Wisconsin Department of Health Services Ashlie Dowdell HAI
Surveillance Coordinator SEW APIC, February 5, 2015 National
Healthcare Safety Network (NHSN) in 2015 Wisconsin Department of
Health Services
Slide 2
Agenda Review the 2015 definition change highlights. Recap
state and federal NHSN reporting requirements. Whats coming in 2015
for: Ambulatory surgery centers (ASC). Long-term care (LTC)
facilities. ICD-10. 2
Slide 3
When Do I Need To Incorporate These Changes? All
definition/surveillance protocol changes took effect January 1,
2015. Changes to fields/reporting rules will be part of the
database after the first 2015 version update (January 31). Wait
until after the version update to enter 2015 reporting plans, data
and the annual facility survey for CY 2014. 3
Slide 4
PATIENT SAFETY COMPONENT Protecting and promoting the health
and safety of the people of Wisconsin 4
Slide 5
General NHSN Changes NHSN Infection Window Event Date Repeat
Infection Timeframe Secondary Bloodstream Infection (BSI)
Attribution Period CDC/NHSN Surveillance Definitions for Specific
Types of Infections (aka Chapter 17) Note: These general changes do
not apply to Long- Term Care Component users. 5
Slide 6
NHSN Infection Window Replaces gap day methodology from 2014.
All elements of the criteria must be part of this window. For
criteria that include diagnostic testing: Day the first positive
diagnostic test included in the infection criteria was obtained.
Three calendar days before the test. Three calendar days after the
test. 6 Day -3Day -2Day -1Day of first positive test Day 1Day 2Day
3
Slide 7
Event Date 2014: Date the last element of the criteria was met.
2015: Date the first element of the criteria occurs for the first
time within the seven-day infection window. Event date still
determines whether an infection is present on admission (POA) or
healthcare- associated. Event dates on the date of admission, two
days before and the day after are POA. Events dates on or after
hospital day 3 (hospital admission day is day 1) are HAIs for NHSN
surveillance. 7
Slide 8
Repeat Infection Timeframe (RIT) 14-day period during which
repeat infections of the same type cannot be reported. Any
additional pathogens collected during this timeframe should be
added to the original infection report. Event date for the first
infection is day 1 of the RIT. 8
Slide 9
Secondary BSI Attribution Period Must meet the Secondary BSI
Guideline criteria and fall during this time period. 14-17-day
period (depending on where the event date falls within the
Infection Window): 7-day Infection Window of the primary infection.
14-day Repeat Infection Timeframe of the primary infection. 9
Slide 10
SunMonTueWedThuFriSat Nov 23Nov 24Nov 25Nov 26Nov 27Nov 28 Day
-3 before culture = Beginning of Infection Window Nov 29 Day -2
before culture Nov 30 Day -1 before culture Dec 1 Fever, + culture
= CAUTI Date of Event Day 1 of RIT Dec 2 Day 1 after culture Day 2
RIT Dec 3 Day 2 after culture Day 3 RIT Dec 4 Day 3 after culture
(End of IW) Day 4 RIT Dec 5 Day 5 RIT Dec 6 Day 6 RIT Dec 7 Day 7
RIT Dec 8 Day 8 RIT Dec 9 Day 9 RIT Dec 10 Day 10 RIT Dec 11 Day 11
RIT Dec 12 Day 12 RIT Dec 13 Day 13 RIT Dec 14 Day 14 RIT (End of
RIT) Dec 15Dec 16Dec 17Dec 18Dec 19Dec 20 Infection Window Repeat
Infection Timeframe Secondary BSI Attribution Window
Slide 11
Excluded Modules for Certain General HAI Rules Protecting and
promoting the health and safety of the people of Wisconsin 11
Slide 12
Specific HAI Definitions/ Chapter 17 HAI definitions for
anything without a devoted module. First significant update since
the 1990s. Bring them up to date and make them consistent with
other NHSN changes over the years. 12 Available at:
http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
Slide 13
BSI Protocol Secondary BSI Guide Will no longer ask whether
blood culture organism is a logical pathogen for the primary site
of infection. Introduction of the Secondary BSI Attribution Period
(Infection Window + Repeat Infection Timeframe for the primary
infection). Core temperatures no longer required for infant fevers.
