national healthcare safety network (nhsn) update...
TRANSCRIPT
National Healthcare Safety Network (NHSN) Update for 2015 Data Submission: An Overview
Martha Jaworski, RN, MS, CIC Jamie Moran, MSN, RN, CIC
February 27, 2015
2
And
• Qualis Health is one of the nation’s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day
• Serving as the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Idaho and Washington
• QIOs: the largest federal network dedicated to improving health quality at the community level
3 http://medicare.qualishealth.org/projects/healthcare-associated-infection/webinar-series
October, 2014 HAI Prevention: Impact of SIRs, VBP, and HAC on Reimbursement February, 2015 National Healthcare Safety Network (NHSN) Update for 2015 Data Submission: An Overview Spring, 2015 Ventilator Associated Events: 2015 Update …And more to come!
Reducing Hospital Acquired Infections Series
4
Presentation Objectives
• Identify how hospital acquired infections fit into the CMS reimbursement programs
• Describe major changes to NHSN reporting for CY 2015
• Understand and apply new definitions related to CLABSI, CAUTI, SSI and LabID events
• Identify resources for data benchmarking and prioritizing your Infection Prevention efforts
5
6 http://www.cdc.gov/nhsn/
7 7
8
9
CURRENT and PROPOSED NHSN EVENT REPORTING CMS
REQUIREMENTS
http://www.cdc.gov/nhsn/settings.html Go to “CMS Requirements” on left bar
CMS Resources on right bar
10
11
12
13
The Devil is in the Details
• Location mapping • Facility surveys • CDI assay type • Data quality
14
Polling Questions
What best describes your recent surveillance experience (select all that apply):
A I have applied the 2015 surveillance definitions to HAI’s in my facility
B I viewed part or all of the live streamed NHSN update course on 2/17-2/19/2015.
C I have read the new definitions or have viewed the hot topics .
D. I am not familiar with the new NHSN definitions
15
CAUTI and CLABSI
16
New Concepts!
• Infection Window • Event Date • Repeat Infection Timeframe (RIT) • Sampling • Secondary BSI Attribution Period
17
18
Event Date
• The date the first element used to meet criteria occurs for the first time during the 7-day Infection Window
• If Date of Event falls on hospital day 1 or day 2, infection will be considered Present on Admission
19
Repeat Infection Timeframe
• A 14-day period following the Date of Event during which repeat infections of the same type will not be reported.
• New site-specific pathogens identified during the RIT will be added to the original infection
20
Sampling • An alternative method for collecting CAUTI and
CLABSI denominators
• Requires data collection on device days and patient days on just a single day once per week during a month
• Sampled locations must have an average of 75 device days per month in the year prior to sampling
• Collection of all patient days will still be required
Under any infection type: “Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance”
21
Secondary BSI Attribution Period
• Bloodstream infection (BSI) occurring within the primary CAUTI or CLABSI’s Window of Infection plus its Repeat Infection Timeframe (RIT), will be considered secondary
• Attribution period is 14 days from the event date plus the Infection window days prior to the event date
• Secondary BSI can occur before the event date if within the infection window
22
23
Device-Associated Changes CAUTI • Only bacteria can be considered causative organisms • Only urine cultures with at least 100,000 CFU/ml of
bacteria can be used • SUTI 1a – catheter must have been in place >2 calendar
days and for the entire day of the event date • ABUTI will use same pathogen list as SUTI • Core temperatures no longer required for infants • No temperature conversions due to route needed • Dysuria no longer a criterion for infants
CLABSI • No additional changes
24
25
Definitions in Action
26
27
28
29
30
31
32
33
34
35
Other Tips
36
Secondary BSI Attribution
Secondary BSI can be attributed to another infection IF either
• Positive BC pathogen matches the pathogen in the BC used to meet the primary infection criteria (per Ch 17)
• Positive BC pathogen is an element used to meet the primary site infection criteria (Ch 17)
• Not applicable to VAE
37
Secondary BSI Attribution Period
• 14-17 days in length • Includes the Infection Window Period and
the Repeat Infection Timeframe • Primary BSI’s are excluded from having
secondary BSI’s attributed to them • Logical pathogens removed from definition
38
39
40
41
Surgical Site Infection
• Infection Window and Repeat Infection Timeframe do NOT apply
• Date of Event is the date of the first criteria used to meet the surveillance definition
• PATOS: Present at time of surgery • Diagnostic codes for diabetes (250-250.93)
42
Surgical Site Infection
• Designation of Inpatient/Outpatient OR’s • SCOPE: Unless converted to an open
procedure, report as scope. • Closure type: “all tissue levels” removed • Site specific SSI criteria (ch 17) is updated
New!
43
Lab ID Events
• Exclude different CCN’s from patient days and counts (ie IRF or IPF)
• Include FacWIDEIn, IRF and IPF in your monthly reporting plan
• Must map ER and 24 Hour Observation areas • Events will be attributed to these locations • Other affiliated outpatient areas are reported to
the inpatient admitting location (if collected on day of admission – no change from 2014)
44
45
46
47
Lab ID Events: Optional Questions
• Last physical overnight • LTC • Personal residence • Other acute care setting • unknown
• Discharged from facility in last 4 wks: • SNF • Other IP healthcare setting • IRF • LTAC
48
Polling Question
The following is true about my knowledge and skill level at running and using the data analysis output options in NHSN A Very confident B Somewhat confident C Not confident
49
Data Analysis
50
• New in Reports: • Indicators for Lab ID events
• Evaluation of data quality and completeness • CMS reports • SSI SIR report: excluded procedures • Summary data line list (no events) • Alerts • Facility Annual Survey
Data Analysis
51
TAP Reports
• Available to hospitals now • Use CAD to prioritize data in a new way • Requires goal – currently uses the HHS
HAI goals
52
The Standardized Infection Ratio: Where we’ve been
• SIR: Method of benchmarking in NHSN: ratio of observed/expected events
• Current SIRs • Expected values are calculated based on
historic data: • 2006-2008 (SSI and CLABSI) • 2009 (CAUTI) • 2011 (Lab ID events)
• Rationale – track improvement over time with same baselines to evaluate progress toward HHS HAI reduction goals
53
The Standardized Infection Ratio: Where we’re going
• Update all baselines to 2015 for 2016 data and beyond
• CAUTI and CLABSI will have new SIRs calculated in 2015 • ICU only (as previously) • ICU + WARD (medical, surgical and med-surg
wards as required by CMS)
54
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C1-QH-1662-02-15
Questions?
Your Feedback is Important to Us! Please complete the brief Survey Monkey evaluation when you close out of the webinar in order to provide feedback and to receive your Certificate of Participation:
https://www.surveymonkey.com/s/JJ3X63M www.medicare.qualishealth.org/