good morning my name is Dominique Godfrey Johnson I’m one of the subject matter experts for the BSI event chapter welcome to all our participants whether you are joining us in person or via web stream so let’s continue with with day two and move to a hot topic primary BSI this may take this presentation may take one cup of coffee or two but we will get through it together I will discuss laboratory-confirmed bloodstream infections our primary BSI my colleague Latasha Powell will discuss secondary BSIs in a later session so one of my expectations I have expectations of you I expect that everyone is alert and excited about primary BSI after all is our favorite topic what I do not expect is an audience that has fallen asleep before we reached the exciting topics and believe you me there are some exciting things in this presentation so what are the objectives the objectives are to provide an overview of the training resources protocol and supporting materials define key terms for device associated infections specifically clamp C’s and discuss device-associated infection surveillance changes for 2019 and provide an overview of the data collection process from out NHSN locations and this will include both the numerator and denominator and finally we will assess our knowledge about current BSI through case studies this is just a plug for the healthcare associated infections progress report since this presentation was posted to the web say the 2017 hei report has been published I would like to highlight a few important points related to the report and specifically classes as you know CDC is working towards the elimination of HIV the infection data included in this report are those that are reported to NHSN US hospitals reported a significant decrease in collapses between 2016 and 2017 and the HAR progress report provides some real select har s across for health care settings these settings are your acute care your critical access inpatient rehabilitation facilities and long-term acute care hospitals so where can I find the BSI protocol under the protocols tab the BSI chapter is milt listed first next is the bloodstream infection week and this will open the BSI protocol we will discuss this protocol in great detail today you should also familiarize yourselves with chapter 2 which was presented which was presented yesterday this last highlighted area is the link that will take you to chapter 2 this chapter provides the foundation on how to identify a JIS including BSI under the training tab you will find numerous training videos and accompanying slides these resources are kept current and new content is added when it becomes available for example our new is BSI quick learn on denominator device day counts and central line day counts for making a CLABSI determination was posted on December of 2018 what about the frequently asked questions the frequently asked questions tab contains those pressing questions we receive from IPS about bloodstream infections bloodstream infection surveillance analysis and annual surveys these are just examples of the information found on this page the BSI FAQ is an invaluable document that contains answers to most of the to some of the most frequent and more difficult concepts related to BSI surveillance as you can see from the screenshot the SI cubes are sorted by topic finally under the supporting material section you will find important resources such as key terms or chapter 17 which is the site specific infection definitions for secondary BSI determination and the NHSN organism list that you would need for BSI surveillance this organism lives is an excel file with individual tabs at the bottom listing all organisms your common commensals and your in MBI organisms please make sure you are referencing the most recent material now we will move on to definitions that you will use when identifying BSI events let’s begin with the infection window period the infection window period in which o is the period in which all BS eyes must be met it includes the collection date of the first blood specimen that identifies an organism the three calendar days before and the three calendar days after the lcbi date of event is always the date of the of the blood specimen the positive blood specimen with a recognized pathogen is the only element needed to meet this criterion so for lcbi one no signs or symptoms are needed this is in contrast to lcbi two and three criteria for lcbi two or three the data event is the date the first element is used to me lcbi two or three criteria and if that occurs during the BSI infection window period there are two elements needed to meet lcbi two and three a symptom and two blood specimens that are matching common commensals or companion cultures if the two blood specimens are collected on consecutive days they are considered a single element for meeting the criteria the date of the first blood specimen will set the iwp all bs eyes are a very primary source of infection our secondary to another site-specific infection such as your urinary tract infections your surgical site infections your ventilator associated events your pneumonia or one of the chapter 17 definitions laboratory confirmed bloodstream infections or LCB is our bloodstream infections that occur when an organism has been identified in the blood and it is not related to an infection at another source all primary BSI is created 14-day repeat infection time frame or rit this repeat infection time frame is a period of time in which no new infections of the same type are reported secondary BSIs our bloodstream infections that are not reported as an lcbi because they are associated with a site-specific infection at another body site which has seeded the bloodstream secondary bloodstream infections do not create an RIT but rather the primary source of the secondary BSI creates the RIT and no new infections of that specific type will be reported your secondary BSI attribution period or your s valve is the period in which a blood specimen must be collected for secondary BSI attribution the s map includes the infection window period and the repeat infection timeframe it can be 14 to 17 days depending on the date of event now let’s review ineligible organism this is an organism eligible to meet lcbi or mbi-lcbi criteria eligible BSI organisms are not excluded organisms the definition of a central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion was drawl of blood or hemodynamic monitoring neither the type of device nor the insertion site will determine if a mine qualifies as a central