[ silence ] >> good morning everyone andwelcome to our third and final day of the 2014 nhsn training course. we want to acknowledge again, all of you here who have given your undividedattention and great participation. everyone in the room as well aseveryone watching the live web-stream, we do appreciate your participation. i have multiple updates that i'll givethroughout the day but i have a couple of important things that you'llneed to know first thing.
we wanted to remind you that theevaluation forms are in the back on the back table outside of this room. i was told that if you are getting ce's,well, when you apply for that you'll be able to do the evaluation on the computer so youdon't necessarily have to complete it today. but if you aren't going to beapplying for ce's then we ask that you do complete the evaluation form today,and leave it on the table before you have to go. we really appreciate your feedback andyour input and it is important to us, so we do ask that you complete thatif you are able to give your input. with regards to feedback and input we wantedto let you know, we know some of the people
in the front have a hardtime with the bright lights. we can't unfortunately dim the lights any more than we already have becauseof the live web-streams. so we apologize if they're a littlebright or hot on the tops of your heads. we also know that the round tableshaven't been ideal for you in the room. again, hoping that you've been ableto see the presentations with all of the drop-down slide viewing but i knowit's difficult if you have to have your back or have to turn around to face the front. just so you know, the reason we chose todo it this way was because we really wanted
to maximize the amount of people we could get ina room and get here to this in-person training so that you'd be able to actuallybe in the room if you wanted to. so many people enroll and register to try to geton the random list that we felt that we should, you know, try to do this so that wecould maximize to the 300 or over, but we will evaluate for next year to see if there's any way we can fixthat or get a bigger room. let's see, i wanted to remind you that the teamoutside the door is in the back to help you with your transport to the airport. so, they can help you with all of that but theyneed you to sign up on a sheet and let them know
when your flight is so thatthey can group people together and make sure everybody getsto the airport on time. and if you are leaving early, which wewant you to stay today as late as possible to hear all the important information beingpresented today, but if you do need to leave and you know that it's going to be ahead ofschedule, please let them know now or as early as possible so that they can make sureto set you up front aside to get you out early for the transportation. we ask that -- oh, yes this is very important. so, you have met many of the individualswho answer the nhsn mailbox for you.
there is a group of user supportteam that you were not able to meet because they were not presenters and they'veactually been working behind the scenes to continue to answer the mailbox of questionsthat come in over the course of this training and are always the front lineindividuals that help you. so there's a group of those. the individuals, the infection preventionists,a lot of the data analysts, data analyst methods and analytics team, you've met here, sonow you know that there's not hundreds of people behind the scenesavailable to answer your questions and when we give the training we always knowthat there's going to be a hike in the mailbox
because of all the importantinformation that was presented. so over the next few weeks themailbox is going to double. over the next two weeks we're actually downone ip because she'll be away for two weeks, so we ask that you give us a littlebit of leeway and understanding if it takes a little bit longer toanswer questions in the next few weeks and give us your support with that, justto make sure that we catch everybody back up with all the informationthat's been presented. so we just wanted to bring thatto your attention because i know when you ask questions it's very important
and you need those answersbecause you need to do your job. we do recognize that too, so we will do thebest that we can to keep up with the questions that already have begun tocome in in these past two days from viewers watching the live web-streaming. and a reminder for thesepresentations, they've all been taped. they will be archived and posted. we expect them to be up by mid to late apriland this way for your reviewing pleasure, and anyone that you want to pass the informationon to -- individuals who couldn't come, people who weren't able to getonto the live web-streaming.
they will be broken up intosections and sessions by topic so that individuals can watch them whenit fits into schedules and do it even in a little more piecemealthan three days in a row. because i know it's a lotof information to take in. there's something you might want to watchagain, it'll be available for you to watch. so i think with those, i will havekathy come up and talk about cauti, and we'll give some moreannouncements right before lunch. thank you. [ applause ]
>> good morning. well, today we're going to talkabout catheter-associated uti's, and we're going to try to have a little bit offun today so, since you've had two long days. hopefully you'll enjoy thismorning's presentation. so, i'm am going to have to cover a littlebit of information that i've already covered, such as hai definitions, poa's, because wehave people tuning in for the web-streams that may have not listened tothe [inaudible] definition. so if you want to tune out in those situationsyou can, and hopefully you'll tune back in when it's something new for you,but just a little bit of a warning.
so, today we're going to go overthe cauti, definitions and key terms that are utilized in cauti surveillance. we're going to talk about how to collectthe urinary catheter and patient data. we're going to again identify the datacollection forms and then we're going to apply the definitions tosome patient case studies. so, same general overviewthat we've done in the past. and we're going to cover the epidemiology,the definitions, and the changes for 2014. talk about denominator collectionand i'll provide you some resources, we'll do case studies, and then lastly ido want to give you an update on, you know,
what's going on with the cauti definitions. you probably have heard that weare reviewing those definitions. we've actually been reviewing them since the endof 2012 and hope to have some changes for 2015. i might not be able to give you alot of specifics because i've learned that don't give specifics until it'sactually totally done because as sure as you know what it's going to change. so -- but i can tell you what, you know,what is being done and then for those of you that are coming to apic i'll also be goinga presentation there and maybe i'll be able to give a little bit moredetails at that time, so.
so again, we're not going to go over in-depthtoday requirements for the centers for medicare and medicaid services inpatient qualityreporting program or the oncology, the cancer exempt hospitals reporting. all that information's availableon our website or through the qio's and i've provided you those resources here. also, we will not be going through step bystep data entry and maggie's been covering all of the data analysis for us verywell, so we don't have to do that. so, cauti's, who cares about cauti's? right? who cares?
