or was removed the
day before the DOE. The remainder of the
definition is unchanged. Comments have been added
to UTI and ABUTI criteria. The following excluded
organisms cannot be used to meet the UTI definition. Any Candida species as
well as the report of yeast that is not otherwise specified. Also catheter, Foley,
Foley catheter and urinary catheter
have been replaced with indwelling urinary catheter
or IUC throughout the protocol. For the next few minutes
we will review chapter two, identifying healthcare
associated infections in NHSN for the definitions
as they relate to UTI. Until you become familiar with
these rules you will be working with both chapter
two and chapter seven in your hands side by side. Also note and I will repeat
this throughout the next hour, that NHSN primary site
of infection is your UTI. User sending cases for reviewing to call UTI secondary
to another site. You cannot, UTI is a
primary site of infection. So let’s review the IWP,
the DOE and the RIT. The UTI for the infection
prevention of the infection window
period is always set by the first positive urine that
is used to meet the definition. The IWP is not set by
UTI signs or symptoms. This slide illustrates elements that fall outside the
IWP period cannot be used in the determination. Elements are defined
as urine culture. And UTI signs and symptoms
or a matching blood sample. The DOE is the date of
the first element used to meet the NHSN site
specific infection criterion, occurring the first time
during the seven day infection window period. Keep in mind that the DOE
could be the urine culture or the signs and symptoms,
whichever comes first. The RIT applies to both
POA and HAI determinations. The date of event is day
one of the 14 day RIT. If criteria for the same type of
infection are met and the date of event is within 14 days of the RIT a new event is
not identified or reported. Additional pathogens
specifically a bacterium that is greater than 100,000
recovered during the RIT from the same type of infection
are added to the event. Note the original date of
the event is maintained in the original 14 day RIT. Device association
determination and the location of attribution are not
to be amended in any – any UTI criterion sets
an RIT in an SBAP, including the POA events and
non-catheter associated events. Okay that’s the basic
chapter two definitions as they apply to UTI. Now let’s look at chapter seven
UTI concepts and definitions. This is the NHSN definition of
an in dwelling urinary catheter, specifically inserted into a urinary bladder
including a neo bladder through the urethra
and left in place. For a bit of trivia Foley was
named for Frederick Foley. He was a surgeon who first
designed the urinary catheter. A word about neo bladder because
we’ve had several questions about this. In effect these devices
become the urinary bladder for the patient and therefore if
a urinary catheter is inserted through the urethra into one
of these bladders it is included in the CAUTI surveillance. The neo bladder is
made from a piece of a person’s own small
intestine, which is formed into a pouch and
positioned inside the body in the same position as
the original bladder. With this procedure most
patients can void normally. This is – there are some concern for intestinal flora
colonizing the bladder. NHSN definitions
currently account for contamination
of urine specimens. Remember that to
remove such cases from CAUTI surveillance would
require the IP to identify which patients with these
catheters had these type of devices and to remove
all associated catheter days from the summary data. This would be pretty
labor intensive. A specimen with a
culture result of no more than two organisms
is excluded for use in meeting a UTI definition. A urine sample collection
should only be collected when there are apparent signs and symptoms correlating
to a UTI. These are not in dwelling
urinary catheters, a straight cath, a condom cath or a Texas catheter,
and in and out caths. A suprapubic catheter
does not count as a catheter unless there
is a catheter inserted into a urethra. The following also do not apply. A nephrostomy, a
urostomy, an ileal conduit and a perineal urethostomy. A urine from any of these
sites should be used in the determination of a UTI. Let’s talk about urine
cultures for a brief minute. If you have not visited your
micro biology department at your facility, I
recommend that you do so when you get back home. The micro supervisor
can be your best friend and the most helpful
on your IC committee. Get a tour. Watch a urine culture
being plated. A urine sample is placed
on a blood auger plate and a selective media plate for
gram negative organism growth. The micro biologist sees – the microbiologist uses a
calibrated inoculated loop to streak across the
plate through the middle and then perpendicular
streaks across the first. This is one method for plating. There are others. After 18 to 24 hours of incubation the microbiologist
will count the number of colonies on the plate. One colony on the Petri plate
represents one viable cell or one colony forming unit. For example if you use 1/1000 of a ml that’s plated the
colony count must be multiplied by 1,000. If the micro biologist sees 10
colonies that’s 10,000 colony forming units per ml. Now back to interpreting
our culture. Excluded organisms. Candida species or yeast not
otherwise specified, mold, dimorphic fungi or parasites
are excluded as organisms in the UTI definition. Therefore blood with these
organisms cannot be used secondary to UTI. Excluded organisms may
be present in the urine. A urine culture with yeast can
be used as long as there is at least one bacterium greater
than 100,000 or equal to – and no more than two organisms. For example, greater than
100,000 mls of E. Coli and greater than
100,000 colonies of C. albicans is
acceptable culture result that you can use as an element. For usable or unusable
culture results you have to have remember
no more than two. So you may have for example,
contaminated cultures that are not used
for UTI surveillance. For example greater than
100,000 E. Coli, staph aureus, C. albicans, that’s
three organisms but you only got one
number there, right? So just remember only two. Only two, just like Noah. Urine cultures including
mixed flora or equivalent such as perineal
flora, vaginal flora and normal flora cannot be used. And if you’re wondering
what flora is, the bacteria and other microorganisms that normally inhabit
bodily organ or part. So for example if you should
see a culture that says greater than 100,000 mls of E.
