NHSN Updates. Linda R Greene RN, MPS, CIC

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1 NHSN Updates Linda R Greene RN, MPS, CIC linda.greene@urmc.rochester.edu

2 Objectives Describe changes to NHSN definitions Explain how these changes are consistent with the HHS action plan Identify new prevention practices or implementation strategies related to SSIs, CAUTIs, C difficile and CLABSIs

4 Feelings of Helplessness Broken escalator

5 General Changes in NHSN Reporting Requiring Medicare Number

6 Surgical Site Infections (SSIs) Data Source: National Healthcare Safety Network (NHSN) Metric: Standardized Infection Ratio (SIR) = Observed # of HAIs Baseline Period: Predicted # of HAIs 5 year target: 25% reduction in SSIs following SCIP-like procedures on admission or readmission (SIR=.75) 2012 Procedure Specific SIR 2012 Preliminary: 20% reduction (SIR=.80) Overall.80 Colon Surgery.80 Abdominal Hysterectomy.89 Knee Replacement.76 Hip Replacement.84 Coronary Artery Bypass.71 Other Cardiac.68 Vaginal Hysterectomy.90 Rectal Surgery.76 Peripheral Vascular Bypass.74 Source: Excerpted from Presentation of Paul Malpiedi, Health Scientist, CDC

7 Changes to Reporting CPT Codes used for billing Not readily available in inpatient

Reporting Requirements- SSI Will require height and weight Diabetes ( definition: oral agent or insulin) Include procedures not primarily closed- indicate if not primarily

9 Reporting Requirements- SSI Will require height and weight Diabetes ( definition: oral agent or insulin) Include procedures not primarily closed- indicate if not primarily closed for risk adjustment Musculoskeletal Disease Society definition- SSI PJI will replace SSI JNT (Periprosthetic) HPRO and KPRO ( additional details hemi, total, resurfacing)

10 Challenges Denominator data readily available? Redesigning collection forms ICD-10 may be challenging

11 OK, I m no statistician what s all this mumbo jumbo about? The SIR In simple terms- you are compared to the average of a referent population adjusted for risk. In this case it is a historical control.

12 What about CMS? Rate reported as a SIR (Deep and Organ space only) Risk adjusted Expected/Observed Complex risk adjusted methodology

13 Simply Put A SIR of 1.0 means the observed number of infections is equal to the number of expected infections. A SIR above 1.0 means that the infection rate is higher than that found in the "standard population." For HAI reports, the standard population comes from data reported by the hundreds of U.S. hospitals that use the NHSN system. The difference above 1.0 is the percentage by which the infection rate exceeds that of the standard population. A SIR below 1.0 means the infection rate is lower than that of the standard population. The difference below 1.0 is the percentage by which the infection rate is lower than that experienced by the standard population

14 The SIR PROS Surgical risk adjustment is a significant improvement Consistent with other types of data such as mortality Advantages with rare events CONS Risk adjustment still suboptimal especially with CLABSI data Not designed to compare 1 institution t another- only to compare with national average Potential problems with ranking,etc Overall rates can cloud the big picture

15 NHSN Current National Results 25 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with hip arthroplasty 30 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with knee arthroplasty 20 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with colon surgery 15 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with abdominal hysterectomy

16 Ambulatory Surgery Centers Coming soon: Identify a set of ASC procedures for which HAI definitions and measures should be developed Support a plan for routine surveillance that can be consistently be implemented Reporting through NHSN

Hospital Analysis summaryyproccount infcountcomplexnumexpcomplexsircomplex SIRComplex_pvaSIRComplex95CI proccode months 2012H1 813 12 9.467 1.268 0.245 0.655, 2.214 2012H1 90 4 2.605 1.536 0.265 0.

17 Hospital Analysis summaryyproccount infcountcomplexnumexpcomplexsircomplex SIRComplex_pvaSIRComplex95CI proccode months 2012H , H , COLO H , HPRO H , HYST 6 Where is my greatest opportunity for improvement? What is your interpretation of my overall SIR? Where am I performing well?

18 How about evidence on prevention? New HICPAC guidelines on SSI public comment soon. No post-operative doses of antibiotics for clean and cleancontaminated cases Re-dose if procedure exceeds half life of antibiotic, excessive blood loss or extensive burns Alcohol based prep Do not use antimicrobial sutures to prevent SSI Maintain normothermia No method suggested Antimicrobial dressings- unresolved issue

CAUTI Proposed CAUTI definitional changes with anticipated implementation in NHSN in 2015 Two approaches in consideration includes: o Simplified approach; more stream-lined; more specific/ less