urinary tract infection is tied, believeit or not, you probably know this, with pneumonia as the second most commontype of health care associated infection, and it's really only secondto ssi's in overall incidents. and we know that the majority of themare associated with indwelling catheters. i don't know if you're aware but alittle over 5% of icu cauti's result in bloodstream infections and innon-icu cauti's that is up to about 7.4. so, interestingly enough, highersecondary bsi rate outside of the icu. 13,000 people die every year for uti's,so you know, it does cause some morbidity and mortality, and interestingly, up to1/3 of asymptomatic bacteriuria is treated
with antimicrobials even though this is, youknow, in conflict with published guidelines and results in a lot of unnecessaryantibiotic usage, c. difficile infections, adverse reactions. and so, that's one of the main reasons thatasb was removed back in 2009 from our criteria. so, it's important for us to shine a light, sortof, on cauti and what we can do to prevent that and how we can treat it andidentify it correctly. and a lot of people are saying now that, youknow, cauti's may be a proxy measure for the overall general qualityof care for patients. so, you know, that's another reason
that we might be concernedabout what happens in this area. so again, we just want to make sure thatall of our data that we enter is good data. and so, things to considerfor cauti surveillance. so, nice thing is that unlike ssisurveillance, all cauti's are going to require a positive urine culture. so you can start with your laboratoryas your basis for case finding. so hopefully you're all able toget a routinely generated report of your positive urine culturesand that's your starting point. but i do want to point out thatit's really important for you
to know your laboratory's urineculture reporting policies. specifically, what are the ranges ofcolony-forming units that they're reporting? some facilities don't report down to10 to the third, which is, you know, part of the definition for uti's. some of them don't quantify yeasts, and so yourfacility's not able to meet all the criterias that are currently written since we includeyeast as a pathogen for cauti's at this time. sometimes positive urine cultures are reportedfor the unit on which they were collected and not necessarily on theunit that the patient is on. so you may need to check to makesure that you're attributing
that cauti to the right location. it seems to happen a lot withpatients that are discharged. sometimes the discharge location -- orlocation for the culture is not accurate. so just -- you need to considerthe transfer rules and how the laboratory reportmight be affecting that. and finally, you know, just to take into accountthat you need to account for positive cultures from the emergency department because thosecould really represent cauti's from patients that had recently been dischargedand might be -- should be attributed to thatdischarging location.
so again, what are you going to look at firstand where is it going to be on the record? those are, you know, thingsthat you need to think about. you're going to be looking for your urineculture results and your laboratory results. and then probably what you want to lookfor -- unless you're in pennsylvania, most facilities -- not a lot offacilities are doing surveillance for non-catheter associated uti's,so you know, you're going to look -- maybe the next thing you look at is whether or not they had a urinary catheterin place in the time period. you know, and you're going to belooking for nursing documentation
and graphic sheets for thosetypes of information. this is a sample worksheet that, you know, thatwe put out for your use for data collection. you guys -- some facilities create theirown data collection sheet, which is fine, just as long as it collects all ofthe information you need for nhsn, but this one is availableon the website for your use. and then, you know, the old spiel about makingsure that we're all doing things the same way. i went over this pretty well with clabsi. you know, we need to all beconsistently applying the definitions. standardizing your chart review willhelp you to be consistent over time.
so if you get into a routineof how you collect data and how you identify cases,that will really help. maintain the focus on the criteriaand don't deviate from that. cauti is one of those areas sometimes wherepeople feel that maybe they're not capturing all of the patients that theyclinically believe have a uti. we hear this a lot with patients that are onventilators or spinal cord injury patients, maybe because, you know, they're notable to communicate, for whatever reason, suprapubic tenderness or cva pain. surprisingly, though, honestly only --well, 80% of our patients that are reported
as cauti's have fever as their only symptom. that may be surprising to you or it may not be. so, if you think about it that way,the spinal cord injury patients or the ventilated patientsare maybe not that different. i mean, most patients when we identifyit it's through the use of a fever. you know, the other thing to think aboutwith that, i always tell people is that just because a patient is ventilated doesn'tmean they can't communicate pain. especially with these sedation vacationsand depending on the level of sedation, patients can exhibit signs of pain iftheir physical assessments are done.
so, i don't -- i always hate for people tojust say, "well they're on a ventilator, we can't tell whether or notthey have an suprapublic pain. so that's not always the case. so again, think about surveillance definitionsversus clinical definitions and the fact that sometimes the two are not going to meet. you know, we're looking -- we're usingthe definitions for surveillance different than clinicians are using to makedeterminations about what's going on with a patient and what they should do. and our data elements are going to be limited.
they're going to be finiteand the clinicians are able to use everything that's available to them. so, it's okay if they don't always match. we obviously try to make our criteria so thatthey are as close to clinical definitions as possible, but we have a long wayto go, especially in cauti, i know. but we are definitely working on that now. was that a laugh [laughter]. so, sometimes, you know, sometimes it'shelpful to remind your staff about surveillance or to educate staff aboutsurveillance in clinical definitions.
how many people here have had to havethis conversation in their -- yeah. yeah, yeah. yep. and surprisingly, sometimes it's infectiousdisease physicians that you have to have that conversation with, whichis always surprising to me because i would have thoughtthey understood that. but we always want to make sure obviouslythat we're using the surveillance definitions as a determinant of what we report. and we're always here atnhsn@cdc.gov, as dawn told you, to receive your questionsand try to help you out.
oh! so, i want to make a disclaimer. i thought it would be fun if ishared some of the funny emails that we get from users, because we get some. i didn't include any identifierson these, so if it's from you and you recognize it don'ttell anybody [laughter]. and they will not know. so i'm going to share -- as we goalong today i'm going to share a couple of funny emails that we have gotten. so, here's one that i got from a user.
she said, "i am looking at a patient thatpresented to our facility on 2/15/13. a foley was placed in theer on the admission date. during her stay she was afebrileand symptom-free with one exception. a temp of 102 was documented at midnight. the nurse manager feels that this is possibly amisdocumentation and would like some guidance. do we still call this a cauti?" no, you can just discount that [inaudible]. don't worry about it. it's probably a mistake.
yes, you have to still call this a cauti. all right, so we're going to get intothe nuts and bolts of the definitions and we're not really going to be talking aboutnon-catheter associated uti's here today. as you may or may not know, theyhave their own criteria designated as the b criteria's for suti. the a criterias are all catheter-associated, theb criteria's are all non catheter-associated. and i want to identify that abutican also be non-catheter associated or they can be catheter-associated. and if you are determiningwhether or not an lcbi,
bsi is secondary to a non-catheterassociated uti, you have to make sure that you use non-catheter associateddefinitions and you'll see as we go along, if you don't already know, why that's important. so, there are basically twospecific types of uti. symptomatic uti, or suti, oran asymptomatic bacteremic uti, or abuti, as we like to refer to it. i do want to point out sometimes people areconfused between asymptomatic bacteremic uti and asymptomatic bacteriuria orasb, which we used to have in 2009. asymptomatic bacteriuria just meansthat there are organisms in the urine,
but an asymptomatic bacteremic uti is onewhere there's not only organisms in the urine but there's also a matchingorganism in the blood stream. so the patient has a blood stream infectionas a result or concurrently with the uti. so that is the difference,they're not the same animal, and it's important that you understand that. both types of infections, both suti's andabuti's, if they're catheter-associated, need to be reported as part of any cms,cauti surveillance that you're doing. that's another thing that's sometimespeople don't quite understand. you can't just report the suti's,you also have to report the abuti's.