Coli with perineal flora. It is not an acceptable culture. Some other clarifications,
if you see 75,000 to 100,000 mls this is
not an acceptable culture. It’s 65 or is 99,000? Or is it greater than 100,000. You don’t know. Organisms of the same genus with different species
are two organisms. Example here is pseudomonas
aeruginosa and pseudomonas fluorescens. The same organism with different
micro susceptibilities, these one organisms
such as MRSA, methicillin resistant
staphylococcus aureus is the same as MSSA as far as
counting it as one organism. IWP set – IWP is set on the urine collection
date, not the result date. Not the result date. Do not add multiple
urine cultures together, for example on March 1
you have a culture result of two organisms. On March 2 you have a culture
result with one organism. Do not add those to
exclude those cultures to be greater than
two organisms. We get the question, I’m sorry. Use urine collection
from anybody location. For example as I said
earlier nephrostomy or suprapubic catheter. You got urine, you can use it. So let’s put it all together. There are two specific
types of UTI’s. You have symptomatic
and asymptomatic. Both types if catheter
associated must be reported as part of any CMS, CAUTI
reporting requirements. So now we’re going to go through
a protocol here one by one. For a SUTI1a the catheter
associated urinary tract infection the patient must
meet one, two and three below. The patient had an in dwelling
catheter that had been in place for more than two
consecutive days in the inpatient location
on the date of event. And was either present for a
portion of the calendar day on the date of event or removed
the day before the day of event. Here is that reminder statement
I talked to you before. To use fever in a patient
greater than 65 years of age. The IUC needs to be in place for
more than two consecutive days in an inpatient location
on the date of event. It would be impossible to
determine – let’s back up. Because a fever is nonspecific
sign of infection it is possible that an individual may
run a fever due to more than one infection at a time. It would be impossible to
determine which infection if not both was the
cause of the fever. If a fever is present it must
be used in the UTI definition. This process negates the use of clinical subjective
decision making to determine the
NHSN, HAI events. Hence there’s no asterisk as you
can see here for temperature. If you’ve got one,
you’ve got to use it. With no other recognized
cause is addressed in frequently asked
question number 14. To use no other recognized
cause it should be clear that the symptom relates
to the other cause and is clearly differentiated
from the UTI symptom and that’s for suprapubic tenderness and for costal vertebral
angle pain or tenderness. These symptoms cannot be used
when the catheter is in place. Urinary frequency,
urgency or dysuria. Once that catheter is removed
you can use those symptoms and then the third, the patient
has a urine culture with no more than two species of
organisms identified. At least one must be
a bacterium greater than or equal to 100,000. And remember all the elements of the UTI must occur
during the IWP. So knowledge check,
get your phones out. On March 25 the patient
was admitted to acute care hospital
for trauma. A Foley was inserted. The catheter was in
place from 26 to the 27. On the 28 that catheter was
removed early in the morning. At noon there was a complaint
of urinary frequency. There was no fever on the 29th. There were elevated
wbc’s on the 30th and on the 31st we have a
positive culture of E. Coli. True or false, the patients
complaint of urinary frequency on 3/28 after the Foley
was removed can be used to meet SUTI. So – we need music guys. Next time. And the answer is true. So let’s look at
the rationale here. The 3/31 positive urine culture
sets your IWP from 3/28 to 4/3. On 3/28 urine frequency
is the first element to occur within the IWP. Therefore, it is
the date of event. The catheter was in place for
greater than two days on the day of event, so you
have a CAUTI HAI. So let’s talk about when
you go to report this. You’re going to select
risk factors for the urinary catheter. You’re going to check
one of the following. Because there’s two
choices here. In place, if the urinary
catheter has been in place for more than two consecutive
days in an inpatient location and was present for any portion of the calendar day
on the date of event. Or you could select remove if
the urinary catheter had been in place for more than
two consecutive days in an inpatient location. And was removed the
day before the event. In this case we have in place
with urinary frequency, urgency or dysuria is selected as we see
here frequency has selected a pop up will alert
you as a reminder that you have selected
