- Email: [email protected]
Present or absent on admission: Results of changes in National Healthcare Safety Network surveillance definitions
American Journal of Infection Control 43 (2015) 1128-30
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Present or absent on admission: Results of changes in National Healthcare Safety Network surveillance definitions Lauren Farrell MS, MLS(ASCP)CM,CIC a, *, Margaret Gilman CIC a, Eva Teszner RN, CIC a, Susan E. Coffin MD, MPH a, b, Julia Shaklee Sammons MD, MSCE a, b a b
Department of Infection Prevention and Control, The Children’s Hospital of Philadelphia, Philadelphia, PA Department of Pediatrics and Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Key Words: Hospital-acquired infections Mandatory reporting
In January 2013, the National Healthcare Safety Network definition of “present on admission” was created. Using existing surveillance data from 2013, we identified health care-associated infections (HAIs) that met prior present on admission criteria but not the new definition. We identified a number of infections classified as HAI despite evidence that infection was clinically present on admission. These findings have important implications for states with mandatory HAI reporting using National Healthcare Safety Network definitions. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Surveillance for health care-associated infections (HAIs) is a key element of infection prevention programs. Application of National Healthcare Safety Network (NHSN) methodology provides a standardized way in which HAIs are identified, enabling health care institutions to trend infection rates and monitor quality improvement initiatives. Before 2013, an infection was considered present on admission (POA) if evidence of infection was present/incubating on admission.1 In 2013, the NHSN created a POA surveillance criterion stating infections must fully meet a definition within 2 calendar days of admission to receive this designation. NHSN further stipulated that symptoms must be documented by a health care professional during the POA time frame, and physician diagnosis is only considered evidence when it is an element of the definition being met.2 Pennsylvania requires that all HAIs are reported using NHSN definitions. We aimed to assess the influence of the POA definition on mandatory reporting of HAIs at the Children’s Hospital of Philadelphia (CHOP).
academic, tertiary care pediatric hospital with 521 beds and approximately 28,000 annual admissions, to assess the influence of changing surveillance definitions on HAI reporting. This project met criteria for quality improvement work by CHOP’s institutional review board guidelines and was exempt from review board oversight.
METHODS
CHOP performs active surveillance on inpatients using all 43 of the NHSN HAI definitions, as required by Pennsylvania regulations. Infections meeting 2013 NHSN HAI criteria were determined to be CPOA if the electronic medical record included evidence of infection within 2 calendar days of admission (Fig 1). Evidence of infection for skin/soft tissue infections (CPOA-SSTIs) was defined as having at least 1 sign/symptom listed in Table 1.
Study design and setting We conducted a retrospective, cross-sectional study within the Department of Infection Prevention and Control at CHOP, an * Address correspondence to Lauren Farrell, MS, MLS(ASCP)CM, CIC, Department of Infection Prevention and Control, The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail address: [email protected] (L. Farrell). Conflicts of interest: None to report.
Case finding and data sources In response to the January 2013 POA definition, all infection control professionals (ICPs) prospectively documented in the electronic surveillance system clinically present on admission (CPOA) infections that met the definition for HAI. Cases were identified during routine surveillance and electronic medical record review. For this analysis, we reviewed existing HAI data from January through December 2013 and captured all infections documented as CPOA. Study definitions
Analysis CPOA infections were categorized by infection type. Frequencies of each CPOA-HAI were calculated to identify trends (Fig 1). For
0196-6553/$36.00 - Copyright Ó 2015 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.2015.05.023
L. Farrell et al. / American Journal of Infection Control 43 (2015) 1128-30
1129
Fig 1. Flow diagram. *Using previous criteria for present on admission. **All infections fell into the subcategories of skin or soft tissue infections. No breast, burn, circumcision, decubitis, pustulosis, or umbilicus infections were categorized as CPOA. CPOA, clinically present on admission; HAI, health care-associated infection.
