Clostridium difficile Infection (CDI) Intervention Kick-Off Webinar Wednesday, January 17, 2018 National Nursing Home Quality Care Collaborative (NNHQCC) Health Services Advisory Group (HSAG)
Introduction and Overview James H. Barnhart III, BSH, LNHA
Today s Objectives Summarize the 10-month baseline reporting period and identify steps that need to be completed to maintain the National Healthcare Safety Network (NHSN) user and facility access in 2018. Analyze state and national CDI rates and present the 2018 intervention strategy to maintain or reduce CDI rates. Demonstrate how to develop a CDI-focused performance improvement project (PIP) and explain how to access facility-level CDI rates from NHSN. 3
What is a QIN-QIO? Funded by the Centers for Medicare & Medicaid Services (CMS) QIN-QIO in each state Dedicated to improving health quality at the community level Ensures people with Medicare get the care they deserve, and improves care for everyone Department of Health & Human Services Centers for Medicare & Medicaid Services 4
HSAG s QIN-QIO Responsibility Nearly 25 percent of the nation s Medicare beneficiaries 5 5 HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.
Improve Hand Hygiene and Injection Practices in ASCs* QIO Work Cardiac Health Disparities in Diabetes Adult Immunizations Transforming Clinical Practice Support of Clinicians in the Quality Payment Program Patient is at the center of care Antibiotic Stewardship in Communities Healthcare- Acquired Conditions in Nursing Homes Behavioral Health Coordination of Care 6 *ASCs=Ambulatory Surgical Centers
Improve Hand Hygiene and Injection Practices in ASCs QIO Work Cardiac Health Disparities in Diabetes Adult Immunizations Transforming Clinical Practice Support of Clinicians in the Quality Payment Program Patient is at the center of care Antibiotic Stewardship in Communities Healthcare- Acquired Conditions in Nursing Homes Behavioral Health Coordination of Care 7
What is the National Nursing Home Quality Care Collaborative (NNHQCC)? An all-teach, all-learn CMS quality improvement initiative designed to ensure residents receive the highest quality of care Aligned with other nursing home (NH) quality initiatives, led by QIN-QIOs Support recruited member NHs: In using QAPI as a framework to achieve system-wide improvement In reducing inappropriate use of antipsychotic medications managing CDI with the CDI Initiative Use Quality Measure Composite Score to monitor progress 8
HSAG s CDI Initiative
CDI Initiative in AZ, CA, FL, and OH 483 Nursing Homes NHSN enrollment 10-month data collection for baseline Quality improvement As of April 10, 2017, 2,341 NHs are enrolled in the CDI NHSN database Approximately 15% of the nation s NHs 10
CDI Initiative Baseline March 2017 through December 2017 Consecutive Don t miss a month! Analysis 11
2018 NHSN Action Items: CDI Cohort Members Tara Rhone, MPH, BS
2018 NHSN Action Items New long-term care facility (LTCF) annual survey Updated NHSN Agreement to Participate and Consent Adding Additional NHSN Users 13
New LTCF Annual Survey New LTCF NHSN Annual Survey The data is based on calendar year 2017 (Jan. 1, 2017 Dec. 31, 2017) This mandatory survey must be completed in NHSN to provide updated information on LTCF characteristics and practices All required questions must be answered before the NHSN application will save the survey The paper version of the survey is available at: https://goo.gl/ig4zt9 The table of instructions to complete the survey is available at: https://goo.gl/wyujex Due Date: January 31, 2018 14
Updated NHSN Agreement to Participate and Consent The January 23, 2018 release of the NHSN 8.8.1 application will introduce an updated electronic NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled prior to 12/02/2017. Once the consent form is available, an alert will appear on all NHSN component home pages Primary contacts and NHSN facility administrator (NHSN FA) will receive an email notification Primary LTCF contacts or NHSN FA must agree to this updated consent form online as soon as possible, or risk losing access to NHSN Submission will be done electronically through the NHSN application rather than a paper copy that is mailed, scanned, or faxed manually The Consent Form Then and Now NHSN 8.8 Release Due Date: February 15, 2018 15