so, you know, over the years asi've presented this information, i've presented it in different waysand sometimes it's hard for people to understand the logic of whythe definitions are as they are. sometimes they seem like they're reallycomplicated, so i've tried to present it in different ways and thistime i thought i'd tell you -- just present the logic behindthe suti definitions. and one of the important points is that thesymptoms of a true uti are going to vary whether or not the patient has a foley in place. if the patient has a catheter in place they'regoing to have urgency sometimes, you know.
i mean, how many people have had a patient andthey said, "i've got to go to the bathroom." and you say, "you've got acatheter in, just relax." you know, "you can go." so, that foreign body causes urgency, it cancause burning, a burning sensation sometimes. you shouldn't be having frequency,so we took those out of patients -- you know, they used to be in thecriteria for patients that had foleys and they didn't make any sense to be in there. so that's why we've takenthem out of the criteria for patients that are currently catheterized.
infants, we know exhibit differentsymptomatology as well for infections and that's why we provide some infant-specificcriteria, and those additional ones are apnea, bradycardia, lethargy, vomiting, or hypothermia. because, you know, patients can have instabilityin temps when they have an infection. so, these are sort of the two big concepts ofwhy we have some complexity to our uti criteria. so this is sort of an overviewof the uti definitions. so, we can see that i'vedivided these by age groups. suti one and suti two arefor patients of any age. suti three and suti four are for infants.
and then we have our abuti's, whichagain, are for patients of any age. now, i told you yesterday that infants not onlycan meet these but they can meet any of these. it's just the patients that are over oneyear of age that cannot meet three or four. okay. within each of these differenttypes of uti's we have catheter-associated or non-catheter associated uti's. make sense? all right. so now we're going to look at how thecolony-forming units are applied to these. so, for suti one and suti threewe're dealing with patients that have
at least 100,000 colony-forming units. and i have an asterisk here, you'llnotice that it goes down to -- they have to have no more than twoorganisms in that urine culture. and that's because we want to make sure thatthis is not a contaminated urine culture. if there's three or more organismsthe chances are pretty high that that's been just a poorlycollected culture, we don't want to use it tosay that somebody has a uti. we don't want to over-call these uti's. abuti also requires greater than 100,000.
you'll never have an abuti that has lessthan 100,000, and that's for a reason. you know, we -- this patient is asymptomatic,so we want to have a high degree of -- as high a degree as we can ofconfidence that this is truly a uti and so that's why we're going to requirea high colony-forming unit count. you'll notice, though, there's twostars there and that means that not -- we don't use organisms, we use uropathogens. so there cannot be more than two uropathogens and we provide you a list ofwhat those uropathogens are. it's a pretty broad list, but there are afew organisms that are not on that list.
that list is included inthe nhsn cauti protocol. i'm trying to remember. i think we have it on our organismlist, too, that's on the website where we have mbi and we have common commensals. people are nodding, so. so that leaves suti two and suti four. so you'll notice that one of the infants,the suti three, has 100,000 or more. one of the infants has greaterthan 1,000 or less than 100,000. so we have adult and child, adult and child.
or, i say adult -- any ageand child, any age and child. so this group here, suti two and fourhave a lower colony-forming count, 1,000 or more, but less than 100,000. again, no more than two organismsin the culture. because this is a smaller colony-formingcount, we are going to require some symptoms -- i'm sorry, some supportive positiveua to give more credence to the fact that this is truly a good cultureand indicative of an infection. so that's why this criteria requires this lowerlevel colony count and a supportive positive ua, again, within a time period of no more thana single gap day between adjacent elements.
okay. is this a good way to present this? does this make sense? okay. good. thank you for the feedback. okay, so when we're looking at a symptoms reallythe main question that you have to ask yourself, and i went over this a little bit, was thecatheter in place at the date of the event? if the answer is yes, then you're going to havea limited number of symptoms that you can use. you can only use suprapubic tenderness,costovertebral angle pain or tenderness, or fever greater than 38 degrees celsius.
if it's a baby you can additionallyuse hypothermia, less than 36, apnea, bradycardia, lethargy, or vomiting. okay? you'll notice what we've takenout of there when you look at the no. so there was no catheter inplace on the date of the event. you'll see here i bolded. you now have dysuria, frequency,or urgency that you can utilize. and then you have all thatyou had for the yes answer. you have your suprapubic tenderness, cva pain ortenderness, fever, and then the infant criteria. so we simply remove thesethree, dysuria, frequency,
or urgency if the catheter is in place. as i said, when there's more than two speciesof microorganisms that's routinely regarded as a contaminated culture and wedon't want to use it for nhsn. we do get questions about culturereports that come back as mixed flora, and generally mixed flora representsmore than two organisms, two species, so if you have mixed flora and youhave any additional organism recovered from the same culture that's goingto have more than two organisms. so, for example, if you have toreport that maybe there's a greater than 100,000 pseudomonasaeruginosa, and there's mixed flora,
clinically we probably wouldbelieve that greater than 100,000, but unfortunately we have mixed florain there so we can't utilize that. this is one of the issues that we're kind oftalking about with the new definitions also. you know, can we say if there'sa preponderant organism, can we say that that should be utilized? as it stands right now, in that situationyou would not use that culture report. if the organisms are the samegenus but two different species, they're considered two different organisms. so if you had a pseudomonas and aeruginosa --
aeruginosa and a pseudomonas stutzeri[assumed spelling], that's two organisms. if you add anything onto that you'renot going to be able to use the culture. and kind of the flip side ofthat, if you have an organism that has just simply the same organism but hasdifferent susceptibility pattern such as mrsa or mssa, those are considered justone organism because, you know, we know that how the laboratory works thoseup they may just pick different colonies from, you know, that -- cultures or coloniesthat represent the same organisms and there is some variationand resistance within those. so, we don't want to say that thoseare different organisms all together.
so those will be considered just one organism. okay. sometimes, obviously patients willhave a positive urine culture -- excuse me -- shortly after their catheter is removed. so, for those patients ifthe event date, the uti date, is on the day of device discontinuation or thefollowing calendar day, just like for clabsi, these are going to be considereddevice-associated. as long as the device had alreadybeen in for greater than two days. and, for this criteria you areable to utilize urgency, frequency, and dysuria because the catheterhas been taken out.
so i've given you two examples. first one, the foley is placed andit's there, it's placed on day one. day two it's still there. day three it's in place for partof the day and then only for part of the day and then it's removed. the next day the patient meets uti criteria,this is going to be considered a cauti. unlike here, where the foley's placedon day one, it's taken out on day two. it was there for part of the day, taken out. the next day they have no foleyand they meet criteria on day four.
