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Healthcare-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration—LabID Clostridium Difficile event 2013
American Journal of Infection Control 41 (2013) 916-7
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Clinical case study
Healthcare-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaborationdLabID Clostridium Difficile event 2013 Joan N. Hebden MS, RN, CIC a, *, Angela Anttila MSN, RN, NPC, CIC b, Kathy Allen-Bridson BSN, MScPH, RN, CIC b, Gloria C. Morrell MS, MSN, RN, CIC b, Marc-Oliver Wright MT(ASCP), MS, CIC c, Teresa Horan MPH d a
Wolters Kluwer HealthdSentri7, Bellevue, WA National Healthcare Safety Network, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA Department of Infection Control, North Shore University Health System, Evanston, IL d Rollins School of Public Health of Emory University, Atlanta, GA b c
This is the first in a series of case studies that will be published in American Journal of Infection Control following the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) surveillance definition update of 2013. These cases reflect some of the complex patient scenarios infection professionals encounter during daily surveillance of health care-associated infections using NHSN definitions. Answers to the questions posed and immediate feedback in the form of answers and explanations are available at: http://www.surveymonkey.com/s/AJIC-NHSN-LbId2013. All individual participant answers will remain confidential, although it is the authors’ hope to share a summary of the findings at a later date. Cases, answers, and explanations have been reviewed and approved by NHSN staff. Active participation is encouraged and recommended. Review/reference Chapter 12eMultidrug-resistant organism & C difficile infection module protocol, of the NHSN Patient Safety Component Manual (http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf), for information you may need to answer the case study questions. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
On January 1st at 10:30 AM, a 75-year old man presented to our emergency department (ED) from a long-term acute care facility (LTAC) with the chief complaints of shortness of breath, abdominal cramping, and a 3-day history of multiple episodes of diarrhea. His past medical history included a myocardial infarction and a 3-vessel coronary artery bypass grafting procedure performed on December 2nd at this hospital that was complicated by a prolonged postoperative stay in the intensive care unit (ICU). During the ICU stay, he was treated for a urinary tract infection with levofloxacin. He was discharged to undergo rehabilitation at the LTAC on December 23rd where he had his onset of diarrhea. While in the ED on January 1st, a chest radiograph revealed bilateral pleural effusions and pulmonary edema. Before being admitted to an inpatient location, aggressive diuresis was initiated and a diarrheal stool specimen was collected and sent to the laboratory for Clostridium difficile toxin testing. The test result indicates
* Address correspondence to Joan N. Hebden, MS, RN, CIC, Wolters Kluwer HealthdSentri7, 3535 Factoria Blvd SE, Bellevue, WA 98006. The findings and conclusions in this case study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Conflicts of interest: None to report.
positive C difficile toxin A/B. The patient was admitted at 3:45 PM on January 1st to 2N telemetry. On January 2nd during the night, the patient experienced respiratory deterioration requiring mechanical ventilation and was subsequently transferred to the ICU. He continued to have abdominal cramping and multiple episodes of diarrhea. Another diarrheal stool specimen was collected and sent from the ICU for C difficile toxin testing. The result was positive for C difficile toxin A/B. Metronidazole was started. 1. Would you identify the January 1st C difficile toxin positive assay as a Clostridium difficile infection laboratory-identified (CDI LabID) event for facility-wide inpatient (FacWideIN) reporting? a. No. The patient was admitted with diarrhea from the LTAC facility and the transfer rule applies. b. Yes. The result would be identified as a CDI LabID event for 2N because the specimen was collected from the facility’s ED on the same calendar day as inpatient admission to 2N. c. Yes. The result would be identified as a CDI LabID event for the ED because this is where the specimen was collected. d. No. The patient presented to the ED with diarrhea suggestive of C difficile infection, so this is considered community-
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.05.009
J.N. Hebden et al. / American Journal of Infection Control 41 (2013) 916-7
onset and, therefore, should not be considered a CDI LabID event for FacWideIN reporting. 2. Would you identify the January 2nd positive C difficile toxin result as a CDI LabID event for FacWideIN reporting? a) No. His symptoms started <4 days after admission. b) Yes. As there were no other C difficile-positive specimens for this patient and location (the ICU) in 2weeks, the result would be identified as a CDI LabID event for the ICU. c) Yes. The result would be identified as a CDI LabID event for 2N because the patient was in that location within the prior 2 calendar days and the transfer rule applies. d) No. Because this is the second positive C difficile isolate collected from this patient within 14 days, it is considered a duplicate CDI LabID event. 3. If the January 1st positive C difficile toxin result is a CDI LabID event, how will the event be categorized by the National Healthcare Safety Network (NHSN) application? a) Community-onset because the specimen was collected 3 days after admission to the facility. b) Health care-facility-onset because the specimen was collected >3 days after admission to the facility. c) Community-onset health care facility-associated because the specimen was collected 3 days after admission to the facility and the patient was discharged from the facility 4 weeks prior to the current date of stool specimen collection. d) The NHSN application will not categorize the event. I will categorize the CDI LabID event based on the current NHSN health care-associated infection criteria. The patient remained in the ICU until January 14th, after which he was transferred back to 2N telemetry. He completed a course of