a symptom not usable if the IUC was in place. This is not a hard stop. You may want to keep this
slide for future reference. So now we’re going to look at SUTI1b non-catheter
associated urinary tract infection of any age. The patient must meet
one, two and three below. For one the patient has
an in dwelling catheter but it has not been in place
for one and two consecutive days in an inpatient location
on the date of event. The patient did not
have a urinary – or the patient did not have
a urinary catheter in place on the date of event nor on the
day before the date of events. The patient has at least one
of these signs or symptoms, so there’s that fever again so let’s talk again
about that fever. In older adults specifically
non-catheterized patients who have a fever with
no other localized signs for UTI there is a cause other
than UTI in 90% of the cases. Therefore we have this age
limit on fever in SUTI1b. If you have a fever that
patient needs to be less than or equal to 65 years of age. Suprapubic tenderness and
costovertebral angle pain. There has to be no other
cause as we discussed before and the urinary frequency,
urgency, dysuria. These symptoms cannot
be in place. Of course you wouldn’t’
have these symptoms or you could use these symptoms because catheter
wasn’t present, right? So the patient has a urine
culture also with no more than two species of organisms
identified, at least one of which is a bacterium greater
than or equal to 100,000. And again all these
elements have to be within the UTI criterion IWP. Now let’s check again,
get those phones back out. This patient is 47 on June
11 with a fever of 101.7. History of pseudomonas
aeruginosa in the wound on the previous month. On 6/13 we have a quick
cath done for 50,000 and it was a P.
aeruginosa at 50,000. And 100,000 for C.
albicans, no fever. On 6/15 patient spikes
a fever 101.3 and the urine is collected
via quick cath again and the result is greater than
100,000 pseudomonas and greater than 100,000 C. albicans which urine culture will
be used to set the IWP? 6/13 or 6/15? And there you go. And the answer is
6/15, very good job. Good job. So let’s look at
the rationale in this one. The 6/13 urine culture
is not eligible due to the bacterium count
that’s less than 100,000. The 6/15 urine culture sets
the IWP from 6/12 to 6/18. The 6/11 fever on
admission cannot be used because it did not
fall in the IWP of the 6/15 positive
urine culture. The 6/15 fever is in the IWP
and it’s an acceptable element, remember the patient is
less than 65 years of age. To meet the SUTI the DOE is 6/15
there is no catheter in place on the DOE, nor the day before. So this meets SUTI1b
non-catheter associated UTI and it says our RIT
and our SBAP. Now we’re going to look
at SUTI2, which is a CAUTI or a non-CAUTI in patient –
that’s one year of age or less. And the patient must
meet one, two and three. The patient is less than
one year of age with or without an indwelling
urinary catheter. The patient has at least one of
the following signs or symptoms. Patient has a fever. And then hypothermia,
apnea, bradycardia, lethargy and vomiting are all
significant signs for our baby here
that’s one year or less. So that’s why I had them
a different color here. No other recognized cause
goes with apnea, bradycardia, lethargy and vomiting. Our little ones can have
other things going on with it. And then suprapubic
tenderness of course. The patient has a urine
culture that has no more than two specimens of organisms. One of which is a
bacterium equal to or greater than 100,000. So we will go through
a little case here and remember all elements of the UTI criterion
must be within the IWP. So we have a two month
old admitted for diarrhea. A catheter is inserted and
the patient vomits twice and the urine culture grew out
greater than 100,000 of E. Coli. This meets our SUTI2 and remember it can be
used non-CAUTI or CAUTI. Let’s look at ABUTI now. And this goes for any age and the patient must meet
one, two and three below. The patient with or without an
indwelling urinary catheter has no signs or symptoms of SUTI1
or SUTI2 according to age. Now remember your patients
greater than 65 years of age with a non-catheter associated
ABUTI may have the fever and still meet the
ABUTI criterion. Patient has a urine culture
with no more than two species or organisms, one of which
is bacterium that’s equal to or greater than 100,000. And the patient has an organism
identified from blood specimen with at least one
matching bacterium to the bacterium identified
in the urine specimen, or meets LCBI criterion
two without a fever and matching common
commensals in the urine. And we will come back to
this again as a case study. And remember all elements
have to be in the IWP. Catheters associated ABUTI if
reported, if they’re CAUTI – if CAUTI selected in your
monthly reported plan for this location