Adding Additional NHSN Users HSAG and the Centers for Disease Control and Prevention (CDC) highly recommend that each NH have more than one user with a SAMS grid card To protect the NH from missing data submissions in the event of staff member turnover, vacations, illnesses, etc. Since SAMS cards are personal and are not to be shared throughout a facility To help distribute the NHSN surveillance workload among multiple users Since infection control and prevention is a team effort having multiple NHSN users spreads knowledge/awareness among team members Steps to add a User to NHSN available at: https://goo.gl/smuoqz 16
NHSN CDI Rates Buffy Lloyd-Krejci, MS, CIC
CDI: About the Data CDI data reported to NHSN during the 2017 baseline time-period (March 1, 2017 through December 31, 2017) Aggregate CDI event and summary data used to derive CDI rates Self-reported data without CDC validation 18
CDI Rates in NHSN Total CDI Rates Community-onset (CO) Facility-onset CDI rates Facility-Onset CDI Rates Long term care facility-onset (LO) Acute care transfer long term care facility-onset (ACT-LO) 19
HSAG QIN-QIO and National CDI Rates Total Number of Resident Days Total Facility Onset Count of CDI CDI Rate * Count of CDI CDI Rate ** Arizona 466,434 106 2.273 101 2.165 California 3,500,030 257 0.734 238 0.680 Florida 2,589,367 203 0.784 169 0.653 Ohio 2,399,709 187 0.779 176 0.733 National 44,756,634 3,085 0.689 2,708 0.605 * Total CDI Rate: (Total CDI Count/Total Number of Resident Days) * 10,000 Resident Days ** Facility Onset CDI Rate: (Facility Onset CDI Count/Total Number of Resident Days) * 10,000 Resident Days 20
HSAG QIN-QIO and National CDI Rates Total Number of Resident Days Total Facility Onset Count of CDI CDI Rate * Count of CDI CDI Rate ** 2 1 3 Arizona 466,434 106 2.273 101 2.165 California 3,500,030 257 0.734 238 0.680 Florida 2,589,367 203 0.784 169 0.653 Ohio 2,399,709 187 0.779 176 0.733 National 44,756,634 3,085 0.689 2,708 0.605 Example: AZ Facility Onset CDI Rate: (101 / 466,434) * 10,000 = 2.165 21
2018 CDI Reduction Strategy Keith Chartier, MPH
2018 CDI Reduction Goal To maintain or lower the facility-onset CDI rate over baseline by September 2018. State-by-state goals State 2017 Baseline Stat 2018 State Goal Arizona California Florida 2.165 CDIs per 10,000 resident days 0.680 CDIs per 10,000 resident days.0653 CDIs per 10,000 resident days 1.5 CDIs per 10,000 resident days 0.578 CDIs per 10,000 resident days >.0653 CDIs per 10,000 resident days Ohio 176 CDI Events 145 CDI Events 23
Key CDI Reduction Strategies Antibiotic Stewardship NHSN Data Entry and Analysis QAPI CDI Management Communication 24
Antibiotic Stewardship/CDI Management Collaborative will support NHs with antibiotic stewardship principles and practices, including CDI prevention and control practices. Resource Nursing Home Training Sessions CDC Core Elements of Antibiotic Stewardship in Nursing Homes Link https://goo.gl/mhah8b https://goo.gl/ln3eom 25
NHSN Enrollment, Data Entry, and Analysis NHSN Enrollment Goal: Two users per facility to mitigate staff member turnover, workload, and vacation. State Turnover Facilities with One User Arizona 41% 7 facilities California 37% 91 facilities Florida 50% 89 facilities Ohio 40% 72 facilities Resource HSAG NHSN Website NHSN Enrollment Videos Link https://goo.gl/ne9vbr https://goo.gl/nskl5q 26
NHSN Enrollment, Data Entry, and Analysis (cont.) NHSN Data Entry Goal: Continue entering monthly data into NHSN HSAG will continue with technical assistance Red, yellow, and green deadline alerts Resource HSAG NHSN Website NHSN Reporting Videos Link https://goo.gl/ne9vbr https://goo.gl/hxlkzq 27