that is going to be a health careassociated uti, but it's not going to be considered a catheter-associated uti. whether or not you clinically agree with thator not, that's the definitional interpretation. okay. so let's just go overthe criteria as a whole here. so these are the a criteriafor suti's, symptomatic uti's. a, meaning that these are goingto be catheter-associated. on the first you'll see its split,the first half of this is for patients that have the catheter inplace on the day of event. the second half are for those thathad it in for greater than two days
but had it removed the day ofor the day before the event. okay? so for the first ones, it's inplace, it's been in place for greater than two days on the day of event. they can have fever, suprapubictenderness, cva angle pain or tenderness, and they have to have a positive urineculture of greater than 10 to the fifth, and no more than two species of microorganisms. and again, the gap day for-- single gap day does apply. if the catheter had been in place for greaterthan two days and it was removed the day of or the day before the event, then we add indysuria, urgency, frequency, and then, again,
fever, cva, suprapubic/sp tenderness, and thesame requirements for the positive urine culture of greater than or equal to 10 to the5th and no more than two microorganisms. now, you'll notice that there is an asteriskhere for with no other recognized cause and for those astute clinicians, you'llnotice that it's not there for fever. and this is one of the questions thatwe get the most and one that, you know, we are discussing how best to approach this. the reason it's not there is because, to allow-- and this happens more with cauti than it does with clabsi because, you know, with clabsione you don't have to have any symptoms. but you know, if the patient has a pneumoniaand they have a positive urine culture
because they've pan cultured the patient,if the fever is there the fever has to be utilized to meet the uti criteria. if you're doing pneumonia surveillance, you'llalso have to use it for the pneumonia criteria, and that's because at this pointwe haven't figured out a good way to operationalize clinicaljudgment about where that uti go -- or where that fever is responsible for. and it may be responsible -- itmay be due to both infections. if the patient has both infections theymay be running a fever because of both. i mean the body doesn't --does the body differentiate?
i don't know. so, the only way i think that we couldget around this would be if we were to identify a hierarchy of infections. okay, if they have this and they havethis infection and this infection, you apply the fever to this infection. but you see that quickly becomes very complex. and so, that's what we're wrestling with. so for now the fever is a non-specificsymptom and you have to apply it to all potential infection types.
criteria in two, again this is in a so theseare catheter-associated infections you'll see. two, again, is for those patients that haveless than 100,000 but greater than 1,000. if the catheter is in place the symptomsare exactly the same as they were for a. you're going to have those symptomsminus dysuria, frequency, and urgency. additionally, however, you'regoing to have to have a positive ua and by positive we mean a dipstick that'spositive for leukocyte esterase or nitrite. or pyuria, that means greater thanor equal to 10 wbc's of unspun urine. how many of you know whether ornot your lab spins your urine? okay, how many of you don't know?
yeah, so you need to see if it's being reportedout to you or if not you need to clarify that with your laboratory because if it'sspun urine, it's greater than or equal to 10, if it's unspun urine they're going to belooking at it under a high-powered field and it's greater than five wbc's to be positive. okay? and, you could alsomeet this using a gram stain if there's microorganisms seen on unspun urine. not many laboratories do this anymore. questions that we do getsometimes is what is trace? is trace positive?
yeah, trace is positive. so if you have a trace leukocyteesterase, it's positive. just like with one a; you know, we havethis top portion that was in place. we have the bottom portion that the catheterwas taken out the day of or the day before, that means that we've added backin urgency, frequency, or dysuria. just as above, this is the ones that have equalto or greater than 1,000 but less than 100,000. and they have to have oneof the same positive ua's. so the only difference between the top and thebottom is the additional criteria of urgency, frequency, and dysuria, if thecatheter had just been removed.
clear? yeah? looks like everybody's with me. yay. so i'm not going to go over this diagram, i just want to point outthat it is in the protocol. some people are very, youknow, they do much better with a flow chart than they do all of the text. so we do have it there. one is for -- this one it happensto be if the foley is in place. we have one if the foley is removed.
there are similar flow chartsfor three and four and for abuti. now the criteria for the infants, oneyear of age or less, is very similar. you'll notice that three is very similar to one in that the colony-forming units isgreater than or equal to 100,000. the only difference between the adults -- orthe all-age criteria and one and the three is that we've added, again, hypothermia,apnea, bradycardia, lethargy, and vomiting. other than that it's exactly the same. the one difference that i'm goingto say is that you'll notice that we have two asterisks down here.
rather than splitting this up, we havesimply said between those patients that have the catheter or those that hadit removed, we've just asterisked down here that if they had the catheter in place forgreater than two calendar days with the day of device placement being done and thecatheter was placed on the date of event, that they can utilize these symptoms here. four is very similar to two, it's the analogy oftwo in that the colony-forming count is lower, it's greater than 1,000 less than 100,000. because of that you need a positive ua. the positive ua results are no differentfor children than they are for adults.
and, again, those additionalsymptoms that i mentioned above. so, this, just to point out that thisdouble asterisks is how you're going to determine whether or not this is acatheter-associated device -- or uti or not. asymptomatic bacteremic uti -- i'll give youa little bit of background for those of you that don't know how this definition came about. back in 2009 when we removed asb, asymptomaticbacteriuria, we didn't anticipate a problem that would occur from that, and that was thatif a patient had a positive urine culture, but they didn't have any symptoms,it could no longer be called an asb. it used to be that that couldbe reported as an asb.
if it was recorded as an asb, then it could besaid that an lcbi that occurred at the same time with a matching organism was secondary to that. well, when we took away asb, we nowhad these positive blood cultures that matched a urine culture butthey couldn't be called secondary and so if the central-line wasin place they became clabsi's. and that didn't sit well withpeople, it didn't sit well with us. so, we developed asymptomatic bacteremic uti. so this is for a patient that has a urinarycatheter in place or doesn't have one, it could be catheter-associatedor not, and any age patient.
so, we don't have an infant one. they can have none of the symptoms that we'vementioned for any of the other criteria. okay? so, i'm not going to go through all those. they simply can't have anyof the earlier uti symptoms. additionally, they have to have a positiveurine culture or greater than 10 to the fifth. again, no more than two species, and a list ofspecific uropathogens that have to be involved. and we'll go over those in just a second. there has to be an accompanying,matching blood culture with at least one organism to the urine culture.
