NHSN Update. Margaret A. Crowley, RN, PhD. 7 March 2016

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1 NHSN Update Margaret A. Crowley, RN, PhD 7 March 2016 This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, 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. 11SOWQIN_XXXXXXXX.

2 CMS and NHSN QIN-QIO Programs Brief history Where we are now Where we are headed HAC Reduction Program Analysis of data for CMS Important dates and Requirements

3 New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO) Regional approach, six New England states State based implementation Each state has a full compliment of QIO staff Assistance and education to physicians, hospitals, and nursing homes in achieving quality improvement goals Five year contract 3

4 Reducing HAIs in Hospitals Catheter Associated Urinary Tract Infections (CAUTI) Catheter Utilization Clostridium difficile Infections (CDI) Ventilator-Associated Events (VAE) 3/25/2016 4

5 Long-term care facility infection surveillance Sept 2012: CDC released the LTCF infection reporting component within NHSN Oct 2012: Updated infection surveillance definitions for LTC published by CDC/SHEA 2013: 61 Facilities enrolled in 14 states; 2016: 280 Facilities enrolled in 38 states 3/25/2016 5

6 CMS CDI Reporting and Reduction Project, Working within the National NH Quality Care Collaborative (already recruited 7,400 NHs into the collaborative) Goal is to recruit 15% of nursing homes Enroll in NHSN Sustain CDI reporting over the course of the project Participants will receive training and support on CDI reporting and prevention activities including: NHSN enrollment, CDI event reporting and analysis Training in LTC communication (TeamSTEPPS) Antibiotic stewardship 6

7 CDC Reports Hospital-Specific HAI Event Data to CMS NHSN opening page 7

8 Landmark Healthcare Legislation: Major Emphasis on Quality Measurement and Improvement Mentions quality measures, performance measures, or measures of quality 128 times Calls for a national quality strategy Ratchets up non-payment for hospital-acquired conditions Introduces value based purchasing Expands scope of publicly reported quality measure data 8

9 HAI Surveillance in the Current U.S. Environment and the Impact on NHSN NHSN at Launch (2005) 300 Hospitals 1. Purely voluntary and confidential system 2. Healthcare facilities initially enrolled had all participated in the legacy CDC system(s) 3. Primary motivation for facilities is internal quality of care improvement 4. Expectation that facilities are motivated to submit data to CDC that are high quality and complete Environment Public Reporting Pay for reporting Pay for performance Impact Changes in NHSN s purposes, infrastructure, and operations New scrutiny of HAI case criteria Pressure to simplify HAI definitions and move to electronic HAI detection and reporting Increasing attention to data quality NHSN at Age 10 (2015) > 18,000 facilities 1. Predominantly mandatory and public reporting system 2. Vast majority of healthcare facilities enrolled had not participated in legacy CDC system(s) 3. Primary motivation for facilities is compliance with reporting requirements 4. Uncertainties about quality and completeness of data submitted to CDC 9

10 HAI public reporting, pay for reporting, and pay for performance programs are part of a larger trend toward more transparency and accountability in healthcare 10

11 CMS Payment Programs and Hospital Infection Prevention: Making the Connections Programs created under the ACA to reward Federal programs for high performance (quality) vs provision of services (volume) Hospital Acquired Condition (HAC) Reduction Program Value Based Purchasing Hospital Readmission Reduction Program 11

12 History of CMS Payment re: HAC In October 2008, CMS discontinued additional payments for preventable HACs. Vascular-catheter-associated infection Catheter-associated urinary tract infection Pressure ulcers (stage III and IV) Falls and trauma Surgical site infection after bariatric surgery for obesity Certain orthopedic procedures Bypass surgery (mediastinitis) Administration of incompatible blood Air embolism Foreign object unintentionally retained after surgery 3/25/

13 Hospital-Acquired Conditions are defined as: Conditions that patients acquire while receiving treatment for another condition in an acute care health setting. 3/25/