line patients must have one or more qualifying central lines to be included in CLABSI surveillance in order to meet the central line definition you must ask yourself two questions what does the till terminate and how is the line being used a few points regarding central lines our patients must have one or more qualifying central lines for inclusion and collapsing surveillance infection surveillance where NHSN is not aimed at a particular device but instead is identifying the risk patients have as a result of using the device NHSN also does not attribute any bloodstream infection to a specific device on the slide you will see a list of great vessels available for use in making determinations about central lines for CLABSI reporting in device des chemins if a line has a lumen and terminates at or close to the heart or in one of the great vessels and is used for the purposes listed above it is a central line once it is deemed a central line it continues to be a central line until it is discontinued which means removal from the body or the patient is discharged whichever comes first we receive a fair amount of questions about a line that hasn’t migrated out or sometimes has intentionally been pulled back and this is seen on the chest x-ray this does not eliminate the lung from being an eligible from being eligible for a collapse event nor does it stop the central line they can when considering eclipses the event you must consider access access is defined as the performance of any of the following activities during the current and patient admission line placement and use of any central line for infusion with a drawl of blood or hemodynamic monitoring once a central line has been accessed in an inpatient unit it is eligible for a collapse event until the day after is discontinued or the patient is discharged whichever comes first discontinued in this case means again removal from the body access has a reported concept especially when you have a central line or implanted port that is present on admission if it was not placed during the kind admission the first time it is used as an inpatient for medication administration blood draws or fluid administration the line is then considered access an eligible central line is a central line that has been in place greater than two consecutive calendar days following the first access of the central line in an inpatient location during the current admission these lines remain eligible for collapse events until the day after removal from the body or the patient is discharged whichever comes first dialysis patients who have a line that is only used by dialysis personnel are included in central mine day counts for the location where they are physically housed and the patients must be including in any CLABSI surveillance being performed in that location for NHSN reporting purposes centralized are categorized as temporary permanent and in neonates umbilical catheters a temporary line is a non tunnel non implanted catheter compared to a permanent line which is a tunnel catheter including certain dialysis catheters which may which may include your implanted ports finally an umbilical catheter is inserted through the umbilical artery or vein in a neonate it is only necessary to distinguish between temporary or permanent lines when reporting specialty care areas like oncology dialysis or your transplants unit in these locations central lines are stratified by lying type 4 monthly denominator reporting because these specialty care areas serve high serve patients with a higher risk and therefore more likely to use permanent lines because they have a lower risk of infection compared to your temporary lines for specialty care areas if a permanent and temporary line are present report the temporary line in your denominator if there is a BSI event the NHSN application will attribute the BSI event to the temporary line and include this line in the denominator count other than specialty care areas many patients have more than one central line and can have a combination of different types of lines for NHSN reporting purposes when multiple lines are present in the same patient report only one central line per day this is a list of devices that are not considered central lines for NHSN reporting purposes now let’s briefly discuss introducers introducers may or may not count as a central line most people don’t think of an introducer as a central line but realize that they are considered intravascular devices depending on the location of the tip the protocol states that pacing wires and other non lumen catheters are not considered centralized and this is true but there are casing wires that have a lumen specifically designed for infusion withdrawal of blood and hemodynamic monitoring if a patient has a line that you are unsure about just contact us and in interest at NHSN at cdc.gov and let us know the line type how it’s being used and any other pertinent information and we’ll be happy to provide guidance regarding the line so here’s a little note on excluded organisms any organism not on the common commensal list is it is considered a recognized pathogen for reporting LCB eyes with the exception of the organisms listed on this slide you may notice that all of these excluded pathogens our enteric or gut bugs these organisms are eligible for use in secondary BSI determinations but will not be reported as the sole pathogen in a primary BSI new in 2019 is the removal of viruses and parasites from the lcbi definition however these pathogens are also eligible for use in secondary BSI determinations organisms in the right column are excluded from all NHSN organism from all NHSN definitions these infections are almost always community-acquired and since they tend to have really long incubation periods they may be incorrectly identified Group B Strep remains excluded as a causative organism for a CLABSI in the first six days of life Group B Strep often causes infections and newborns as a result of vertical transmission transmission or passage through the birth canal when Group B Strep when the Group B Strep exclusion is met these events are considered LC be honest and we’ll create a BSI RIT but are not central line-associated we have reviewed the definitions key to being us – BSI surveillance now let’s recap denominator device day counts and central line day counts for making a CLABSI determination so for central lines do we count days of admission or days of access we’ve received questions on how to count denominator device days for denominator device day count you would