remember, reporting to CMS, if its catheter associated
you got to report it. So here we go with the case. A patient was admitted
for an MI. The catheter was
inserted on the 20th. 21st to the 23rd there
are no signs or symptoms. February 24 we have
elevated WBCs. No UTI symptoms. We do have a positive
blood with staph aureus and a positive urine
culture greater than 100,000 of staph aureus from the 25th
through the 27th, no signs. And on February 28 we
were allowed to go home and that Foley was removed. So let’s look at
the rationale here. The 2/24 urine sets our
IWP 21 to the 27th . There are no symptoms however, we do have a matching blood
organism within the IWP. We meet that ABUTI
with a DOE on 2/24. A urinary catheter
was in place greater than two days on
the date of event. Therefore this is a CAUTI with matching blood
organism and it is secondary. The catheter associated
ABUTI is reported. I told you you were going
to hear this a lot, didn’t I? in the location of the
facility reporting plan. Data collection forms and table of instructions we’re
going to go through those. This is where you go to get
your forms, data collection form and table of instructions
are found on this page as I have selected here. We’re going to open
that up and have a look at the very first two
documents that are there, the event form and the TOI form. When you select the event form
there are two possibilities, you can get a PDF or you
can get a word document. If you’re new to IP you’d
probably want to print out that PDF and keep track
of all your notes on that PDF. If you’re real experienced you’ll
know this by heart, right? You probably don’t print it out, but when you start
training some new folks – when you start talking to your
nurses, print it out and talk to them about what you do. There’s also that word
document if you’re trying to track say an outbreak
that would be very helpful if you needed some extra fields
in there to swap some out. That you can edit that are not
mandatory fields, and use those to pull reports if you’re trying to select something
for an outbreak. So that’s another way that
you can use your word document and here’s a blow up of
that remember anything that is asterisk remember
you have to gather that data and put it into NHSN. This is the end of
that document. This is actually
page three of four. Examine the result codes
a little bit closer here in case you haven’t
examined those. Some of you I know have
got electronic surveillance and you may not see this
page, black and white in a word document or PDF. So let’s look at these
codes a little bit closer. Your microbiology labs
may not do all the drugs that we have listed in NHSN, so
if they don’t test it go ahead and put that in there, don’t
freak out and say oh my gosh, we didn’t test this,
that’s okay. Just put not tested. And of course you know S is
susceptible, I is intermediate. NS, what is NS? The non-susceptible is another
way the micro biologist can say we don’t know if the drug
is resistant but we do know that it’s not sensitive
to that particular drug. And the SDD is susceptible
dose dependent, susceptibility of the isolate, it depends on the
dose – dosing that’s needed. You may need more
dosing, more frequently for that particular drug. This is not in your hand out,
but I wanted to get it in front of you just to talk
real quickly for any of those who are real new. And haven’t had to put
in the sensitivity yet. Each one of these major blocks
here is a class of drugs. So let’s take a look
over here at this group where we’ve got Cipro,
Lepro and Amoxicillin. Note that we had
two drugs reported, but Amoxicillin is not selected. As long as you get one
drug listed in here with a result you’re good to go. You don’t have to have this
other one with any kind of not tested or
any kind of marking. A colistin and PB
this facility did not do either and they just marked
one box as not tested. And then of course we just had
one drug here CEFUR wasn’t tested at all. So I just wanted to get
this in front of you in case you hadn’t
analyzed that before. And at the bottom
of this screen is where you would find
description of alerts for unusual sensitivities. It’s a nice little document,
if you haven’t opened it up before during those
15 minutes I talked about earlier in
the presentation. Take a look at this document. This is your TOI
instruction form. It’s very, very useful. It explains every field
that’s on the document for the urine event form. And you’ll be surprised
what you might learn here if you would print it
out and read every field. So take a look at that one. Now we’ve already
talked about in place for the risk factors
and removed. The third one we didn’t
talk about is neither. When you go in and pick your
risk factor, that’s for USI. But there’s two other
fields here that I wanted to talk about. Again if you’re looking
