2019 NHSN Training – Pneumonia Events


>>Okay, so we’re
tailing pneumonia on after secondary
BSI presentations. In the past we’ve
always talked about this in conjunction with VAE. But this year we’ve
pulled it out to talk about it specifically, and
we decided the nice to place to slide this in is with following secondary
BSI attribution period. So it is the most common, at least from our
perspective what we see use of the pneumonia definition as. Dr. Cardo and Dr. Pollock mentioned pneumonia is an HAI that occurs
quite frequently, and we do see that in our EIP prevalence
studies. So when you’re doing a
CLABSI surveillance you quite often are probably looking
to see if you can attribute that BSI to a pneumonia. So with that let’s
get going here. So what we’re going to do
today is just do a quick review of what is available as a
lower respiratory tract event. I’m going to cover some
pearls of wisdom if you will. We’ll review imaging
test evidence because that’s the tricky part
of the pneumonia definition. And then as I said we’ll circle
around and talk about pneumonia as it is used for a
secondary BSI assignment. And then at the tail end
we have a couple updates to the protocol in 2019. So we have four lower
respiratory tract events within the NHSN patient
safety manual, pneumonia, LRI, lower respiratory infection and lung is the specific
infection, VAE and PedVAE. So before we go on I just want
to remind you what in-plan and off-plan refers to
which I’m sure you all know, but let’s just make sure
we’re all on the same page. In-plan surveillance
is indicating that you have selected
that particular event in your monthly reporting plan
for the specific location. And you by doing so are
swearing, cross your heart and hope to die that you’re
going to follow the protocol in its entirety, and you’re
not going to make any mistakes or misidentifications
when you’re doing that particular surveillance. Just kidding. Not kidding about
following the protocol, just the cross heart part. The facility for off-plan
surveillance you can do any of those infections that
are in our protocol off-plan by not selecting them in
your monthly reporting plan. Maybe it’s a state requirement. Maybe it’s your facility
just wants you to follow certain events so
that would be your off-plan. So I talk about that
because as we go through and I discuss these lower
respiratory tract events that we have I’m going to point
out which you can do in-plan and off-plan and where. So with pneumonia the only
location where you are able to do in-plan pneumonia
surveillance is in a pediatric location, and
that is on ventilated patients. And we refer to that as PedVAP. It is still an event
that’s available like Latasha reminded
you just like UTI, just like all the events
that are in Chapter 17 for secondary BSI assignment or
for just off-plan surveillance in any location,
any age patient, whether the patient is
ventilated or not ventilated. For LRI/lung it’s
very similar to that. You can use LRI/lung as a site
for secondary BSI assignment. Or if your facility or
your state requires you or another reporting
entity requires you to do lung surveillance
you can certainly do that. It’s just that you
cannot select that event in your monthly reporting plan. You can do the surveillance,
you can report it into NHSN. We will just not be using
that reported information when we aggregate the data
and provide benchmarking. And, of course, it’s
not sent off to CMS. Now VAE that is available for only ventilated
patients in adult locations. And that’s the only place
that you can select the event as an in-plan event in your
monthly reporting plan. With VAE you do have the ability
to attribute a BSI as secondary. But you must progress
to the third tier of the VAE algorithm PVAP. PedVAE, a new event
this year, is available for ventilated patients in
pediatric and NICU locations. Now, this is a single tier, and
we’re going to talk about both of these events later. We’ll have separate
presentations. But I just want to cover
them as they relate to secondary BSI assignment. For PedVAE you cannot
attribute a BSI as secondary to a PedVAE event. Okay, now if you didn’t capture
all that or if I confused you, you can go to the
pneumonia FAQ location on the pneumonia website, there
is a specific FAQ that deals with what events are available for lower respiratory
tract infections and when they can be used, when
they can’t be used, in-plan, off-plan, secondary BSI. And there’s also a very similar,
in fact it’s probably word for word the same, FAQ on the
VAE and the PedVAE web pages. As far as using pneumonia
