HAI, NHSN and VBP: What s New and What You Need To Know Christine Martini-Bailey RN, BSN, CSSGB Director, Quality Improvement and Patient Safety Health Services Advisory Group (HSAG) April 27, 2017
Objectives Review the 2017 updates to National Healthcare Safety Network (NHSN) Patient Safety Component for Healthcare Associated Infections (HAI) Understand the changes in NHSN due to the re-baselining Identify the impact of NHSN re-baselining on the Centers for Medicare & Medicaid Services (CMS) Value-Based Purchasing (VBP) 2
2017 NHSN Patient Safety Component Updates 3
Updates to Organisms Lists Updates and additions to: NHSN All Organism list NHSN Mucosal Barrier list NHSN Common Commensal list Complete lists available from the Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html (Under Supporting Materials section) 4
Flow Diagram Event Determination 5 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf
Building Blocks of NHSN Patient Component Surveillance Definitions *See SSI surveillance protocol See LabID and VAE surveillance protocols N/A = Not applicable SSI = Surgical Site infection VAE = ventilator-associated pneumonia prevention 6 https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf
Transfer Rule If the date of the event is the day of transfer/discharge, or the next day, the infection is attributed to the transferring location. 7
Endocarditis (ENDO) Extended Infection Window Period (IWP) 21 days 10 days before diagnostic test 10 days after the diagnostic test Extended Repeat Infection Timeframe (RIT) Duration of admission Extended ENDO Secondary Bloodstream Infection (BSI) Attribution Period to the ENDO IWP and remaining duration of the admission for the organism that is used to meet the ENDO criterion 8
GIT (GI Tract) Criterion 2c Modification Patient has at least two of the following signs or symptoms compatible with infection of the organ or tissue involved: fever (>38 C), nausea, pain or tenderness, odynophagia or dysphagia And at least one of the following: Organisms identified from blood by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment. The organism(s) identified in the blood must contain at least one MBI organism: See Appendix A of the BSI protocol. AND Imagining test evidence suggestive of gastrointestinal infection, which if equivocal is supported by clinical correlation. 9 MBI = mucosal barrier injury
Other Definitional Changes for 2017 ORAL Added back to criterion 3a, from mucosal scrapings or exudate 3. Patient has at least one of the following signs or symptoms with no other recognized cause: ulceration, raised white patches on inflamed mucosa, or plaques on oral mucosa And at least one of the following: a. Virus identified from mucosal scraping or excaudate by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment. 10
Other Definitional Changes for 2017 LUNG, SA, and NEC-provided guidance to allow clinical correlation to be used in cases where imaging tests are equivocal for infection. (LUNG 3) Patient has imaging test evidence of abscess or infection (excludes imaging test evidence of pneumonia) which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for lung infection). 11 SA = Spinal abscess without meningitis NEC = Necrotizing enterocolitis
Pathogen Assignment Additional eligible pathogens identified within a RIT are added to the event. Pathogen exclusions for specific infection definitions (ex. UTI, PNEU) also apply to secondary BSI pathogen assignment. Excluded pathogens must be attributed to another primary site-specific BSI. A BSI pathogen may be reported for more than one infection source. 12 UTI = urinary tract infection PNEU = pneumoccal
Central Line-Associated Bloodstream Infection (CLABSI) Changes MBI Exclusion All facility types Exclude MBI-laboratory confirmed bloodstream infections (LCBIs) Resources: MBI-LCBIs Guide: http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/mbianalysis.pdf Summary Data Line List: http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/summarylinelist.pdf 13 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/rebaseline/2015-rebaseline-sirchanges-applicable-to-cms-qrp.pdf
Surgical Site Infection (SSI) Changes SSI Exclusions Acute care hospitals American Society of Anesthesiologists (ASA) missing BMI: If BMI>60 or BMI<12 Gender is missing or gender is O Medical affiliation is missing/incomplete (annual survey) Bed number missing (annual survey) Present at time of surgery (PATOS) Age > 109 years Procedure duration outliers Closure technique missing BMI = body mass index 14 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/rebaseline/2015-rebaselinesir-changes-applicable-to-cms-qrp.pdf