14 HAI Reporting and Hospital Payment Inpatient Prospective Payment System (IPPS): new regulations are published by CMS annually by August 1; changes become effective beginning of next fiscal year (October 1) These regulations also address hospital quality reporting programs including: Hospital Acquired Conditions (HAC) Reduction (among others) 3/25/

15 HAC Domains and Measures for FY 2015 and Beyond Domain 1: AHRQ PSI 90 Composite PSI-3: Pressure Ulcer PSI-6: latrogenic Pneumothorax PSI-7: Central venous catheter-related blood stream infection rate. PSI-8: Hip fracture rate PSI-12: Postoperative PE/DVT rate PSI-13: Sepsis rate PSI-14: Wound dehiscence rate PSI-15: Accidental puncture Domain 2: CDC Measures 2015: CAUTI and CLABSI FY 2016: Addition of SSI (Colon and Abdominal Hyst) FY 2017: Addition of MRSA and C.difficile 3/25/

16 Hospital-Acquired Condition Reduction Program: Impact N=700 hospitals with Medicare payments reduced 1% in FY 2015 Payments for all hospital discharges occurring after Oct 1,2014 reduced by 1% CMS estimate: overall payments will drop by approx. $330 million in 2015 due to the hospital HAC program 3/25/

17 Total HAC Score Total HAC Score Domains Domain 1 Weighted at 25% in FY 2016 Domain 2 Weighted at 75% in FY 2016 Measures PSI 90 Composite CLABSI CAUTI SSI 17

18 Readmissions Reduction Program (HRRP) Effective for discharges Oct 2012 Requires CMS to reduce payments to IPPS hospitals with excess admissions 18

19 Example of a Monthly Reporting Plan with an IRF Unit 19

20 Data for CMS Quality Reporting Programs Due Soon DEADLINE: February 15, 2016 Inpatient Rehabilitation Facilities (IRFs): IMPORTANT The CMS IRF Quality Reporting Program has extended the deadline for Q1 and Q2 CAUTI, MRSA LabID, and CDI LabID data submitted to CMS The new deadline for submission of Q1, Q2 and Q NHSN data for the IRFQRP is February 15,

21 Monthly Reporting Plan (Top) 21

22 Monthly Reporting Plan (Bottom) 22

23 Critical Access Hospitals: MBQIP: OP-27 - Influenza Vaccination Coverage among Healthcare Personnel Beginning September 1, 2015 included as a required measure for MBQIP reporting The Influenza Vaccination Summary within the HCP Vaccination Module is designed to assist staff in healthcare facilities to monitor influenza vaccination percentages among HCP Influenza season: 1 October 31 March 23

24 Location Mapping in NHSN Instructions for Mapping Patient Care Locations in NHSN - Section 15 (pg. 217) of manual Decision making tool for adding new units or change in patient mix Review locations annually Begin with determination of Acuity Level Type of Service 24

25 A couple of quiz questions How would you map A unit that is comprised of 60% Medical ICU and 40% Step Down patients? 25

26 How would you map An ICU that is 55% Medical and 45% Surgical 26

27 Managing temporarily closed locations 27

28 Reporting: Temporarily Closed Location Unit Closed (for Renovation, Remodeling, etc) Everybody moves (staff and patients) Change: Your Code and Your Label values on new location Include patient data on the unit where they reside. Keep closed location mapped ACTIVE and on Monthly Reporting Plan. Report 0 Denominator and NO Events

29 Section: New Reference Guide for Acute Care Hospital Reports Help to create record of changes in NHSN reporting (e.g. with CMS) and analyze YOUR data for: modifications (e.g. when an event was first entered) takes you to Frequently Requested/Output Reports

30 Patient Safety Component Section: Updates to the NHSN Antimicrobial Use Option Standardized Antimicrobial Administration Ratios 30

31 Ventilator Associated Events (VAE) 31

32 VAE Reporting VAE is included in CMS Hospital Inpatient Quality Reporting program for LTACH facilities in 2016 VAE is not included in CMS Hospital Inpatient Quality Reporting program for acute care or inpatient rehab facilities What rates are appropriate for use in public reporting, inter-facility comparisons, etc? Overall VAE rate = rate of ALL events meeting at least the VAC definition IVAC-plus rate = rate of ALL events meeting at least the IVAC definition Individual events may be useful for internal use Rates of individual events: VAC only, IVAC only, PVAP only 32

