美国导管相关尿路感染(CAUTIS)的预防指南2009-翻译

呼吸机相关性肺炎(ventilator-associated pneumonia，V AP).概念：是指无肺部感染的患者，在气管插管或气管切开行机械通气治疗48 h后所并发的肺部感染。

接受机械通气患者最常见的医院内感染。

国外报道V AP发病率为9%～70%，病死率可高达50%～69%。

国内据文献报道，V AP发生率在18%～60%，病死率高达30%～50%。

V AP集束化管理：也称V AP bundles，采用各种被循证医学证明行之有效的措施对V AP进行诊断、治疗和预防。

呼吸机相关性肺炎的集束化护理一、严格执行手卫生措施二、加强口咽护理，每日至少2次洗必泰口腔护理。

三、重视气道湿化，采用人工鼻、加温湿化器等方式四、定时监测气囊压五、声门下分泌物引流，指南意见：建议临床医师应考虑进行声门下分泌物引流。

六、呼吸机管路的管理，.根据1项2级临床试验，得出的结论是：呼吸机通气管道的更换频率不影响V AP的发生率。

较少更换呼吸机通气管道并不与害处相关，而较多更换呼吸机通气管道与费用增加相关。

.指南意见：建议每例病人都使用新的通气管道；如果管道被污染，则也要进行更换；但不要定期更换通气管道。

七、维持30-45°半坐卧位，定时翻身.研究目的：确定机械通气病人半卧位的可行性以及预防V AP效果的实验研究，研究认为平卧位胃肠营养病人较半卧位病人胃液反流增加．取半卧位可将胃内容物误吸降到最低程度，半卧位能减少V AP的发生。

八、正确有效的吸痰2010年AARC临床实践指南（机械通气患者气道吸痰）1.气管内吸痰仅仅是在病患有痰的时候，而不是常规性的。

也就是说病患有需要吸痰的指征时才吸痰(It is recommended that endotrachealsuctioning should be performed only when secretions are present andnot routinely) ；2.如果病患在吸痰时，临床上有明显的血氧饱和度下降的问题，建议吸痰前提高氧浓度(It is suggested that pre-oxygenation be considered ifthe patient has a clinically important reduction in oxygen saturationwith suctioning）；建议在吸痰前的30-60秒，向儿童和成人提供100%的氧；向婴儿提供基础氧浓度的10%（10% increase of baseline in neonates)；3.建议在给呼吸机上的病患吸痰时不要让病患与呼吸机分离（Performingsuctioning without disconnecting the patient from the ventilator issuggested)；4.基于对婴儿和儿童所做的研究证据，建议使用浅吸痰而不是深吸痰。

集束化护理策略对预防留置尿管患者相关性尿路感染的探讨目的研究集束化护理策略在预防患者留置尿管期间相关性尿路感染（CAUTI）中的效果，探讨预防CAUTI的有效护理方法。

方法选取2012～2013年住院患者留置尿管7d以上患者95例作为实验组，采取集束化护理策略。

另外选取2010～2011年住院患者留置尿管7d以上患者95例，作为对照组，采用常规护理措施。

对比两组CAUTI的感染率。

结果实验组CAUTI的感染率明显低于对照组。

结论集束化护理策略能降低患者留置尿管期间CAUTI的感染发生率，减轻患者的痛苦，节省了住院费用，提高了护理质量。

标签：集束化护理；尿路感染；留置尿管感染尿路感染占院内感染的35%～45%，仅次于呼吸道感染，80%与留置尿管相关，尤其长期留置尿管者，每留置1d，感染发生率就会提高7%，分析其原因与下列因素相关：①导尿操作本身是直接原因；②尿管留置是其危险因素；③集尿系统因素；④抗菌药物的不合理应用；⑤膀胱冲洗；⑥其他因素例如女性患者、免疫力低下的患者等。

1 资料与方法1.1一般资料将2010年～2011年收治留置导尿管的患者95例，平均年龄44岁，且平均留置尿管时间在7d以上，作为对照组，采用传统的常规护理措施。