if all that occurs within a time-frame thatdoesn't exceed a gap of one calendar day between two adjacent elements, then this is anabuti, and you would not call it primary bsi. okay? that list of uropathogens are listedhere, as i told you it's pretty broad -- gram negative bacilli, staphspecies, yeast, beta hemolytic strep, enterococcus, gardnerella vaginalis. we took these lists from --i can't remember the source, but we didn't make this list up [laughter]. i can get you the list atthe source if you want it. aerococcus urinae and choroni bacterium.
you know, it's very seldom that i hearof an organism that doesn't fit in here. so, and that complete list is,you know, listing up the species as well as the genus, is on our website. okay. so, just to say again, only the events forabuti that had catheters in place for greater than two calendar days prior to the date of onset are catheter-associatedotherwise they are none. and then uti's is one of them that we geta lot of questions about the recurrence. is it new or is it a recurrence? do we have to report a whole separate uti?
and the guidance here is nodifferent than it was for lcbi. we say look to see what evidenceof infection is still occurring, does it appear that the infectionhas resolved clinically or are they still being treatedfor the first uti? if either of those is yes, then we would notassign a uti, we would say it's a continuation. and that is irrespective of whetheror not it's the same organism. so, i always use yeast as anexample because it happens so often. somebody's being treated for e. coli uti and four days later they have apositive urine culture for yeast.
they're probably still being treated atfour days and in that case, if they are, then you're just going to add that yeast onto --if you've reported the uti, you're going to add that yeast on as a pathogen to that, ratherthan calling it a separate infection. okay, you ready for another email? they get funnier as we go along. so, this is one we got. "good afternoon. i have a patient who met all the criteria forcauti on 1/21 when she spiked a fever, however, she was declared brain-dead on1/18 and was only being kept
around so her organs could be harvested. would she be considered a cauti." i thought, that's a reallystrange way to phrase that. she was only being kept aroundso her organs could be harvested. the answer is yes, we do includepatients that are in hospital, you know, they're organ-donation patients, because weshouldn't be giving them uti's even though, you know, they're here for organ-donation. so, and we actually have reviewedthat decision with our patient -- our organ transplant team and theywere in agreement with it, so yes.
that got people talking. okay, now we're going to go on to key terms. so, obviously all cauti's have to hai. so we're going to talk about poa versus hai. here's where you might want to tune out ifyou've heard this all more than you want to. a poa infection is one thatall criteria, all criteria, are present during the two calendardays before the day of admission, the first day of admission,and/or the day after admission, and are documented in the medical record.
if it's poa, you shouldn't be reportingit to nhsn, we are only interested in health care associated infections,and acceptable documentation, again, does not include that reported by the patient. if the patient says i wasfebrile, you can't utilize that. you can if a report comes from the otherhospital that the patient's febrile. and something i didn't mentionis that we really, you know, we're trying to balance what werequire for you to know and whatnot. we didn't want you to have to go backand ask the facility what the fever was. so, as long as it's documentedthat the patient was febrile,
you can use that to meetthat part of the criteria. physician diagnoses is not apart of the cauti definition. so, a patient coming in and a physician sayshe has a uti, that is not sufficient to say that the patient had a uti on admission. okay? patient is going to have to meetthe criteria during that time period. so here's the unlucky family again. grandpa unlucky has been in an inpatient rehabfacility following multiple fractures sustained in a multi-car pileup when atlanta sustainedthe snowmageddon of 2014 [laughter], otherwise known as a halfan inch of snow [laughter].
yep. he's now transferred by the way, to yourhospital with a foley catheter which has been in place for two weeks andreported by health care worker of fever the day before transferand a change in mental status. he's afebrile on admission and his urinecultures collected on admission are positive for greater than 100,000 cfu's of e. coli. so, we're going to vote again this morning. which of the following is most accurate? he does not have a uti. has a uti attributed to the new hospital.
or he has a uti attributable to the rehabfacility and is poa to the hospital. okay. let's see how you've done. couple more seconds. so, 96% of you think that the patient hasa uti attributable to the rehab facility and poa to the hospital, andthat is the correct answer. and let's see why. so, he -- on the date that he's admittedto your hospital there was a report of fever the day before transfer, whichwas reported by a health care professional. and he had a urine culture collected,which was greater than 100,000 of e. coli.
so he meets suti one a, present on admission. actually, attributable to the other hospitaland we do encourage you to communicate with other facilities to let them know whenyou identify an infection that is attributable to them and if i was you i certainly would,because i don't want to be compared to somebody that was not collecting all of their data. definition of a health care associatedinfection, again, it's considered hai if all of the infection's specific criteria were notpresent during the poa definition time period. so, not poa, but they were all present on orafter the third calendar day of admission. again, they have to occur within atime period that does not exceed a gap
of a single calendar day betweenany two adjacent elements. and, did we define a gap dayas a calendar day in which none of the infection criteria are present. the transfer rule, as you all know, is ifthe patient meets the criteria on the day of transfer or the next day,we're going to attribute that back to the transferring location. if it occurs after that time period,after the day of transfer, the next day, it's going to be attributableto the receiving facility. and, you know, this applies alsoto patients that are discharged.
if they go home and then you find outthe next day, they come back and you find out that they have -- even if theydon't come back, if you find out, maybe you have communicationswith your medical offices. but if you're aware of it you're goingto attribute that back to your facility if it occurs on the day oftransfer, the next day. i'm sorry, i said transfer, i meant discharge. okay, warning. the next slide is very important. does this work?
[ambulance sound] all right, here's an example. and i say it's really important because weactually get this question all the time. i know that people don't understandthis as well as they should. so this is an example that is notpresent on admission, it is an hai. day one, the patient's admitted. they're asymptomatic. they have, however, a urine culture that'scollected for 10,000 cfu's of e. coli in the urine, but they're asymptomatic,as i said, and there's no documentation in the two days prior thatthey were symptomatic either.
second day they're asymptomatic. the third day they run a fever. and the fourth day they have a culture, again, and they're now 100,000 colony-formingunits of e. coli in the urine. this meets the symptomatic uti criteria. they didn't meet it in the poa. they had a positive culture butthey didn't have any symptoms. you left that catheter in,you know, for four days. it doesn't say they had onehere, but you're only going
to report it if they did, probably, so. so, this is a uti that's got tobe reported for your facility. okay? this is one of those exampleswhere it's neither poa nor hai and you're not going to report anything. patient came in and they were asymptomatic. they had a fever on the second day. the third day they're asymptomatic again. the next day, i don't know why, butthey do a culture on the patient. it happens.
and it's positive for 100,000 of e. coli. asymptomatic five and six. so, we didn't meet the criteria in the firsttwo days, and we didn't meet them after that and we only had a positiveculture on day three or later. day seven would be too long because therewould be a gap day here -- two gap days here. so, this is one of those cases wherethey don't meet either criteria and it's not going to be reported. although, you and i believe theyhave -- may believe they have a uti. okay. good news is we probably also wouldthink that they probably came in with it.