start the first day the central line is present on an inpatient location if the line is inserted during the current admission day one is the first day excuse me for denominator device count you would start the first day the central line is present on an inpatient unit if the line is inserted during the current emission day one is the first day the central line it’s present on an inpatient unit if the central line was present on admission today one is the first day the patient is admitted to an inpatient location regardless of access the second count is the central line day counts for making a CLABSI determination to attribute a central line to a BSI event you must count the days of access a central line becomes an eligible central line for a CLABSI determination once the central line has been accessed for greater than two consecutive calendar days let’s look at the next two slides to further explain these concepts patient a has a central line inserted in the ICU because the central line was inserted in an inpatient location the day one will begin the denominator device date count patient a will have seven denominator device days from 331 through four six patients C has a central line at the time of admission to ICU because patient C is admitted to ICU on 331 the denominator device day count will begin on the day of admission on day three the central line was removed and replaced on day four because a calendar day did not pass without a central line in place the denominator device day count will continue until four five when the central line is removed on four six there is no device in place patient C will have six denominator device days beginning three thirty one through four five and lastly patient e patient he has a non excess port at the time of admission to ICU the denominator device day count will begin on the date the patient is admitted to ICU assessing the port on four three does not change the denominator device day count patient e will have seven denominator device days three thirty one through four six this is a snippet of the table from the BSI protocol the complete table it’s packed sound on page four – 22 now let’s look at the days of excess in the central line day count for making a clabsi determination this is a snippet of examples from Table four in illustrates device Association as determined by the presence of an eligible central line on the BSI date of event or the day before so patient a becomes eligible for CLABSI on four four because an access port had been in place for some portion of greater than two consecutive calendar days making it an eligible central line on for for the port remains eligible for a CLABSI until it is removed or the patient is discharged whichever comes first patient B becomes eligible for a CLABSI on for four central line day three through four five an access central line had been in place greater than two consecutive calendar days making it an eligible central line on four four please note the central line was in place a portion of the day on four for a BSI date of event on the day of or the day after device removal or the patient is discharged will still be considered a device-associated infection or in this case a Class C and finally patient C patient C becomes eligible for a CLABSI on three thirty one through four six because the center line had been in place greater than two consecutive calendar days a BSI date of event occurring on the day of or the day after device removal or paste patient discharge is considered a device and associated infection or a Class C although the central line was removed don’t Ford – the patient remains eligible for a claps event through 4-6 because a full calendar day did not patents without a central line in place therefore the central line counts continued okay we’ve made it through the denominator device they counts and central line day counts for making a CLABSI determinations if you still have any questions about that I will be available after the primary BSI session and you can come up and ask me then or if we have time for Q&A whichever you prefer next we will discuss changes and revisions in 2019 specifically collapse the exclusions a CLABSI exclusion is provided if a patient has an ECMO device or a ventricular assist device in place greater than two consecutive calendar days on the blood stream infection date of event and the device is still in place on the date of event or the day before if the patient meets criteria for either of the above exclusions you would under central line equals yes there is an lcbi event and a 14-day BSI RIT is created with day one being the date of event the ECMO and VAD data fields are required in 2019 please note this is a change in the UM in the reporting instructions from 2018 now I want to put a pin here and say for all of the CLABSI exclusions that we will discuss you should keep in mind that the patient has an eligible organism identified and an eligible central line there is also a CLABSI exclusion provided for observed or suspected patient self injection into their vascular access please note that this exclusion requires an observation or suspicion of patient injection behaviors such as biting picking AK or sucking on the central line access will not meet this exclusion the top the documentation must indicate the observation or suspicion of injection occurred during the iwp of the positive blood specimen and must be entered concurrently the next exclusion is for epidermolysis bullosa which is a genetic connective tissue skin disorder that makes the skin extremely fragile this disorder causes the skin to blister and/or tear EB patients tend to develop wounds that are heavenly colonized with bacteria placing individuals with this condition at an increased risk for bloodstream infections additionally clinicians are unable to collect scam cultures on these patients because they are so heavily colonized and the culturing process is painful and exclusion is provided for this condition if a clinician documents this disorder during the patient’s current admission munchausen syndrome by proxy also known as fictitious disorder and post on another is a mental illness condition in which a caregiver makes up our causes an illness or injury in a person under his or her care such as a child an elderly patient or person with disabilities for personal attention to meet this criteria a clinician must document a confirm or suspected diagnosis during the patient admission if a patient meets criteria for any of the above exclusions you would answer central line equal no into the