Benefits of Reporting in NHSN. April 24, 2018

Transcription

1 Benefits of Reporting in NHSN April 24, 2018

2 HealthInsight Team Donna Thorson Project Manager Nevada Leah Brandis Project Manager Oregon Shannon Cupka Project Manager New Mexico Shylettera Davis Project Manager Utah 2

3 HealthInsight Supports Lynn Kemper Assistant Director Long Term Care Eric Sather Multi-State Analyst Lisa Barton Project Coordinator 3

4 Objectives Participants will be able to Describe the benefits of reporting into NHSN Generate and interpret an NHSN report Discuss related regulations that impact nursing home operations 4

5 HealthInsight Overview of the CDI Cohort To determine if CDI is a problem in Nursing Homes Establish a state and national baseline Identify opportunities for preventing CDI 5

6 Benefits of Reporting into NHSN NHSN provides nursing homes a customized system for tracking infections in a streamlined and systematic way. Provides national rates for facilities to use as a baseline for assessing their own rates and prevention efforts. In addition, your facility can chose to share data with other partner facilities, corporate staff, or other entities (i.e., public health agencies) 6

7 Benefits of Reporting into NHSN (cont.) Can also report other data into NHSN (i.e., UTI, hand hygiene, PPE exposure and monitoring). You and your facility will already be prepared if this process becomes mandatory in your state. (NHSN reporting for CDI and UTI are already required in Nevada.) 7

8 Reports Available in NHSN Line Listing All CDI LabID Events Resident ID Current admission date Event date Specimen organism type Specimen source Location (within building) Transfer from Transfer from within last 4 weeks Line Listing for All Summary Data Number of resident days Number of catheter days Number of resident admissions 8

9 Additional Reports Rate Tables for CDI LabID Event Data Total CDI Rate CDI Treatment Prevalence on Admission Total CDI Percent that is Community-Onset (CO) Total CDI Percent that is LTCF-Onset (LO) and CDI LO Percent that is Acute Care Transfer (ACT LO) Total CDI Percent that is Recurrent LTCF-Onset (LO) CDI Rate LTCF-Onset (LO) Incident Rate Line Listing LTCF Adherence to Seven Core Elements of Nursing Home Antibiotic Stewardship Program Line Listing Antibiogram 9

10 Generating Reports in NHSN Before using the analysis function, make sure to clear alerts (incomplete/missing events, incomplete/missing summary items) Remember to generate a new data set to ensure all data is included Unresolved alerts will prevent data from showing up in Rate reports even if new data sets are generated 10

11 Tracking Tool National Nursing Home Quality Improvement Campaign 11

12 Data Entry 12

13 Process Tracking 13

14 State-Specific Data (NHSN CDI Cohort) State Baseline (Mar 2017-Dec 2017) Quarter Nevada New Mexico Oregon Utah

15 Revised Data Reports 15

16 Connection to Regulations November 28, 2017 Regulation (SOM Appendix PP, ) (a)(2) (i) A system of surveillance: routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility s surveillance system must include a data collection tool and the use of nationally-recognized surveillance criteria such as but not limited to CDC s National Healthcare Safety Network (NHSN) Long Term Care Criteria to define infections or updated McGeer criteria (a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. NHSN LTCF HAI Module Utilization of nationally-recognized surveillance criteria in NHSN Inputting data into NHSN as a data collection tool Running NHSN reports for analysis and interpretation Tracking CDI is a component of a good antibiotic stewardship program 16

17 Connection to Regulations November 28, 2019 Regulation (SOM Appendix PP, ) (b) Infection preventionist (b)(4) Have completed specialized training in infection prevention and control. NHSN LTCF HAI Module NHSN facility administrator and NHSN user could be the infection preventionist Training to use NHSN for data collection, analysis and interpretation of infection data is a component of infection prevention and control training 17

18 Upcoming Infection Prevention Webinars Preventing the Spread of CDI Tuesday, June 26, :30 a.m. PT / 12:30 p.m. MT What to Do if There Is a CDI Outbreak Tuesday, July 17, :30 a.m. PT / 12:30 p.m. MT Be sure to invite any of your staff who would benefit from this information. 18

19 Action Items Go to NHSN to pull reports and review rates for trends What is it that is affecting your rates Present this information at your next QAPI meeting 19

20 Visit Us Online! HealthInsight s nursing home web pages provide many resources specific to nursing home staff. CDI / NHSN Material: Infection prevention and antibiotic stewardship: Resident Safety Collaborative main page: The Nursing Home Resource Library and Collaborative materials are linked in the right sidebar please explore! 20

21 Resources and References AHRQ Nursing Home Antimicrobial Stewardship Guide (Includes toolkits) NHSN training for nursing homes The recording and handouts from today s webinar will be saved 21

22 Questions? 22

23 We want your feedback! Please complete the evaluation in the Chat Link 23

24 Contact information Donna Thorson, MS, CPHQ Project Manager Leah Brandis, RDN, CSG Project Manager Shannon Cupka, EdM Project Manager Lisa Barton Multi-state Project Coordinator Shylettera Davis, BSN, RN Project Manager Lynn Kemper Assistant Director, Long-Term Care healthinsight.org/nh-collaborative 24

25 Thank you for your time and commitment! This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, 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. 11SOW-C /24/18 25