okay, i've covered this, the gapday rule or the gap day definition. so, i'll give you an exampleof the gap day again. patient is admitted on april 1st to the icu. they put in the foley sixdays later they had a temp. on 4/8 they're asymptomatic, they're afebrile. this is a gap day. they don't have any suprapubic tenderness,they have no cva pain, they have no fever. it's a gap day. the next day they have a positive urine culture.
so, because there's a single gap day hereand the foley's been in longer than two days, this is going to be a catheter-associated uti. again, if 4/9 had been asymptomatic, and 4/10 the urine culture had beencollected it would not be considered a uti. because there would have been two gap days. okay. our definition of anindwelling catheter has not changed. that's good to hear, hey? so it's simply a tube that's inserted intothe urinary bladder through the urethra, that's left in place and isconnected to a collection system.
it includes those patientsthat are getting irrigations. those patients are probably at higher risk ofuti's, so we include those patients as well. it doesn't include straight, in and outcatheters, nor suprapubic catheters, no nephrostomy tubes, but if a patient hassuprapubic catheter or nephrostomy tubes, which happens sometimes, and a foley, they are included in yourcatheter-associated uti surveillance. if the foley's there, they're included. i got a question this week fromsomebody that they had a patient, i think it was a spinal cord injurypatient, that they were doing --
he was doing intermittent self-caths andthen at night the nursing staff was putting in a foley catheter, and theywere taking it out every day. is this something that you guys see? no? okay, so she wanted to know if they wereeligible for cauti and my answer is yes, because the catheter wasin place each day for -- an indwelling catheter was inplace some point of each day. so on the third night, they nowbecome eligible for a cauti. we get all sorts of crazy questions. okay. and i think we've pretty much covered whatis the definition of a catheter-associated uti.
so, the only thing i want to highlight is itis the date of the event that you're looking at to determine whether or notthe catheter had been in two days. the date of the event, the date of thelast element used to meet the criteria. discontinuation and reinsertion. we get this all the time, and as i said, we're coming out within thenewsletter with guidance for this. but if the foley catheter is discontinued and a full catheter day passes before afoley is reinserted then the day count for determining catheter-associateduti begins anew.
otherwise, it continues fromthe previous catheter. so, i have two examples. patient has a foley, day three, day four. they took it out on day five. they put it back in on day six. and -- i'm sorry, they took it outon april 2nd, and they put it back in on april 3rd, this becomes day six. continues from day five for foley because therewas not a full calendar day without a foley as opposed to this example down here wherethey took the foley out on april 2nd.
there was no foley for the whole day onapril 3rd and they replaced it on april 4th, this becomes new foley day one, foley daytwo, and foley day three on april 6th. on this date they're eligible for another cauti. okay? again, somewhat arbitrarybut just trying to make a rule so that we all do it all the same. we just pretty much covered this; the dateof the event is the date of the last symptom. so if you have a temp on one day and aurine culture the next day, this is -- you've now met criteria,this is your date of event. so, quick examples of a device-associated.
patient has a foley inserted onday one, they're asymptomatic. the foley remains in place andthey spike a fever on day two. they still have a fever on day three and theyhave a positive urine culture on day four. that meets criteria, e. coli. because they didn't meet thecriteria in the first two days, even though they had a fever here, thisis a device-associated, this is a cauti. okay? they would have had to have their culturein the first two days for this to be a uti but not a catheter-associated uti. you're just going to ignore this feverthen and utilize day three or day four.
i'm sorry, i want to correct that. you can count the fever in here because what wetell you to do is to look at the date of event. so scratch what i just saidbecause i don't want to confuse you. it's easy to do. it's easy for me to get confused,so just look at your date of event. your date of event is day four here. it's the date of the last element, becausethat day is not in the first two days of the catheter, this is considereda catheter-associated uti. that's really the easiest way to do it, andit'll get you into the least amount of trouble.
and i can get in trouble sometimes,in case you hadn't guessed that. this is not a cauti. foley is inserted on day four. they have a temp of 100.6 the next day. they send the urine culture and it's positivefor 100,000, they meet the suti criteria on this date, day five, but the foleyhadn't been in place for greater than two calendar days onthe date of event here. it had only been in, it was on its second day. so this is not catheter-associated uti.
this is also not a catheter-associated uti. foley inserted on day four, removed. they're asymptomatic four days later, day eight. on day nine there's stillno foley, they have a fever. and on day 10 they have afever and they have candida. the date of event in this caseis day 10 and it was not the day of removal nor the next day, it was after that. so, it's not considered cauti. last example, i think.
patient comes into the icu,has a foley put in on day four, removed on day eight, reinserted on day nine. and on day 10 they meet criteria. this is one of those reinsertion ones. this is going to be considereda catheter-associated -- oh wait, this patient has a foley in placefor some part of each calendar day for greater than two days, and there was not a fullcalendar day without a foley in place. so this is a cauti. is that clear?
location of attribution for cautiis the same as it was for lcbi, it's the location where the patient wasassigned on the day of the uti event. and, again, the date of thelast element for the criteria, with the only exception being the transferrule which, i think, we've pretty much covered. if it occurs on the day of transferor discharge and the next day, it goes back to the attributing location. i'm just going to go over one examplehere that we get a lot of questions about and that's the small tie transfer rule. so in this case, patient isin the icu on day one of admit
and on day two they're also in the icu. on day three they start in the icu, thenthey go to five west, then they go to ccu. and the next day they havean hai, in this case a uti. this hai is going to be attributable to the icu since that was the firstlocation the day before the event. so this is, you know, your transfer rule timeperiod here, the day of transfer, the next day. and so this is the icu here. trying to expand that incubationperiod, you know, to the longest time we can in those two days.
okay. oh, this came through [inaudible]. i wanted -- this was supposed tocome through in two different pieces. so we send out an email to people that said,"it appears a user from your organization with user name xxx is in the process ofupdating their sdn digital certificate. cdc is in the process of reviewing their status and will notify the user via emailwhen the process is complete. at that time the user will be able to log in." so we get an email back from this personthat says, "i've already installed it on two computers a couple of weeks ago.
you better make sure it works rightbecause it is a hassle to get this done and i did it all myself and it worked fine. please do not screw it up." [ laughter ] apparently, she's workedwith us before [laughter]. aren't you glad those digitalcertificates are going away? has anyone here been sammified[assumed spelling]? okay. do you like it? >> yes.