NHSN application or the BSI event form entering no in the central line field will look will remove these events from the numerator and the events are not considered central line-associated these events are also lcbi s and a 14-day BSI rit is created with day one being the date of event these exclusions are available on the BSI event form on these fields are optional in 2019 but will become required in 2020 the last collapse li exclusion we will discuss its post at the vascular access site if a patient meets all elements for this exclusion listed on the slide you would enter central line is equal to no in the NHSN application the event again is considered an lcbi in a 14-day BSI RIT is created with day one being the date of event this exclusion is also available if you’re reporting using the BSI event form again this field is optional in 2019 but will become required in 2020 here is a list of vascular access devices located in the pus at the vascular site clacks the exclusion this is a summary of the 29 2019 CLABSI exclusions pre Willick previously discussed this is table 3 on page four – thirteen now I will discuss lcbi criteria this is the air RTO for laboratory-confirmed bloodstream infections as mentioned earlier all BS is re very primary source of infection our secondary to another site-specific infection like your urinary tract infections your surgical site infections your ventilator associated events pneumonia or any of the chapter 17 definitions there are three different lcbi criteria lcbi one lcbi two and lcbi three this is a step by step process that may help when making a BSI determination CLABSI surveillance will always start with a positive blood specimen whether it’s culture or non culture base if you determine you have a POA event as in step four there is nothing to report step five is where you are determined if the CLABSI definition is met as a reminder all blood specimens regardless of the collection site or the reason for collection must be included in CLABSI surveillance an lcbi is identified when a patient of any age has a recognized bacterial or fungal pathogen not included on the NHSN common commensal list identified from one or more blood specimens by culture or non-culture based microbiologic testing and the organism identified in the blood is related is not related to an infection at another site if the BSI is secondary to another primary source of infection it will not be reported to NHSN as an lcbi or as the primary source may be reported dependent depending on your monthly reporting plan and state mandates but the secondary BSI will not primary BSI s are identified by ruling out secondary sources a bloodstream s section cannot be secondary to another bloodstream infection therefore a primary BSI will never have a secondary BSI attribution period I will not discuss secondary BSIs in this presentation however you must always consider a primary source for all B sis so let’s switch gears and perform a few knowledge checks I know you’ve been sitting for a while and taking in all of this wonderful information this is what I was talking about in the beginning let’s see if you can make a determination about this scenario using poll everywhere if you are joining us joining us via Web stream please participate as well okay are we ready so some of you may be familiar with poll everywhere this is the same slide that you saw on yesterday and many of you have participated in several of the polls on yesterday as a reminder once I asked the question and list the answer choices cell phone users can participate by testing the message NHSN two two two three three three to join again the number is two two three three three and the message you are texting is NHSN next your receipt you will receive a text confirming date you have joined Cheryl Williams polling session once you receive that confirmation text you can text back the letter that corresponds to your answer lastly for cell phone users that join via text message once you join the polling sessions for today you will not need to rejoin for the remainder of my presentation or the presentations that follow throughout the day if you choose to participate via web browser on your cell phone computer or any other mobile device here’s the website that you can visit you should see the following welcome screen in your browser okay so let’s begin so we have mr.

On edge who was admitted to him ICU after having an heart attack that’s denoted by his name he’s on edge on February 4th a central line was placed in M ICU on February 7th a blood culture was collected due to fever and chills and the blood culture was positive for Serratia marcescens which is a recognized pathogen no other source of infection was identified is this an lcbi please choose the letter that corresponds to the correct response okay well we basically we all answer that one and so yes this is an lcbi let’s look at mr. on edges rationale mr. on edge had a positive blood specimen force Serratia marcescens on to seven because this is the only element required to meet lcbi one criterion to seven is the date of event the to seven blood culture will create a BSI iwp from two for two to ten a BSI rit is established from two seven two two twenty the BSI event is central line-associated because the central line was in place for calendar days on the date of event let’s move on to lcbi two three criteria when reviewing lcbi two and three definitions these definitions share some similarities with the exception that the symptoms for meeting the criteria are based on age so lcbi two is for use in any age patient and lcbi three provides symptoms that are commonly present in patients less than or equal to one year of age such as hypothermia apnea and or bradycardia please note patients less than or equal to one year of age also may meet lcbi one or lcbi two criteria because these criteria are for any aged patient additionally the organisms identified are not related to an infection at another site in the common commensals are drawn on separate occasions and must match let’s review matching organisms or companion cultures when determining the sameness of organisms only the genus and species should be used to make this determination if one organism is less definitively identified than the other the identification must be complementary for NHSN reporting purpose for example a blood culture growing eco add negative staph and a blood culture growing staph epidermidis are considered a managed because staph epidermidis is a co a gig ative staff in another example a blood culture