另将2012年～2013年2年间收治留置导尿管的患者95例，平均年龄46岁，且平均留置尿管时间在7d以上，作为实验组，采用集束化护理策略，对CAUTI 的发生率进行对比。

1.2方法对照组采用传统的常规护理措施包括膀胱冲洗2次/d、会阴护理2次/d，更换集尿袋（普通）2次/w，妥善固定导尿管低于膀胱水平。

留取尿标本时将导尿管与引流间分开留取。

留置尿管时限遵医嘱。

而对照组则采用集束化护理策略，措施如下：①避免不必要的留置尿管，诱导无效情况下采用留置导尿管，操作前认真评估患者，选择合适种类和型号的导尿管，操作过程严格无菌操作，注意手卫生，正确消毒，动作轻柔，避免损伤粘膜；②采用密闭式防逆流引流袋，妥善固定，更换1次/w，更换时注意接头处严格消毒两遍；③不常规采用膀胱冲洗方法预防感染（有絮状物或血块者除外）；④会阴护理2次/d；⑤妥善固定导尿管，低于膀胱水平，并增加在同侧大腿内侧采用胶布固定导尿管，防止尿管牵拉和气囊滑脱，避免机械性损伤的发生；⑥留取尿标本时采用碘伏消毒导尿管分叉处，再用5ml注射器抽取尿液，留取标本，避免人为破坏其密闭性；⑦每日评估留置尿管的必要性，尽早拔除导尿管；⑧拔除导尿管时抽净气囊内的液体后，再向内注射0.4ml空气，防止气囊皱褶损伤尿道粘膜，再拔除导尿管，消除机械损伤的风险，减轻患者的痛苦，大大地降低了再次插管的机率。

留置导尿管高举平台法固定对减少外科重症患者尿路感染的临床研究卢婕楠;沈鸣雁;卢芳燕【摘要】目的观察留置导尿管高举平台法固定对减少外科重症患者导尿管相关尿路感染的效果.方法对符合研究条件的161例外科重症患者随机分为观察组(81例)和对照组(80例).观察组用3M透气胶带以高举平台法将导尿管固定在大腿内(前)侧上1/3,对照组留置导尿管不予体表固定.结果观察组和对照组导尿管相关尿路感染发生率分别为7.41％和18.75％,差异有统计学意义(P＜0.05).观察组患者每天的舒适度评分均较对照组低.结论留置导尿管高举平台法固定有利于降低外科重症患者导尿管相关尿路感染的发生率,并能促进患者舒适.【期刊名称】《护理与康复》【年(卷),期】2016(015)005【总页数】3页(P451-453)【关键词】留置导尿;导尿管;体表固定;高举平台法;尿路感染【作者】卢婕楠;沈鸣雁;卢芳燕【作者单位】浙江大学医学院附属第二医院,浙江杭州 310009;浙江大学医学院附属第二医院,浙江杭州 310009;浙江大学医学院附属第二医院,浙江杭州 310009【正文语种】中文【中图分类】R472.9+2留置导尿技术在外科重症患者治疗中，主要用于解除排尿困难、精确记录尿量、评估腹腔内压力等，由此引起的导尿管相关尿路感染(catheter associated urinary tract infection，CAUTI)是最常见的医院获得性感染之一 [1]。

外科重症患者发生CAUTI，住院时间平均延长6 d，住院费用增加7 000～30 000元人民币[2]。

如何减少该类人群CAUTI的发生率一直是临床工作者研究的方向。

本院外科根据《2009年美国感染病学会预防导管相关性尿路感染指南》[3]“留置导尿后要加以体表固定以预防滑动和对尿道的牵拉”的建议，对81例外科重症患者用3M透气胶带以高举平台法[4]将导尿管固定在大腿内(前)侧上1/3，进行随机对照试验研究，探讨该体表固定方法对降低外科重症患者尿路感染发生率的影响。