as a secondary site, ability to attribute a
secondary BSI, we have reminders in both the BSI protocol
and the pneumonia protocol to keep you clued in that
you can still use pneumonia. It’s not available for in-plan
reporting in adult locations and in NICU locations. But you can still use this event
as a way to attribute to look to see if the BSI is secondary. Okay, with that being
said we have a question. Get your phones and computers,
however you’re participating. When can you use the
pneumonia definition? Never. Always use VAE
for adults and PedVAE for children and neonates. When conducting in-plan
surveillance on mechanically ventilated
children who are in a pediatric location. When opting to conduct off-plan
surveillance in ventilated or non- ventilated
patients in any location. When determining if
a BSI is secondary to a lower respiratory site. Or B, C and D. You get a little more time here. All right, we’ll cut
this right off right now. That will give you
a little more time. The web streaming individuals
there’s a little bit of delay so we want to make sure we give
them a little bit adequate time to provide a response. And I can’t control
my mouse here. So where is the mouse? All right, and the
answer is E, very good. Now we’re going to go on
a little bit more just to make sure that you
remember that by the end. So if you’re going to
use pneumonia for all of those different purposes
where do you find it? Well, it’s not found
in Chapter 17. It’s found on the acute care, the long-term acute
care inpatient rehab and the inpatient site
facility pages as shown here. You can click on that, it
will take you to a location that looks like this regardless
of what the facility type is. We have the protocol
section, click on that, click on the link, and wallah, you’re into the pneumonia
protocol. Within the pneumonia protocol
pneumonia is the major type of infection, and there
are three algorithms within the pneumonia
protocol, PNU1, PNU2 and PNU3. PNU1 has three different
algorithms, one for any patient, one that is specific for infant
less than or equal to one year of age, and one that is
specific for children greater than one year and
up to less than or equal to 12 years of age. Any patient can — you can use that any patient pneumonia
1 algorithm for any patient. So you aren’t just
limited to the infant and the child algorithm
for those age categories. Now, the PNU2 algorithm there
are two of those as well. One that is specific
for common bacterial or filamentous fungal pathogens. And then another that
covers viral, legionella and bacterial pneumonias that have very specific
laboratory findings. And then the third
specific type infection in the pneumonia
protocol is PNU3. This is limited only to patient
who are immunocompromised. And that immunocompromised
status is determined by the definition
provided in the protocol. So when you’re meeting
PNU1, PNU2 and PNU3, regardless of which
algorithm you’re following, you have to make sure you have
the imaging requirement met, and that’s a good
place to start. If you don’t have imaging
don’t even carry on to see if you have symptoms
or laboratory findings. If you can’t meet the imaging
requirement unfortunately you’re done. You can’t use pneumonia. You must meet the signs and
symptoms and requirements that are outlined in PNU1, 2 and
3, and they do change depending on which algorithm
you’re looking at. And this is a very important
part, and I will stress this as we continue on today, you need to meet the
footnote requirements. So I’ll point some
of those out to you. And then when you’re
meeting PNU2 and PNU3 this is where you’ll find the use of a
laboratory, a culture result, a non- culture based
testing result that you can use
identification of a pathogen to help you meet the
pneumonia definition. So some pearls of wisdom. And these little pearls happen
to be found in the protocol. So when we’re done today if I
have confused you or if you want to read a little bit
more about the pearls, rush back to your hotel and
whip out your protocol. So as I alluded to earlier, although the specific criteria
are included for infants and children and for the
immunocompromised populations, any patient can meet the
other pneumonia criteria. So an immunocompromised
patient is not just limited to meeting PNU3. They can meet PNU1,
they can meet PNU2. Same with a child
who is an infant. You can still use
PNU1 for any patient, and you can use PNU2 or PNU3. There is a hierarchy if you
are reporting into an NHSN where you report as the highest
level met or the highest number. It’s not necessarily that
