Infection Window Period

1 Infection Window Period

3 (First positive diagnostic test, 3 days

4 1 Urine culture:

before and 3 days after)

>100,000 cfu/ml

K. pneumoniae Repeat Infection Timeframe

5 2 Fever > 38.0 C

6 3 (RIT)

7 4 (date of event = day 1)

8 5 Fever >38.0 C, Abdominal pain 9 6 CT Scan :

Secondary BSI Attribution

Abdominal

Period (Infection Window Period +

abscess

RIT)

10 7 Blood culture:

Blood culture:

K. pneumoniae

K. pneumoniae Date of Event (DOE)

11 8 (Date the first element occurs for the first 12 9 time within the infection window period)

IAB & Secondary

Secondary BSI

BSI

Date of Event = 4

Date of Event = 8

Pathogen: K.

Pathogen: K.

pneumoniae pneumoniae

Pathogens excluded from specific infection definitions (e.g., yeast in UTI, or Enterococcus spp. for PNEU) are also excluded as pathogens for BSIs secondary to that type of infection (i.e., they cannot be added on to one of these infections as a pathogen). In example 2 below, the excluded organism must be accounted for as either 1) a primary bloodstream infection (BSI/CLABSI) or, 2) a secondary bloodstream infection attributed to another primary infection (e.g., IAB, SINU). A blood culture with yeast and E. faecalis is collected during the SUTI RIT. A BSI secondary to SUTI is identified. E. faecalis is already documented as a pathogen, but the yeast will not be reported as a secondary BSI pathogen, because yeasts are excluded as organisms in the UTI definition. Because no other primary source of infection for which the yeast BSI can be assigned as secondary is found, a primary BSI with yeast is identified. January 2016

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Note: The Enterococcus faecalis is not reported as a pathogen for the primary BSI because if an excluded organism had not been identified, a primary BSI would not have been reported.

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Example 2: Pathogen Assignment (continued)

Hospital BSI RIT

Window Period

Window Period

Infection Window Period

1 (First positive diagnostic test, 3 days before

2 and 3 days after)

3 1 Dysuria 4 2 Urine culture:

Repeat Infection Timeframe

> 100,000 cfu/ml

E. faecalis (RIT)

5 (date of event = day 1)

7 5 Secondary BSI Attribution

Period

9 7 (Infection Window Period + RIT)

11 9 Blood culture:

Blood culture:

E.faecalis / Yeast

E. faecalis / Yeast

Date of Event (DOE)

12 10 2 (Date the first element occurs for the first 13 11 3 time within the infection window period)

UTI & Secondary Primary BSI BSI

Date of Event =

Date of Event = 3

Pathogen: E.

Pathogen: Yeast

faecalis

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Figure 3: Secondary BSI Guide for eligible organisms* ‡

(Not applicable to Ventilator-associated Events [VAE], See Figure 4 )

‡ Exception: Necrotizing enterocolitis (NEC) criteria include neither a site-specific specimen nor organism identified from blood specimen, however an exception for assigning a BSI secondary to NEC is provided. A BSI is considered secondary to NEC if the patient meets one of the 2 NEC

criteria AND an organism identified from blood specimen collected during the secondary BSI attribution period is an LCBI pathogen or the same common commensal is identified from 2 or more

blood specimens drawn on separate occasions on the same or consecutive days.

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Figure 4: VAE Guidance for Secondary BSI Determination

*Secondary BSIs may be reported for possible VAP (PVAP) events, provided that at least one organism identified from the blood specimen matches an organism identified from an appropriate respiratory tract specimen (including respiratory secretions, pleural fluid and lung tissue). The respiratory tract specimen must have been collected on or after the 3rd day of mechanical ventilation and within 2 calendar days before or after the day of onset of worsening oxygenation to be considered as a criterion for meeting the PVAP definitions. In addition, the blood specimen must have been collected during the 14-day event period, where day 1 is the day of onset of worsening oxygenation.

 In cases where PVAP is met with only the histopathology criterion and no culture or non-culture based test is performed on an eligible respiratory specimen, and there is also a positive blood specimen, a secondary BSI to VAE is not reported.