导管相关性感染的危险因素和预防控制王彩（成都市第二人民医院，四川成都 610017）随着医疗技术的不断发展，置管技术已经是临床医疗工作中不可缺少的，但随之伴发的导管相关性感染的发生率也越来越多，如今已成为最常见的院内获得性感染途径之一，美国National Healthcare Safety Network(NHSN)监测数据显示其以呼吸道感染占第1位[1]。

林金丝等[2]的调查资料中则以血流感染(31．7% )居高，其次是泌尿道感染(25．9 %)、呼吸道感染(22．9% )。

采取医院感染预防干预措施能明显降低感染率。

1.危险因素1.1 导管相关性血流感染（CRBSI）：①导管类型：导管越粗、越硬、越复杂越容易发生感染。

薛华春等[3]研究发现，单腔导管感染率为1.1% ，双腔导管感染率高达2.9% 。

双腔导管与单腔相比，管腔增多，操作增多，感染机会也增多。

多腔导管发生CRBSI的危险性较单腔导管明显增加，可能的原因是导管的每一个腔都是CRBSI发生的来源，多一个腔就相对增加了感染的机会[4]。

②置管部位：中心静脉置管的感染发生率与导管留置部位有着明显的关系。

经外周静脉置入中心静脉导管感染率最低。

股静脉置管感染率最高[5]。

导管接头被认为是污染导管内面的起始部位[6]。

③导管留置时间：导管留置时间是影响CRBSI发生的主要危险因素之一，随着静脉导管留置时间延长，皮肤细菌沿静脉导管侵入血流的概率大大增加[7]。

导管相关性血流感染率与长期置管而致管腔内细菌定植有关。

④医护人员的操作技能：目前认为操作人员和患者皮肤上的表皮葡萄球菌是最主要的病原菌来源。

医护人员不执行严格无菌制度、技术不熟练、对导管的频繁操作、导管留置期间的护理不当等都可增加发生CRBSI的风险。

⑤病人的基础疾病：伴有严重的基础疾病及免疫力低下的危重病人，感染的发生率高。

⑥年龄：高龄病人(>80岁)体质弱、抗感染能力差；年龄较小者(14岁～2O岁)血管管腔相对较成人小，而导管粗细未变，导管对血管内膜刺激性较大，发生静脉炎的几率较成人高[8]。

Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) EventsIntroduction: Urinary tract infections (UTIs) are the fourth most common type of healthcare-associated infection, with an estimated 93,300 UTIs in acute care hospitals in 2011and account for more than 12% of infections reported by acute care hospitals1. Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract.CAUTI can lead to such complications as prostatitis, epididymitis, and orchitis in males, and cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis in all patients. Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality2. It has been estimated that each year, more than 13,000 deaths are associated with UTIs.3Prevention of CAUTI is discussed in the CDC/HICPAC document, Guideline for Prevention of Catheter-associated Urinary Tract Infection4.Settings: Surveillance may occur in any inpatient location(s) where denominator data can be collected, such as critical intensive care units (ICU), specialty care areas (SCA), step- down units, wards, inpatient rehabilitation locations, and long term acute care locations. Neonatal ICUs may participate, but only off plan (not as a part of their monthly reporting plan). A complete listing of inpatient locations and instructions for mapping can be found in the CDC Locations and Descriptions chapter.Note: Surveillance for CAUTIs after the patient is discharged from the facility is not required. However, if discovered, any CAUTIs with a date of event on the day of discharge or the next day is attributable to the discharging location and should be included in any CAUTIs reported to NHSN for that location (see Transfer Rule). No additional indwelling catheter days are reported.Definitions:Present on Admission (POA): Infections that are POA, as defined in Chapter 2, are not considered HAIs and therefore are never reported to NHSN.Healthcare-associated infections (HAI): All NHSN site specific infections must first meet the HAI definition as defined in Chapter 2 before a site specific infection (e.g., CAUTI) can be reported to NHSN.Urinary tract infections (UTI) are defined using Symptomatic Urinary Tract Infection (SUTI) criteria, Asymptomatic Bacteremic UTI (ABUTI), or Urinary System Infection (USI) criteria (See Table 1 and Figure 3).Date of event (DOE): For a UTI, the date of event is the date when the first element used to meet the UTI infection criterion occurred for the first time within the 7-day Infection Window Period. See definition of Infection Window Period in Chapter 2.Synonyms: infection date, event date.Indwelling catheter: A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a drainage bag (including leg bags). These devices are also called Foley catheters. Condom or straight in-and-out catheters are not included nor are nephrostomy tubes, ileoconduits, or suprapubic catheters unless a Foley catheter is also present. Indwelling urethral catheters that are used for intermittent or continuous irrigation are included in CAUTI surveillance.Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement beingDay 1,ANDan indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated.Example of Associating Catheter Use to UTI:A patient in an inpatient unit has a Foley catheter inserted and the following day is the date of event for a UTI. Because the catheter has not been in place >2 calendar days on the date of event, this is not a CAUTI. However, depending on the date of admission, this may be a healthcare-associated UTI.Notes:•SUTI 1b and USI cannot be catheter-associated.•Indwelling urinary catheters that are removed and reinserted: If, after indwelling urinary catheter removal, the patient is without an indwelling urinary catheter for atleast 1 full calendar day (NOT to be read as 24 hours), then the urinary catheter daycount will start anew. If instead, a new indwelling urinary catheter is inserted before a full calendar day has passed without an indwelling urinary catheter being present, the urinary catheter day count will continue.Figure 1: Associating Catheter Use to UTIMarch 31(Hospital day 3)April 1 April 2 April 3 April 4 April 5 April 6Patient A FoleyDay 3FoleyDay 4Foleyremoved(FoleyDay 5)Foleyreplaced(FoleyDay 6)FoleyDay 7Foleyremoved Day 8NoFoleyPatient B FoleyDay 3FoleyDay 4Foleyremoved(FoleyDay 5)NoFoleyFoleyreplaced(FoleyDay 1)FoleyDay 2FoleyDay 3Rationale: NHSN surveillance for infection is not aimed at a specific device. Instead surveillance is aimed at identifying risk to the patient that is the result of device use in general.•In the examples above, Patient A is eligible for a CAUTI beginning on March 31, through April 6th, since a Foley was in place for some portion of each calendar day until April 6th. A UTI with date of event on April 6th would be a CAUTI since thecatheter had been in place greater than 2 days and was removed the day before thedate of event.