917
metronidazole, had no abdominal complaints, and his stools were formed with no further C difficile toxin testing having been performed. On January 16th, following readmission to 2N telemetry he experienced an episode of diarrhea after eating breakfast and another episode of diarrhea in the afternoon. A sample was sent for C difficile toxin testing and the result was positive for C difficile toxin A/B. 4. Would you identify the January 16th positive C difficile toxin result as a CDI LabID event for FacWideIN reporting? a) Yes. The result would be identified as a CDI LabID event for 2N because the specimen was collected in a location with no prior C difficile specimen reported within 14 days for the patient and location. b) No. The result would be considered a duplicate episode of C difficile and would not be reported as a separate CDI LabID Event for FacWideIN reporting. c) Yes. The result would be identified as a CDI LabID Event for the ICU because the specimen was collected 14 days after the last positive specimen for the ICU and the patient was in that location within the previous 48 hours and the transfer rule applies. 5. If the January 16th positive C difficile toxin result is a CDI LabID event, how will the event be categorized by the NHSN application? a) A recurrent CDI LabID event, as the January 16th specimen was obtained >2 weeks and 8 weeks after the most recent CDI LabID event for the patient. b) This CDI LabID event would not be further categorized by NHSN because it represents a duplicate episode of C difficile. c) An incident C difficile infection assay as the January 16th specimen result is considered a new CDI LabID event for the patient for this location.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Clinical case study
Healthcare-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaborationdLabID Clostridium Difficile event 2013 Joan N. Hebden MS, RN, CIC a, *, Angela Anttila MSN, RN, NPC, CIC b, Kathy Allen-Bridson BSN, MScPH, RN, CIC b, Gloria C. Morrell MS, MSN, RN, CIC b, Marc-Oliver Wright MT(ASCP), MS, CIC c, Teresa Horan MPH d a
Wolters Kluwer HealthdSentri7, Bellevue, WA National Healthcare Safety Network, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA Department of Infection Control, North Shore University Health System, Evanston, IL d Rollins School of Public Health of Emory University, Atlanta, GA b c
This is the first in a series of case studies that will be published in American Journal of Infection Control following the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) surveillance definition update of 2013. These cases reflect some of the complex patient scenarios infection professionals encounter during daily surveillance of health care-associated infections using NHSN definitions. Answers to the questions posed and immediate feedback in the form of answers and explanations are available at: http://www.surveymonkey.com/s/AJIC-NHSN-LbId2013. All individual participant answers will remain confidential, although it is the authors’ hope to share a summary of the findings at a later date. Cases, answers, and explanations have been reviewed and approved by NHSN staff. Active participation is encouraged and recommended. Review/reference Chapter 12eMultidrug-resistant organism & C difficile infection module protocol, of the NHSN Patient Safety Component Manual (http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf), for information you may need to answer the case study questions. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
On January 1st at 10:30 AM, a 75-year old man presented to our emergency department (ED) from a long-term acute care facility (LTAC) with the chief complaints of shortness of breath, abdominal cramping, and a 3-day history of multiple episodes of diarrhea. His past medical history included a myocardial infarction and a 3-vessel coronary artery bypass grafting procedure performed on December 2nd at this hospital that was complicated by a prolonged postoperative stay in the intensive care unit (ICU). During the ICU stay, he was treated for a urinary tract infection with levofloxacin. He was discharged to undergo rehabilitation at the LTAC on December 23rd where he had his onset of diarrhea. While in the ED on January 1st, a chest radiograph revealed bilateral pleural effusions and pulmonary edema. Before being admitted to an inpatient location, aggressive diuresis was initiated and a diarrheal stool specimen was collected and sent to the laboratory for Clostridium difficile toxin testing. The test result indicates
* Address correspondence to Joan N. Hebden, MS, RN, CIC, Wolters Kluwer HealthdSentri7, 3535 Factoria Blvd SE, Bellevue, WA 98006. The findings and conclusions in this case study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Conflicts of interest: None to report.