one is worse than the other. It’s just if you meet PNU1 and
PNU2 report it as it as a 2. If you meet PNU1, PNU2, PNU3
report it as a PNU3 and so on. Pearls of wisdom
number two, pathogens and secondary bloodstream
infections can only be reported for PNU2 and PNU3. You cannot report a bloodstream
infection as secondary to PNU1. There is not, one, a site
specific specimen included in meeting PNU1 algorithm
or, two, there is not a blood specimen. So since Latasha spent a
wonderful time with you talking about how you meet a secondary
BSI without that site specific or without a blood
culture you’re unable to attribute a BSI as secondary. And, in fact, if you
enter a pneumonia into the NHSN algorithm, the secondary BSI assignment
field defaults to no and you can’t change it. So here’s our pearl
of wisdom three, don’t forget the footnotes. There’s a lot of really
important information, those little numbers
that are highlighted here on the screen give lots
of very pertinent very important information. And if you don’t take the time
to read those you may be, one, either missing meeting
a definition or, two, meeting a definition in error. So these footnotes follow the
algorithms in the protocol. Okay, now this is our little
quickie knowledge check. I did note in your
reference manual if you look at day five there the
PNU algorithms are in there and the footnotes. So if you want to work through
this particular knowledge check you can refer to
those algorithms. We have the checklist actually
in your reference book. So we have a definitive
imaging test evidence, so just take my word for
it the imaging is met, the patient has a fever of 38.9. There is documentation
of new onset cough, rales and the Pseudomonas
aeruginosa has been identified in an expectorated
sputum specimen. All of the above have a
date associated with them such that they’re all falling within a seven day
infection window period. What is identified? PNU1, PNU2, nothing,
I don’t know. And I’ll hope that I don’t
see any I don’t know answers. Don’t succumb to peer pressure. Don’t make your answer and then
change it and go back and forth. What is the trick to get
this mouse over here? All right, I’m just going
to hold it right there. Okay, all right. All right, that’s
not what I wanted. There we go. Okay, the answer is PNU1. Why is that? Because sputum is not a
minimally contaminated specimen. You cannot use that
to meet PNU2, and guess where you
would find that out? In the footnotes. We have a footnote number nine
which tells you that sputum if it’s an expectorated sputum
or it’s a tracheal secretions, it’s not being collected
from a protected airway, an ET or a tracheostomy that
the specimen is not eligible. So you cannot meet PNU2
with that sputum specimen. What if we changed
the specimen to a BAL? Same scenario, same
symptoms, same organism. It’s just that now you have
Pseudomonas coming from a BAL. Can PNU2 be met in
this scenario? [ Inaudible Background
Conversation ] Okay, sorry. I think I liked it better with the results hidden then we
don’t have peer pressure getting you to change the answer. Okay, so the answer is maybe. You do have an eligible
specimen, it’s a BAL. But you need to know
the quantity. We don’t have the quantity
of the Pseudomonas. And, again, guess
where you find this? In the footnotes. You have to check for
table 5, you need to know if you have an acceptable
quantity that can be used to meet PNU2 even
with the BAL specimen. And if your laboratory
doesn’t happen to report out these specimen types
using colony counts, you’ll see the little
note below. And this is actually the same
little transition or comparison in BAE. If the specimen is reported
with a semi- quantitative result of moderate, heavy growth, many,
two plus, three plus, four plus, depending on how
your lab quantitates, that will make the
specimen eligible for use. Okay. All right, now let’s
talk about the favorite part of pneumonia, imaging
test evidence or not the favorite
part of pneumonia. It is challenging. It’s what makes this
definition difficult. It’s what made this
definition be removed from use in the NICU location
back in 2014. The findings must be
new and persistent or progressive and persistent. So unlike our other definitions where we have imaging test
evidence used, you don’t have that persistent requirement. But you do when you’re
conducting pneumonia surveillance. Simply finding the words that
are listed in the protocol, infiltrate, consolidation,
opacity, air space disease is not enough. So you can’t just do a word
