CDI Initiative: Accessing your Data Reports from NHSN

Transcription

1 Thank You for Joining! CDI Initiative: Accessing your Data Reports from NHSN New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888) Access Code: This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE 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 CMSQINC

2 Jacky Haskell, MS Health Information Analyst Janet D. Robinson, RN, MEd, CIC Senior Program Administrator

3 Introduction SAMS card Facility enrolled in NHSN Events reported monthly Summary data reported monthly Education in progress Clostridium difficile Antibiotic stewardship TeamSTEPPS

4 Next Steps Validate the monthly data entries. Locate the cumulative facility data. Select relevant facility reports. Use the cumulative data reports to inform policy & procedure.

5 Objectives Review the monthly data definitions. Describe how to generate data sets. Identify available reports. Describe how to generate facility reports.

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7 CDI LabID Event Definitions CDI LabID Event - REPORTED A C. difficile positive laboratory assay obtained while a resident is receiving care in the LTCF and the resident has no prior C. difficile positive laboratory assay collected in the previous 14 days while receiving care in the LTCF This is also called a non-duplicate LabID Event Note: If a resident leaves the facility for less than 48 hours (ER, DOC OFFICE) and has a C diff test done that is positive, that result would be considered a reportable event because the resident is still currently admitted to the facility. Duplicate CDI LabID Event NOT REPORTED Any C. difficile positive laboratory test from the same resident following a previous C. difficile positive test within the past 2 weeks (14 days) while in the facility

8 Positive Tests same resident October 1st CDI LabID Event REPORTED October 6 Duplicate NOT REPORTED October 17 Duplicate NOT REPORTED November 6 CDI LABID Event REPORTED

9 Admission Date Definitions Date of First Admission to Facility- date resident first entered facility. If resident leaves facility for >30 days and returns, enter date of return to facility. Short stay: <=100 days from date of first admission Long stay: >100 days from date of first admission Date of Current Admission to Facility most recent date resident entered facility. If resident has not left facility for >2 calendar days, then date of current admission will be same as Date of First Admission.

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11 Summary Data Definitions Monthly totals Resident admissions For each day, record the number of admissions (include readmissions when a resident was out of the facility for >2 calendar days), and then add up the numbers for the monthly total. Resident days For each day, record the number of residents present (do not include bedholds), and then add up the numbers for the monthly total. Number of Admissions on C. difficile treatment For each day, record the number of residents admitted while receiving antibiotic therapy for C difficile infection, and then add up the numbers for the monthly total. ***If there are NO LabID Events for the month, the Report No Events box must be checked off on the Summary Data page.

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13 Generating Datasets First step before starting any analysis of your NHSN data Any changes to your data are not reflected in reports until the next time you generate datasets

14 Generating Datasets

15 Available Reports Line Listing All Summary Data Line Listing All CDI LabID Events Rate Tables for CDI LabID Event Data

16 Summary Data Line Listing All Summary Data View a summary of the data you entered for all months, or for a specific timeframe Identify months when events occurred

17 Summary Data Modify the report by selecting a time period

18 Summary Data Facility data used to calculate CDI rates orgid summaryym summarytype eventtype numresdays numltucathdays numresadm noevents numurinecultord numresadmcdifrx M05 MDRO CDIF 3, N M06 MDRO CDIF 2, N M07 MDRO CDIF 2, Y M08 MDRO CDIF 2, Y M09 MDRO CDIF 2, Y. 0 Year and month (summaryym) e.g., 2017M05 is May 2017 Number of resident-days (numresdays) Number of resident admissions (numresadm)

19 Summary Data Overview of CDI event data orgid summaryym summarytype eventtype numresdays numltucathdays numresadm noevents numurinecultord numresadmcdifrx M05 MDRO CDIF 3, N M06 MDRO CDIF 2, N M07 MDRO CDIF 2, Y M08 MDRO CDIF 2, Y M09 MDRO CDIF 2, Y. 0 No events reported in a given month (noevents) N = events reported, Y = no events, Missing = incomplete data # of admissions on C. difficile treatment (numresadmcdifrx)

20 Line Listing of CDI Events Line Listing All CDI LabID Events Allows you to review each event Can be used for data quality checks