33 Ventilated Patients and Surveillance Efforts Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation but other adverse events also happen to patients on ventilators No valid, reliable definition for VAP PNEU-VAP definition includes subjective elements and is neither sensitive nor specific for VAP Not ideal in an era of public reporting of healthcareassociated (HAI) rates, comparisons among facilities and pay-for-performance program 33

34 VAE Surveillance VAE Surveillance Working Group convened in 2011 January 2013 new approach finalized by the working group and implemented in NHSN Ventilator-Associated Events (VAE) replaced inplan VAP surveillance for ventilated patients in adult locations Focus on objectivity, reliability and ability to automate Enhance ability to use surveillance data to drive improvements in patient care and safety 34

35 Pathogen Exclusions apply to both PNEU/VAP and VAE Candida species or yeast not otherwise specified, coagulase negative Staphylococcus species, and Enterococcus species are excluded unless isolated from lung tissue or pleural fluid Indication of isolation of commensal flora of the oral cavity or upper respiratory tract Candida species will continue to be included as a pathogen for meeting PNU3 (immunocompromised patient) Cryptococcus, Histoplasma, Coccidioides, Paracoccidioides, Plastomyces, Pneumocystis Community associated fungal pathogens Rare cause or are not known to cause healthcare-associated infections 35

36 Identifying HAI for NHSN Surveillance Key Concept SSI LabID VAE Infection window period N/A Date of event Yes POA N/A HAI N/A Repeat Infection Timeframe (RIT) N/A Not applicable Not applica ble Secondary BSI Attribution Period * 36

37 Who is eligible for surveillance? Inpatients of acute care hospitals, long term acute care hospitals, inpatient rehab facilities Patients in adult locations are eligible for VAE surveillance Pediatric patients * in adult locations included in VAE surveillance Adults in pediatric locations included in ped/vap surveillance * NOT recommended to include in VAE surveillance young children housed in adult ICU location who are not thought to be physiologically similar to the location s adult patient population (consider virtual location) 37

38 Who is NOT eligible for surveillance? Patients who have been ventilated <3 days are not eligible Patients on high frequency ventilation (HFV) or extracorporeal life support (ECLS) are not eligible for VAE surveillance (during the time they are receiving those therapies) 38

39 If a patient is admitted with a community acquired pneumonia (CAP), they are excluded from VAE surveillance for 14 days. 1. True 2. False 39

40 VAE Definition Algorithm Summary No CXR Needed! Respiratory Status Component PP Patient on mechanical ventilation >2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC) Infection/ Inflammation Component Additional Evidence General evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC) Positive results of microbiological testing Possible VAP (PVAP) 40

41 VAE Algorithm Algorithm is progressive in terms of criteria to be met (from VAC to IVAC to PVAP), but this is not to imply that each subsequent tier is more clinically significant than the one before IVAC is not necessarily worse than having VAC PVAP is not necessarily worse than having IVAC The fundamental definition within the algorithm is the VAC defined on the basis of respiratory deterioration. IVAC additional evidence that the event may be infectious vs. non-infectious PVAP additional evidence the infection may be respiratory related. 41

42 Tips for Getting Started Get familiar with the protocol and review the FAQs Experiment with the VAE Calculator Version

43 Preparing for VAE Surveillance Establish relationships with Respiratory Therapy and/or Critical Care colleagues: Share the protocol Discuss options for collection of minimum daily PEEP and FiO2 for each MV day (IP, RT, electronically generated) Inquire about frequency with which excluded therapies (HFV, ECLS) and APRV are used Determine your laboratory s approach to Gram stain and culture result reporting How does your hospital lab report Gram stain results? Does your hospital laboratory report culture results quantitatively? What quantitative ranges correspond to the semi-quantitative reports? 43

