CMS and NHSN: What’s New for

Infection Preventionists in 2013 –

Part II

Joan Hebden RN, MS, CIC

Clinical Program Manager – Sentri7

Wolters Kluwer Health - Clinical Solutions

• Define the two major changes to CMS reporting requirements in

2014/15 for acute care facilities

• Understand the NHSN recent and proposed definitional changes for

CLABSI, VAE and SSI

• Define SAMS and when this will impact you

• State how to access the NHSN demo site

• Understand the rationale for the correct answers to the case study

scenarios

Objectives

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2011

• CAUTI – Acute Care ICUs (except NICUs) (Jan.)

• CAUTI – LTCH, IRF, Cancer Hospitals (Oct)

• SSI – Colon Surgeries and Abdominal Hyst. – Acute Care (Jan)

• Dialysis Events – ESRD (Jan)

• CLABSI – LTCH, Cancer Hospitals (Oct)

2012

2013

• HCP Influenza Vaccination – ASCs (Oct.)

• SSI – Cancer Hospitals (Jan.)

• HCP Influenza Vaccination – IRF (Oct.) 2014

• CLABSI – Acute Care ICUs (Jan.)

• C. Diff LabID Events – Acute Care (Jan.)

• MRSA Bacteremia LabID Events – Acute Care (Jan.)

• HCP Influenza Vaccination – Acute Care (Jan.)

• HCP Influenza Vaccination – LTCH (Jan.)

2015

CMS Mandated HAI Reporting To NHSN

• CLABSI – Acute Care Med, Surg, Med/Surg Units (Jan.)

• CAUTI – Acute Care Med, Surg, Med/Surg Units (Jan.)

• MRSA Bacteremia LabID Events – LTCH (Jan.)

• C. Diff LabID Events – LTCH (Jan.)

CMS Rules for Acute Care Facilities – 2014-15

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NHSN Updates

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NHSN SSI Reporting Changes for 2014

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NHSN SSI Surveillance:Transition from ICD-9-CM

codes

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Ventilator-Associated Event (VAE) Surveillance

Update – July 2013

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• VAE surveillance initiated in adult patients in Jan 2013

• Over 1200 facilities submitting data

• VAE Definition Working group received feedback:

• VAC detected in clinical scenarios as a result of usual processes of

care or ventilator strategy differences between providers rather than

an actual clinical worsening of the patient

• July 2013 Change to the definition: daily minimum PEEP values of 0-5

cm H2O are considered equivalent

• Patients must have an increase in the minimum daily PEEP value to 8

cm H2O AND sustained at or above 8 cm H2O for at least 2 calendar

days to meet the VAC definition

Ventilator-Associated Event (VAE) Surveillance

Update – July 2013

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Is it a CAUTI?

2012 Criteria 2013 Change

SUTI/ABUTI in a patient that had

a urinary catheter within the 48

hour period before the

SUTI/ABUTI

No minimum amount of time for

device to be in place prior to

meeting the CAUTI infection

criteria

SUTI/ABUTI had an indwelling urinary catheter place for >2 calendar days when the criteria for SUTI/ABUTI were met.

If the SUTI/ABUTI occurs on the day the urinary catheter is discontinued or the following calendar day, the CL must have already been in place > 2 calendar days to be considered a CAUTI.

CAUTI Definition Changes on the Horizon

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CAUTI Definition Changes on the Horizon

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CAUTI Definition Changes on the Horizon

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CAUTI Definition Changes on the Horizon

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LabID Event Update

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LabID Event Update

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NHSN Updates: Coming Soon

• Secure Access Management Services: SAMS

• Will replace the Secure Data Network (SDN) that is currently used for

user identity verification

• Will no longer need to install a digital certificate annually!!

• Gradual migration which will take up to 2 years to complete

• Migration will occur based on each individual’s digital certificate

expiration date

• Each individual NHSN user will receive an invitation 60 days prior to the

expiration of your digital certificate to become “SAMified”

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NHSN Demo

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NHSN Demo

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Identifying HAIs in NHSN

HAI: An infection is considered an HAI if all elements of a CDC/NHSN

site-specific infection criterion were first present together on or

after the 3rd hospital day (day of hospital admission is day 1).

For an HAI, an element of the infection criterion may be present

during the first 2 hospital days as long as it is also present on or

after day 3. All elements used to meet the infection criterion must

occur within a timeframe that does not exceed a gap of 1 calendar

day between elements.

What were the NHSN 2013 changes?

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USE CALENDAR DAYS

HAI Event -

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An infection meeting the HAI definition is considered a device-

associated HAI if the device was in place for >2 calendar days

when all elements of a CDC/NHSN site-specific infection criterion

were first present together.

HAIs occurring on the day of device discontinuation or the following

calendar day are considered device-associated HAIs if the device

had been in place already for >2 calendar days.

Device –Associated HAIs

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CLABSI Reporting in Dialysis Patients

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CLABSI Reporting in Dialysis Patients

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Q: Can I use a fever from day 2 to meet the CAUTI criteria?