Use the documented temperature and do not convert. 13
Slide 14
UTI Protocol No longer included: Colony counts less than
100,000 CFU/ml. Urinalysis results. Cultures positive only for
yeast, mold, dimorphic fungi, or parasites. Uropathogen list for
asymptomatic bacteremic UTI (ABUTI) (will use the same list as for
symptomatic UTI). Protecting and promoting the health and safety of
the people of Wisconsin 14
Slide 15
New Denominator Sampling Option Alternate method for collecting
CLABSI and CAUTI denominator data. Can only be used in ICUs and
wards with 75 or more device-days per month. Collect patient days
and device days one day per week (e.g., every Tuesday) at the same
time and provide the total number of patient days for the month.
NHSN will estimate the device days based on the collected data for
use as the denominator. 15
Slide 16
Ventilator-Associated Events (VAE) Protocol Combine possible
VAP and probable VAP into one event: PVAP. Exclude typically
environmental pathogens (i.e., community- associated fungal
pathogens) not known/rarely acquired in healthcare for PVAP. New
optional denominator: Episodes of Mechanical Ventilation. Vent days
and APRV days continue to be required. Daily minimum PEEP/FiO2 when
there is no value documented as maintained for 1 hour during the
calendar day: Use the lowest value documented in that calendar day.
16
Slide 17
Pneumonia/Ventilator- Associated Pneumonia Changes Bringing
testing, pathogens in line with VAE definitions. Cannot report
pathogens or attribute secondary BSIs for PNU1 definition. If blood
cultures are collected and pathogens identified within the required
period, modify the designation to PNU2. Protecting and promoting
the health and safety of the people of Wisconsin 17
Slide 18
SSI Protocol Inpatient/outpatient procedures. **Changed
2/3/15**: Back to the 2014 definitions. Inpatient procedure
different dates of admission and discharge. Outpatient procedure
same date of admission and discharge. Infection present at the time
of surgery (PATOS). SSIs with PATOS excluded from SSI SIRs
beginning in 2016 with the new baseline. 18
Slide 19
SSI Protocol, cont. Prior infection at the index joint for
HPRO/KPRO revisions. Primary closure: Any portion closed at the
skin level rather than all tissue levels. Diabetes:
Medication-based definition of diabetes or ICD-9 discharge codes.
Scope field: Y if the procedure was coded as a lap procedure
performed using a laparoscope/robotic assist. 19
Slide 20
MDRO/CDI Protocol: Denominator Be prepared to exclude
unit-based inpatient rehab facilities (IRF), inpatient psychiatric
facilities (IPF) and skilled nursing facilities (SNF) with a
different CMS Certification Number (CCN) than the acute care
hospital. New denominator screen will walk through that removal:
Total patient days/admissions = all locations. MDRO patient
days/admissions = exclude IPF/IRF/SNF. CDI patient days/admissions
(if reporting CDI) = exclude IPF/IRF/SNF and NICU/well baby counts.