21 Line Listing of CDI Events Categorizing LabID events (e.g., communityonset) orgid CCN resid curadmdate eventid eventdate spcorgtype specimensource location xferfrom xferfrom4wk /15/ /21/2017 CDIF STOOL A N /5/ /14/2017 CDIF STOOL B Y Current admission date (curadmdate) Event ID, which is assigned after entering the event in NHSN (eventid) Transferred from acute care facility in past 4 weeks (xferfrom4wk)

22 Line Listing of CDI Events Categorizing LabID events Category Community onset (CO) Long-term care facility (LTCF) onset (LO) LTCF-onset related to acute care transfer (ACT-LO) Specimen was collected 3 calendar days after current admission date > 3 calendar days after current admission date 4 weeks after the last transfer from an acute care facility

23 Line Listing of CDI Events orgid CCN resid curadmdate eventid eventdate spcorgtype specimensource location xferfrom xferfrom4wk /15/ /21/2017 CDIF STOOL A N /5/ /14/2017 CDIF STOOL B Y Event date (June 14) is >3 calendar days after the current admission date (June 5) LTCF-onset (LO) Less than 4 weeks since transfer from acute care facility LTCF-onset related to a recent acute care transfer (ACT-LO)

24 Rate Tables for CDI Events Rate tables for CDI LabID Event Data View facility CDI rates calculated in NHSN Review categorization of CDI LabID events

25 Rate Tables for CDI Events Total CDI Rate CDI Treatment Prevalence on Admission Total CDI Percent that is: Community-Onset (CO) LTCF-Onset (LO) and Acute Care Transfer- Long-term Care Facility-onset (ACT-LO) Recurrent LO CDI Rate LO Incident CDI Rate

26 Rate Tables for CDI Events All reported CDI events Total CDI rate per 10,000 resident days (ltccdirate) = CDI Count / Number of Resident Days 10,000 summaryym location ltccdicount numresdays ltccdirate 2017M05 FACWIDEIN 1 3, M06 FACWIDEIN 1 2, M07 FACWIDEIN 0 2, M08 FACWIDEIN 0 2, M09 FACWIDEIN 0 2,864 0

27 Rate Tables for CDI Events summaryym location numresadmcdifrx numresadm cditreatprev 2017M05 FACWIDEIN M06 FACWIDEIN M07 FACWIDEIN M08 FACWIDEIN M09 FACWIDEIN CDI treatment prevalence on admission (cditreatprev) = Residents Admitted on C. difficile Treatment / Number of Resident Admissions 100

28 Rate Tables for CDI Events summaryym location ltccdicount ltccdicocount ltccdi_pctco 2017M05 FACWIDEIN M06 FACWIDEIN M07 FACWIDEIN M08 FACWIDEIN M09 FACWIDEIN 0 0. Number of CDI LabID Events that are CO CO events: specimen collected 3 calendar days after current admission date CO Percent (ltccdi_pctco) = CO Events / Total Events 100

29 Rate Tables for CDI Events summaryym location ltccdicount ltccdilocount ltccdi_pctlo ltccdiactlocount ltccdilo_pctactlo 2017M05 FACWIDEIN M06 FACWIDEIN M07 FACWIDEIN M08 FACWIDEIN M09 FACWIDEIN LO events: specimen collected > 3 calendar days after current admission date ACT-LO: LO event with specimen collected 4 weeks after last transfer from acute care facility

30 Further Analysis using NHSN Reports Additional rate tables Modifying report titles, variables, and filtering the data Group reports if you have access to multiple facilities in a corporation

31 Questions

32 State Contacts for the Clostridium difficile Initiative Connecticut Cynthia Hayle Maine Danielle Watford Massachusetts Ileizy Victor New Hampshire Margaret Crowley Rhode Island Janet Robinson Vermont Regina Cooper This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-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. CMSRIC

33 Mark Your Calendars Upcoming NE-NHQCC Events DEC 14 WEBINAR: Preventing and Managing C. Diff Part I Dec 14 th from 11:00am - noon JAN 4 WEBINAR: Preventing and Managing C. Diff Part II Jan 4th from 11:00am - noon 33

34 The Learning Center Captures valuable data such as: Pre and post tests Knowledge checks Surveys Learners course specific reports: Test responses Activity completions Feedback Number of Attempts Access at Learning4Quality.org Questions, comments, or concerns,

35 Connect with the New England QIN-QIO on Social Media! 35