•Patient B is eligible for a CAUTI on March 31 (Foley Day 3) through April 3. The catheter had been in place > 2 days and an HAI occurring on the day of devicediscontinuation or the following calendar day is considered a device-associatedinfection.•IF the patient did not have a CAUTI by April 3, the patient is not eligible for a CAUTI until April 6, when the second indwelling urinary catheter had been in place for greater than 2 days. (Note: NHSN will not require the UTI to be attributed to aspecific indwelling urinary catheter when reporting.)Location of attribution: The inpatient location where the patient was assigned on the date of the UTI event. See Date of Event definition (above). See Exception to Location of Attribution (below).Exception to Location of AttributionTransfer Rule: If the date of event for a UTI is on the date of transfer or discharge, or the next day, the infection is attributed to the transferring/discharging location. This is called the Transfer Rule and examples are shown below. Receiving facilities should share information about such HAIs with the transferring location or facility to enable accurate reporting.Examples of the Transfer Rule:•Patient is transferred in the morning to the medical ward from the MSICU after having the Foley catheter removed, which had been in place for 6 days. The day of transfer is the date of event for the CAUTI. This is reported to NHSN as a CAUTI for the MSICUbecause the date of event (date when the first element of UTI criteria first appearedduring the infection window) was the day of transfer from that location.•On Monday, patient with a Foley catheter in place is transferred from the medical ward to the coronary care unit (CCU). Wednesday in the CCU, patient has a fever and urineculture collected that day is positive for 100,000 CFU/ml of E. coli. This is reported to NHSN as a CAUTI for the CCU, because the UTI date of event is LATER THAN the day after transfer.• A patient has a Foley catheter removed on catheter day 5 and is discharged the same day from hospital A’s urology ward. The next day, the IP from Hospital B calls to report that this patient has been admitted to Hospital B meeting UTI criteria. This CAUTI should be reported to NHSN for Hospital A and attributed to the urology ward because the date of event is the next day after transfer.•Patient in the MICU with a Foley catheter, which has been in place for 4 days, is transferred to the medical ward. The day after transfer is determined to be the date of event for a catheter-associated ABUTI. This is reported to NHSN as an ABUTI for the MICU because the date of event was the next day after transfer.Multiple TransfersIn instances where a patient has been transferred to more than one location on the date of a UTI, or the day before, attribute the UTI to the first location in which the patient was housed the day before the UTI’s date of event.Figure 2: Multiple Transfers within the Transfer Rule Time Frame3/22 3/23 3/24Locations in which patient was housed Unit A Unit AUnit BUnit CUnit CUnit DThis is also the date of event for a CAUTI.CAUTI is attributed to Unit A since Unit Awas the first location in which the patientwas housed the day before the date of event.Table 1. Urinary Tract Infection CriteriaCriterion Urinary Tract Infection (UTI)Symptomatic UTI (SUTI)Must meet at least one of the following criteria:SUTI 1a Catheter- associated Urinary Tract Infection (CAUTI)Patient must meet 1, 2, and 3 below:1.Patient had an indwelling urinary catheter that had been in place for > 2 dayson the date of event (day of device placement = Day 1) AND was either:•Present for any portion of the calendar day on the date of event†, OR•Removed the day before the date of event‡2.Patient has at least one of the following signs or symptoms:•fever (>38.0°C)•suprapubic tenderness*•costovertebral angle pain or tenderness*•urinary urgency ^•urinary frequency ^•dysuria ^3. Patient has a urine culture with no more than two species of organismsidentified, at least one of which is a bacterium of ≥105 CFU/ml (SeeComment Section on page 7-8). All elements of the UTI criterion must occur during the Infection Window Period (See Definition Chapter 2 IdentifyingHAIs in NHSN).† When entering event into NHSN choose “INPLACE” for Risk Factor for Urinary Catheter‡ When entering event into NHSN choose “REMOVE” for Risk Factor for Urinary Catheter*With no other recognized cause (see Notes below)^ These symptoms cannot be used when catheter is in placeNotes:•An indwelling urinary catheter in place could cause patient complaints of “frequency” “urgency” or “dysuria” and therefore these cannot be used assymptoms when catheter is in place.