NHSN Updates Linda R Greene RN, MPS, CIC linda.greene@urmc.rochester.edu
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
Feelings of Helplessness Broken escalator
General Changes in NHSN Reporting Requiring Medicare Number
Surgical Site Infections (SSIs) Data Source: National Healthcare Safety Network (NHSN) Metric: Standardized Infection Ratio (SIR) = Observed # of HAIs Baseline Period: 2006-2008 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
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 closed for risk adjustment Musculoskeletal Disease Society definition- SSI PJI will replace SSI JNT (Periprosthetic) HPRO and KPRO ( additional details hemi, total, resurfacing)
Challenges Denominator data readily available? Redesigning collection forms ICD-10 may be challenging
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.
What about CMS? Rate reported as a SIR (Deep and Organ space only) Risk adjusted Expected/Observed Complex risk adjusted methodology
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
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
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
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 0.418, 3.932 COLO 6 2012H1 379 1 3.792 0.264 0.108 0.007, 1.469 HPRO 6 2012H1 343 7 3.055 2.291 0.036 0.921, 4.721 HYST 6 Where is my greatest opportunity for improvement? What is your interpretation of my overall SIR? Where am I performing well?
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 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
Other Issues Lab Survey Looking at Candiduria
CAUTI
States with SIR above 1 Colorado 1.001 Iowa 1.012 California 1.014 Michigan 1.066 Mississippi 1.089 Indiana 1.095 Kentucky 1.098 Illinois 1.103 North Carolina 1.126 Arizona 1.138 Washington 1.142 Idaho 1.149 Nevada 1.208 Montana 1.226 Arkansas 1.234 Delaware 1.235 Oregon 1.239 New York 1.38 Rhode Island 1.385 Vermont 1.408 New Hampshire 1.444 Tennessee 1.453 Nebraska 1.499 District of Columbia 1.514 Minnesota 1.575 Massachusetts 1.603 South Carolina 1.719 Connecticut 1.771 Maine 1.892 Utah 1.9
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).
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
Historically No Respect for CAUTIs
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. http://www.cdc.gov/nhsn/pdfs/ltc/ltcf-utiprotocol_final_8-24-2012.pdf
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
Connect the Safety Dots Immobility Urinary Catheter Harm Trauma Falls? Decubs? Discomfort Satisfaction DVT? CAUTI Delays, LOS Antibiotic Resistance C Diff infection Cost$
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 unit, but will give organizations the opportunity to analyze these infections and Identify opportunities not specific to their unit. Expand electronic capture of data
Research Priorities Understand Role of Biofilm Understand barriers to implementation of evidence based practices Optimal strategies for catheter maintenance
Focus More focus outside of ICU 2015- Report in non ICU location Challenges: Daily review for necessity of line Maintenance issues
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
C difficile Goals: 1. Improve Antimicrobial Stewardship 2. Improve environmental contamination
C difficile bundle A- Antibiotic Stewardship B- Barrier Precaution C- Compulsive Hand washing D- Disinfection of Environment E- Executive Sponsorship
summary YQ CDIF HO Count numexp CDI SIR SIR_pval sir95ci 2012Q1 14 18.615 0.752 0.1705 0.411, 1.262 2012Q2 25 18.625 1.342 0.0909 0.868, 1.982 2012Q3 20 18.018 1.110 0.3504 0.678, 1.714 2012Q4 16 17.938 0.892 0.3805 0.509, 1.449 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
Summary Ongoing changes in NHSN Attempting electronic capture Role of the EHR Implementation science is the greatest challenge