growing co add negative staph in a blood culture growing Staphylococcus are not considered matching because Staphylococcus can either be Co AG negative or Co AG positive the table listed at the bottom of the page can be found on page 4 – 20 of the BSI protocol and can help answer questions about reporting different lab results all right let’s look at MIT’s positive poly on March 18th miss positive poly was admitted to the art to the oncology ward in a port was placed for chemotherapy on march 19th she developed a fever of 102 degrees Fahrenheit March 21st blood cultures were collected that grew coagulates negative staph x 2 on March 22nd repeat blood cultures were collecting growing the same organism no other source of infection was identified is this a POA or H AI bloodstream infection okay this is a POA blush tournament section let’s look at miss positive Polly’s rationale miss Polly had two positive blood specimens for CNS on 321 with 321 positive blood specimen creates a 318 through 324 infection window period a fever is noted on 319 because the fever is the first element identified during the iwp 319 is your date of event note the date of event occurs during the POA timeframe and the patient would have a POA BSI and a POA BSI RIT is established from 319 – for one let’s look at the next scenario on April 1st 4 month old baby gray was admitted a free brow with no symptoms of an infection on April 2nd he developed fever and periods of bradycardia 2 blood cultures were collected one specimen grew Micrococcus does this meet lcbi criteria few more seconds okay so the correct answer is C baby gray was admitted with no signs or symptoms on Hospital day two he developed fever in periods of bradycardia a single common commensal was identified baby gray does not meet either lcbi two or three criteria remember you must have at least two matching common commensals and only a single common commensal Micrococcus was identified in this case all right now let’s move on to baby girls Belle and Bella on five five baby girls Belle and Bella were admitted to NICU after being born one month premature on 5-8 there was new onset of apnea and a central line displays both develop a low-grade fever of 100 degrees Fahrenheit and two sets of blood cultures were drawn separately both growing Staphylococcus homeless no other source of infection works identified were identified what lcbi criterion is met by baby girls Belle and Bella okay I hear some discussion going on I’ll give you a few more seconds before we discuss this case the correct answer is C lcbi 3criteria yes let’s look at that let’s do this question and then I’ll provide the explanation on on the next slide is this a POA or H AI infection so it’s this POA or h AI for baby girl Belle and Bella this infection is a POA I’m sorry this infection should be in H AI yeah you’re correct not a POA but in a cha all right let’s look at it on five nine staff common is blood cultures were collected times two you have a central line that was inserted on five eight the date of event is 5 8 and your iwp is 5 and then iwp is created which is five six through five 12 apnea is noted on five eight five eight again is your date of event because that is your first element used to meet the site-specific infection this is an h AI h AI event because the date of event occurred on calendar day 4 is this event central line-associated there’s no pole just is this event central line-associated no no it’s not your central line was inserted on 5 8 and your positive blood cultures were collected on 5 9 okay so now let’s move on to mbi-lcbi mbi-lcbi s are a subset of lcbi s before you can determine if a BSI event is an mbi-lcbi you must first fully meet lcbi criteria the mbi-lcbi category enables NHSN to identify bloodstream infections that are believed to be the result of gastrointestinal translocation due to a patient’s weakened immune and alterations of the duct they are still considered primary BSI s because there is not an identifiable infection at another site however the gut is believed to be the ceding source of the blood stream with colonizing organisms MB eyes are reported to nhsn but since 2015 with the rebase line they are removed from the data shared with CMS for reimbursement determinations this is the mbi-lcbi table which provides an overview of the mbi-lcbi criteria this table is located on page 4 – 10 mbi-lcbi one is a patient of n includes a patient of any age that meets criteria for lcbi with at least one blood specimen identified by culture or non-culture based microbiologic testing testing with only intestinal organisms from the MBI organism with a partial list of MBI organisms can be found on page 4 – 31 or you can review the MBI organisms tab on the NHSN organisms list the patient also must meet at least one of the following the patient is an allogenic hematopoietic stem cell transplant recipient within the past year with one of the following document during the same hospitalization as your positive culture grade 3 or 4 gastrointestinal graft-versus-host disease or greater than a liter of diarrhea in a 24-hour period with onset on are within seven calendar days before the date the positive culture is collected the patient may also meet the neutropenic element which is defined as two separate days with values of absolute neutrophil count or your ANC are total white blood cell count less than 500 cells per millimeter cube within a seven day period which includes the date the positive blood culture was collected which is they wanted the three calendar days before and the three calendar days after for an ANC RWC value to be eligible for youths they must occur within the seven days that includes the day of the positive blood specimen the three days before in the three days after this timeframe looks like an iwp and sounds like an iwp but in this case it is not for the purpose of meeting mbi-lcbi criteria low AMC and WBC values are indicators or risks for infections not symptoms of infection and therefore not consider elements when apply this definition this table is in the protocol and provides guidance on how to correctly determine if an A and C or WBC value are eligible for use in meeting mbi-lcbi criteria in the first example patient aid first fully meets lcbi one with the positive blood culture growing a record recognized pathogen next we can consider the mbi-lcbi criteria because Canada’s species is also an intestinal organism that is on the MBI list the patient has the qualified neutropenia on two separate days with WC values less than 500 cells in this