44 Preparing for VAE Surveillance Develop a plan for organizing the data elements needed to identify VAEs PEEP and FIO2 WBC/ Temperature Antimicrobial agents (administration not orders) Laboratory results Explore use of tools for data collection 44

45 Section: VAE: Rates Dataset and Output 2016 Reminder: Current specific event types with VAE are VAC (Ventilator Associated Condition) IVAC (Infection-related Ventilator Associated Complications) Possible VAP (PVAP) 2016 release: Some new comparison data available (Nation Pooled Mean Rates) Pay close attention to rate output Titles will designate what is included (e.g. IVAC Plus = VAC + IVAC)

46 Can I use the PNEU definitions to assign a secondary BSI when doing CLABSI surveillance? YES, PNEU definition can be used as a site-specific infection for secondary BSI attribution when conducting CLABSI surveillance PNEU definition can be used as a site-specific infection for secondary BSI attribution when conducting CLABSI surveillance even for adult patients Remember that secondary bloodstream infections can only be reported for PNU2 and PNU3 specific events Remember that PNEU has excluded pathogens 46

47 C.difficile and MRSA: Lab ID Reporting 47

48 Patient Safety Component 4 Modules Patient Safety Component Device-associated Module Procedureassociated Module Antimicrobial Use and Resistance (AUR) Module MDRO & CDI Module 48

49 Reporting Requirements and Options Active Participants must choose main reporting method Infection Surveillance (MDRO/CDI) LabID Event Reporting (MDRO/CDI) Additional options then become available Prevention Process Measures Adherence to Hand Hygiene Adherence to Gown and Glove Use Adherence to Active Surveillance Testing (for MRSA/VRE only) Outcome Measures AST Prevalence/Incidence (for MRSA/VRE only) 49

50 2016 Changes to LabID Reporting Form Two questions changed from optional to conditionally required: Last physical overnight location of patient immediately prior to arrival into facility Has the patient been discharged from another facility in the past 4 weeks? 50

51 Definitions MRSA: S. aureus testing oxacillin, cefoxitin, or methicillin resistant: or positive from molecular test for meca and PBP2s C.difficile: A positive result for a laboratory test for C.difficile toxin A and /or B (e.g. enzyme immunoassay, or EIA test), OR a toxin-producing C.difficile organism detected in the stool specimen by culture or other laboratory means (e.g. nucleic acid amplification testing by polymerase-chain reaction, or PCR) 51

52 Acute Care If participating in the CMS Inpatient Quality Reporting (IQR) Program Acute care hospitals (PPS) must report MRSA Bacteremia and C.difficile LabID Events at Facility-wide Inpatient (FacWideIN*) level * FacWideIn includes E.D.s and 24-hr Observation locations 52

53 Inpatient Rehab Facility Quality Reporting Program (IRFQR) If participating in the CMS Inpatient Rehabilitation Facility Quality Reporting Program (IRFQR) Program MRSA Bacteremia and C.difficile LabID event reporting is required for free-standing IRFs (facilitywide inpatient (FacWideIN) and for IRF units within an acute care or ciritcal access hospital (by specific location). Effective date: January 1,

54 Why LabID? LabID event reporting allows laboratory testing data to be used without clinical evaluation of the patient, allowing for a much less labor intensive methods to track C.difficile and MDROs, such as MRSA. These provide proxy infection measures of healthcare acquisition, exposure burden, and infection burden based primarily on laboratory and limited admission data. 54

55 Facility-Wide Inpatient FacWideIN Option for LabID Event reporting only! Includes inpatient locations*, including observation patients housed in an inpatient location PLUS outpatient emergency departments and 24-hour observation locations * See C.difficile LabID event protocol for location exclusions 55

56 LabID events are attributable to the location where the specimen was collected. The Transfer Rule does NOT apply to LabID event reporting. 56

57 Provision to FacWideIN LabID Event Reporting Specimens collected from any other affiliated outpatient location (excluding ED and 24-hour observation locations) can be reported for the inpatient admitting location IF collected on the same calendar day as inpatient admission) In this circumstance, the admitting inpatient location should be assigned. 57