20
Slide 21
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Slide 22
MDRO/CDI Protocol: New Locations Map ERs and dedicated 24-hour
observation locations. Any time you use FACWIDEIN as a location,
you also need to report the same organism for the ER and
observation. Attribute cultures taken in the ER to the ER (not the
admitting inpatient unit as was done in 2014). 22
Slide 23
CRE Changes CRE = E. coli, Klebsiella pneumoniae/oxytoca, and
Enterobacter. Definition changes: Ertapenem has been added. Only
includes pathogens testing resistant to a carbapenem (intermediates
will no longer count). CRE-Klebsiella will be limited to Klebsiella
oxytoca and Klebsiella pneumoniae. 23
Slide 24
New CRE Definition Any Escherichia coli, Klebsiella oxytoca,
Klebsiella pneumoniae, or Enterobacter testing resistant to
imipenem, meropenem, doripenem, or ertapenem by standard
susceptibility testing methods (i.e., minimum inhibitory
concentrations of 4 mcg/mL for doripenem, imipenem, and meropenem
or 2 mcg/mL for ertapenem) or by production of a carbapenemase
(i.e., KPC, NDM, VIM, IMP, OXA-48) demonstrated using a recognized
test (e.g., PCR, metallo--lactamase test, modified-Hodge test,
Carba-NP). Protecting and promoting the health and safety of the
people of Wisconsin 24
Slide 25
MDRO/CDI Protocol Optional questions to be added to LabID Event
form: Last physical location of patient immediately prior to
arrival to facility (if specimen is community-onset). Has patient
been discharged from another facility in the past four weeks? (this
includes NH, rehab, other hospitals, LTACs, etc.). Protecting and
promoting the health and safety of the people of Wisconsin 25
Slide 26
DIALYSIS COMPONENT Protecting and promoting the health and
safety of the people of Wisconsin 26
Slide 27
2015 Changes (All Optional Not Part of CMS Reporting) 5 new
process measures: Hemodialysis catheter connection/disconnection.
Hemodialysis catheter exit site care. Arteriovenous fistula and
graft cannulation/decannulation. Dialysis station routine
disinfection. Injection safety. Influenza vaccination for dialysis
patients. Analysis data quality reports. 27
Slide 28
Dialysis Events Form New question: Where was this positive
blood culture collected? Responses include dialysis clinic,
hospital (day of or day following hospital admission) or ER, and
other location. Loss of vascular access field under the outcomes
section will now be required. 28
Slide 29
LONG-TERM CARE FACILITY COMPONENT Protecting and promoting the
health and safety of the people of Wisconsin 29
Slide 30
New Required Denominator Fields Enter the monthly total for
each new field when entering the monthly total resident days: If
reporting UTI: Number of new antibiotic starts for UTI indication.
If reporting CDI: Number of admissions on CDI treatment. Protecting
and promoting the health and safety of the people of Wisconsin
30
Slide 31
General HAI Surveillance Definitions New terms used in the
Patient Safety Component (infection window, repeat infection
timeframe, etc.) do not apply to the LTC Component and should not
be used at this time. Refer back to the LTC module protocols
instead. Updated LTC Component protocols and training slides
available now at http://www.cdc.gov/nhsn/LTC/index.html.
http://www.cdc.gov/nhsn/LTC/index.html 31
Slide 32
NHSN REPORTING REQUIREMENTS Protecting and promoting the health
and safety of the people of Wisconsin 32
Slide 33
33 CMS Healthcare Facility NHSN HAI Reporting Requirements
Reporting SpecificationsExisting RequirementNew Requirement for
2015 Acute Care Hospitals (Prospective Payment System PPS) CLABSI
(ICUs, PICUs, NICUs) CAUTI (ICUs, PICUs) SSI (COLO and HYST) MRSA
Bacteremia LabID Event C. difficile LabID Event HCP Influenza
Vaccination CLABSI and CAUTI Expansion (Medical, Surgical and
Medical/Surgical Wards) Outpatient Dialysis IV antimicrobial start
Positive blood culture Signs of vascular access infection HCP
Influenza Vaccination Long-Term Acute Care (LTAC) Hospitals CLABSI
CAUTI HCP Influenza Vaccination MRSA Bacteremia LabID Event C.