at outbreak situation or you’ve got an
uptick in your CAUTI’s. Maybe you want to start
documenting the location that CAUTI or that catheter was
inserted as well as the date. So make use of those, if
you’re in that situation. So now we’re going to look at
denominator and summary data. Denominator data, patient days and devices days
should be collected at the same time every day for each location performing
surveillance to ensure that the differing collection
methods don’t inadvertently result in device days being
greater than patient days. And you’ve heard about that
from the previous two speakers. Once the month is completed,
go to the summary data tab and add the patient
safety data by location. Don’t forget to select
report no events box if you had no events
for that month. Data sampling can also be
collected electronically or weekly sampling. We talked about that but we
will talk about it again. Electronically collected data. We validate the electronic
method against the manual method. That’s our gold standard. Collect three months of concurrent data
using both methods. And then calculate the data
to be within 5% plus or minus of the manually collected. Weekly sampling reduces
staff time collecting surveillance data. A once week sampling
of denominator data to generate estimated
urinary catheter days. May be used as an alternative
to daily collection in non-oncology ICU’s and
wards to ensure the accuracy of estimated denominator
data is obtained by sampling. Only ICU and ward locations
with the average of 75 or more urinary catheter
days per month are eligible to use this method. Sampling may not be used
in specialty care areas. Oncology locations
or NICUs, evaluations of this method
have recently shown the use of Saturday or Sunday generate
the least accurate results of estimating the
denominator data. Therefore these days should
not be selected for sampling. When these data are entered, the NHSN application will
calculate the estimate of the urinary catheter days. The day designated
for the collection of the sample date is
missed; collect the day on the next available
day instead. Pitfalls. Common
misapplication pitfalls, calling UTI secondary
infection, positive urine on admission automatically
being counted as POA. And UTI signs or
symptoms such as fever on admission automatically
called as POA. UTI as secondary infection. Nope, nope, never, never, never. UTI is a primary site of infection and cannot
be considered secondary to another site. So let’s see why positive urine
culture on admission equals POA, as I said is a no, no. On January 2 a positive urine
culture during the POA time frame without UTI signs or symptoms nor a
matching blood culture in the IWP is not an event. Therefore this does
not meet POA. Later down we have
1/9 positive culture. It sets our IWP,
from 1/6 to 1/12. We do have a fever on
1/10 our DOE is 1/9. The catheter was in place
for greater than two days on the date of event; therefore
this meets SUTI1a CAUTI, which is HAI. Our third one is
just the opposite. You think you got UTI
symptoms on admission, no. A urine criteria is
not met the POI – POA requires a positive
urine culture. 3/11 the urine culture sets
the IWP at 3/8 through 3/14. We have fever at 3/10. And this can be used because
it occurs in the IWP set by that urine culture of 3/11. The DOE is 3/10. We cannot use the 3/1
fever greater than 38 because did not occur
in the IWP. So you will have
problems from time to time and you’ll be sending
questions to NHSN. So when you do send those
questions please give us the date of admission when
the catheter was inserted and removed. The age of the patient, the
results of urine cultures with the colony count,
signs and symptoms, any results of any positive
blood cultures. Include what you
think it might be. Do not include confidential
personal identifiable information. As Kathy said earlier
please don’t send us names, we’ll delete it and ask
them to please resend. Take a look at the
frequently asked questions. They are your friend because
sometimes you’ll find the answers there if you’re not
visiting here very often. You can visit here and see
frequently answered questions for UTI’s as well as analysis. Your annual surveys or
locations, miscellaneous and CDA. I have got five case
studies here and look like we’re doing
pretty good on time so we probably will go
through all of these. If not, I will stop
and answer questions. So this is going to have –
we’ll start looking at these. When you go through case
studies I would like for you to follow this pattern
each time. You’re going to determine the
date of the urine culture. If you don’t have a urine
culture there’s no reason to start investigation. So get your urine
culture from the date of the urine culture
set your IWP. Determine if all the
elements are within the IWP. Determine when the DOE is. If the data – the first