SSI Changes (cont.) Resources Exclusion Criteria http://www.cdc.gov/nhsn/pdfs/ps-analysisresources/ssi-sir_tips.pdf Line List of Procedures http://www.cdc.gov/nhsn/pdfs/ps-analysisresources/faq-procedure-line-list.pdf Analyzing Procedure Closure Technique http://www.cdc.gov/nhsn/pdfs/ps-analysisresources/proceduresclosuretechnique.pdf 15
Tools Available Electronic HAI Present on Admission (POA) Worksheet Generator Requires user to ensure infection criterion are met and to enter correct dates Generates worksheet with IWP, DOE, RIT, 2 nd BSI Attribution Period Located under Supporting Materials Does not store information or send information to NHSN 16 Source: CDC, available at https://www.cdc.gov/nhsn/poa/index.html
American Journal of Infection Control NHSN Case-Study Series Additional educational tool Quarterly publication Addresses common surveillance scenarios CLABSI, CAUTI, VAE, SSI, MDRO/CDI Test your knowledge Quiz and answers via web link 17 CAUTI = catheter-associated urinary tract infections MDRO/CDI = multidrug-resistant organism & Clostridium difficile infection
Complete List Revisions 18 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/pscmanual/psc-january-2017-revisions.pdf
19 NHSN Changes and Re-baseline
NHSN v8.6 Re-baseline Highlights Baseline 2 = New Standard Population Significant changes with definitions and decreased incidence of HAIs Used calendar year (CY) 2015 in-plan data as baseline No more pooled means New predictive/risk models Multivariable Logistic Regression Models (risk-adjustment) Negative Binomial Regression (probability) Logistic Regression (predictive) Standard Infection Ratios (SIRs) for Critical Access Hospitals (CAHs) More SIRs for long-term acute care hospitals (LTACH) and Inpatient Rehabilitation Facilities (IRFs) 20
Baseline Progression HAI Type Acute Care Hospitals (ACH) Original National Baseline Data Long-term Acute Care Hospitals (LTACH) Inpatient Rehabilitation Facilities (IRF) 2015 Re-baseline CLABSIs 2006 2008 2013 2013 2015 CAUTIs 2009 2013 2013 2015 SSIs 2006 2008 None None 2015 (ACH only) Hospital-onset C. difficile Hospital-onset MRSA bacteremia VAE 2010 2011 None None 2015 2010 2011 None None 2015 2015 MBI 2015 Standardized Utilization Ratio (SUR) (all device types) New No Previous National Baseline Data 2015 21 MRSA = Methicillin-resistant Staphylococcus aureus
Measures By Facility HAI ACHs CAHs LTACHs IRFs CLASBI (non-mbi) Central Line SUR MBI CAUTI Separate from ACHs Urinary Catheter SUR VAE Ventilator SUR All SSI Models Adults All SSI Models Peds Complex A/R Models Adults Complex A/R Models Peds Complex 30-day Models Adults (COLO and HYST) MRSA Bacteremia LabID CDI LabID 22 COLO = Colon HYST = Hysterectomy A/R = Admission/Readmission
SSI SIR Model Review All SSI SIR Model Inpatient only Superficial, deep and organ/space SSI Primary incision (superficial and deep) On admission, readmission and post-discharge Complex A/R SSI Model (CDC HAI Progress Report) Inpatient only Only deep and organ/space SSI On admission, readmission to facility Complex 30-Day SSI Model (CMS SSI Reporting) In plan, Inpatient Colo and Hyster Deep incisional primary and organ/space Within 30 days of procedure 23
Impacting SIRs Annual Survey CDI Test Type Other Potential Risk Factors: Facility bed size Medical school affiliation Status as a cancer hospital Intensive care unit (ICU) location Pediatric location 24
Risk Variables Factor CLABSI CLABSI (NICU) CAUTI VAE CDI MRSA CDC Location Facility Type Medical School Affiliation Inpatient Quarterly CO Prevalence Rate CDI Test Type Birthweight Length of Stay Reporting from ED/Obs Locations Facility Bedsize ICU Beds 25
Risk Variables (cont.) Factor COLO HYST Cancer Hospital Patient Level Factors Age ASA Score BMI Closure technique Diabetes Gender 26
SIR Reference 27 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/ps-analysisresources/nhsn-sir-guide.pdf
New Locations Added Can now produce SIRs for the below units: Mandatory CMS Reporting: All Critical Care All Medical Wards All Surgical Wards All Medical/Surgical Wards IMPORTANT REMINDER! CMS Value Based Purchasing FY 2018: All Critical Care CMS Value Based Purchasing FY 2019: All Critical Care Med, Surg, Med-Surg Wards 28
Standardized Utilization Ratio Summarized risk-adjusted measure Focuses on device use Coming Soon Uses multivariable logistic regression models SUR = # observed device days # predicted device days Predicted number = 1 >1 is higher utilization <1 is lower utilization 29
Implications To Data CAUTI Example 1 Baseline 1: Year # CAUTI # pred SIR P-value 95% CI Cath Days 2015 7 10.401 0.673 0.2931 0.294,1.331 5,996 New Baseline 2: Year # CAUTI # pred SIR P-value 95% CI Cath Days 2015 7 2.523 2.774 0.0193 1.213, 5.488 5,996 30
Implications To Data CAUTI Example 2 Baseline 1: Year # CAUTI # pred SIR P-value 95% CI Cath Days 2015 30 60.650 0.495 <0.0001 0.340, 0.697 16,963 New Baseline 2: Year # CAUTI # pred SIR P-value 95% CI Cath Days 2015 30 26.772 1.121 0.5218 0.770, 1.580 16,963 31