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 In cases where a culture or non-culture based test of respiratory secretions, pleural fluid or lung tissue is performed and does not identify an organism that matches an organism identified from blood, a secondary BSI to VAE is not reported.

Note: Candida species or yeast not otherwise specified, coagulase-negative Staphylococcus species, and Enterococcus species identified from blood cannot be deemed secondary to a PVAP, unless the organism was also identified from pleural fluid or lung tissue.

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Central Line Insertion Practices (CLIP) Adherence Monitoring

Introduction: Central line-associated bloodstream infections (CLABSIs) may be prevented through proper placement and management of the central line. The CDC’s Healthcare Infection Control Practices Advisory Committee (CDC/HICPAC) Guidelines

i for the Prevention of Intravascular Catheter-Related Infections , 2011 recommend evidence-based central line insertion practices known to reduce the risk of subsequent

central line-associated bloodstream infection. These include hand hygiene by inserters, use of maximal sterile barriers during insertion, proper use of a skin antiseptic prior to insertion, and time to allow the skin antiseptic to dry before catheter insertion.

Several centers have found it useful to monitor adherence to evidence-based central line insertion practices as a method for identifying quality improvement opportunities and strategically targeting interventions. Feedback of adherence data has been a component of multifaceted interventions that have successfully reduced CLABSI rates.

Participation in NHSN CLIP surveillance enables participating facilities and CDC to:  Monitor central line insertion practices in individual patient care units and facilities

and provide aggregate adherence data for all participating facilities. Facilities have the option of recording inserter-specific adherence data.

 Facilitate quality improvement by identifying specific gaps in adherence to recommended prevention practices, thereby helping to target intervention strategies for reducing CLABSI rates.

Participating facilities may perform surveillance for insertion practices during the following:

 a month when concurrent CLABSI surveillance is being conducted;  a month when no CLABSI surveillance is being conducted;

If participating facilities wish to identify associations between insertion practices and outcomes (i.e., CLABSI), surveillance for insertion practices and CLABSI must be done concurrently.

Settings: Surveillance may occur in any type of patient care location where central lines are inserted.

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Numerator and Denominator Data: The Central Line Insertion Practices Adherence Monitoring Form (CDC 57.125) is used to collect and report central line insertion practices for every central line insertion attempt, including unsuccessful attempts, occurring during the month in the unit(s) selected for surveillance. The Table of Instructions for Completion of the Central Line Insertion Practices Adherence Monitoring Form contains directions for collection and entry of each data element on the form. The form can be completed at or near the time of insertion either by the inserter or an observer present at the insertion (e.g., nurse assisting with the catheter insertion), or the form can be completed from documentation in the patient chart (only if all elements of the monitoring form have been incorporated into standard central-line insertion procedure notes). The form includes information pertaining to demographics of the patient, information pertaining to the inserter, information on maximal sterile barriers used, the reason for central line insertion, whether the insertion was successful, skin antisepsis, hand hygiene practice before insertion, type of central line including whether it was antimicrobial coated, insertion site and, if placed because of suspected existing central line infection, the use of a guide wire. Elements of these data will be used to calculate adherence to recommended insertion practices.

Data Analyses: Adherence rates for specific insertion practices will be calculated by dividing the number of central line insertions during which the recommended practice was followed by the total number of central line insertions and multiplying the result by 100. Such calculations can also be done for a bundle of practices that have been shown to reduce the incidence of CLABSI (i.e. NHSN CLIP Bundle). In NHSN for CLIP insertions dated January 1, 2014 and forward, adherence to the bundle requires a “Yes” to all of the following:

 Hand hygiene performed  Appropriate skin prep*

o Chlorhexidine gluconate (CHG) for patients ≥60 days old unless there is a documented contraindication to CHG

o Povidone iodine, alcohol, CHG, or other specified for children <60 days

old  Skin prep agent has completely dried before insertion  All 5 maximal sterile barriers used

o Sterile gloves o Sterile gown o Cap o Mask worn

o Large sterile drape (a large sterile drape covers the patient’s entire body)

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Note: These calculations are performed separately for different types of locations in the institution. Participants have the option of calculating inserter-specific adherence rates.

*The Food and Drug Administration (FDA) has labeled CHG to be used with care in premature infants and infants < 2 months of age.

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