positive C difficile toxin A/B. The patient was admitted at 3:45 PM on January 1st to 2N telemetry. On January 2nd during the night, the patient experienced respiratory deterioration requiring mechanical ventilation and was subsequently transferred to the ICU. He continued to have abdominal cramping and multiple episodes of diarrhea. Another diarrheal stool specimen was collected and sent from the ICU for C difficile toxin testing. The result was positive for C difficile toxin A/B. Metronidazole was started. 1. Would you identify the January 1st C difficile toxin positive assay as a Clostridium difficile infection laboratory-identified (CDI LabID) event for facility-wide inpatient (FacWideIN) reporting? a. No. The patient was admitted with diarrhea from the LTAC facility and the transfer rule applies. b. Yes. The result would be identified as a CDI LabID event for 2N because the specimen was collected from the facility’s ED on the same calendar day as inpatient admission to 2N. c. Yes. The result would be identified as a CDI LabID event for the ED because this is where the specimen was collected. d. No. The patient presented to the ED with diarrhea suggestive of C difficile infection, so this is considered community-
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.05.009
J.N. Hebden et al. / American Journal of Infection Control 41 (2013) 916-7
onset and, therefore, should not be considered a CDI LabID event for FacWideIN reporting. 2. Would you identify the January 2nd positive C difficile toxin result as a CDI LabID event for FacWideIN reporting? a) No. His symptoms started <4 days after admission. b) Yes. As there were no other C difficile-positive specimens for this patient and location (the ICU) in 2weeks, the result would be identified as a CDI LabID event for the ICU. c) Yes. The result would be identified as a CDI LabID event for 2N because the patient was in that location within the prior 2 calendar days and the transfer rule applies. d) No. Because this is the second positive C difficile isolate collected from this patient within 14 days, it is considered a duplicate CDI LabID event. 3. If the January 1st positive C difficile toxin result is a CDI LabID event, how will the event be categorized by the National Healthcare Safety Network (NHSN) application? a) Community-onset because the specimen was collected 3 days after admission to the facility. b) Health care-facility-onset because the specimen was collected >3 days after admission to the facility. c) Community-onset health care facility-associated because the specimen was collected 3 days after admission to the facility and the patient was discharged from the facility 4 weeks prior to the current date of stool specimen collection. d) The NHSN application will not categorize the event. I will categorize the CDI LabID event based on the current NHSN health care-associated infection criteria. The patient remained in the ICU until January 14th, after which he was transferred back to 2N telemetry. He completed a course of
917
metronidazole, had no abdominal complaints, and his stools were formed with no further C difficile toxin testing having been performed. On January 16th, following readmission to 2N telemetry he experienced an episode of diarrhea after eating breakfast and another episode of diarrhea in the afternoon. A sample was sent for C difficile toxin testing and the result was positive for C difficile toxin A/B. 4. Would you identify the January 16th positive C difficile toxin result as a CDI LabID event for FacWideIN reporting? a) Yes. The result would be identified as a CDI LabID event for 2N because the specimen was collected in a location with no prior C difficile specimen reported within 14 days for the patient and location. b) No. The result would be considered a duplicate episode of C difficile and would not be reported as a separate CDI LabID Event for FacWideIN reporting. c) Yes. The result would be identified as a CDI LabID Event for the ICU because the specimen was collected 14 days after the last positive specimen for the ICU and the patient was in that location within the previous 48 hours and the transfer rule applies. 5. If the January 16th positive C difficile toxin result is a CDI LabID event, how will the event be categorized by the NHSN application? a) A recurrent CDI LabID event, as the January 16th specimen was obtained >2 weeks and 8 weeks after the most recent CDI LabID event for the patient. b) This CDI LabID event would not be further categorized by NHSN because it represents a duplicate episode of C difficile. c) An incident C difficile infection assay as the January 16th specimen result is considered a new CDI LabID event for the patient for this location.