search and find a report, radiology report that
notates one of these. You need to make sure
that it’s persistent, you need to make sure that
the notation is saying that it is representative
of pneumonia. And, again, as I said unlike
the other definitions you have to have persistence. And you can only use definitive
or equivocal findings. And for purposes of pneumonia
surveillance atelectasis is not evidence of pneumonia for use in meeting imaging the
requirement for pneumonia. So let’s talk a little
bit about this. So we need evidence that’s
suggestive of pneumonia. You need new or worsening
finding of infiltrate, consolidation, cavitation,
pneumatoceles if the patient is less than
or equal to one year of age, or other descriptive words
that we consider to be useful. For example, opacity, air
space disease, density. And in the report they
cannot be attributed to something other
than pneumonia. That’s a catching point. And then if you have more
than one imaging test, and in some cases you’re
required to have more than one imaging test with
the evidence of pneumonia, there has to be evidence
of persistence. There can’t be rapid resolution. A pneumonia does not
resolve rapidly on imaging. Whatever was reported
with using one of those little key words was
probably not representative of pneumonia. And you can’t have a subsequent
finding which now is saying, oh, the opacity is probably
related to pulmonary edema. Or there was a report
of opacity, no qualifier of what it was representing, but now two days later
they’re saying, yeah, we’re still seeing this opacity,
this is likely pulmonary edema. It’s no longer eligible for use for meeting the imaging
test evidence for pneumonia. What if the findings
are equivocal? So when we say equivocal it’s
not positive, it’s not negative, it may be this, it may
be that, it may be iffy. For example, infiltrate
versus atelectasis. Opacity may be pneumonia or it
may be congestive heart failure. I mean you can’t
fault the radiologist. They don’t have the
patient next to them when they’re writing the report. They’re giving the report as what they think it
could or couldn’t be. And it’s up to the clinician
who is dealing with the patient to correlate that result. So for you you’re looking
in the medical record, you find this kind of a report,
we would call that equivocal. You’re going to look for
further imaging, test evidence that clarifies the
equivocal finding. You’re going to verify that
the finding is suggestive of pneumonia and that there is
persistence, and that will make that equivocal finding
available for use. Or if it verifies that the
finding is not suggestive of pneumonia then you’re done. You don’t have imaging
test evidence of pneumonia. What happens if it just
continues to be equivocal? Well, in that case in the
absence of verification of whether you can use
it of you can’t use it, then and only then will you
use clinical correlation. And that would be
the physician saying, all right, it’s clear as mud. We don’t know if it is or isn’t,
but my interpretation based on this patient’s clinical
presentation is this is evidence of pneumonia. He doesn’t have to
say this is evidence of pneumonia by the way. He is saying I’m treating
this patient for pneumonia, and there’s antibiotics
specifically designated for pneumonia. Then you can use that. That’s the only time you
can use physician diagnosis and treatment for pneumonia. Because diagnosis and
treatment is not an element of the pneumonia definition. You’re using it to support
an equivocal finding. Okay, knowledge check
number four. The imaging requirement
for pneumonia is met with the following
imaging test results. On the 16th, and this by the way
came directly from a question from a user, the 16th airspace
opacity overlying the heart, more likely to be
atelectasis than pneumonia; 17th another imaging test
persistent dense left lower lobe atelectasis and/or
infiltrate and small effusion; the 18th improving left lung
base opacity and left effusion; and then on the 19th lower
lobe opacities have improved, no infiltrates. What do you think? Is there imaging test
evidence to meet pneumonia? So the answer is it is false. That first imaging
test was equivocal. The second one was equivocal. By the third day the
results of improving opacity. And, in fact, that’s the only
thing we had that is a key word that you’d even be
able to pull out. You’ve already got
some improvement. And then on the fourth day
they’re saying they improved, and now they’re specifically
saying there’s no infiltrate. So this would not be imaging
