CDI Event Reporting for the National Healthcare and Safety Network (NHSN)

Transcription

1 CDI Event Reporting for the National Healthcare and Safety Network (NHSN) Aimee Ford, MS, RN Jason Lempp, MPH,CIC Quality Improvement Consultants November 9, 2016

2 Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIO Program One of the largest federal programs dedicated to improving health quality at the local level 2

3 Housekeeping 3

4 Speakers for Today s Call Aimee Ford, MS, RN QI Consultant Washington Jason Lempp, MPH, CIC QI Consultant Washington 4

5 Objectives Review common terms and definitions used in NHSN monthly reporting Identify what qualifies for LabID event reporting Learn how CDI LabID events are defined and categorized Understand what information staff will need to enter into NHSN on a monthly basis 5

6 6

7 What Is a LabID Event? 7

8 CDI LabID Event Reporting Checklist Verify that locations are correctly mapped in NHSN Review monthly reporting plan and update as needed Enter facility-wide denominator data for each month under surveillance Identify and enter all C. difficile LabID events into NHSN by location Resolve Alerts, if warranted 8

9 Mapping Locations 9

10 Monthly Reporting Plan 10

11 Ready for Reporting! 11

12 Required Information Events = Numerator Each CDI event that meets definition of LabID event Summary Data = Denominator data Resident-days per month Resident admissions each month Residents admitted on CDI treatment each month 12

13 Denominator 13

14 Denominator 14

15 Denominator 16

16 Denominator 17

17 Events! 18

18 What if There Are No Events? 19

19 C. difficile Positive Lab Assay 1. A positive lab test result for C. difficile Toxin A and/or B 2. A toxin-producing C. difficile organism detected by culture or other lab means *Testing should be performed only on liquid stool samples 20

20 CDI LabID Event A C. difficile positive laboratory assay obtained: When the resident is receiving care in the nursing home, and The resident has no prior CDI positive laboratory assay collected in the previous 14 days Two types: Incident and recurrent 21

21 CDI LabID Event Duplicates positives resets 14 window Keep track of these outside of NHSN 22

22 All identified CDI LabID events must be entered into NHSN using the specific location where the resident was assigned at the time of the specimen collection LabID Event reporting requires facility-wide inpatient ( FacWidIN ) surveillance, meaning all residents in all locations must be monitored for CDI Lab results from outside facilities (before admit) should NOT be included in LabID event reporting 23

23 LabID Event Categorization Community-onset: Date specimen collected 3 calendar days after current admission to the nursing home (i.e., days 1, 2, or 3 of admission) LTCF-onset: Date specimen collected > 3 calendar days after current admission to the nursing home (i.e., on or after day 4) 24

24 Numerator 25

25 Numerator 26

26 Alerts 27

27 Alerts Facilities must resolve Alerts before data is considered complete The most common reason for alerts when reporting in the LabID Event module are: 1.Missing summary (denominator) for the month 2.Incomplete summary (denominator) when no CDI LabID Events were identified during the month Report No Events 28

28 Live Demonstration

29 Q&A 30

30 Take Home Points Number of CDI LabID events (including zero) will need to be entered into NHSN monthly Lab results from outside facilities (before resident admission) should not be included in Lab ID event reporting Suggest keeping a log of positive CDI lab results from residents and recent hospitalizations to help track duplicate test results Don t forget to save events! 31

31 Next Steps Develop and implement a plan to enter data every month If you don t have one, create a succession plan to ensure continuity of access to NHSN. **At least 2 users in your facility! Qualis Health is here to support your success in reducing CDIs and using NHSN 32

32 References 1. Centers for Disease Control (CDC) LabID Event Training: TCF-LABID-Event-training.pdf 2. National Healthcare and Safety Network (NHSN) data collection forms: 33

33 More Information Aimee Ford, MS, RN QI Consultant (206) Jason Lempp, MPH, CIC QI Consultant (206) Please let us know what you thought of this presentation: 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-C2-QH