NHSN Enrollment, Data Entry, and Analysis (cont.) NHSN Data Analysis Goal: Create performance improvement project (PIP) and monitor and track data for QAPI. HSAG will continue with technical assistance Resource HSAG NHSN Website NHSN Analysis Videos Nursing Home Change Package QAPI At-a-Glance Link https://goo.gl/ne9vbr https://goo.gl/rys89f https://goo.gl/z7fwc5 https://goo.gl/muykft Note: Change Package includes C. difficile and QAPI change bundles 28
TeamSTEPPS Communication Instruct NHs in TeamSTEPPS Long-Term Care Communication Module Resource Nursing Home Training Sessions Agency for Healthcare Research and Quality Link https://goo.gl/mhah8b https://goo.gl/wbpq7n 29
2018 Education and Outreach HSAG Website Monthly Quality Care Connection Email Nursing Home Training Program Certificates Red/Yellow/Green Reminders PIP assistance 30
2018 Education and Outreach (cont.) Monthly Educational Webinars Date January, 17, 2018 February 22, 2018 March 22, 2018 April 19, 2018 May 31, 2018 June 21, 2018 July 19, 2018 August 16, 2018 September 13, 2018 Topic CDI Intervention Kick-Off Antibiotic Stewardship Exploring the Role of Antibiotics Case Study: CDI Reduction and QAPI Strategies to Decrease Antibiotic Resistance CDI Part 1: Clinical Overview CDI Intervention PIP Progress Report CDI Part 2: Prevent, Track, and Monitor TeamSTEPPS Communication Registration Information to Follow. Check www.hsag.com/events often for upcoming webinars and events. 31
Ongoing Technical Assistance State Name Email Phone Number Arizona Buffy Lloyd-Krejci blloyd-krejci@hsag.com 602.801.6878 California Rose Chen Ezrah Lasola rchen@hsag.com elasola@hsag.com 818.653.9380 818.265.4644 Florida Tara Rhone trhone@hsag.com 813.865.3191 Ohio Angila Anderson aanderson@hsag.com 614.704.1216 32
Using QAPI to create a CDI-focused PIP Ezrah Lasola, BSN RN, RAC-CT
Objectives Utilize QAPI tools and techniques to create a PIP Review the step by step process of a CDI-focused PIP Recognize how to utilize NHSN data to drive performance improvement in your NH 34
Transforming the lives of nursing home residents through continuous attention to quality of care and quality of life
Five Elements of QAPI 36
Final Rule ( 483.75) Required to conduct distinct PIP Required to implement at least one PIP annually 37 Source: https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
Case Study Happy Acres Nursing Center is a 99-bed Skilled Nursing Facility (SNF). The facility is divided into two neighborhoods, Neighborhood A, which mostly comprises of short-term residents, and Neighborhood B, long-term residents. 38
Case Study (cont.) NHSN CDI Report Facility Org ID Resident ID Resident Type* Date of Current Admission Days: Admit to Event Event Date Location** Transferred from Acute Care Facility in Past 4 Weeks? 45188 555258 SS 12/13/2017 21 1/2/2018 NH A Y 45188 30259 SS 2/15/2018 10 2/24/2018 NH A Y 45188 39820 LS 6/14/2017 237 2/5/2018 NH A N 45188 28596 SS 1/8/2018 30 2/6/2018 NH A N 45188 58762 SS 3/1/2018 4 3/4/2018 NH A Y 45188 87952 SS 2/14/2018 24 3/9/2018 NH A N 45188 55589 LS 9/13/2017 182 3/13/2018 NH A N *SS = Short Stay; LS = Long Stay **ST A = Station A 39
Case Study (cont.) The Issue 1 C. diff event in January 3 C. diff events in February 3 C. diff events in March 40
Case Study (cont.) The Plan Started an Infection Prevention and Control Team Appointed the ADON as the Infection Control Officer (ICO) Started a PIP 41
PIP Process 42
PIP Process Step 1 43
PIP Process Step 2 44
PIP Process Step 2 (cont.) 45
PIP Process Step 2 (cont.) 46
PIP Process Step 3 47
PIP Process Step 4 48
PIP Process Step 4 SMART Goal: To decrease the number of C. diff events within Neighborhood A of Happy Acres Nursing Center from 7 events to 0 events by October 31, 2018, based on the NHSN CDI report. 49
PIP Process Step 5 50
PIP Process Step 5 (cont.) Goal To decrease the number of C. diff events within Neighborhood A of Happy Acres Nursing Center from 7 events to 0 events by October 31, 2018, based on the March 2017 NHSN report. 51
PIP Process Step 6 52