case on day negative 1 the WBC’s are 320 and on day one are 400 so the final determination of this case is mbi-lcbi 1 now let’s look at patient be patient be fully meets lcbi 2 criteria with two positive blood specimens groin only very dance group strength plus a qualifying fever greater than 38 three Celsius this patient is also neutropenic on at least two separate days with ANC values less than 500 in this example the value for day negative 1 is 110 and day negative 2 is 120 so the final determination in this case is mbi-lcbi – please note days 2 3 & 4 are also eligible for use as the ANC values are less than 500 cells you can use a combination of ANC and WBC values provided they occur in the seven-day time frame since these values are considered risk factors and do not affect the date of event this table uses WBC’s and two of the examples and ANC values in the other but a combination of either ANC or WBC values can be used provided they are collected on different calendar days within the seven-day time frame previously mentioned this calculation is available in the BSI chapter if your laboratory does not provide an absolute agency okay let’s try this again let’s move on to miss patty patty on June 13th miss patty had a central line inserted on admission on June 16 she had an 8 a and C level of 400 and on June 17th two blood cultures were drawn that were positive for Enterococcus faecalis on June 19 the WBC levels were 210 cells per millimeter no other source of infection was identified did the patient meets mbi-lcbi 1 so the correct answer is yes we first need to determine if lcbi criterion is met miss patty is admitted on 613 and the positive blood cultures occur on 617 because e.coli is a recognized pathogen lcbi one criterion is met on 617 now we can evaluate for an mbi-lcbi one the organism identified ecoli is an MBI organism the risk factor present is neutropenia is neutropenia the patient has an A and C value of 400 and a WB C value of 200 therefore mbi-lcbi criterion is met please note any combination of a and C and/or WBC values can be used to meet neutropenic criteria provided they are collected on separate days within the seven-day period that includes the data of the positive blood specimen the three calendar days before and the three calendar days after we’ve already discussed lcbi 2 & 3 criteria and the differences in the cyst symptoms used based on age mbi-lcbi 2 & 3 requires only viridans group strep and rossi of species these organelles are both common commensals and MBI organisms in addition to the organism requirement you must meet one of the following elements the first element the allergen aid stem-cell transplant patients with gastrointestinal graft-versus-host disease or qualifying diarrhea and the second is immunocompromised patients as demonstrated by qualifying atropine e’en these are the same risk factors identified for mbi-lcbi one criteria it is possible for a patient to meet both mbi-lcbi 1 and mbi-lcbi 2 at the same time when this occurs report the mbi-lcbi 1 with the recognized path pathogen first in the variance group strep or Rafi of species as pathogen – this is a reporting requirement of the NHSN application please note the phrase no other organisms and keep in mind that if a single common commensal is identified it is considered a contaminant when this occurs mbi-lcbi 2 or 3 criteria is not met because the patient would not meet lcbi 2 or 3 criteria in addition when a blood specimen positive for an organism not included on the NHSN MBI organisms list is collected during the BSI rit of an mbi-lcbi the initial mbi-lcbi event is edited to an lcbi and the identified non MBI organism is added that was a mouthful so just put a star on that slide review later it’s like a little homework here alright first the patient fully meets lcbi 2 with at least two blood specimens and matching common commensals in this case viridans group strep plus a fever greater than 38 point 1 degrees Celsius because we have neutropenia on two separate days occurring within the seven day time frame the patient will meet mbi-lcbi criteria with anc levels of less than 500 cells please note values on days negative 5 and negative 6 cannot be used because they are outside of the seven-day time frame that includes the day of the positive blood culture three days or four and three days after so we have performed knowledge checks over lcbi and mbi-lcbi criteria now let’s look at the information needed when you send in a BSI BSI email for review if investigating a positive blood culture the BSI team would like for you to send all organisms identified in the blood cultures signs and symptoms and associated dates if evaluating for an lcbi 2 or 3 data the first access in an inpatient location if the patient was admitted with the central line in place in your mbi-lcbi risk factors if evaluating mbi-lcbi criteria this is a new FAQ for 2019 in addition to this if investigating the positive blood cultures all organisms identified in the blood cultures are needed signs and associate signs and symptoms associated dates if evaluating sorry this is slight it’s a duplicate alright so let’s move on to your CLABSI data in accuracy the accuracy of NHSN data is dependent on the accuracy of the surveillance determinations data collection and entry it is very important that we get accurate numerators by strict adherence to the definitions and reporting instructions and accurate denominators by mapping your locations appropriately collecting device days and patient days accurately based on the location type which may have specific requirements this is the BSI event data collection form that can be found under the data collection forms tab as a reminder the fields outlined in orange are the require CLABSI exclusions beginning in 2019 however the fields outlined in teal greenish bluish color are the CLABSI exclusions that are optional for 2019 but will become required in 2020 this is just the BSI event collection form in the NS NHSN application the highlighted sections are from the BSI event data collection form and I’m sure you’re familiar with both the event information and detail section what I’d like for you to pay attention to is that middle section which are your risk factors and you will see the required fields as denoted by the asterisks and the conditions that were added to the BSI form this year your denominator requirements by location and device remember if you if the patient has greater than two central lines only report one central line day for your specialty care areas of both the permanent