element occurs the first time in the IWP. If the DOE is POA time period
well if yes, then it’s POI. If it is after that third day, [Inaudible] earlier
or later sorry. If no, it’s an HAI. And remember that POA time
period is defined as the day of admission to an inpatient
location the two days before admission and the calendar
day after the admission; so just the clarification
on that. And then determine if
its device associated. So that’s how we will
look at each one of these. You want to save this,
especially if you’re a newbie. You’ll want that. So let’s look at a patient
less than 65 years of age. Our patient is 57 on
February 2 they were admitted to ICU on February 3. He had a temp on the
third and the fourth. We got our urine culture
collected and positive or greater than 100,000
coag negative staph. So I don’t believe – yeah
this is not a Poll Everywhere, so stay cool. So the first question is on
2/3 can the fever be used as an element in this age? Yes it can. Our patient is less
than 65 years of age. What is the case determination? Now this is a poll
everywhere question. What is the correct
determination of this case? All right, well let’s see. We still have answers coming in. This patient has a
SUTI1b, it’s non CAUTI. So let’s take a look. What is the rationale? 2/5 positive urine culture
sets the IWP to February 8. The 2/3 fever is
eligible in this patient because it’s the first
element within the IWP. The catheter was not in place
for greater than two days in the inpatient
location on the date of event therefore this is a
SUTI1b non-catheter associated UTI and the UTI,
RIT and SBAP is set. Okay now we’re going to look at
a patient greater than 65 years of age, almost the
same scenario. On February 2 the patient
is age of 75 in the ED and we have a catheter inserted. Admitted to ICU, we have temps
on the third and the fourth. The urine culture is collected
for coag negative staph. On 2/28 the catheter is
removed and discharged home. So the 2/3 fever can be used as
an element in this age patient. No it cannot. Can the 2/4 fever be used as
an element in this patient? No it cannot. So what is the correct
determination in this case? Give it a thought. This patient does
not meet a UTI event. So let’s map it out. 2/5 positive cultures sets
the IWP from 2/2 to 2/8. The 2/3 and two fevers
cannot be used as an element in this age patient because
the catheter was not in place in the patient on the date of
event for greater than two days. There are no UTI
elements within the IWP. So there is no event,
no RIT is set. You cannot call this a SUTI1b. You cannot call this period. So consider other
signs and symptoms. If they collected
this culture, why? Is there something that
didn’t get documented, then that would not be good. Okay we’re going to do a
knowledge check on this one. The patient was admitted to
med surg unit for influenza. They had a headache and body
aches, they’ve got nausea. The urine culture was positive
for greater than 100,000 E. faecium and 20,000 for Pseudomonas
aeruginosa. A blood culture was
collected on the same day that grew pseudomonas. The blood culture can be used to meet the ABUTI
definition true or false? We’ve half and half going here. Okay I’ll put you
out of your agony. It’s false. Okay. So let’s look
at the rationale here. To use the blood as an element in the ABUTI the blood organism
must match the urine organism greater than 100,000 and
occur within the IWP. That pseudomonas
organism was only 20,000; therefore the pseudomonas
in the blood cannot be used as an element for the ABUTI. There are no UTI signs or
symptoms nor matching blood within the IWP of the
culture with E. faecium; therefore there is no UTI event
and no RIT nor an SBAP is set. Investigate the positive
blood sample as primary BSI, used as an element
or used as an element at another site specific
infection. Okay case four. We’ve got a prolonged
hospital stay, we have a catheter
in place since 1/30. On 2/11 we have a positive
wound culture, a staph species and an enterococcus faecalis. We have a urine culture
of greater than 100,000, staph epidermidis and we
also have a blood culture that is staph epidermidis. Two blood cultures drawn
on separate occasions. We have hypotension. No fever greater than 38. And there are no
other UTI signs. Knowledge check so get
your phones back out. Be ready. So what is the correct
determination in this case? SUTI1a CAUTI, is it a
cath associated ABUTI, this patient does not meet
anything, or a primary LCBI 2 This patient meets
associated ABUTI. So let’s look at the rationale. 2/14 positive urine culture sets
the IWP at 2/11 through 2/17. We’ve got no UTI
signs within the IWP. We do have a blood
culture that’s positive that is an LCBI – that is LCBI 2. And so we have our
date of event on 2/14. The catheter is in
place for greater than two days on