•Fever is a non-specific symptom of infection and cannot be excluded from UTI determination because it is clinically deemed due to another recognized cause.SUTI 1b Non- Catheter- associated Urinary Tract Infection (Non- CAUTI)Patient must meet 1, 2, and 3 below:1.One of the following is true:•Patient has/had an indwelling urinary catheter but it has/had not been in place >2 calendar days on the date of event†OR•Patient did not have a urinary catheter in place on the date of event nor the day before the date of event †2.Patient has at least one of the following signs or symptoms:•fever (>38°C) in a patient that is ≤ 65 years of age•suprapubic tenderness*•costovertebral angle pain or tenderness*•urinary frequency ^•urinary urgency ^•dysuria ^3. Patient has a urine culture with no more than two species of organismsidentified, at least one of which is a bacterium of ≥105 CFU/ml. (Seecomment section on page 7-8) All elements of the SUTI criterion must occur during the Infection Window Period (See Definition Chapter 2 IdentifyingHAIs in NHSN).† When entering event into NHSN choose “NEITHER” for Risk Factor for Urinary Catheter*With no other recognized cause (see Notes below)^These symptoms cannot be used when catheter is in place.Notes:•An indwelling urinary catheter in place could cause patient complaints of “frequency” “urgency” or “dysuria” and therefore these cannot be used assymptoms when catheter is in place.•Fever is a non-specific symptom of infection and cannot be excluded from UTI determination because it is clinically deemed due to another recognized cause.SUTI 2 CAUTI or Non- CAUTI in patients 1 year of age or less Patient must meet 1, 2, and 3 below:1.Patient is ≤1 year of age (with‡ or without an indwelling urinary catheter)2.Patient has at least one of the following signs or symptoms:•fever (>38.0°C)•hypothermia (<36.0°C)•apnea*•bradycardia*•lethargy*•vomiting*•suprapubic tenderness*3.Patient has a urine culture with no more than two species of organismsidentified, at least one of which is a bacterium of ≥105 CFU/ml. (Seecomment section on page 7-8) All elements of the SUTI criterion must occur during the Infection Window Period (See Definition Chapter 2 IdentifyingHAIs in NHSN).‡ If patient had an indwelling urinary catheter in place for >2 calendar days, and catheter was in place on the date of event or the previous day the CAUTI criterion is met. If no such indwelling urinary catheter was in place, UTI (non-catheter associated) criterion is met.*With no other recognized causeNote: Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination because they are clinically deemed due to another recognized cause.Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)Patient must meet 1, 2, and 3 below:1.Patient with* or without an indwelling urinary catheter has no signs orsymptoms of SUTI 1 or 2 according to age (Note: Patients > 65 years of agewith a non-catheter-associated ABUTI may have a fever and still meet theABUTI criterion)2.Patient has a urine culture with no more than two species of organismsidentified, at least one of which is a bacterium of ≥105 CFU/ml (seeComment section below)3.Patient has organism identified** from blood specimen with at least onematching bacterium to the bacterium identified in the urine specimen, ormeets LCBI criterion 2 (without fever) and matching common commensal(s)in the urine. All elements of the ABUTI criterion must occur during theInfection Window Period (See Definition Chapter 2 Identifying HAIs inNHSN).*Patient had an indwelling urinary catheter in place for >2 calendar days, with day ofdevice placement being Day 1, and catheter was in place on the date of event or theday before.** Organisms identified by a culture or non-culture based microbiologic testingmethod which is performed for purposes of clinical diagnosis or treatment (e.g., notActive Surveillance Culture/Testing (ASC/AST).Comment“Mixed flora” is not available in the pathogen list within NSHN. Therefore it cannot be reported as a pathogen to meet the NHSN UTI criteria. Additionally, “mixedflora” represent at least two species of organisms. Therefore, an additional organismrecovered from the same culture would represent >2 species of microorganisms. Sucha specimen also cannot be used to meet the UTI criteria.The following excluded organisms cannot be used to meet the UTI definition:•Candida species or yeast not otherwise specified•mold•dimorphic fungi or•parasitesAn acceptable urine specimen may include these organisms as long as one bacterium of greater than or equal to 100,000 CFU/ml is also present. Additionally, these non-bacterial organisms identified from blood cannot be deemed secondary to a UTI since they are excluded as organisms in the UTI definition.Device-associated ModuleUTITable 2. Urinary System Infection CriteriaCriterion Urinary System Infection (USI) (kidney, ureter, bladder, urethra, or tissue surrounding the retroperitoneal or perinephric space)Other infections of the urinary system must meet at least one of the followingcriteria:1.Patient has microorganisms identified** from fluid (excluding urine)or tissue from affected site2.Patient has an abscess or other evidence of infection on grossanatomical exam, during invasive procedure, or on histopathologicexam3.Patient