Pennsylvania Department of Pennsylvania Department of Health - PDF document

Pennsylvania Department of Pennsylvania Department of Health (PADOH) – – CLABSI, CLABSI, Health (PADOH) CAUTI, and SSI Audit CAUTI, and SSI Audit Mary Andrus, BA, RN, CIC Mary Andrus, BA, RN, CIC Infection Preventionist Consultant Infection Preventionist Consultant APIC CONSULTING SERVICES, INC. APIC CONSULTING SERVICES, INC. Provisional CLABSI Results Provisional CLABSI Results Provisional CLABSI Results Provisional CLABSI Results A total of 120 records were reviewed

Provisional CLABSI Results Provisional CLABSI Results Auditors reviewed 23 patients that had been reported to NHSN Provisional CLABSI Results Provisional CLABSI Results Bloodstream infections that were reported by hospitals and confirmed by auditors Provisional CLABSI Results Provisional CLABSI Results Bloodstream infections that were reported by hospitals and not confirmed by auditors

Provisional CLABSI Results Provisional CLABSI Results Total number of positive blood cultures reviewed by audit. Provisional CLABSI Results Provisional CLABSI Results Bloodstream infections that were identified as CLABSI by audit but were not reported to NHSN Provisional CLABSI Results Provisional CLABSI Results Positive blood cultures that were not identified as CLABSI by audit and were not reported by the hospital to NHSN

CLABSI Misreported Cases CLABSI Misreported Cases • Under-reported (5) – 3 cases were not reported because the hospital identified the BSI as secondary to another infection. In each case, the criteria for the primary infection were not met – 2 cases were missed by the hospital • Over-reported (4) – 2 cases were reported as a primary BSI (CLABSI) when criteria for an infection at another site with the same organism was identified by the auditor – 1 case was reported by the hospital, but it appears to be associated with a CLABSI on an earlier date – 1 case was reported as CLABSI, but no corresponding blood culture was identified by the auditor Laboratory Laboratory- -confirmed Bloodstream Infection (LCBI) confirmed Bloodstream Infection (LCBI) ���������������� Notes about Criterion 1 Notes about Criterion 1

Laboratory- Laboratory -confirmed bloodstream infection confirmed bloodstream infection (LCBI) (LCBI) ���������������� � Common commensal � Diphtheroids ( Corynebacterium spp.) � Bacillus spp . (not B.anthracis ) � Proprionibacterium spp. � Coagulase-negative staphylococci (including S. epidermidis ) commensal � Viridans group streptococci � Aerococcus spp. � Micrococcus spp. Two or more blood cultures on separate occasions Two or more blood cultures on separate occasions “Two or more blood cultures drawn on separate occasions” means 1.Blood from at least 2 blood draws were collected within two days of each other and 2.At least one bottle from each draw is reported as having grown the same common commensal “ “Sameness Sameness” ” of organism of organism ���������������������������������� ������������������������������������� ������������������������������������� �������������������������������������� ����������������������������������������� �������������������������������������� ���� !�����"�������������������� �������������������������� ������������������������������ ������������������� ���������������� ������������������������������������� ������������������������������������������������� ��� �����������

“Sameness “ Sameness” ” of organism of organism ������������������������������������� �����������������������������������#���� ���� �������� ������#����������#�������� ��������������������������������������� ��������������������������������� ���������������������� Blood Culture Specimen Collection Blood Culture Specimen Collection ���������#����������������������������������#�� �#������������������������#���������������� ��������������������������������������������� ������������������ $�����#������������������#������������ ���������������������������������������������� ���������������������������������� �������������������������������������#����� ���������������������������%������������������ ��������&��������������������������#�������������� ���������������������������������������������� #����������������������������������������#����� �������� Laboratory Laboratory- -confirmed bloodstream infection confirmed bloodstream infection (LCBI) (LCBI) ���������������� � Common commensals � Diphtheroids ( Corynebacterium spp.) � Bacillus spp . (not B.anthracis ) � Proprionibacterium spp. � Coagulase-negative staphylococci (including commensal S. epidermidis ) � Viridans group streptococci � Aerococcus spp. � Micrococcus spp.