the date of event. So this meets a catheter
associated ABUTI and the matching blood
culture is secondary. It is secondary to that
ABUTI infection either chills or hypotension. Reportable, if the location
is in the reporting plan. Okay this is your last one. We do have a knowledge check. We have a patient
who is admitted with a catheter with 100.3 temp. The temperature of 100.7
on the seventh of January. On 1/8 we have 100.8. The Foley was discontinued we
have a temp 99.6 on the 10th. On the 11th we have a urine
culture that’s greater than 100,000 for
proteus mirabilis and E. Coli that’s
about 50,000 CFU. We have max temp
on the 12th at 99.6 and then they are
discharged to rehab. How do we categorize this? A SUTI1a, a SUTI1b? Or no event – so
what do you think? So let’s see the rationale. It meets a SUTI1a
catheter associated UTI with the date of event 1/8. Even thought the positive
urine culture occurred two days after the Foley catheter was
removed the 1/8 fever was the first element in
that seven day IWP. Therefore it’s the
date of event. On the date of event
the catheter was in place greater than two days. This meets a SUTI1a catheter
associated UTI, date of even 1/8 with pathogen of
proteus mirabilis. So what have we covered
very quickly in this last hour is we reviewed
the protocol, key concepts and your common pitfalls. Remember positive urine
cultures or UTI symptoms on admission does not
automatically meet POA. UTI is a primary
site of infection and cannot be secondary
to another site. Do not change your device
association during the UTI RIT. We identified how to
count catheter days and to determine
infection association. Remember that the catheter
counts on the day of insertion and if the catheter is in place
prior to admission it begins with the date of admission to
the first inpatient location. We discussed some updates to our
protocol, terms and definitions. We reviewed the data
collection form on the table of instructions. We made a correct
UTI determination through some case studies. We reviewed fever, age
and device association. And we reviewed ABUTI. So remember you got homework. You got two things; remember
to take some time to look at each one of those pages for your particular
surveillance needs. And take some notes. And visit your microbiology
department. Make friends with
your microbiologist. So, whether you are a young
whipper snapper ready to take on the world or if
you are sophisticated and well seasoned IP I hope that your week here will
be an educational one. You will make friends and
do a lot of networking; so we do have time
for questions. [ Applause ]>>So during the infection
window if you have two UA’s, one that reflects – reflects
to culture and was positive, greater than 100,000
and the second one that was done hours later. Didn’t reflect but it was
a completely clean culture, is there any way to
utilize that second specimen in the determination
of the case?>>Okay so your first culture
grew out multiple organisms.>>No, just one.>>Oh it just grew
out one organism.>>Correct.>>You would start
with that one. You set your IWP, it’s
the first one you got. You got to go with that.>>Okay. I knew the answer but ->>Could you please reiterate
for me and perhaps some others in the group the 65
and older criterion when you can’t use the fever,
what the other things are because I think that a catheter
associated UTI would knock out a couple of those criteria,
if you know what I mean. It’s like for instance
frequency; you’re not going to have frequency, right? So could you just reiterate
what you said about the 65 and older population for me?>>If the only thing
you have is a fever and it’s not catheter
associated, first thing if you’re
considering fever in someone greater
than 65 years of age. Is it catheter associated? That means they have to
have that catheter in place for greater than two days. Then if you only have
fever what’s your DOE? If your DOE isn’t on
catheter day three or after you can’t
use that fever. If you got frequency, use that. If it’s before your culture
say, it’s always good to look for another symptom. But if you’ve got fever then
you’ve got to bring that – and then you’ve got
to count your days. How long was that
Foley in place? And even though we’re trying
to get rid of the word “Foley” it’s a hard habit.>>This is another question that
I think I know the answer to. If you have a patient that comes
in with an existing catheter, Foley catheter and they
have yeast growing. And then few days later they
have E. Coli, you can’t – still can’t call that
present on admission because the first one didn’t
count because it was yeast. Is that correct? And is there any way around –
not around that but I mean ->>What you have not
given me any dates on when things were collected,
when the symptoms happened. I can’t set you an
IWP; so it sounds like you’re trying