PIP Process Step 6 (cont.) Action Item Person(s) Responsible Start Date End Date Educate all staff members on their responsibility to prevent C. diff Infection Prevention and Control Officer Director of Staff Development May 2, 2018 May 12, 2018 Conduct competency testing for nurses and nursing assistants on proper hand washing techniques Director of Staff Development May 2, 2018 May 19, 2018 Request the Medical Director to speak with other Physician s regarding new guidelines in antibiotic administration Nursing Home Administrator May 2, 2018 May 31, 2018 Establish an Infection Prevention and Control Team, identify an Infection Control Officer Director of Nurses May 2, 2018 May 12, 2018 Start an Antibiotic Stewardship Program (including policies and procedures) Infection Control Officer, Director of Nursing, Medical Director, Nurse Home Administrator May 2, 2018 May 31, 2018 Have additional staff members gain access and start reporting C. diff data to NHSN Director of Nursing, Director of Staff Development, and Charge Nurse May 2, 2018 May 31, 2018 53
PIP Process Step 6 (cont.) 54
PIP Process Step 6 (cont.) 55
PIP Process Step 6 (cont.) 56
PIP Process Step 7 57
PIP Process Step 7 (cont.) Residents in Neighborhood A with C. diff 58
PIP Process Step 8 59
PIP Process Step 9 60
Summary of What Happy Acres Did: Trended and reviewed data Identified the problem Started a PIP Set a SMART goal Used Root-Cause Analysis Determined action items based on RCA Identified staff members as additional NHSN users Implemented an antibiotic stewardship program Involved patients, family, and staff members Used the PDSA to test the effectiveness of the changes Implemented and spread changes to Neighborhood B 61
Accessing Your Facility-Level CDI Rates in NHSN Angila Anderson, BSHA, LPN
Generate Data Sets Select Analysis Generate Data Sets Generate New Click Ok 63
Generate Data Sets - continued Data set processing Data set successful 64
Analysis Reports Next Select Analysis>Reports MDRO/CDI Module All C. difficile LabID Events Rate Tables for CDI LabID Events Run Report 65
Modify Analysis Reports Select Time Frame Tab Summary YM> 3/2017-12/2017 Display options Select Run 66
Facility-Specific Rate Tables Report opens in browser 7 facility specific rate tables Total CDI Rate 67
Rate Tables for CDI LabID Events 1. Total CDI Rate 2. CDI Treatment Prevalence on Admission 3. Total CDI Percent that is Community-Onset (CO) 4. Total CDI Percent that is LTCF-Onset (LO) and CDI LO Percent that is Acute Care Transfer (ACT-LO) 5. Total CDI Percent that is Recurrent 6. LTCF-Onset (LO) CDI Rate 7. LTCF-Onset (LO) Incident CDI Rate 68
LTCF-Onset (LO) CDI Rate 69
Categorization of LabID Events Community-onset (CO) Date specimen collected 3 calendar days after current admission (i.e., days 1, 2, or 3) Long term Care facility-onset (LO) Date specimen collected > 3 calendar days after current admission (i.e., on or after day 4) Acute care transfer long term care facility-onset (ACT-LO) LabID Event specimen collection date 4 weeks following date of last transfer from an Acute Care facility 70
Click to edit Master title style What Should You Do Next? Submit your December 2017 CDI data. Check your rate. Register for CDI Initiative February webinar. Add another NHSN user to your account.
Are You Receiving Both of the Monthly Email Updates? 72
Have you visited our website? www.hsag.com/nh-nhsn-resources 73
Contact us! Questions? Comments? Assistance? Reach out to your state Quality Improvement Organization (QIO). State Name Email Phone Number Arizona Buffy Lloyd-Krejci blloyd-krejci@hsag.com 602.801.6878 California Rose Chen Ezrah Lasola rchen@hsag.com elasola@hsag.com 818.653.9380 818.636.8242 Florida Tara Rhone trhone@hsag.com 813.865.3191 Ohio Angila Anderson aanderson@hsag.com 614.704.1216 74
Questions?
Click to edit Master title style Thank You!
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Ohio, Florida, 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-C.2-01162018-01