19 CAUTI Proposed CAUTI definitional changes with anticipated implementation in NHSN in 2015 Two approaches in consideration includes: o Simplified approach; more stream-lined; more specific/ less sensitive o Correlated with Clinical determination utilizing treatment for UTI as element of criteria Moving ahead to look at symptoms with spinal cord injury for a stream-lined definition Allow for fever with other recognized cause Pilot the criteria and definitions and pilot both approaches(comparing to current CAUTI definition) Mini pilot and will tweak to the data collection form and then expand to more settings Any changes would be made by January, 2015

20 Other Issues Lab Survey Looking at Candiduria

21 CAUTI

22 States with SIR above 1 Colorado Iowa California Michigan Mississippi Indiana Kentucky Illinois North Carolina Arizona Washington Idaho Nevada Montana Arkansas Delaware Oregon New York 1.38 Rhode Island Vermont New Hampshire Tennessee Nebraska District of Columbia Minnesota Massachusetts South Carolina Connecticut Maine Utah 1.9

23 Concern over CAUTI HHS Action Plan Basic and/or Laboratory Science Facilitate research to enhance our understanding of factors leading to the development of CAUTI and the optimal modes of prevention, diagnosis, and therapy. A logical area for attention is biofilms. Identify methods to differentiate bladder colonization from CAUTI in patients with catheters. Epidemiology Explore the epidemiology of CAUTI and asymptomatic bacteriuria, including incidence, outcomes, and relative contributions to the use of antimicrobials. Identify methods to improve the surveillance of CAUTI, including determining the accuracy of surveillance definitions in select populations (e.g., elderly patients) and developing methods for electronic capture of CAUTI. Study the epidemiology of antimicrobial resistance in uropathogens, considering the role of different urinary catheter systems as reservoirs for resistant bacteria and the presence of resistance to antimicrobial/antiseptic coatings. Quantify the unnecessary use of urinary catheters and its consequences (trauma, encrustation).

24 Other concern over CAUTIs Most significant reductions in Non- ICU settings Device utilization in ICUs has not decreased dramatically Thought that all critical care patients should have a catheter HICPAC Guidelines non specific on this issue Work underway to improve precision on this metric

25 Historically No Respect for CAUTIs

26 Long Term Care New NHSN reporting in Long Term Care Facilities is currently available for certified skilled nursing facilities/nursing homes and intermediate/chronic care facilities for the developmentally disabled.

29 What is new since HICPAC Guidelines? Technical evidence minimal Pickard Study ( RCT) no support for antiseptic catheters Much more evidence on socio- adaptive aspects of prevention and on hard wiring insertion and removal protocols ( nurse-driven protocols, stop orders, indications for insertion) Connection to other causes of patient harm

30 Connect the Safety Dots Immobility Urinary Catheter Harm Trauma Falls? Decubs? Discomfort Satisfaction DVT? CAUTI Delays, LOS Antibiotic Resistance C Diff infection Cost$

31 Challenges While rounding in the ICU, one of the nurses notes that Ms. X no longer requires a urinary catheter The physician replies Why don t you just leave it in, it makes life easier for the nurses. What is the issue? How can we resolve it? 31

CLABSI In 2014, an additional field will be added to the CLABSI module, indicating an inpatient dialysis unit This will still be attributed to the inpatient

32 CLABSI In 2014, an additional field will be added to the CLABSI module, indicating an inpatient dialysis unit This will still be attributed to the inpatient unit, but will give organizations the opportunity to analyze these infections and Identify opportunities not specific to their unit. Expand electronic capture of data

33 Research Priorities Understand Role of Biofilm Understand barriers to implementation of evidence based practices Optimal strategies for catheter maintenance

36 Focus More focus outside of ICU Report in non ICU location Challenges: Daily review for necessity of line Maintenance issues

37 C difficile- NHSN Reporting Continue to use lab ID Event For C difficile SIR- report lab testing type on quarterly basis to allow for changes in testing methodology through the year ( this is used for the risk adjustment) New lab ID calculator coming Data module for long term care

38 C difficile Goals: 1. Improve Antimicrobial Stewardship 2. Improve environmental contamination

39 C difficile bundle A- Antibiotic Stewardship B- Barrier Precaution C- Compulsive Hand washing D- Disinfection of Environment E- Executive Sponsorship

40 summary YQ CDIF HO Count numexp CDI SIR SIR_pval sir95ci 2012Q , Q , Q , Q , Which statement is not correct? A. The table demonstrates a possible opportunity for improvement A. The yearly SIR is below 1 C. The Hospital performed well the first quarter D. The second quarter contributes the most to the determination of the yearly SIR

41 Summary Ongoing changes in NHSN Attempting electronic capture Role of the EHR Implementation science is the greatest challenge

Health Care Associated Infections in 2015 Acute Care Hospitals

Health Care Associated Infections in 2015 Acute Care Hospitals Alfred DeMaria, M.D. State Epidemiologist Bureau of Infectious Disease and Laboratory Sciences Katherine T. Fillo, Ph.D, RN-BC Quality Improvement