and temporary line are present report the temporary line this guidance is correct in the patient safety menu patient days report all inpatient days in all locations and your s CAS for your patient days in your NICU location report the patient days by birth weight and this is just your birth weights highlighted here now we just briefly mentioned if your central line denominator that denominator data is incorrect it can impact your SAR leading to inaccurate data examples of some potential problems are accounting a patient with two central lines as two rather than one central line day or your electronic data import is happening twice a day rather than once per day this is your denominator for your denominator form for your intensive care unit in other locations not including your NIC use or your s CAS this is the same information in the NHSN application you will want to provide a sum of your total patient days and central line days for the month if you have no claps events be sure to check the no event box under class II for all locations remember to report at the same time remember to count at the same time each day the number of patients on the unit and the number of patients with the central line apologize for being cut off at the top but this is your denominator form for specialty care areas and your oncology areas please report the number of patients with at least one central line if a patient has both a temporary and permanent central line again this is the form in the NHSN application for your denominator for your denominator counts provide the sums for your total patient days your temporary central-line days and your permanent central line days check know if a CLABSI event if there are no claps events report it for by the type of central line so if there are no CLABSI events reported you would take note depending on the type of central line the patient has the central lines are stratified by device type device type so you would look at the number of patients on the unit the number of patients with a permanent central line number of patients with your temporary central line and again for patients with both report the temporary line only and this is your denominator reporting form for your neonatal intensive care units this is the same form in the NHSN application provide monthly sums for both your patient days in central line days and check the appropriate box if there is no CLABSI events to report in the birth weight category patient days is centralized in the NICU are stratified by birth weight so the number of patients on the unit by birth weight the number of the number of patients with a central line by birth weight and again your birth weights are listed here so a few words on electronic data validation electronic collection of summary data is acceptable but you must collect three months of concurrent data with both electronic and manual and the difference must be within plus or minus five 5% once weekly denominator collection reduces the NHSN data collection burden and as LG when I see use and locate and warrant location types but you must have 75 or more central line days per month for your patient days collect the information daily record both the total of weekly samples so for example if you collect this information every Tuesday and your monthly total which is your total for every day in the month the central line days are collected on a sink may be collected on a single day once a week and again we use the example of every Tuesday remember if you are doing sampling you need to feel am both your total patient days in your central line days for the month and your sample patient days and central line days there is a calculation that requires this information so let’s recap the 2019 BSI protocol changes exclusion of viruses and parasites occurred in 2019 for lcbi criterion your data fields for ECMO and VAD became required and these are two of the CLABSI exclusions additional data fields were added that are optional in NHSN for CLABSI exclusion and these are your epidermolysis bullosa your much housing syndrome by proxy your payslip patient self injection or IV da post at the vascular in Group B Strep in the first six days of life so in summary we know that surveillance and clinical definitions may not always align surveillance definitions must be adhere to strictly and consistently Clapp sees result in significant morbidity and mortality and US hospitals progress has been made but the journey continues according to the 2017 H AI report naturally among the Q care hospitals there was about a nine percent decrease between 2016 and 2017 to wrap-up primary BSI we have reviewed the forms the data collection techniques and data entry requirements for BSI events we review key definitions for BSI and CLABSI surveillance I’ve also provided an overview of the 2019 protocol with key changes located through protocols and training materials on the NHSN website and we were able to assess our current knowledge of the BSI protocol through knowledge checks this year we are accepting comments related to the BSI module of the patient safety component this is a pilot and comments can be submitted between February 14th and April 15th of this year this is an opportunity to identify issues and areas for potential improvement beginning in 2020 if you would like to submit your comment for review please use the information provided in the last bullet this is a reminder of the American Journal of infection control NHSN case study series resources that were used in the presentation you know and do you have any questions I’m not sure if we have time are there any questions hi there so it doesn’t make sense to me that we can count an on accessed port say in the denominator but it wouldn’t count for it in the numerator statistically that just doesn’t make any sense because your denominator should account for all of the patients eligible for the risk which in this case is a CLABSI okay I mean I’m just is that just designed tip for ease of use because it would be tough to count your denominator days yes okay so in several of the other modules the device is counted when the when it is present for CLABSI surveillance if you remember it used to be counted when the central line was accent and some facilities indicated that this was difficult to determine whether central line was access or whether it wasn’t access so in 2018 we made a decision to include all central lines regardless of access in your denominator device day count sorry for well thank you because it could I mean essentially you’re allowing