58 Case #1 LabID Sally presents to the ED with a 2 day history of nausea, vomiting and diarrhea. She complains of abdominal pain and being dizzy. While in the ED, a loose stool specimen is collected for C.difficile testing. She is admitted to the 24-hr observation unit: 2 South. After admit, the stool specimen returns positive for C.difficile toxin B. What location is used for LabID event attribution? 1. ED 2. 2 South 3. Location is left blank 4. FacWideIN 58

59 Steps in LabID process Set up locations Create monthly reporting plan Enter Events 59

60 Case#2 LabID Your PPS facility is following FacWideIN LabID event reporting. It has four medical and surgical inpatient locations as well as one ED and one unique CCN inpatient rehab units. How many rows should show under the facility MDRO reporting module? 1. 2 (FacWideIN for MRSA and CDI) 2. 3 (FacWideIN, ED, IRF) 3. 6 (FacWideIN : MRSA and CDI; ED: MRSA and CDI; IRF: MRSA and CDI) 4. I give up! 60

61 Do active surveillance testing specimens (AST) count with MRSA LabID? Yes No 61

62 Note on C.difficile specimens C. difficile testing only on unformed stool samples!! Stool should conform to the shape of the container. 62

63 Methods for CDI LabID Model to predict healthcare facility-onset (HO) CDI LabID Events After 2014, CDI LabID SIRs require the CDI Test Type on a quarterly basis The CDI test type is reported on the denominator records each quarter If Other is selected when a more appropriate response is available on the form, your facility s data will not be risk-adjusted to the most appropriate level. Other should not be used to name specific laboratories, reference laboratories, or the brand names of C.difficile test; most methods can be categorized accurately by selecting from the options provided 63

64 New Data Quality Output for 2016 New analysis data output option to alert when the CDI Test Method has been downgraded Does not necessarily indicate a problem Line Listing CDI Test Method History 64

65 Things to remember about events counted in the numerator MRSA Bacteremia Only hospital onset (HO) MRSA LabID events from blood specimens are included in the SIR. If a patient has a positive MRSA bacteremia LabID event within 14 days of a previous MRSA bacteremia LabID event (regardless of location) the second event is not counted in the SIR C.difficile Only hospital-onset (HO) C.difficile incident LabID events are counted in the SIR and cdiassay = Incident 65

66 Data for CMS Quality Reporting Programs Due Soon Acute Care Hospitals that participate in the Hospital Inpatient Quality Reporting (IQR) Program: 2015 Quarter 3 (7/1 9/30) CLABSI and CAUTI data All ICU locations Adult and pediatric medical, surgical, and medical/surgical wards 2015 Quarter 3 (7/1 9/30) Inpatient COLO and HYST SSI data 2015 Quarter 3 (7/1 9/30) MRSA Bacteremia and C. difficile LabID Events (all healthcare onset and community onset) FacWideIN ED, and 24-hour observation locations 66

67 Data for CMS Quality Reporting Programs Due Soon Cancer Hospitals that participate in the PPS- Exempt Cancer Hospital Quality Reporting Program: 2015 Quarter 3 (7/1 9/30) CLABSI and CAUTI data (all bedded inpatient care locations) 2015 Quarter 3 (7/1 9/30) Inpatient COLO and HYST SSI data 67

68 Data for CMS Quality Reporting Programs Due Soon Long-Term Acute Care Facilities (LTACs/LTCHs): IMPORTANT: The CMS Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) has extended the deadlines for Q1, Q2, and Q CLABSI, CAUTI, MRSA LabID, and CDI LabID data submitted to CMS via the CDC s NHSN. The new deadline for submission of Q1, Q2, and Q NHSN data is February 15, Quarters 1,2,& 3 (1/1-9/30) CLABSI, and CAUTI data all bedded inpatient locations 2015 Quarters 1,2,&,3 (1/1-9/30) MRSA Bacteremia& C. diff LabID events FacWideIN, all healthcare onset and community onset 68

69 Contact Information NEW HAMPSHIRE Margaret Crowley

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