CPOA-SSTI, we enumerated the frequencies of each element of the NHSN definition documented in the electronic medical record (Table 1). RESULTS In 2013, we identified 632 HAIs. Forty-four were CPOA. The most common were SSTI (n ¼ 23; 52.3%). All had documentation of at least 2 symptoms required by NHSN to be defined as SSTI within 2 calendar days of admission. None fully met the SSTI criteria because they lacked an element of the definition, such as positive lab test on blood/urine, diagnostic antibody titers, or positive blood culture (Table 1). All CPOA-SSTI met the definition after the POA time frame due to positive culture. Diagnostic procedures yielding positive culture were performed on hospital day 3 in 12 cases (52.2%). Most cases of CPOA-SSTI had other evidence of infection documented within 2 calendar days of admission, including fever (n ¼ 17; 73.9%), positive findings on radiographic imaging (n ¼ 15; 65.2%), prescription of antibiotic agents (n ¼ 21; 91.3%), or documented physician diagnosis (n ¼ 19; 82.6%). Past surveillance data showed a 69.7% increase in total number of SSTIs reported as HAIs in 2013 (n ¼ 56) versus 2012 (n ¼ 33). DISCUSSION Mandatory reporting and public disclosure of HAIs creates challenges for surveillance programs.3 The NHSN POA definition led to a number of infections being classified as HAI despite evidence of
infection within 2 days of hospitalization. Although SSTIs are not typically included in hospital quality metrics, these findings have important implications for states with mandatory reporting of all HAIs. In most CPOA-SSTIs, a diagnostic procedure yielding positive culture was delayed. More than half of CPOA-SSTIs had the procedure performed on hospital day 3. There may be barriers to Table 1 Elements of 23 clinically present on admission skin and soft tissue infections (SSTIs) meeting surveillance criteria for health care-associated infection
Element of SSTI definition
Calendar day 1 or 2
Purulent drainage, pustules, vesicles, 0 boils Pain/tenderness 20 Redness 14 Swelling 16 Heat 7 Positive culture 0 Abscess found during invasive 0 procedure/histopathologic exam Organisms cultured from blood 0 Positive lab test on blood/urine 0 Diagnostic antibody titer 0 Other evidence of infection not included in definition Fever 17 Radiographic evidence of infection 15 Antibiotic agents prescribed 21 Documented physician diagnosis 19
Calendar day 3
Calendar day 4þ
9
6
1 2 0 0 12* 1
0 0 0 0 11 1
0 0 0
0 0 0
1 1 1 5
0 1 2 1
*Seven of the positive cultures taken on calendar day 3 were obtained within 48 hours of admission.
1130
L. Farrell et al. / American Journal of Infection Control 43 (2015) 1128-30
obtaining cultures within 2 days of admission. Some patients need to be NPO (take nothing by mouth) before a procedure or surgery, which may delay culture until the next day. In addition, all infection criteria must be met within 2 calendar days to be categorized as POA. Many patients are admitted to the hospital in the evening; thus, it is possible for HAI criteria to be met less than 48 hours after admission but on hospital day 3, as in 7 of the CPOA-SSTI cases. The POA definition may have unintended consequences for states with mandatory HAI reporting. Time spent by ICPs performing chart review/documentation and reporting of CPOA infections may lead to less time for implementation of other infection prevention activities/requirements.4 In addition, reporting HAIs in Pennsylvania includes an obligatory notification letter to the patient/family, making accurate identification of HAI particularly important.5 At CHOP, physicians are notified when an infection meets an NHSN definition so they can discuss the infection and the mandatory notification process with the patient/family. When a CPOA infection must be reported as an HAI, it may be confusing to both the physician and the letter’s recipients. After the POA definition was added, it was presented at the hospital’s Infection Prevention and Control Committee and to unit leaders to increase awareness of the definition and its influence on reporting. Our analysis has limitations. Although our patient population was diverse, our project included assessment of data at a single pediatric center, so our findings may not be generalizable to all institutions. Our sample of CPOA-HAI was also relatively small. Still, our housewide surveillance and mandatory reporting provides an ideal setting to evaluate the ability of surveillance definitions to accurately capture HAIs. CONCLUSIONS Because hospital-acquired conditions are increasingly used as metrics of health care quality for interinstitutional comparisons,