>> all right, cool. sammified is a new system that youguys will all be moving over to. instead of digital certificates theygive you these cool little bingo cards that they'll have you put in codesfor and they're good forever. so, i like this. okay, now we're just going tovery, very quickly, like i said, i'm not going to spend alot of time on data entry. i do just want to highlight threefields here on this section. urinary catheter -- we're goingto ask you to identify whether
or not there is a urinary catheter in placegreater than two calendar days on date of event or if it had been removed but was inplace for greater than two calendar days. or neither. there was not urinary catheter in place onthe day of event or not in place greater than two days on the date of event. okay? this is going to drivethe system to identify this as either catheter-associatedor non-catheter associated. the location for device insertionis optional, if you want it. sometimes we get questions from facilities thatsay, "well, they put one in and they took it
out then they put another one in. and there are different unitswhat do we put in?" we say, "you can make your own determination,your own policy about what you want to do with that because we don'tutilize that field right now. so, you know, you get to make your decision. and the date of device-insertionis also optional at this point. i did get a question this week from somebody. it looks like on the form -- i don't seeit on here, maybe it's on the screen. it actually says urinary catheter at timeof specimen collection and that's an error.
we missed pulling that off when wechanged the definition, so this is correct and it's been there for a yearand a half and nobody noticed it until a user emailed me yesterday. so, just know that it's at the date of event, is what we're concerned aboutwith a catheter presence. not the date of specimen collection. okay, your summary data is collected pretty muchthe same way it's on the same forms as for lcbi. again, you're going to collect the numberof patients that are present at the time of the count, each day on the unit,and enter that in this field here.
and then the number of patients that have aurinary catheter that are there at that time on that unit and enter it here for eachday, and then you'll sum the numbers at the bottom at the end of the month. for nicu, i do want to point out that thereis no in-plan cauti surveillance for nicu's. we no longer allow that becausethey're just used so infrequently in that patient population thedata's not really that meaningful. but some facilities are optingto continue to do this off-plan. so if you're doing that,those will be entered here. urc days and you'll be stratifyingit by the different birth weights.
and again, birth weight, not weight at thattime, but the weight of the baby at birth. special care areas, there's no differencein how the data is collected here between a special care areaand an icu or a ward. unlike, you know, clabsi's you have permanentor temporary central lines for lcbi's, here it's just a urinary catheter and it'senter -- i do again, for all of these events or all of these location types you are goingto have to tell us if you've had no events for this month and that's where you'regoing to check it here -- cauti. if you don't check that and you don't enter anycauti events you'll get an alert and it'll say, you know, we don't know, doyou really not have any uti's
or have you just forgotten to enter them? you'll also get an alert if youdon't enter your patient days or your urinary catheter days for that month. and so, this is the example of the alert. in-plan denominators are reported forthese locations with no associated events. so in this case the icu, you entered summarydata, you told us how many patient days you had and how many urinary tract days youhad but you didn't enter any cauti's and you didn't tell us thatthere were no events. so you can -- handy-dandy little thing here.
you can just go down hereand check these if that's so. a smart person might wait and do that. probably not a good idea,but you could do that, so. again, if you want to collect your dataelectronically, we're happy to have you do that. we just ask that you concurrentlycollect your data manually. you go on the unit or have whoever doesit on the unit collect it manually, do the patient count and the catheter day count at the same time each day andcollect it electronically. also, compare those two for three months.
as long as there's no difference more than 5%in either direction, you can then do that for that location, just use your electronic methods. if there is a deviation of greater than5% than you got to start all over again and try to figure out where the problemis, get it right, until you, you know -- make changes until you are able toget an accurate count electronically and then you can move ahead with that. so, you need to do it in locationfor three months, minimum. just another sign. i do want to say that oncology hospitals have toreport separately for all locations and units.
anybody from an oncology hospital here? nobody. okay. and to remind you that you'recms reportable data has to be included in your monthly reporting plans. if you don't put it in your monthlyreporting plan it will not be sent to cms and you won't be happy, they won't be happy. here's your resources. this is the training site forurinary tract infection information. we have lectora, which is a self-pacedsoftware program and does have self-testing,
and there's questions in there andyou have to score greater than 80%. we do expect that people will do the trainingat least once before they utilize the system. and then we have -- these webinars will beon there as people have told you in april. i believe, i hope this one is down,i think it is because it's outdated. these are just the forms that you'll use toreport your data, and more resources for you. this is a summary online listing ofall the training that's available that would be pertinent toyou doing cauti training. okay, so another funny email. so we sent this out, you know, we sent-- this is what we call blast email,
to everybody that's a participant, you know. we said, "we will be restarting nhs applicationin a few minutes, please plan accordingly." you know, because if people havegot data on there we want them to save it so it doesn't get lost. and somebody reported back, "i haven't startedbaking yet, i don't know if i'll get to it." i'm not sure what that meant, but [laughter]. i don't know what she was referringto, like baking the data, you know, like she didn't get it in or if she was thoughtshe was talking to somebody else or what, but we weren't really sure how to respond, so.
okay, so we have finished about 15 minutesearly and i'm going to look to courtney to see before we get into the case studies. do you want to take a break now or doyou want me to start for 15 minutes. [ inaudible speaker ] what's that? i'm sorry? keep going? for 15 minutes? okay. we'll keep going for 15 minutes.
>> [inaudible] questions. >> i can, but i would rather wait becausewe might cover the question in the -- you're going to be extra special, you're the only person that'sgoing to get to ask a question. how do you like that? go ahead. go ahead [laughter]. page 23. okay. gap day. page 23, oh my page is different-- my page is different than your page. >> i'm trying to resolve your three-day foleyrule plus the gap day example of symptomatology.
so you said that you have tohave the foley in for three days by the last day of symptomatology. so in your gap day example you have atemperature on 4/7, like monday, whatever, and then you have a gap day, day two. and then you have a cultureon day three, wednesday. you're saying that if thefoley was inserted on monday? >> this one? >> this would count? >> no i didn't [laughter].
>> on the same day that theyhad the first element or some -- >> thank you, is it this one? >> okay, so -- >> so, if instead of thefoley being placed on 4/1 -- >> the foley was placed on 4/7. >> okay. >> because i'm trying to determine if thefoley has to be in place for three days on the first day of symptoms, or on thelast day, and you just said the last day. okay. so that means in this example,this foley can be placed on 4/7,
the day of the temperature,and then there's a gap day, and then the day of the urine is thethird day, that's three or more days. >> that is correct. >> so this would be counted as a cauti. foley placed on the day of thefirst symptom, that makes no sense. >> well, hopefully, if the patient hasthe fever they're going to be looking to find out why the patient has a fever. okay? >> correct, but they placed the foley on thesame day so it shouldn't be related to that.
