American Journal of Infection Control xxx (2015) 1-2
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Comparison of two methods of documenting urinary and central venous catheters at an academic medical center Bladimir R. Quijano Rondan MD *, Anna Stachel MPH, CIC, Michael Phillips MD New York University Langone Medical Center, New York, NY
Key Words: Catheter-associated urinary tract infections Central lineeassociated bloodstream infections Accuracy Missed documentation
Accurate documentation of the use of invasive devices, such as urinary and central line catheters, is important to track potential catheter-associated infections. Real-time identification of device infections allows practitioners to initiate timely apparent-cause analyses, therefore allowing rapid improvement of practice. For this reason, it was crucial to ensure our institution’s mechanism to capture possible catheter-associated infections is validated after the adoption of a new electronic medical record system. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hospital-associated urine and bloodstream infections are associated with prolonged hospital stays and increased cost and mortality. Urinary tract infections account for >15% of infections reported by acute care hospitals.1 According to the Centers for Disease Control and Prevention, in 2012, approximately 37,000 catheter-associated urinary tract infections (CAUTIs) and >16,700 central lineeassociated bloodstream infections (CLABSIs) were documented in the United States.2 In 2013, the Infection Prevention and Control (IPC) Department at New York University Langone Medical Center (NYULMC) identified 79 CAUTIs (rate ¼ 2/1,000 device days) and 29 CLABSIs (rate ¼ 1.1/1,000 device days). The IPC department uses 2 methods to identify potential CAUTIs and CLABSIs in hospitalized patients. The first method involves the daily device report (DDR), which identifies the presence of a urinary catheter (UC) or central venous catheter (CVC) through nursing documentation of device insertion or removal in our electronic medical record. The DDR was provided as a standard feature of our electronic medical record. Potential CAUTIs and CLABSIs are determined by merging positive blood and positive urine culture results and urinalysis results daily with the DDR. These potential cases are reviewed by the data team and IPC practitioners to identify CAUTIs and CLABSIs according to the National Healthcare Safety Network’s definitions. Apparent-cause analyses are initiated by practitioners to review the infections with the clinical team in near real time and identify potential * Address correspondence to Bladimir R. Quijano Rondan, MD, Infection Prevention and Control Department, NYU Langone Medical Center, Greenberg Hall, SC1-132, 545 First Ave, New York, NY 10016. E-mail address: [email protected] (B.R. Quijano Rondan). Conflicts of interest: None to report.
causes. It is important that the DDR captures all devices because missed device documentation may lead to missed device infections. The second method used at the NYULMC is the customized report (CR), created by our internal data group, which is performed periodically to identify the presence of a device through nursing documentation of insertion, maintenance, and removal of the device in multiple data elements within our electronic medical record. The IPC department considers the CR the gold standard because multiple data elements are used to determine whether a device is present; the CR is used to provide device day data for health careeassociated infection reports within our institution and for public reporting. This study was undertaken to compare the accuracy of both surveillance methods after the adoption of a new electronic medical record. METHODS Medical or surgical units at the NYULMC were randomly selected during a 4-month period. A list of patients from a selected unit was printed, and each patient was evaluated for the presence or absence of a UC or CVC and whether the device was recorded in the electronic medical record. Both the DDR and CR were reviewed to verify if the device was included in the report for that day. Sensitivity, specificity, and accuracy were calculated for each report. Report accuracy was defined as true positive (device present and included in report) plus true negative (device not present and not included in report) divided by the total number of observations. High accuracy was defined as >95%. Low accuracy was defined as 90% for UC or CVC.
CONCLUSIONS The CR, which incorporates multiple data elements to identify the presence of a device, is more accurate than the DDR method provided as a standard feature of our electronic medical record for identification of UCs. The accuracy of the CR and DDR methods was similar for CVCs. Because we depend on the DDR to identify CAUTIs and CLABSIs in real time, it is important that all devices are included in the DDRs. Finally, because the IPC department relies on the CR to create denominators for rates, it is important that the presence or absence of a device is accurately documented in the report. Our findings allowed us to identify the following interventions to improve the accuracy of the CR:
1. Document insertion and removal of devices in the electronic chart by hospital staff; 2. Dressing changes documentation triggers documentation of the presence of a device by hospital staff; 3. Frequent evaluation of the data fields used by report writers to create the CR to ensure accuracy with version changes of the electronic medical record; and 4. Periodic revalidation by the IPC department to verify improved accuracy: the IPC department will need to follow-up with the least accurate units to improve documentation. This validation study helped the NYULMC’s IPC Department better understand the accuracy of reported data and implement improvement projects when needed. With improved reports we will be able to identify suspect device-related infections and intervene promptly, with a goal of preventing future device-related infections. Facilities must validate the methods used for electronic reporting of invasive devices to allow timely identification of infections and accurate reporting. References 1. Magill SS, Hellinger W, Cohen J, Kay R, Bailey C, Boland B, et al. Prevalence of healthcare-associated infections in acute care facilities. Infect Control Hosp Epidemiol 2012;33:283-91. 2. Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. Am J Infect Control 2013;41:1148-66.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Comparison of two methods of documenting urinary and central venous catheters at an academic medical center Bladimir R. Quijano Rondan MD *, Anna Stachel MPH, CIC, Michael Phillips MD New York University Langone Medical Center, New York, NY