our findings have important implications. Although NHSN definition changes in January 2015 may eliminate some CPOA infections identified in our analysis,6 frequent modifications to definitions make it challenging to maintain accurate historical data and may require rebaselining of data for statistical comparisons to be valid. Because the application of surveillance definitions is increasingly tied to institutional reputation and hospital reimbursement,7 additional studies of the influence of changing definitions are needed to provide more reliable HAI data for reporting. References 1. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health careeassociated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32. 2. Centers for Disease Control and Prevention (CDC). CDC/NHSN Surveillance Definitions for Specific Types of Infections. Atlanta: CDC. Available from: http:// www.cdc.gov/nhsn/PDFs/pscManual/validation/2013-PSC-Manual-validate.pdf; 2013. Accessed January, 2013. 3. McKibben L, Horan T, Tokars JI, Fowler G, Cardo DM, Pearson ML, et al. Guidance on public reporting of healthcare-associated infections: Recommendations of the healthcare infection control Practices Advisory committee. Am J Infect Control 2005;33:217-26. 4. Hartmann CW, Hoff T, Palmer JA, Wroe P, Dutta-Lin MM, Lee G. The Medicare Policy of Payment Adjustment for health care-associated infections: Perspectives on Potential unintended consequences. Med Care Res Rev 2012; 69:45-61. 5. Medical Care Availability and Reduction of Error (MCARE) ActdCh. 4, Health CareeAssociated Infections, P.L. 331, No. 52 (2007). http://patientsafetyauthority. org/PatientSafetyAuthority/Governance/Documents/act_52_of_2007_final_(2). pdf. Accessed January 5, 2015. 6. Centers for Disease Control and Prevention (CDC). Identifying Healthcareassociate Infections (HAI) for NHSN Surveillance. Atlanta: CDC. Available from: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent. pdf; 2015. Accessed January, 2015. 7. Talbot TR, Bratzler DW, Carrico RM, Diekema DJ, Hayden MK, Huang SS, et al. Public reporting of health care-associated surveillance data: Recommendations from the healthcare infection control Practices Advisory committee. Ann Intern Med 2013;159:631-5.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Present or absent on admission: Results of changes in National Healthcare Safety Network surveillance definitions Lauren Farrell MS, MLS(ASCP)CM,CIC a, *, Margaret Gilman CIC a, Eva Teszner RN, CIC a, Susan E. Coffin MD, MPH a, b, Julia Shaklee Sammons MD, MSCE a, b a b
Department of Infection Prevention and Control, The Children’s Hospital of Philadelphia, Philadelphia, PA Department of Pediatrics and Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Key Words: Hospital-acquired infections Mandatory reporting
In January 2013, the National Healthcare Safety Network definition of “present on admission” was created. Using existing surveillance data from 2013, we identified health care-associated infections (HAIs) that met prior present on admission criteria but not the new definition. We identified a number of infections classified as HAI despite evidence that infection was clinically present on admission. These findings have important implications for states with mandatory HAI reporting using National Healthcare Safety Network definitions. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Surveillance for health care-associated infections (HAIs) is a key element of infection prevention programs. Application of National Healthcare Safety Network (NHSN) methodology provides a standardized way in which HAIs are identified, enabling health care institutions to trend infection rates and monitor quality improvement initiatives. Before 2013, an infection was considered present on admission (POA) if evidence of infection was present/incubating on admission.1 In 2013, the NHSN created a POA surveillance criterion stating infections must fully meet a definition within 2 calendar days of admission to receive this designation. NHSN further stipulated that symptoms must be documented by a health care professional during the POA time frame, and physician diagnosis is only considered evidence when it is an element of the definition being met.2 Pennsylvania requires that all HAIs are reported using NHSN definitions. We aimed to assess the influence of the POA definition on mandatory reporting of HAIs at the Children’s Hospital of Philadelphia (CHOP).
academic, tertiary care pediatric hospital with 521 beds and approximately 28,000 annual admissions, to assess the influence of changing surveillance definitions on HAI reporting. This project met criteria for quality improvement work by CHOP’s institutional review board guidelines and was exempt from review board oversight.