has at least one of the following signs or symptoms:•fever (>38.0°C)•localized pain or tenderness*And at least one of the following:a)purulent drainage from affected siteb)organisms identified** from blood and imaging test evidence ofinfection (e.g., ultrasound, CT scan, magnetic resonance imaging[MRI], or radiolabel scan [gallium, technetium])1.Patient <1 year of age has at least one of the following signs orsymptoms:•fever (>38.0°C)•hypothermia (<36.0°C)•apnea*•bradycardia*•lethargy*•vomiting*And at least one of the following:a)purulent drainage from affected siteb)organisms identified** from blood and imaging test evidenceof infection, (e.g., ultrasound, CT scans, magnetic resonanceimaging [MRI], or radiolabel scan [gallium, technetium])* With no other recognized cause** Organisms identified by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis ortreatment (e.g., not Active Surveillance Culture/Testing (ASC/AST).Notes:•Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from USI determination because they are clinically deemed dueto another recognized cause.•All elements of the USI criterion must occur during the Infection Window Period (See Definition Chapter 2 Identifying HAIs in NHSN). Comments•Report infections following circumcision in newborns as SST-CIRC.•If patient meets USI criteria and they also meet UTI criteria, report UTI only, unless the USI is a surgical site organ/space infection, in which case,only USI should be reported.•For NHSN reporting purposes, Urinary System Infection (USI) cannot be catheter associated, therefore, USI will only present as specific event type ifurinary catheter status is marked “Neither”.Figure 3: Identifying SUTI and ABUTI FlowchartNumerator Data: The Urinary Tract Infection (UTI) form is used to collect and report each CAUTI that is identified during the month selected for surveillance. The Instructions for Completion of Urinary Tract Infection form include brief instructions for collection and entry of each data element on the form. USIs are never included in CAUTI data and are reported separately on the HAI Custom Event Form. The UTI form includes patient demographic information and information on whether or not an indwelling urinary catheter was present. Additional data include the specific criteria met for identifying the UTI, whether the patient developed a secondary bloodstream infection, whether the patient died, and the organisms isolated from cultures and their antimicrobial susceptibilities.Reporting Instructions:If no CAUTIs are identified during the month of surveillance, the” Report No Events” box must be checked on the appropriate denominator summary screen, (e.g., Denominators for Intensive Care Unit (ICU)/Other Locations (Not NICU or SCA/ONC).Denominator Data: Device days and patient days are used for denominators (See Key Terms chapter).The method of collecting device-day denominator data may differ depending on the location of patients being monitored. The following methods may be used: Denominator DataCollection MethodDetailsManual, Daily (i.e., collected at the same time every day of the month) Denominator data are collected at the same time, every day, per location.Indwelling urinary catheter days, which are the number of patients with an indwelling urinary catheter device, are collected daily, at the same time each day, according to the chosen location using the appropriate form (CDC 57.117 and 57.118). These daily counts are summed and only the total for the month is entered into NHSN. Indwelling urinary catheter days and patient days are collected separately for each of the locations monitored.Manual, sampled once/week (i.e., collected at the same time on the same designated day, once per week) For locations other than specialty care areas/oncology (SCA/ONC) and NICUs (e.g., ICUs, step-down units, wards), the denominator sampling method can be used.To reduce staff time spent collecting surveillance data, once weekly sampling of denominator data to generate estimated urinary catheter days may be used as an alternative to daily collection in non- oncology ICUs and wards. The number of patients in the location (patient-days) and the number of patients with an indwelling urinary catheter (urinary catheter-days) is collected on a designated day each week (e.g., every Tuesday), at the same time during the month.DetailsDenominator DataCollection MethodEvaluations of this method have repeatedly shown that use ofSaturday or Sunday generate the least accurate estimates ofdenominator data, and, therefore, these days should not be selected asthe designated day.5-7 If the day designated for the collection ofsampled data is missed, collect the data on the next available dayinstead.The following must be collected and entered into NHSN:1.The monthly total for patient-days, based on collection daily2.The sampled total for patient-days3.The sampled total urinary catheter-daysWhen these data are entered, the NHSN application will calculate anestimate of urinary catheter-days.Notes:•To ensure the accuracy of estimated denominator dataobtained by sampling, only ICU and ward location types withan average of 75 or more urinary catheter-days per month areeligible to use this method. A review of each location’surinary catheter denominator data for the past 12 months inNHSN will help determine which locations are eligible.