Key Words: Catheter-associated urinary tract infections Central lineeassociated bloodstream infections Accuracy Missed documentation
Accurate documentation of the use of invasive devices, such as urinary and central line catheters, is important to track potential catheter-associated infections. Real-time identification of device infections allows practitioners to initiate timely apparent-cause analyses, therefore allowing rapid improvement of practice. For this reason, it was crucial to ensure our institution’s mechanism to capture possible catheter-associated infections is validated after the adoption of a new electronic medical record system. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hospital-associated urine and bloodstream infections are associated with prolonged hospital stays and increased cost and mortality. Urinary tract infections account for >15% of infections reported by acute care hospitals.1 According to the Centers for Disease Control and Prevention, in 2012, approximately 37,000 catheter-associated urinary tract infections (CAUTIs) and >16,700 central lineeassociated bloodstream infections (CLABSIs) were documented in the United States.2 In 2013, the Infection Prevention and Control (IPC) Department at New York University Langone Medical Center (NYULMC) identified 79 CAUTIs (rate ¼ 2/1,000 device days) and 29 CLABSIs (rate ¼ 1.1/1,000 device days). The IPC department uses 2 methods to identify potential CAUTIs and CLABSIs in hospitalized patients. The first method involves the daily device report (DDR), which identifies the presence of a urinary catheter (UC) or central venous catheter (CVC) through nursing documentation of device insertion or removal in our electronic medical record. The DDR was provided as a standard feature of our electronic medical record. Potential CAUTIs and CLABSIs are determined by merging positive blood and positive urine culture results and urinalysis results daily with the DDR. These potential cases are reviewed by the data team and IPC practitioners to identify CAUTIs and CLABSIs according to the National Healthcare Safety Network’s definitions. Apparent-cause analyses are initiated by practitioners to review the infections with the clinical team in near real time and identify potential * Address correspondence to Bladimir R. Quijano Rondan, MD, Infection Prevention and Control Department, NYU Langone Medical Center, Greenberg Hall, SC1-132, 545 First Ave, New York, NY 10016. E-mail address: [email protected] (B.R. Quijano Rondan). Conflicts of interest: None to report.
causes. It is important that the DDR captures all devices because missed device documentation may lead to missed device infections. The second method used at the NYULMC is the customized report (CR), created by our internal data group, which is performed periodically to identify the presence of a device through nursing documentation of insertion, maintenance, and removal of the device in multiple data elements within our electronic medical record. The IPC department considers the CR the gold standard because multiple data elements are used to determine whether a device is present; the CR is used to provide device day data for health careeassociated infection reports within our institution and for public reporting. This study was undertaken to compare the accuracy of both surveillance methods after the adoption of a new electronic medical record. METHODS Medical or surgical units at the NYULMC were randomly selected during a 4-month period. A list of patients from a selected unit was printed, and each patient was evaluated for the presence or absence of a UC or CVC and whether the device was recorded in the electronic medical record. Both the DDR and CR were reviewed to verify if the device was included in the report for that day. Sensitivity, specificity, and accuracy were calculated for each report. Report accuracy was defined as true positive (device present and included in report) plus true negative (device not present and not included in report) divided by the total number of observations. High accuracy was defined as >95%. Low accuracy was defined as 90% for UC or CVC.
CONCLUSIONS The CR, which incorporates multiple data elements to identify the presence of a device, is more accurate than the DDR method provided as a standard feature of our electronic medical record for identification of UCs. The accuracy of the CR and DDR methods was similar for CVCs. Because we depend on the DDR to identify CAUTIs and CLABSIs in real time, it is important that all devices are included in the DDRs. Finally, because the IPC department relies on the CR to create denominators for rates, it is important that the presence or absence of a device is accurately documented in the report. Our findings allowed us to identify the following interventions to improve the accuracy of the CR:
1. Document insertion and removal of devices in the electronic chart by hospital staff; 2. Dressing changes documentation triggers documentation of the presence of a device by hospital staff; 3. Frequent evaluation of the data fields used by report writers to create the CR to ensure accuracy with version changes of the electronic medical record; and 4. Periodic revalidation by the IPC department to verify improved accuracy: the IPC department will need to follow-up with the least accurate units to improve documentation. This validation study helped the NYULMC’s IPC Department better understand the accuracy of reported data and implement improvement projects when needed. With improved reports we will be able to identify suspect device-related infections and intervene promptly, with a goal of preventing future device-related infections. Facilities must validate the methods used for electronic reporting of invasive devices to allow timely identification of infections and accurate reporting. References 1. Magill SS, Hellinger W, Cohen J, Kay R, Bailey C, Boland B, et al. Prevalence of healthcare-associated infections in acute care facilities. Infect Control Hosp Epidemiol 2012;33:283-91. 2. Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. Am J Infect Control 2013;41:1148-66.