>> and, clinically, i'm going to agree with you. and the hope is that most of the time if theyhave a fever they're probably going to try to figure out why they havethe fever and they're going to collect that culture sometime sooner. there will be rare instances -- we can sithere and try to come up with situations that don't work and thosesituations do happen rarely. >> this is not an uncommonsituation, where they place a foley because a patient is having problems. not having problems due tohaving the presence of a device.
>> it's a surveillance definitionand we made these rules because people asked forthem, users asked for them. because before we had no minimum time period. right? so, in that case itstill would've been a cauti. >> without the ability to have some clinicalcorrelation, we can't use these numbers to be able to drive performance improvement. i'll just -- >> i understand. okay, so let's -- we'll keep going.
no, i don't think so. well -- okay, let's start with our case study. oh. so actually we'll -- so before we startthe case studies i wanted to share something that on the web that highlights theimportance of making good methodology when performing hai surveillance. so, here we go. escape -- oops, that's right. that's not right, here.
here. okay. >> hi, i'm [inaudible] and myceo says i should talk to you because you're hospital has zero healthcare associated infections for three years. >> yes, as the infectionpreventionist i can say that's true. >> wow, that's amazing. i mean, i have my organization [inaudible]zero infections and we have had some ruts but we had a month here or there where wehave had none, but zero for three years. that's incredible. >> yes. we did it.
i have zero infections, for three years. >> how? i mean, don't you everhave bacterial trans-location where the patient has no infection but the pathogen escapes the gitract and appears in a blood culture? >> we have those cases but my iddoctor throws those out [laughter]. >> your id doctor? what is he doing surveillance for? >> he always does surveillance after ifind the cases that meet the definition. >> has he done any online trainingon how to use the definitions
or done any [inaudible] trainings on the nhsndefinition or gone to a [inaudible] training? >> no he is an id doctor. >> so, despite the fact that you havecases that meet the nhsn clabsi definition, you don't count them because your id physician,who has no training on epidemiologic definitions or nhsn training doesn'tthink they are nhsn cases? >> yes. he is an id doctor [laughter]. >> does he say they don't meetthe nhsn clabsi definition? >> he is an id doctor [laughter]. >> you already said they met thedefinition why even have them look at them?
>> we established that. have you been to trainingon the nhsn definition? >> yes, i have done many classes and do the[inaudible] training on the definitions. >> so, you are having someone who is incompetent at using the definition override yourjudgment as a trained epidemiologist. >> yes, and if i had a centralline infection i would want him to give advice on how to manage that infection. why does he even want tolook at the clabsi cases? >> he is very interested in clabsi.
as chair of the infectioncontrol committee he gets a bonus for lowering the hospital'sinfections [laughter]. >> don't you see that is a conflict of interest. why would you allow that surveillanceto potentially be compromised like that? >> he is an id doctor. >> let's talk about cauti. no cauti? >> we have zero hais. my id doctor reviews them.
>> is your id doctor's name dr. no? let's talk about ssis. no small bowel infections? no colon surgery infections? >> i have had no hais for three years. >> how do you do surveillance for ssis? >> i look at the microbiology resultsand if there are none they are cleared. >> what about radiology results? >> why would a surgeon culture a gut leak, theyuse the x-rays to find abscesses and then treat.
how about md notes, do youread them on the cases? >> doctors at my hospital write a lot. >> yes, how do you assure yourself theyaren't diagnosing a surgical site infection in their notes or describing a woundinfection if you don't read the notes? >> do you do a search for antibiotic therapypost- surgery or returns to the o.r.? >> i have no hais for three years. >> i will take that as a no. so you never had a failed anastomosisthat resulted in an infection? >> doesn't he know that the definitiondoes not exclude them from being cases?
>> yes, but he disagrees with the definition. >> i can disagree with gravity but itdoesn't mean that it no longer applies to me. i have had no hais for three years. >> liar. oh, i feel an hai coming on. >> i also have 100% hand hygiene compliance,do you want to know how [laughter]? all right [laughter]. so, i don't think i want to takecomments after that [laughter]. oh, the author's here? oh!
oh, bravo! bravo. who is the author? greg meyers [assumed spelling]. okay. nice job. so that was just a little light-hearted. i thought you guys would enjoy that. i enjoyed it. somebody sent it to me and, you know, i thinkit's really -- it does drive home, you know, that we all need to do what we're supposedto do and i understand that there are --
that the definitions are not perfect. believe me, we get emails all the timeand we understand it and we are -- i hope that you heard in the last two daysthat we do listen to you and that we are trying to improve them, you know, where we can. so, we can go ahead and start one casestudy and we're going to just look at these, we're not going to get intosurveillance versus clinical. we're just going to learn, make sure thatwe're accurately reporting the definitions or applying the definitions andwe'll try to optimize the consistency and that application and improve data quality.
so, as i said yesterday, when you're lookingthrough these case studies you might want to consider looking at them in this order. is it a poa? if it's a poa and they haven't beendischarged in the last two days you can stop, we don't need to have it reported atnhsn, we're only interested in hai's. is it an hai if it's not poa? if it's not an hai -- rememberwe talked about there's some that are not poa, that are not hai -- then stop. finally -- next you're going to askyourself is it catheter-associated uti.
and then you're going to need to look at whereto attribute it if it is a cauti so case one. mama unlucky is admitted unconsciousafter she fell when three deer ran out in front of her while skiing. she has a broken femur. a foley and a peripheral iv are inserted. on day three her foley is removed, she'sawake and making good recovery progress. on the fourth day she's up with assistancebut she complains of pain on voiding, has a ua collected and it hasslight leukocyte esterase, negative nitrites, and 15 wbc's on spun urine.
the next day they collect a urineculture which has 10 the fourth, or 10,000 cfu's per ml of e. coli. so, questions for you is does thispatient have a cauti and if so what type? choose yes, a suti one a. yes,a suti two a. yes, an abuti. or, no cauti at all. you can vote. a couple more seconds. okay, so let's see what you all say. oh, we have some difference of opinions here.
we have 50% say it's a cauti two a,and some people, 38% say no cauti. this is no cauti. okay, so criteria were not met in the poa timeperiod and the patient does not meet criteria for uti with dysuria and positive urine cultureand a ua -- i'm sorry that do meet that, but the date of event was laterthan the day after removal. right? so, the foley was removed on day three. the patient didn't meet criteriathe date of event, until day five. okay? so, it's a uti but it'snot a catheter-associated uti.
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