test evidence that could be used to meet the pneumonia
definition. And guess what? You’ve got some helpful
hints in the footnotes, 1, 2 and 14 to help
you make decisions on meeting the imaging
test evidence. Okay, let’s talk a little bit
about pathogen exclusions. For pneumonia all
Candida species or yeast not otherwise
identified or specified, all coagulase negative
staph species, and all Enterococcus
species are excluded for use unless they
have been identified in a lung tissue
or a pleural fluid. Those are two specimens
that should be sterile. So if you identify anything
out of there we’re not going to preclude you from using it to meet the surveillance
definition. We do have an exception,
every rule has an exception, and NHSN likes exceptions. You all like our
exceptions sometimes, too, sometimes you don’t. But the exception for Candida is
that if the patient is eligible to meet PNU3 and this requires that they meet the
immunocompromised definition in the pneumonia protocol,
then if they have Candida in their blood and in
a respiratory specimen, and this is the only time you
can use an expectorated sputum by the way, and the collection
date for those two, the blood and the respiratory
specimen are in the same IWP, then Candida can be used. But that’s the only time. There’s a lot of if
this, if this, if this. So it’s not easy to use Candida. And you find this information
highlighted in the footnotes. Here’s where you find the
immunocompromised definition for use when we’re doing
surveillance for pneumonia. And the footnote tells
you that the blood and the site specific
specimen have to have the same
collection date, a collection date
within the IWP. Okay, now we’re going to get
to the meat of the matter here of why we are following
secondary BSI presentation and the CLABSI presentation this morning. So pneumonia can be used for
a secondary BSI assignment. And to do that you have to
meet the pneumonia definition, and then first you have to
meet the secondary BSI either scenario 1 or scenario 2. You’ll see we’re going to run through scenario 1
meeting pneumonia, and our little table B1 in
the BSI protocol you’ll see that pneumonia is listed there. You can use it for scenario 1. You have to have at least one
organism in the blood specimen that matches an organism
identified from a site-specific specimen,
so one of our eligible specimens for use in meeting
pneumonia, and there has to be at least one matching pathogen. So our eligible specimens are
the minimally contaminated specimen, pleural
fluid, lung tissue. And sputum that is expectorated
again is not a minimally contaminated specimen. The organism that you’re
using must be eligible, and the eligible specimen
must have a collection day in the seven day IWP. And then that requires that the
blood culture has a collection date in the SBAP for
the pneumonia event. So here’s some examples of where in the pneumonia 2
protocol you’ll see some of those eligible specimens
that you can use to meet. And now we’re going to run
through a couple examples. This is, again, assume
that the imaging is met when I say imaging
test infiltrate. We’re not going to
get into that part. We’re going to focus on
secondary BSI assignment now. So here we have the
pneumonia 2 definition met with a BAL specimen with
an eligible quantity in the secondary BSI attribution
period for that pneumonia event. We have a blood culture
with a matching pathogen to the site specific specimen. So the blood can be secondary
to the pneumonia event. Here we have the same scenario
only this time the BAL has Acinetobacter baumanii
and staph aureus. And then we have a blood culture with the collection
date and the SBAP. The blood can be
secondary to the PNU2 event. Here we have the same scenario, many Acinetobacter
baumanii, PNU2 is met. We have a blood culture
with staph aureus. What do you think is
going to happen here? Secondary or not? [Inaudible Audience Response]. Good. It’s not a match
so it’s not a match to the site specific specimen
with the pathogen in the blood. So the blood in this case
could not be secondary. You would just be reporting the
pathogen Acinetobacter baumanii. You’d take that blood culture,
you’d continue on your merry way to see if you can find
another site-specific specimen that you can attribute
it to as secondary. And if not then you
have a primary BSI. And if it’s a primary BSI and it’s central line associated
you have a CLABSI that you need to report. So with our excluded pathogens
Candida species and yeast, coagulase negative
staph, enterococcus. They’re excluded as secondary
BSI assignment as well. So here we have the