METHODS
CHOP performs active surveillance on inpatients using all 43 of the NHSN HAI definitions, as required by Pennsylvania regulations. Infections meeting 2013 NHSN HAI criteria were determined to be CPOA if the electronic medical record included evidence of infection within 2 calendar days of admission (Fig 1). Evidence of infection for skin/soft tissue infections (CPOA-SSTIs) was defined as having at least 1 sign/symptom listed in Table 1.
Study design and setting We conducted a retrospective, cross-sectional study within the Department of Infection Prevention and Control at CHOP, an * Address correspondence to Lauren Farrell, MS, MLS(ASCP)CM, CIC, Department of Infection Prevention and Control, The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail address: [email protected] (L. Farrell). Conflicts of interest: None to report.
Case finding and data sources In response to the January 2013 POA definition, all infection control professionals (ICPs) prospectively documented in the electronic surveillance system clinically present on admission (CPOA) infections that met the definition for HAI. Cases were identified during routine surveillance and electronic medical record review. For this analysis, we reviewed existing HAI data from January through December 2013 and captured all infections documented as CPOA. Study definitions
Analysis CPOA infections were categorized by infection type. Frequencies of each CPOA-HAI were calculated to identify trends (Fig 1). For
0196-6553/$36.00 - Copyright Ó 2015 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.2015.05.023
L. Farrell et al. / American Journal of Infection Control 43 (2015) 1128-30
1129
Fig 1. Flow diagram. *Using previous criteria for present on admission. **All infections fell into the subcategories of skin or soft tissue infections. No breast, burn, circumcision, decubitis, pustulosis, or umbilicus infections were categorized as CPOA. CPOA, clinically present on admission; HAI, health care-associated infection.
CPOA-SSTI, we enumerated the frequencies of each element of the NHSN definition documented in the electronic medical record (Table 1). RESULTS In 2013, we identified 632 HAIs. Forty-four were CPOA. The most common were SSTI (n ¼ 23; 52.3%). All had documentation of at least 2 symptoms required by NHSN to be defined as SSTI within 2 calendar days of admission. None fully met the SSTI criteria because they lacked an element of the definition, such as positive lab test on blood/urine, diagnostic antibody titers, or positive blood culture (Table 1). All CPOA-SSTI met the definition after the POA time frame due to positive culture. Diagnostic procedures yielding positive culture were performed on hospital day 3 in 12 cases (52.2%). Most cases of CPOA-SSTI had other evidence of infection documented within 2 calendar days of admission, including fever (n ¼ 17; 73.9%), positive findings on radiographic imaging (n ¼ 15; 65.2%), prescription of antibiotic agents (n ¼ 21; 91.3%), or documented physician diagnosis (n ¼ 19; 82.6%). Past surveillance data showed a 69.7% increase in total number of SSTIs reported as HAIs in 2013 (n ¼ 56) versus 2012 (n ¼ 33). DISCUSSION Mandatory reporting and public disclosure of HAIs creates challenges for surveillance programs.3 The NHSN POA definition led to a number of infections being classified as HAI despite evidence of
infection within 2 days of hospitalization. Although SSTIs are not typically included in hospital quality metrics, these findings have important implications for states with mandatory reporting of all HAIs. In most CPOA-SSTIs, a diagnostic procedure yielding positive culture was delayed. More than half of CPOA-SSTIs had the procedure performed on hospital day 3. There may be barriers to Table 1 Elements of 23 clinically present on admission skin and soft tissue infections (SSTIs) meeting surveillance criteria for health care-associated infection
Element of SSTI definition
Calendar day 1 or 2
Purulent drainage, pustules, vesicles, 0 boils Pain/tenderness 20 Redness 14 Swelling 16 Heat 7 Positive culture 0 Abscess found during invasive 0 procedure/histopathologic exam Organisms cultured from blood 0 Positive lab test on blood/urine 0 Diagnostic antibody titer 0 Other evidence of infection not included in definition Fever 17 Radiographic evidence of infection 15 Antibiotic agents prescribed 21 Documented physician diagnosis 19
Calendar day 3
Calendar day 4þ
9
6
1 2 0 0 12* 1
0 0 0 0 11 1
0 0 0
0 0 0
1 1 1 5
0 1 2 1
*Seven of the positive cultures taken on calendar day 3 were obtained within 48 hours of admission.
