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

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• 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

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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

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6 http://www.cdc.gov/nhsn/

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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

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The Devil is in the Details

• Location mapping • Facility surveys • CDI assay type • Data quality

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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

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CAUTI and CLABSI

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New Concepts!

• Infection Window • Event Date • Repeat Infection Timeframe (RIT) • Sampling • Secondary BSI Attribution Period

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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

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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

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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”

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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

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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

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Definitions in Action

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Other Tips

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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

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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

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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)

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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!

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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)

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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

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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

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Data Analysis

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• 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

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TAP Reports

• Available to hospitals now • Use CAD to prioritize data in a new way • Requires goal – currently uses the HHS

HAI goals

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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

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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)

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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

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