same scenario. We’re meeting with many
Acinetobacter baumanii and we have a blood culture that is Acinetobacter
baumanii and VRE. The VRE is excluded. You will have a blood
secondary to this event. But you have to continue
to investigate that blood culture
specifically for the VRE. Again, find out if it’s able
to be attributed secondary to another site specific
infection. And if not then you
have a primary BSI. Okay. All right, then the
final is just an example of when you can attribute one
of the excluded pathogens. Here we’re meeting PNU2 with
lung, and that is eligible to be used because
it’s a lung tissue. If you have blood in the
SBAP following meeting a PNU2 with a lung tissue, a VRE or any of the other excluded
organisms you are able to call in that case the VRE BSI
secondary to pneumonia. Okay, now let’s go
to scenario 2. We do have the ability
to use blood as element when we’re meeting pneumonia
2 and 3, so let’s run through a couple
scenarios there. Blood collection must be — when
you’re using it as an element, of course, it has to be in the seven day
infection window period. And you’re still going to be applying your
pathogen exclusions. So here’s where we use
blood as an element when we’re meeting PNU2,
and here is the scenario where you can use
blood as an element when you’re meeting PNU3. And incidentally when you’re
meeting PNU3 you can also scoot back to any of the PNU2
laboratory requirements to meet PNU3. It’s just that you’re
meeting PNU3 — you’re calling it PNU3
because the patient is immunocompromised. So here we have blood
used as an element. Again, the old Acinetobacter
baumanii. I happen to like that
organism, I don’t know why. And it is used as an element. So pneumonia 2 is met
and the BSI is secondary to the pneumonia event. Here we have blood with
Enterococcus faecalis . We know that Enterococcus is an
excluded pathogen unless it’s isolated from lung
tissue or pleural fluid. So in this scenario
PNU2 cannot be met. And if you don’t
have another sign or symptom that’s eligible
you also can’t meet PNU1. Okay, here we have
Candida in the blood. In this particular instance
the patient does meet the immunocompromised definition. You have Candida in the blood. You have a sputum. Again, this is one of the
only times you can use that expectorated sputum. With Candida matching the
blood, Candida albicans, they both are in
the seven day IWP. The patient is
immunocompromised. So the Candida can be
attributed as a secondary BSI to the pneumonia event. Okay, now let’s just take
a trip back to yesterday when Kathy covered Chapter 2. And let’s look at the
specific box outlined here. You can meet another
definition in the RIT, and you can attribute pathogens. So this can be an, and
Latasha actually covered this, this can be another way that you
can attribute a BSI as secondary if you can meet the event
using the blood in the RIT. So if you meet PNU1, and I have
a blood that’s trailing in, and you know this is secondary
to the pneumonia event, but it’s not — I didn’t
have the collection date when I met PNU1. If you meet PNU1, and
then within that RIT of the pneumonia event
you have a blood culture, if you can find all
of the elements to meet PNU2 again using
that blood as a specimen, the blood can be
attributed as secondary to the pneumonia event. So you just have a PNU1 that you
now can meet another criterion of the pneumonia definition
so the PNU2 can be secondary. So let’s go back to that
example in our scenario 1 where I said, yup,
can’t meet this. Well, guess what, this is
the example where you can. So here you have a PNU2, and now
you can meet PNU2 again using the blood as the element. Now the blood didn’t match
the site specific specimen, but if you can meet
PNU2 using the blood as an element you can indeed
call the blood secondary to the pneumonia event. And that’s all for
the secondary BSI. The only thing — and
we’re going to do it, we’re going to get you
out of here right at noon. The only thing that I want to
point out to you in closing is that in 2019 we had two
protocol clarifications. These were really
just to help you out. Again, pointing out that
pneumonia is available for secondary BSI assignment. And then the second update
was we just reorganized some of the information as it
pertained to the information and added in a couple little
notes that would help you when you’re trying to determine if your imaging test
evidence is met. And with that I’ll hang out down
here if you have any questions with regard to pneumonia.

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