difficile LabID Event Ventilator-Associated Events (2016) Inpatient
Rehabilitation Facilities (IRF) CAUTI HCP Influenza Vaccination
MRSA Bacteremia LabID Event C. difficile LabID Event Ambulatory
Surgery Centers (ASC) HCP Influenza VaccinationNone Inpatient
Psychiatric Facilities (IPF) NoneHCP Influenza Vaccination
Long-Term Care (LTC) Facilities None
Slide 34
State Reporting Requirements Medicaid P4P Program. CAUTI. PPS
and CAH. April 2014 March 2015 due September 30, 2015. HCP
Influenza Vaccination. PPS, CAH, psych and childrens. 2014-15
season due May 15, 2015. CRE. PPS, CAH, childrens and LTAC
hospitals. Data reported monthly even if no positive cultures have
been identified. 34
Slide 35
Reminder: NHSN 2015 Changes Training 10-minute videos available
now at http://www.cdc.gov/nhsn/Training/patient-
safety-component/index.html
http://www.cdc.gov/nhsn/Training/patient-
safety-component/index.html February 17-19 via live webstream,
includes overview of each module and case studies. DPH January 7
webcast recording available at
http://dhsmedia.wi.gov/main/Play/8d1fc0a5fb8
347fe8d79601709d381c41d.
http://dhsmedia.wi.gov/main/Play/8d1fc0a5fb8
347fe8d79601709d381c41d 35
Slide 36
WHATS COMING IN 2015 FOR AMBULATORY SURGERY, LONG-TERM CARE AND
ICD-10? Protecting and promoting the health and safety of the
people of Wisconsin 36
Slide 37
ASCs in 2015 All should be enrolled or enrolling. Finishing up
the first season of flu reporting (2014-15). Due May 15. Outpatient
Component due to launch in the summer. Protecting and promoting the
health and safety of the people of Wisconsin 37
Slide 38
Outpatient Component - ASCs Focus on SSIs, same day adverse
events, and IV antibiotic prophylaxis timing initially. Start with
ASCs, open up to hospital outpatient departments later. Start with
10 procedures (breast, colon, hernia, abdominal hyst, laminectomy,
gallbladder, fractures, hip and knee replacements, vaginal hyst).
Denominators will be aggregate numbers of procedures, admissions,
etc. Risk adjustment/analysis still TBD. 38
Slide 39
LTC Participation in NHSN 13 Wisconsin facilities live (206
across the country). 3 have conferred rights to DPH so far. Per the
surveillance workshops last fall: 64 facilities plan to use the
protocols outside NHSN. 57 facilities plan to enroll in the near
future. Protecting and promoting the health and safety of the
people of Wisconsin 39
Slide 40
Current LTC Reporting Options MDRO/C. difficile
laboratory-identified events Urinary tract infections Prevention
process measures Hand hygiene Gown and glove use Staff flu
vaccination Protecting and promoting the health and safety of the
people of Wisconsin 40
Slide 41
LTC in 2015 Pilot for interested facilities in 2015. Enroll
(see checklist http://www.cdc.gov/nhsn/LTC/enroll.html).
http://www.cdc.gov/nhsn/LTC/enroll.html Start reporting at least
CRE. Determine the LTC-specific questions, road blocks, tools, etc.
for enrolling and participating. Protecting and promoting the
health and safety of the people of Wisconsin 41
Slide 42
Why NHSN for LTC? Standardized definitions. NHSN = McGeers
criteria. National standard - try to use protocols, even if youre
not ready to enroll. Start to build data for comparison, both
locally and nationally. Helps with the survey/QAPI process. 2013
National HAI Goal to enroll 5% of nursing homes by 2017. 42
Slide 43
Transitioning to ICD-10 NHSN ICD-10 code mapping is expected to
be available by March 2015. ICD-10 coding starts October 2015.
ICD-10 codes will be accepted into NHSN starting January 2016 after
the version update. Between October and January, omit the ICD code
in the procedure record to avoid error messages. Protecting and
promoting the health and safety of the people of Wisconsin 43
Slide 44
Questions? Ashlie Dowdell HAI Surveillance Coordinator
Wisconsin Division of Public Health 608-266-1122
[email protected] Protecting and promoting the health and
safety of the people of Wisconsin 44