Baseline By Year Can use beginning CY* 2015 Do NOT use after CY 2016 Only Use Baseline 2 CY 2017 and beyond *Calendar Year 32
33 NHSN Changes and CMS
Re-baseline SIRs Shared with CMS Hospital IQR LTCHQR IRFQR CLABSI CLABSI CAUTI CAUTI CDI MRSA SSI Hyster SSI Colon CAUTI *Please note: this table does not include Healthcare Provider (HCP) Flu, as it is not impacted by the re-baseline. 34
The Old and New What is CMS Seeing? Baseline 1 Baseline 2 CMS will receive 6 quarters of data under Baseline 2. 35
Hospital Compare Hospital Compare Will use NHSN Baseline 2 data included in the December 2016 Quality Net Preview Reports will be calculated using the updated 2015 baseline and risk models. The Centers for Disease Control https://www.cdc.gov/nhsn/pdfs/rebaseline/hospital-compare-verification-clabsi.pdf https://www.cdc.gov/nhsn/pdfs/rebaseline/hospital-compare-verification-ssi.pdf 36
Value-Based Purchasing FY 2018 and FY 2019 VBP Safety 25% 25% Domain I: PSI 90 Composite 15% PSI 3: Pressure Ulcers PSI 6: Iatrogenic Pneumothorax PSI 7: CLABSI* PSI 8: Post-Op Hip Fx PSI 12: VTE/PE PSI 13:Post-op Sepsis PSI 14: Wound Dehiscence PSI 15: Accidental Puncture 25% 25% Domain II: HAI (NHSN) 85% CLABSI* CAUTI SSI Hysterectomy SSI Colon MRSA Bacteremia CDI 37
VBP Program Thresholds: Safety Domain NHSN Re-baseline Measure VBP FY 2017 (Data CY 2015) VBP FY 2018 (Data CY 2016) VBP FY 2019 (Data CY 2017) CAUTI 0.845 0.906 0.822* CLABSI 0.457 0.369 0.860* CDI 0.750 0.805 0.924 MRSA 0.799 0.767 0.854 SSI Hyster 0.698 0.710 0.762 SSI Colon 0.751 0.8244 0.783 PSI 90 0.777936 0.577321 0.774058 38 *Note: FY2019 CAUTI and CLABSI = CC and MS Wards
VBP and NHSN Baselines 1 Payment Year FY 2018 VBP CY 2016 Data FY 2019 VBP CY 2017 Data NHSN Baseline Used NHSN Baseline 1 NHSN Baseline 2 39
Reminder: CMS IPPS Reports CRITICAL Snapshot of what is being submitted on your behalf to CMS Validation of your submission Only proof your data was entered prior to the deadline Means to verify data accuracy Every submission, every time 40
Important Reminders: CMS HAI Data 41
Every Journey Begins With a Good Map! Accurate mapping is critical Avoids incorrect reporting to CMS x 42 http://www.cdc.gov/nhsn/pdfs/pscmanual/15locationsdescriptions_current.pdf
How Mapping Can Impact Your SIRs Unit Type IN:ACUTE:CC:ONC_M Critical Care Medical Oncology IN:ACUTE:CC:M Critical Care Medical Predicted CLABSI 4 1 Observed CLABSI 3 3 SIR 0.75 3.0 CAD* (Threshold: 0.369) +1.24 +2.6 Correctly Map First: Improve Second! 43 *Cumulative Attributable Difference (CAD)
Mapping Re-evaluate at least annually Location Patient mix Acuity Any changes in location If just move a unit, you can remain. If patient mix or acuity changes, you must map a new unit. Any changes in patient mix Type of patient Acuity of patients 80/20 rule At least 80 percent of a particular patient type Virtual Units When you don t have 80 percent to map to a particular unit type, but enough patients to skew your predicted number of infections Example: a medical ward that routinely has a significant number of oncology patients 44 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/pscmanual/15locationsdescriptions_current.pdf
45 NHSN Data Transition
Review: Baseline By Year Baseline 1 (old): Valid through CY 2016 data Baseline 2 (new): Valid beginning CY 2015 data CY 2017 and beyond, ONLY use Baseline 2 (new) 46
SIR Confusion FY 2018 VBP CY 2016 Baseline 1???? 47
Trending Data You cannot continue trending from Baseline 1 into Baseline 2. 48
Incorrect New Baseline Cannot continue trending beyond CY 2016 49
Correct Option 2.5 2 Community Memorial Hospital Trended CAUTI SIR Baseline 1 Baseline 2 NHSN Re-baseline 1.5 SIR 1 0.5 0 2012 2013 2014 2015 2016 2017 2018 Calendar Year 50
Another Option NOTE: FY2018/CY2016 data will be calculated using Baseline 1. Producing 2016 data using Baseline 2, while valid, may cause some confusion. 51
Accessing Baseline Set 1 Reports Old Baseline Reports Baseline Set 1 52
Data Reporting Facts: 1. For CY 2016 data, facilities will have more than one accurate SIR. 2. VBP will use Baseline 1 and CY 2016 data. 3. Hospital Compare will use Baseline 2 and CY 2016 data. 4. You can go back to CY 2015 data using Baseline 2 for trending purposes. 5. Select a baseline for internal reporting and stick to it for CY 2016 data. 6. Only use Baseline 2 for CY 2017 data and beyond. 53
Questions? Christine Martini-Bailey, RN, BSN, CSSGB Director, Quality Improvement and Patient Safety cbailey@hsag.com 614.307.2936 54
55 This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, 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. Publication No. QN-11SOW-D.1-04122017-01