Day 1 - patient admitted; Foley inserted; patient is afebrile

Day 2 – Foley remains in place; temp 38.4

Day 3 – Foley in place; urine culture sent and is (+) for >100,000 E.

coli

Day 4 - Foley in place; afebrile

Day 5 – Foley in place; afebrile

Is it a CAUTI?

Q: Can I use a fever from day 2 to meet the CAUTI criteria?

Day 1 - patient admitted; Foley inserted; patient is afebrile

Day 2 – Foley remains in place; temp 38.4

Day 3 – Foley in place; urine culture sent and is (+) for >100,000 E.

coli

Day 4 - Foley in place; afebrile

Day 5 – Foley in place; afebrile

This will not meet HAI criteria since the patient did not have fever

present again on day 3, 4 or 5.

Is it a CAUTI?

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9/10 Patient admitted and underwent a hemi-colectomy. Wound

Class =2. Does well post-operatively and is discharged home on 9/15

10/11 Seen in the ED. Temp 38.70 C , abdominal pain. Ultrasound

shows abscess along the abdominal wall

10/14 I&D of the abdominal wall abscess and specimen sent for

culture. Antibiotics initiated. Abscess culture positive for E. coli

Would this patient be reported as an SSI?

1. Yes

2. No

SSI Reporting Case Study

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Would this patient be reported as an SSI?

1. Yes

2. No – the infection occurred > 30 days after the operative

procedure

SSI Case Study

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If the readmission date for this patient was 10/6, would this

be reported as an SSI? If so, what type?

1. Yes:

a) SIP

b) DIP

c) Organ Space: Intraabdominal

2. No

SSI Case Study

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If the readmission date for this patient was 10/6, would this

be reported as an SSI? If so, what type?

1. Yes:

a) SIP

b) DIP

c) Organ Space: Intraabdominal

2. No

SSI Case Study

VAC based

on PEEP not

FiO2 Why?

Date of

Event

3/4/2013 –

Why?

VAE Window

only 4 days

Why?

VAE Calculator

Case Study

A 69-year old female is seen in the ER and subsequently admitted to

the ICU on a ventilator. Review her ventilator settings and determine if

VAE criteria are met.

MV Day Daily minimum

PEEP

Daily minimum

FiO2

1 8 100

2 6 50

3 5 50

4 6 40

5 6 60

6 6 60

7 5 60

8 5 60

9 5 60

A. Yes

B. No

Case Study

A 69-year old female is seen in the ER and subsequently admitted to

the ICU on a ventilator. Review her ventilator settings and determine if

VAE criteria are met. If so, on what MV Day does the event occur?

MV Day Daily minimum

PEEP

Daily minimum

FiO2

1 8 100

2 6 50

3 5 50

4 6 40

5 6 60

6 6 60

7 5 60

8 5 60

9 5 60

There is not

a ≥ 20 point

change from

MV day 3 to

MV day 5

A. Yes

B. No

What if the settings were as follows?

MV Day

Daily

minimum

PEEP

Daily minimum

FiO2

1 8 100

2 6 50

3 5 50

4 6 40

5 6 70

6 6 70

7 5 60

8 5 70

9 5 60

A. Yes

B. No

What if the settings were as follows?

MV Day Daily minimum

PEEP

Daily minimum

FiO2

1 8 100

2 6 50

3 5 50

4 6 40

5 6 70

6 6 70

7 5 60

8 5 70

9 5 60

A. Yes

B. No

The patient eventually develops a fever and is started on

antibiotics. Does this meet the IVAC definition?

MV

Day

Daily

minimum

PEEP

Daily

minimum

FiO2

Temp

Min

Temp

Max

WBC

Min

WBC

Max ABX

1 8 100

2 6 50

3 5 50 37.6 38 4.8 4.9 None

4 6 40 38.6 38.9 5.6 5.8 None

5 6 70 39 39.0 5.6 5.8 None

6 6 70 38.8 39.0 5.1 5.4 None

7 5 60 38.0 38.1 5.2 5.4 None

8 5 70 Yes

9 5 60 Yes

A. Yes

B. No

The patient eventually develops a fever and is started on

antibiotics. Does this meet the IVAC definition?

MV

Day

Daily

minimum

PEEP

Daily

minimum

FiO2

Temp

Min

Temp

Max

WBC

Min

WBC

Max ABX

1 8 100

2 6 50

3 5 50 37.6 38 4.8 4.9 None

4 6 40 38.6 38.9 5.6 5.8 None

5 6 70 39 39.0 5.6 5.8 None

6 6 70 38.8 39.0 5.1 5.4 None

7 5 60 38.0 38.1 5.2 5.4 None

8 5 70 Yes

9 5 60 Yes

A. Yes

B. No

Why not IVAC?

• Temp criterion is

met BUT….

• BUT … new

antimicrobial agent

not started within

VAE Window Period

THANK YOU FOR ATTENDING

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