1130
L. Farrell et al. / American Journal of Infection Control 43 (2015) 1128-30
obtaining cultures within 2 days of admission. Some patients need to be NPO (take nothing by mouth) before a procedure or surgery, which may delay culture until the next day. In addition, all infection criteria must be met within 2 calendar days to be categorized as POA. Many patients are admitted to the hospital in the evening; thus, it is possible for HAI criteria to be met less than 48 hours after admission but on hospital day 3, as in 7 of the CPOA-SSTI cases. The POA definition may have unintended consequences for states with mandatory HAI reporting. Time spent by ICPs performing chart review/documentation and reporting of CPOA infections may lead to less time for implementation of other infection prevention activities/requirements.4 In addition, reporting HAIs in Pennsylvania includes an obligatory notification letter to the patient/family, making accurate identification of HAI particularly important.5 At CHOP, physicians are notified when an infection meets an NHSN definition so they can discuss the infection and the mandatory notification process with the patient/family. When a CPOA infection must be reported as an HAI, it may be confusing to both the physician and the letter’s recipients. After the POA definition was added, it was presented at the hospital’s Infection Prevention and Control Committee and to unit leaders to increase awareness of the definition and its influence on reporting. Our analysis has limitations. Although our patient population was diverse, our project included assessment of data at a single pediatric center, so our findings may not be generalizable to all institutions. Our sample of CPOA-HAI was also relatively small. Still, our housewide surveillance and mandatory reporting provides an ideal setting to evaluate the ability of surveillance definitions to accurately capture HAIs. CONCLUSIONS Because hospital-acquired conditions are increasingly used as metrics of health care quality for interinstitutional comparisons,
our findings have important implications. Although NHSN definition changes in January 2015 may eliminate some CPOA infections identified in our analysis,6 frequent modifications to definitions make it challenging to maintain accurate historical data and may require rebaselining of data for statistical comparisons to be valid. Because the application of surveillance definitions is increasingly tied to institutional reputation and hospital reimbursement,7 additional studies of the influence of changing definitions are needed to provide more reliable HAI data for reporting. References 1. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health careeassociated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32. 2. Centers for Disease Control and Prevention (CDC). CDC/NHSN Surveillance Definitions for Specific Types of Infections. Atlanta: CDC. Available from: http:// www.cdc.gov/nhsn/PDFs/pscManual/validation/2013-PSC-Manual-validate.pdf; 2013. Accessed January, 2013. 3. McKibben L, Horan T, Tokars JI, Fowler G, Cardo DM, Pearson ML, et al. Guidance on public reporting of healthcare-associated infections: Recommendations of the healthcare infection control Practices Advisory committee. Am J Infect Control 2005;33:217-26. 4. Hartmann CW, Hoff T, Palmer JA, Wroe P, Dutta-Lin MM, Lee G. The Medicare Policy of Payment Adjustment for health care-associated infections: Perspectives on Potential unintended consequences. Med Care Res Rev 2012; 69:45-61. 5. Medical Care Availability and Reduction of Error (MCARE) ActdCh. 4, Health CareeAssociated Infections, P.L. 331, No. 52 (2007). http://patientsafetyauthority. org/PatientSafetyAuthority/Governance/Documents/act_52_of_2007_final_(2). pdf. Accessed January 5, 2015. 6. Centers for Disease Control and Prevention (CDC). Identifying Healthcareassociate Infections (HAI) for NHSN Surveillance. Atlanta: CDC. Available from: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent. pdf; 2015. Accessed January, 2015. 7. Talbot TR, Bratzler DW, Carrico RM, Diekema DJ, Hayden MK, Huang SS, et al. Public reporting of health care-associated surveillance data: Recommendations from the healthcare infection control Practices Advisory committee. Ann Intern Med 2013;159:631-5.