•The accuracy of estimated denominator data generated bysampling can be heavily influenced by incorrect or missingdata. Careful implementation of data collection following theguidance in this protocol is essential to avoid erroneousfluctuations in rates or Standardized Infection Ratios (SIRs). Electronic For any location, when denominator data are available fromelectronic sources (e.g., urinary catheter days from electroniccharting), these sources may be used as long as the counts are notsubstantially different (+/- 5%) from manually-collected, once a daycounts, pre-validated for a minimum of three months.The validation of electronic counts should be performed for eachlocation separately.Data Analyses: The Standardized Infection Ratio (SIR) is calculated by dividing the number of observed infections by the number of predicted infections. The number of predicted infections is calculated using CAUTI rates from a standard population during a baseline time period, which represents a standard pop ulation’s CAUTI experience.8, 9 Notes:•The SIR will be calculated only if the number of predicted CAUTIs (numExp) is ≥1 to help enforce a minimum precision criterion.•In the NHSN application, “predicted” is referred to as “expected”.SIR = Observed (O) HAIsExpected (E) HAIsWhile the CAUTI SIR can be calculated for single locations, the measure also allows you to summarize your data by multiple locations, adjusting for differences in the incidence of infection among the location types. For example, you will be able to obtain one CAUTI SIR adjusting for all locations reported. Similarly, you can obtain one CAUTI SIR for all ICUs in your facility.Note: Only those locations for which baseline data have been published will be included in the SIR calculations. For acute care hospitals, the baseline time period is 2009; for long term acute care hospitals and inpatient rehabilitation facilities (IRFs) and IRF units, the baseline time period is 2013.8,9The CAUTI rate per 1000 urinary catheter days is calculated by dividing the number of CAUTIs by the number of catheter days and multiplying the result by 1000. The Urinary Catheter Utilization Ratio is calculated by dividing the number of urinary catheter days by the number of patient days. These calculations will be performed separately for the different types of ICUs, specialty care areas, and other locations in the institution, except for neonatal locations.Descriptive analysis output options of numerator and denominator data, such as line listings, frequency tables, and bar and pie charts are available in the NHSN application. SIRs and CAUTI rates and run charts are also available. Guides on using NHSN analysis features are available at: /nhsn/PS-Analysis-resources/reference-guides.html.REFERENCES1Magill SS., Edwards, JR., Bamberg, W., et al. “Multistate Point-Prevalence Survey of Health Care-Associated Infections, 2011”. New England Journal of Medicine. 370: (2014): 1198-1208.2Scott Rd. The Direct Medical Costs of Healthcare-Associated Infections in U.S.Hospitals and the Benefits of Prevention, 2009. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases,Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention,February 2009.3Klevens, RM., Edward, JR., et al. “Estimating Healthcare-associated Infections andDeaths in U.S. Hospitals”. Public Health Reports 122: (2007):160-166.4Gould, CV., Umscheid, CA., Agarwal, RK., Kuntz, G., Pegues, DA. “Guideline forPrevention of Catheter-associated Urinary Tract Infections”. Infection Control HospitalEpidemiology. 31: (2010): 319-26.5 Klevens, RM., et al. “Sampling for Collection of Central Line Day Denominators inSurveillance for Healthcare-associated Bloodstream Infections”. Infection Control Hospital Epidemiology. 27: (2006):338-42.6Thompson, ND., et al.” Evaluating the Accuracy of Sampling to Estimate Central Line–Days: Simplification of NHSN Surveillance Methods”. Infection Control HospitalEpidemiology. 34(3): (2013): 221-228.7See, I., et al. ID Week 2012 (Abstract #1284): Evaluation of Sampling Denominator Data to Estimate Urinary Catheter- and Ventilator-Days for the NHSN. San Diego,California. October 19, 2012.8Dudeck, MA., Horan, TC., Peterson, KD. National Healthcare Safety Network (NHSN) Report, Data Summary for 2009, “Device-associated Module”, American Journal of Infection Control 39: (2011): 349-67.9Dudeck, MA., et al. National Healthcare Safety Network (NHSN) Report, DataSummary for 2013, Device-associated Module. 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