us to game the system on patients who say come in and they’re nipper the report is never accessed but they’re adding days to the denominator right it will add days to your company all right thank you you’re welcome I have a question on the eligibility for doing the weekly denominator collection in the NICU setting can you do that and is also on those seventy-five days is at seventy-five days for all birth weight categories total or for each birth weight category you must have 75 line days okay so your question is regarding an electronic collection of you know the ones weakly denominator collection yes so you can perform your weekly sampling him that thank you whether or not is by duh is a 75 per birth weight category wait our total I would have to ask a member of the BSI team to make sure that of that answer okay so they’re telling me it is not used in thank you you cannot use that’s for the three okay thank you have a question on the ECMO and bad reporting I know two actually called the BSI it has to have been in place on the day of or the day before and has to been in place greater than two days but on the form where you the data entry form it just says yes or no and so if it were removed say five days before your your BSI event is that is that a yes or no there was one but it wasn’t in that two day period that’s a note okay thank you hello hi so my it’s more of a comment and then a question so in my patient population we’re a cancer hospital seventy-five percent of the classes that I reported in our we reported in 2018 occurred in patients who had a median length of neutropenia before the event of six days and the reason why we couldn’t it what didn’t meet the MBI criteria was because they were not on the list on the MBI list so what we saw though is that the majority of these patients were Co egg negative staph staph aureus and gram negatives such as Pseudomonas all of which had been reported in the literature as being potential colonizers of the GI tract so I would propose that we tend to look through the lens of a general acute care hospital where we’re looking at these definitions and not really identifying the truth the risks that occur in this population I would think that the 2200 square feet of denuded gie surface and the prevent from the chemo and the radiation and the profound neutropenia would have more effect on the that bloodstream 10 that less human factor than actually the presence of a central line so my question to you and we will be commenting is that what kind of data reports or what-have-you would you with the with the CDC like to see regarding evidence for expanding that MBI list we as you said you’ve actually you do plan to comment in the open comment absolutely right period so we would like to see any in addition to your comment attached any literature or evidence-based studies that would support the use of that would support MBI identification with the organisms that you you know that you have indicated that you see most often and will take that information back in and review because to me it sounds as if the MBI definition is not met because in your case in most cases MBI organisms were not identified right they were they met everything except for the mechanism yeah and we often have neutropenia periods that lasts for 30 to 60 days while we wait for our patients will grafting right okay Thank You chair tells to be too unless it isn’t the difference are you differentiate the two between lcbi to you and an lcbi three for lcbi to there are different signs and symptoms that are required and those signs and symptoms are available in the BSI protocol for lcbi three there is an age limitation of less than or equal to a year of age in addition to specific signs and symptoms seen that patient population I just want to remind people that we have a tables of instructions and so the person that quite asked the question about the central line yes or no all of that information we can’t put we simply can’t put all the instructions on the screens that you know you get on the computer so that’s why it’s so important to look at the tables of instructions because if you look for central line at the central line field it will tell you that you only answer yes if the central line has been in place more than two days and was a president was president of the day before or the day of the event so that is probably the most underutilized document that we have or those documents the tables of instructions really important to look at them when you’re if you have a question do you have a coached in from those really dealing via web string there’s another question regarding when a patient has both a permanent and a temporary central-line are we only to count the temporary line yes you should only count the temporary line in your denominator reporting in the slides that are posted on the website and perhaps the slice you have in front of you the instructions provided were incorrect it’s only the temporary line that should be reported in your denominator okay and we have another question for the denominator validation if a health system has multiple facilities using the same electronic software does each individual hospital have to validate manual counts or can the validation for the whole be done by manual counts and a few of the entities I would say that each facility needs to perform the validation and for the manual and the electronic system and one other question for lcbi – and lcbi 3 when it says blood specimens drawn on two separate occasions what does that mean can you not have more than one full counter today between collections so the definition for that or the the guidance provided for that and I can’t recall the page number is that the blood specimen can either be collected on the same or consecutive day so you cannot have a calendar day between the the blood collections what was the other part was that the only part of the question see okay are there any more questions I have one more and what is a non culture-based microbiological test method for CLABSI definition oh you know that’s a that’s a huge question there I can provide you we can provide you with examples but we do not have a list of non-culture based microbiologic testing we do receive questions regarding this so some of the some of the testing methodologies that we see on occasion are your beat be CID pin be CID essays your fun to tell PCR but these are just examples NHSN does not provide a list of non-culture based microbiological testing methodologies

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