to give me a case.>>Let’s say like
yeah, on day one ->>They had a Foley catheter
and they had it at home and were admitted with it and on that same first day they
had a positive urine culture with yeast. And then let’s say four days
later, three days later, whatever down the road so
it’s not present on admission, they have E. Coli
growing with 100,000. You know physicians will say
that was present on admission. They had that yeast but we
can’t use that as a basis for that, is that right?>>The first culture you can
use is one that’s acceptable and if the one was three
or four days down the road, that’s the one that
you’re going to use if it was only one organism,
no more than two that’s where you would set your IWP. You can’t set an IWP on
an unacceptable sample.>>Okay thank you.>>Bonnie we have a couple
questions from the web. Can a blood culture with the
same pathogens set the date of event for the CAUTI? The blood culture was
collected within the IWP prior to urine culture collection and
the first symptom was the day after the blood culture
was collected but before the urine
culture collection. Okay so if we have an IWP
set and we have a symptom within the IWP even though we
have a blood culture that’s positive I understand
this correctly. If you have a symptom within the
IWP you no longer have an ABUTI, what is an ABUTI? asymptomatic
bacterium. If you’ve got a symptom that means you’re
symptomatic with your UTI. Does that make sense?>>Yep it makes sense to me. So they cannot use that – in that instance they cannot
use the blood culture. The blood culture would
be secondary if it’s within the SBAP.>>It would be secondary ->>That matching organism
in urine that was greater than 100,000 that could
use as a secondary.>>Second question, if a
patient has been admitted to an inpatient unit, but due to bed being unavailable
the patient remains in the emergency department
in a holding status. Can the CAUTI be attributed
to the inpatient unit if the patient is
not physically there but is assigned to the unit?>>We start counting
inpatient days, Foley days, any device days on the day
the patient is admitted to room physically. They’ve got to be in that room
and your device days count.>>So the answer is no, you
don’t assign a CAUTI or a CLABSI to an outpatient unit
because they’re not bedded units. It looks like we might
have another one.>>Yes, could you please clarify
the use of urine that comes from a nephrostomy or urostomy
or a suprapubic catheter? You said to look at that urine ->>You can use a
urine that’s obtained when someone has a nephrostomy – that’s where you
obtain that urine from. You can use that culture from
that fluid to set an IWP. If that person has a catheter and a nephrostomy then it can be
catheter associated depending on how long they’ve
had that catheter in. So they could have a
culture with a nephrostomy and a catheter and it
comes from the nephrostomy but you can count as a CAUTI
even though it didn’t come from the indwelling – is the risk
that you’re looking at in there. There’s the risk when
there’s a device.>>Can I expand on that? So a patient has got an
ascending urinary tract infection, you could certainly
get a positive urine culture from the nephrostomy urine. We do have an exception. If you have a positive culture
from the nephrostomy urine and a negative from
the Foley urine, in that case it’s
obviously not ascending so you don’t have to
call that a CAUTI. But if you only have a positive from the nephrostomy urine then
you have a catheter in place, you have to call that. Make sense? I mean we don’t know
that it’s not – that it’s not down
in the bladder. Right? How do we know?>>Just follow up to your
statement, so does the – does the Foley culture
need to be within that infection
window period of the nephrostomy culture? Probably.>>I don’t know that we’ve
ever been asked that question, but yeah a week later you do
a culture and it’s negative. The patient has been treated
for the urinary tract infection. That doesn’t make any sense.>>Okay I have a question
sent by my IP friend who is watching right now.>>Is it a specific case?>>No, no.>>Okay.>>The question is when
you said no other causes, like let’s say abdominal pain
with no other recognized cause; does it have to be documented
by the physician or can that be determined that
there was not a cause?>>That can be documented
by the nurse, the nurse that’s taking care
of the patient if that’s in her notes or his notes. And abdominal pain, FYI is
not an acceptable symptom. It needs to be lower. It needs to be lower.>>Lower abdominal pain.>>That would be good. Get it into the medical records.>>So it has to be
in the record.>>It must be in the records.>>Okay we’re done.>>It’s 12:15.>>All right, thank
you very much. [ Applause ]


Leave a Reply

Your email address will not be published. Required fields are marked *